On Friday I read a tweet from Jane Cummings, England’s Chief Nursing Officer, about creating a culture than encourages compassion in nurses. It linked to her article in The Telegraph, about the distressing findings of the Francis report into conditions at Midstaffordshire.
For several years the papers have covered story after story of failures in NHS care, often centring on nursing care or, more accurately, lack of care, and the issues at Stafford are mirrored in hospitals and aged care centres across England. Indeed, five more trusts are now scheduled for investigation.
Just this week there’s the story of litigation against the University Hospitals Bristol Foundation trust, following the deaths of seven children and hospital-acquired disability of three others. Reading summaries of the breaches of care (which included multiple episodes of alarms being switched off, repeated failures to recognise deterioration, and leaving children covered in vomit and in soiled nappies) one wonders how it’s possible for such inhumanity from anyone, let alone professionals whose job is to provide care.
Descriptions of other medical and nursing breaches are equally horrifying – patients who undeniably died as a result of being denied fluids, fasted for over a week because of repeatedly delayed surgery, failure to provide pain relief, refusal to provide assistance with toileting, or linen changes.
This lack of compassion is most often attributed to nursing and medical education – this article by Yvonne Roberts is typical, mentioning that
a solid and sustained grounding during training would help… For the most part, training for health professionals gives cursory attention to ethics, psychology and simulated patient exercises, while managerial bonding adventures are not enough to remind us that behind the targets behaviour, sometimes aberrant, also requires accounting.
I’ve read a lot about how the NHS needs cultural change, calls over and over for a return to hospital-based training instead of a degree (university educated nurses are deemed “too posh to wash“), and/or an emphasis on personal qualities like compassion over academic ability when selecting student nurses.
That the NHS is in trouble isn’t news, but things are rapidly getting worse, and it’s a situation Australians should be watching with care. Though there are certainly differences, I find it hard to believe that Australia’s health care culture is so markedly different from England’s as to account for this, yet (with rare exceptions), there are no stories like these in our papers. We have the same stereotypes about Gen Y fecklessness. We have the same bemoaning about electronic connection instead of direct interaction. The last Victorian hospital-based nursing education program closed in 1990, yet over twenty years of university-educated nurses hasn’t led to a compassion abyss.
So if it’s not the people, not the switch in education, what’s the difference?
Though there are similarities, there are significant differences between the NHS and Australia’s public hospitals. Unlike Medicare, NHS services vary from Trust to Trust – not only in term of facilities, but even which medications are able to be prescribed. So unlike here, where decisions about subsidised medications are made by the PBS Advisory Committee, and then made available to all who meet prescribing guidelines,expensive drugs can be further restricted by trusts. As I discovered at a 2011 palliative care conference in Manchester, that includes chemotherapy drugs, so that patients in neighbouring suburbs but different trusts may have very disparate treatment options, and the borders between Trusts seem far more rigid, so that a Not For Resuscitation order from one trust may not be recognised when that patients is transported across the boundary of a second trust.
The training systems are also different – instead of the (potentially articulating) enrolled nurse, registered nurse and midwife options, in the UK there are four streams (adult, pediatric, mental health, learning disabilities) with little cross-over. Because there are no diploma-level nurses, less technical duties (the essential care on which all nursing and midwifery is based) often devolve to under-qualified, unregulated health care assistants; though Australian acute care hospitals employ HCA’s, Victoria restricts their employment to rehabilitation, aged care and private hospitals. This was one of the three key elements of our recent EBA campaign, as I’ve explained previously.
Unlike most discussions about this NHS issue, the article I referenced above opens its concluding paragraph with “Cut frontline staff and collaboration splinters.”
And I believe that’s at the heart of this problem. Others have written more comprehensively than I about the link between work load, burnout and compassion fatigue. For a snapshot of the tensions overworked nurses face you can’t go past this account of a week in the life of an NHS nurse.
For Victorian nurses, the key difference between our public hospital system and the NHS, though, is ratios. We have legally mandated minimum staffing – though the ratios are now twelve years old, and inadequately reflect the increase in patients acuity between 2000 and now, they still provide essential protection for nurses and midwives, and patients. Even in states and territories without ratios, it cannot happen here, as it has at University College Hospital, for example, for forty-one postpartum women and their babies to be cared for by only three midwives and a handful of aides.
It worries me that the issues with care provision in the UK are repeatedly rooted in local culture, and individual responsibility, instead of being seen as a symptom of a system-wide problem.
I love my work, and I take enormous satisfaction in knowing that my patients receive excellent nursing care – not just by me, but by my colleagues. When I was a very junior student complaining about a bad shift, a friend asked if my care had made a positive difference to anyone. I replied that I had. “What more,” she asked, “can you ask for in a day?” I can say that I have made a positive difference every single shift of my career.
Yet I can’t give the care I’d like to. I can’t remember the last time I gave all my patients a face-back-and-hands wash at the end of an evening shift – something that used to be routine. When I assist a patient with a meal it’s often a few mouthfuls, off to fix an IV, a couple of mouthfuls, answer the phone…
Last week I hadn’t slept well before my shift. When I got to work it was chaotic – the PM shift hadn’t been able to finish everything, we had admissions coming, a couple of significantly unwell patients, and I had a dozen things that needed doing immediately, but only two of us to do them. When one of my patients buzzed for a pan I turned her on my own, though I would have been better to get my colleague to assist – but she was caught up, and my patient’s need was pressing. I was tempted to leave her to be incontinent – I knew she’d overshoot the pan and would need a linen change anyway.
I got her a pan, with a somewhat forced smile, risked my back turning her alone, and washed her and changed the bed when not all the urine made it into the pan. But I can easily see how, faced with that level of work every day, with more than eight patients, without support and without over two decades of experience, I could have made a different decision.
I responded to the tweet I opened this post with: “Compassion fatigue signals burn out; that it’s endemic in the NHS indicates chronic under-staffing.” The conversation that followed included responses from another nurse that “we have learned with staff burn out its [sic] the totality of life often and work is only one facet” and “we hear sad stories nurses feeling torn we have a range of support but its [sic] always about choices” plus a link to a “great self audit tool for energy to avoid burnout”.
I agree that nurses, midwives and other health professionals have a responsibility to balance their lives, to take care of themselves and thus their patients, to recognise burn out and take steps to combat it. I also think that’s an ideal that for many is hard to meet, particularly when burnout’s already set in.
I also have significant concerns that placing so much of the responsibility of the problem on individuals abrogates the wider responsibility of the institution. Without inquiring beyond the failure of individuals nothing will change. Despite an already near-critical nursing shortage in the UK, the article I linked to at the top of this post is titled Nurses who don’t care about patients must leave the NHS.
The best nurses take steps to get out before they’re burned out – it’s the reason I returned to study, after working with a nurse who was crispy with burn out but had no options and no energy to look at anything except trudging through each day. Without significant change there won’t be any compassionate nurses left in the NHS.