Grasping the Nettle on Health Reform

Unfortunately creating more

Unfortunately creating more tick boxes to be audited by Quality Improvement people who are not clinicians are only creating jobs and not about improving health care. Whilst there is a focus on improvements using measurable tools instead of letting clinicians apply humanistic care that is not easily measureable there will only be an explosion of clip board bosses. Quality of care is actually diluted. Article follows- sorry no ability to provide links to article on this web site.

.http://jrn.sagepub.com
Journal of Research in Nursing
DOI: 10.1177/1744987109353689
Journal of Research in Nursing 2010; 15; 9
Jill Maben, Jocelyn Cornwell and Kieran Sweeney

In praise of compassion

http://www.sagepublications.com

In praise of compassion Journal of Research in Nursing
15(1) 9–13

Compassion, in its original meaning in Latin, means ‘with suffering’. Compassion is usually expressed towards others when we experience their suffering, being there with them in some way that makes their pain more bearable (Firth-Cozens and Cornwell, 2009). A simple definition is that it is ‘a deep awareness of the suffering of another coupled with the wish to relieve it’ (Chochinov, 2007).
The casual reader of recent reports might be forgiven for thinking that nurses have no
interest in compassion. The mainstream media have interpreted the regulator’s shocking and disturbing reports about the quality of care in hospitals in Mid Staffordshire and Maidstone and Tunbridge Wells as poor nursing delivered by insensitive, even bad, nurses.More recently, the Patients Association has fuelled public concern with a report documenting ‘dreadful, neglectful, demeaning, painful and sometimes downright cruel treatment elderly patients had experienced at the hands of NHS nurses’ (Patients Association, 2009).A great many practising nurses share the concern. Nurses’ and ex-nurses’ own accounts of poor experiences of care feature regularly in the nursing press. In interviews and evidence (Dawoud and Maben, 2008; Maben and Griffiths, 2008) over and over again a wide range of
nurses suggested that the essence of nursing, being with patients, performing essential but intimate care, where relationships are forged and built has been passed over to health care assistants. The broad consensus seems to hold: compassion once seen as ‘the essence of caring and therefore the essence of nursing’ is no longer ‘always the central focus of nursing practice’ (Chambers and Ryder, 2009).

Nursing does indeed have long associations with caring, empathy and compassion.
Florence Nightingale, eloquent in her empathy for patients, observed that ‘apprehension, uncertainty, waiting, expectation [and] fear of surprise’ do more harm ‘than any exertion’ (Nightingale, 1860). She was in no doubt that nurses needed to bring science, technical knowledge, skills and evidence to the task of caring for patients together with empathy and compassion. Recognising gross inequalities in health, and the unnecessary suffering of the sick, she felt that nurses should have an innate empathy for their patients.However, after Nightingale, developments within nursing (as in medicine) have tended to set science against humanism, polarising the two and giving more weight to one than the other at different times. In the mid-20th century, for example, after the second World War, the
intellectual shift toward scientific notions of care challenged values grounded in religious ideas of suffering and compassion as the profession emphasised scientific approaches to care (Aita,2000). Nursing practice became functional in its delivery, viewing nursing in terms of ‘what nurses do’ rather than a reflection of nurses’ beliefs and values (McMahon, 1998). Patients were not always treated with compassion, were certainly not seen as partners in the care process and were often kept in ignorance of their diagnosis and plan of care (Melia, 1987).in the late 1980s and early 1990s, the emergence of Nursing Development Units (NDUs) in Burford and elsewhere signalled a return to the humanist base with a new brand of ‘therapeutic nursing’, emphasising ‘holistic’ and ‘person-centred’ care (Costello and Haggart, 2008). Within the NDUs, nurses emphasised the importance of creating therapeutic environments (Ersser, 1988) and structured their work deliberately to promote caring, intimacy, partnership and reciprocity in relationships with individual patients (Meutzel, 1988). However, despite the research showing that patients clearly identified the
value of caring in nursing and discerned the difference between kindly-but-objective and individual person-centred care (Astedt-Kurki and Haggman-Laitila, 1992; Barber, 1989; Ersser, 1991), the NDUs did not last. The humanistic work they had begun did not permeate nursing across the UK. Without wanting to deny the sense within the profession that some of the more fundamental and satisfying aspects of the nursing role are being or have been lost (Dawoud and Maben, 2008; Maben and Griffiths, 2008), we think nurses make a mistake appearing to claim exclusive rights to compassionate care and blaming themselves and their colleagues for the depersonalisation of patients and failures in hospital. We think the roots
of the problems go deeper and affect everyone who works with patients in hospital, across the professions and including administrative and support staff. Unease about the vulnerability of patients in modern hospitals, the industrial scale of modern health care and hospitals becoming what medical historians have called ‘soulless,
anonymous, wasteful and inefficient medical factories’ (Porter, 2002), is widely felt.
Hospitals throughout the developed world are under tremendous pressure, treating
massively increased volumes of patients, expanding continuously both in size and staff numbers in a context of ever-increasing specialisation of medicine and nursing, and continuous drives for increased productivity and efficiency. Contact time between
individual patients and individual members of staff has been sharply reduced, with falling average lengths of stay, greater throughput of patients and more people, in more different specialties and departments, treating the same patients. For the typical inpatient, the day is increasingly broken up: patients spend less time on their own ward and more time being transported around the hospital to investigations and treatments (Goodrich and Cornwell, 2008). Against this backdrop, we identify those forces (digital revolution, audit culture and the role of anxiety) converging on policy formation which have helped to shift the style of delivery of nursing care towards what Iles et al. (2009) call ‘transactional’ models of care (in which the individual is cared ‘for’) and away from ‘relational’ models (where the individual is cared ‘about’). With the digital revolution, counting has become the currency of conversation, and performance is measured by objective activities.
In the audit culture, fuelled by the digital revolution, second-order activities (that is,
measurable activities) are privileged over first-order activities (that is, the intimate
professional–patient interactions) which are important but hard to measure. As Maben (2008) suggests, one consequence is that the art of caring is both invisible and subordinated. In many ways, these activities of measurement and audit have brought benefit, producing vastly increased transparency in medical affairs generally, removing their mystique, and allowing people (including patients and their families) to be clearer about what is going on, and if necessary to challenge it. However, they seem to ignore the anxiety inherent in all clinical practice. And while evidence-based medicine has been of enormous benefit in separating the therapeutic wheat from the chaff, we are in danger of forgetting what Tolstoy (1869) tells us about individuals and their illness: ‘Every living person has his own peculiarities, his own peculiar personal novel complicated disease, unknown to medicine’. The exposure of professionals to scrutiny leads towards the development of protocols and management plans which are most easily defended, rather than most suitable to the patient. And finally, there is overall a conspicuous absence of substantive debate about these matters generally, where politicians find themselves in a position where almost anything they say can be scrutinised and quoted, their tendency, understandably, is to say as little as possible. We speculate that the target-driven atmosphere of contemporary clinical care acts both as an impediment to, and a defence from, proper consideration of the patient experience. The world which the sick inhabit is often distressing and messy. In the course of a professionalcareer, a nurse can spend three decades helping sick folk make sense of the reckless indifference of their disease. Menzies (1970) reminds us that one defence deployed by nurses to avoid interacting with the patient’s experience is to be busy doing technical things (BP measurements, temperatures, clinical assessments), or simply administration.
Really relating to patients takes courage, humility and compassion, it requires constant renewal by practitioners and recognition, re-enforcement and support from colleagues and managers. It cannot be taken for granted. Nurses, along with others who work with patients, need to apply themselves actively and continuously to overcoming what Tallis (2004) calls the ‘congenital tactlessness which afflicts humanity. . .when continuously exposed to suffering’. This is not to deny that nursing has its own specific challenges and problems. We know that, while the majority of nurses enter professional training with a sense of altruism and genuine philanthropy (Lowenstein, 2008), they can become less empathetic during that training, and more distant from their patients. Research showing that ‘exposure to the process of nurse education seems to reduce the capacity for expressive care’ (Murphy et al., 2009) is deeply worrying. Sadly, ideals and values such as individualised and holistic patient care held dear by graduating students can become abandoned and crushed
in a short time, with nurses reporting some degree of burn out within 2 years of qualification, leading in some cases to job hopping or abandonment of nursing altogether (Maben et al.,2007).

Nursing also has its own strengths. Nurses, and their leaders, have been more active and vocal and more willing than other health professions to accept responsibility for failures in care-giving in hospital. In the main, it is nurses who are leading practical initiatives to promote compassionate care and the campaigns to restore respect for patients’ dignity in hospital. Compassionate nursing can transform individual patient’s experience of illness and suffering (see the example of the Schwartz Center, http://www.theschwartzcenter.org/). However, if we want to be sure that patients receiving care are continuously and reliably treated as human beings and with compassion we must look beyond the nursing process at
the totality of the patients’ experience. For patients, compassion in nursing is an important part of the story. However, in the environment of the modern hospital, if we want patients to feel safe and secure, and to know their interests are paramount, nurses at all levels must work with colleagues in other disciplines and staff groups to make it a priority.

I have a close friend who

I have a close friend who works in radiology at a children's hospital, so I hear a lot of stories about emergency wards. The pressure needs to be eased somehow, the question is how.