“It is easy to point to areas of failure but nurses need to be a given a more prominent leadership role in hospitals if standards of acute nursing care are to be improved. Improving the experiences of nurses working in acute care, particularly dealing with the emotional labour of care would make a significant improvement to the overall experience for patients. Whilst many would acknowledge that nursing is an emotionally difficult job, this rarely features in current debates, and organisations rarely discuss nursing in these terms.
Giving nurses systematic support would enhance the experience for all nurses and their patients on acute wards and send a clear message that the role nurses play in acute care is genuinely valued”
Our paper: (Time to Care? Responding to concerns about poor nursing care) makes a series of recommendations to support nurses working in acute hospital care to deliver a better service for patients. As well as recommendations focussed on leadership we also identified the need for a systematic approach to supporting nurses with the emotional stress of caring work and a recognised training programme for healthcare support workers.
The seven core recommendations are:
Environment of care
1. Ward sisters/Charge nurses need to be a given a more prominent leadership role in hospitals if standards of acute nursing care are to be improved according to a new paper from the University of Birmingham’s leading health policy unit the Health Services Management Centre
2. Senior Nurse leaders need to be freed from the competing demands placed upon their time to enable them to fulfil the prime role of leading clinical nursing
3. Where new ward designs limit the visibility of nurses, systems of ‘intentional rounding’ should be introduced to ensure organisational processes enable nurse patient contact to be maintained.
4. Clinical dashboards that measure nursing care indicators, which can then be reported to the Board, are an important tool which should be introduced into every acute hospital trust
Education and development
5. Student nurses need to feel a greater sense of belonging to the nursing profession rather than being identified primarily as a university student.
6. Healthcare support workers would benefit from a recognised training programme in every organisation, underpinned by a probationary period for all new starters.
Emotional Labour of Nursing
7. Boards should recognise the emotional labour of nursing and establish a systematic approach to supporting nurses. This should be evaluated to assess its impact on nurses as carers and the subsequent outcome for patients.
Responding to concerns about poor nursing care.
In the 1950’s Menzies identified that nurses’ deal with situations such as death and dying, on a daily basis whilst most lay people may not experience this in a lifetime. This remains the case with nursing today. In order to avoid them being overwhelmed by anxiety they need ways of coping and these mechanisms need to include systematic support for this emotional aspect of their work. It is rare to find such a system in the day to day realities of ward nursing. In addition, the recognition of nursing as a series of tasks that are “frightening, disgusting and distatsteful” (Menzies 1960) is rarely discussed, and therefore not recognised by organisations or responded to. Coping mechanisms may have been eroded over time because they were not fully understood-for example task based nursing has been replaced by personalised care. Whilst the authors do not argue for a return to this approach, they do highlight the need to recognise the impact of this change and to take appropriate action. For example the Samaritans employ a model of emotional support for their volunteers, which ensure they are able to cope in their role of providing care to others at their time of need.
Caring is seen as an easy task - kindly next door neighbours are described as caring for example, and therefore if it is simple why do nurses not just do it? This rationale then leads to the uni-dimensional approach of blaming the individual nurse and/ or their education - the “too posh to wash” syndrome. This approach belies the complexity of what it means to be a registered nurse in today’s complex healthcare environment, and also ignores the reality of caring which is recognised in other areas of national policy- such as the National Carer’s Strategy. It appears that this recognition of what it means to be human is forgotten once nurses are in paid employment.
Ward and board nurse leadership is recognised throughout the literature as crucially important in setting the right standards for practice and delivery of good, compassionate patient care. The energy required to create a culture of caring and develop, support and inspire the nursing profession does not appear to have been articulated in ways which Boards can understand or relate to. Most Ward Sisters/Charge Nurses and Nursing Directors have a myriad of other responsibilities which take their time away from nursing (Burdett 2006; RCN 2009). In addition Newchurch (1995) identified that 75 per cent of nurse directors did not have line management responsibility for nurses which creates an added dimension when trying to influence practice and standards.
Finally, the paper identifed a sense of dissonance between being a” good” nurse and a “good” employee. A “good nurse” might be expected to know who were the illest patients on their ward, how many needed help with eating, or the number of patients with pressure ulcers. However the mangers may want them to know how many patients are in A&E waiting for a bed, and how many beds they will have on their ward to accommodate this need. Whilst these are not mutually exclusive requirements, it serves to illustrate the tension between system pressures and priorities, and nursing care. For nurses struggling to identify how to measure the components of compassionate care in a way which are widely accepted and can be bench marked, the management culture can distort priorities and the personalisation of care can be overlooked as the needs of the organisation, in terms of achieving high profile performance measures, takes precedence. This can create internal conflict between being a “good nurse” and responding to what is important to individual patients, and being a “good employee” and responding to what is important to the organisation/their managers. The nurses’ Code of Conduct states “make the care of people your first concern, treating them as individuals and respecting their dignity” (NMC 2008), which further compounds nurses sense of conflict.