It’s 30 years since Trevor Clay challenged his fellow nurses to rise up and make their voices heard. The profession had been “remarkably insular”, he wrote, and to its lasting cost had taken little heed of the social, political and economic forces that shaped its practice.
Clay, the charismatic leader of the Royal College of Nursing (RCN) during its period of explosive growth in the 1980s, argued that nursing’s great strength – its overriding focus on the needs of the patient – was at the same time its great weakness. “Too many nurses take that suppression of their individual feelings on a daily basis into political life,” he said. “Nursing is perhaps the most unassertive profession in the UK.”
Three decades after Clay made that claim, it’s timely to revisit it. If he was still alive today, would he be satisfied or still frustrated at the standing of nursing in the UK?
Nurses are certainly not the handmaidens of any other profession
He would certainly find the profession’s agenda changed – or, more to the point, extended. The three core issues he identified as pay, education and advancing the nurse’s role remain valid. But events and trends have added three more: staffing levels and the mix of qualified and support workers; nursing’s response to the changing healthcare agenda; and the recurring accusation that the profession has somehow lost its soul.
The Mid Staffs scandal, which exposed alarming attitudes and practice on the part of some nurses, and the inquiry into fatally poor standards of infection control at the Vale of Leven hospital in Dunbartonshire, Scotland, have unquestionably scarred nursing’s reputation.
Janet Davies, the present chief executive and general secretary of the RCN, argues that care quality, staffing levels and skills mix are inextricably linked. Mid Staffs was as much about insufficient numbers of qualified practitioners as about lack of compassion, she says, and she worries that understaffing – with almost every hospital reportedly now falling short of targets for qualified staff – may be causing “compassion fatigue”.
“Compassion is the absolute essence of nursing, but being one of two nurses with 15 or 20 highly dependent patients is hardly conducive to doing your job in the most compassionate way,” she says.
Compassion was one of the “six Cs” at the heart of the last nursing strategy, led by Prof Jane Cummings, England’s chief nursing officer. That was an approach explicitly designed to help restore the profession’s pride in the wake of Mid Staffs. Her new strategy, launched last summer, shifts the focus to 10 commitments to challenge unwarranted variation in outcomes for patients, their experiences and use of resources.
This represents, in part, a recogniton that nursing must adapt to the new reality of healthcare, with the emphasis shifting away from treating illness towards preventing it, strengthening public health and supporting 15 million people living with long-term conditions.
At the same time, the profession must deal with the implications of Brexit – for recruitment from the rest of the EU – and the likelihood of continued severe pay restraint for the rest of this decade. There is also a raft of workforce reforms coming into effect in England this year, including the end of training bursaries and the removal of a cap on intakes at universities.
The reforms have sparked controversy and nurse leaders have faced criticism for failing to take a clear and united position. Peter Carter, Davies’s immediate predecessor, who is broadly in support of the changes while remaining cautious about the effect of ending bursaries, says: “The profession doesn’t really have a coherent take on these initiatives, but they could ameliorate the shortfall in numbers coming into the profession.”
Davies defends the RCN’s scepticism about the reforms – not least because of the strain they will heap on an already struggling NHS – and insists that the profession overall is in good shape. Since Clay’s era, she points out, it has become graduate-only entry, has adopted three-yearly revalidation and has greatly enhanced its research base. “Skilled nursing is the one thing that really makes a difference in healthcare,” she says. “We’ve always known that, but now we can show it.”
With the advent of a new nursing degree apprenticeship route to complement increased university intakes – as well as the option of becoming a nursing associate – the profession should have no shortage of new blood.
But has nursing found an assertive voice? “Nurses today have much more of a role in the taking of key decisions,” says Davies. “They are certainly not the handmaidens of any other profession.”
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"Nursing makes all the difference in healthcare": how the job has changed
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