Responding to Francis: nursing practice · 12 Nursing Times 12.02.13/ Vol 109 No 6 / Nursing Practice Review Nursing practice W ith a total of 290 recom-mendations, the Francis

Responding to Francis: nursing practice

12 Nursing Times 12.02.13/ Vol 109 No 6 / www.nursingtimes.net

Nursing PracticeReviewNursing practice

With a total of 290 recom-mendations, the Francis report contains much food for thought. How-

ever, while some of the recommendations require strategic or government action, there are actions that nurses can adopt or champion immediately to ensure patient care in their organisation is both safe and of high quality. Here, a selection of clin-ical, academic and professional experts reflect on how the report might be used to inform day-to-day nursing practice.

iNfecTioN: Julie Storr, president of infection Prevention Society

The Infection Prevention Society acknowledges that the report highlights unac-ceptable failures at all levels of the NHS. More than 100

pages focus on infection issues, including basic hygiene and cleanliness.

IPS remains steadfast in its focus: simple measures, such as hand hygiene, prevent patient harm. We welcome the rec-ommendations that risks of infection be handled fairly and safely, including how they are communicated so, in the pursuit of infection prevention, we do not overlook the psychological wellbeing of every patient and every family.

Our contribution to developing an informed workforce, capable of delivering clean, safe care, embraces the call for enhanced education, training and support for all healthcare staff, including leaders and managers. IPS will work as a force for good to help create better, stronger sys-tems that promote safe, clean clinical care.

Keywords: Francis report/Mid Staffordshire/Quality of care/ Patient safety

A competent workforce, the right regu-lation, regulators who “get” infection con-trol, all are necessary to build a strong and impenetrable defence that keeps everyone safe. IPS looks forward to working nation-ally and locally, and playing a key role in making these recommendations a reality.

older PeoPle: deidre Wild, senior research fellow (visiting), consultant r&d older people, University of the West of england, Bristol

The report highlights the damage inflicted on older people from a misguided and uncaring NHS culture. However, if its findings are

to be internalised and recommendations acted on, they will need to prevail over longstanding ageist attitudes.

Where, other than in older people’s care, has the nurse’s role been so eroded by replacement with the minimally trained care assistant, thereby falsely implying high-quality nursing is neither required for older people, nor compatible with cost effectiveness? In terms of common lan-guage, who else is accused of “blocking” beds or being a “burden” on services, both of which older people have equal rights to access? Attitude change requires profes-sional recognition that adult care in hos-pital and the community involves meeting the complex needs of the ageing popula-tion, as much as meeting those of people who are younger.

The recommended registration of healthcare support workers, with a uni-form code of conduct, standards and PA

In this article... Key nursing themes in the francis report How clinical practice could change overview of the recommendations

training to be maintained by the Nursing and Midwifery Council is an important step towards quality improvement, and the recommended role of a registered older person’s nurse is even more welcome. However, if it is to spearhead change towards a non-ageist culture, which enhances care and protects older adults, the role must include specialist geronto-logical nurse training with an emphasis on essential and remedial skills, and it must be held by sufficient numbers of nurses.

cUlTUre: Steve Mee, senior lecturer, faculty of Health and Wellbeing, University of cumbria, lancaster

Mr Francis’ report has por-trayed a vivid picture of a culture with a profound, scarcely believable, lack of care. It rightly focuses on

NHS culture and suggests a host of actions to refocus on caring. These include changing recruitment and training, as well as developing leadership, appraisal by patients, transparency and clarity about the guiding principles we should all adopt.

The overall picture is that of an organi-sation in meltdown. Volume 2 of the first report in 2010 gives 363 pages of chilling individual stories that could lead com-mitted nurses to despair. Yet Mr Francis’ investigation into Stafford includes posi-tive stories such as the patient who could not speak highly enough of the care he received on several wards:

“Everyone who dealt with him was pas-sionate and caring and the staff often worked ‘above and beyond’ the call of duty. He thinks that the constant barrage of criticism is ‘counter-productive and unnecessary’.”

The report rightly focuses on NHS culture, suggesting actions to refocus on caringSteve Mee

The Francis report into failings at Mid Staffordshire includes many recommendations, some of which can be acted on immediately

How should Francis change nursing practice?

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www.nursingtimes.net / Vol 109 No 6 / Nursing Times 12.02.13 13

In all the horror there were people going about their work – at least during that patient’s stay – in a “professional”, “cour-teous” and “timely” manner.

The report also refers to times when care on a ward was generally abysmal, yet an individual nurse still behaved with compas-sion to ensure a patient was well cared for. These individuals had an internal moral compass that ensured they would do the job properly, whatever the culture. As profes-sionals we have a choice: to make a personal commitment to do the moral thing. I salute those at Mid Staffordshire who did just this.

TiSSUe viaBiliTy: irene anderson, principal lecturer, tissue viability, and reader in learning and teaching in healthcare practice, University of Hertfordshire

Sadly pressure ulcers and skin breakdown feature in the report – the detrimental effect of a target-driven cul-ture and staff forced to

comply whatever the consequences. There is a national focus on pressure-ulcer pre-vention; things are improving but there are still failures to record (and act on) pressure-ulcer risk, and patients waiting for equip-ment, lying in wet beds and experiencing poor handling. Making pressure-ulcer pre-vention initiatives public is recommended – and already happening in some services.

The report also points out that basic – or essential – care is not simple, and that patients are harmed when specialist nurse advice is ignored and untrained staff take roles for which they are unprepared. We must ensure patients with other types of wounds are not sidelined by pressure-ulcer targets but that we focus on tissue viability for all patients in all settings; they need and deserve skilled and compas-sionate care.

Ward roUNdS: liz lees, consultant nurse and senior research fellow, Heart of england NHS foundation Trust, Birmingham

Over the last 21 years I have witnessed the insidious demise of nurses routinely participating in multidisciplinary ward rounds.

There is no escaping that some nursing care at Mid Staffordshire was appalling. Some stories beggar belief – for example: how busy do you have to be to ignore a patient with dementia, lying naked, in public view, covered in faeces?

The report gives the profession much to reflect on, but also acknowledges that nursing can put its own house in order. If accepted, Mr Francis’ recommendations will affect nursing staff at every level, from the chief nursing officer to healthcare assistants and could have a positive effect on day-to-day nursing practice and standards of patient care.

Mr Francis calls for a strengthened clinical role for ward managers, in which they are on the ward rather than office-bound. They should act as role models to their teams and know about every patient’s care plan.

This should free ward sisters and charge nurses to fulfil a key aspect of their role, which has been gradually eroded. Their primary focus will be on the quality and safety of patient care, and on managing, motivating and supporting their teams. This will, of course, depend on them having resources to free them from some responsibilities that keep them office-bound – and this has to happen. While wards on which patients suffered and died in Stafford were poorly managed, others provided excellent care thanks to skilled and committed leadership.

A root cause of many problems in Stafford was a lack of clear accountability. No one took responsibility for particular patients because they assumed someone else would. Mr Francis’ solution is the notion of a key nurse for each patient on every shift. This nurse should be responsible for

coordinating the patient’s care and, where possible, be present every time they see a doctor. He also calls for annual revalidation and, until that is set up, mandatory annual appraisals at which nurses must produce a portfolio demonstrating an up-to-date knowledge of nursing practice and evidence of training and other learning.

In calling for the regulation of HCAs, Mr Francis points out that: “the minicab driver who takes a patient to hospital and the security guard who may be at the door when the patient arrives are likely to be subject to regulation under which they can be disqualified from the role if not a fit and proper person, but the healthcare support worker who washes the patient and accompanies him or her to the toilet is not.” How can that be right?

He also wants a code of conduct, the HCA role to be standardised nationally, and nursing staff to wear clear labels and uniforms so patients know who’s who. These suggestions are long overdue. For too long the HCA role has been undefined, benefiting neither HCAs nor patients, and lack of regulation allows bad apples to move from job to job with impunity.

To many nurses the recommendations may be unnecessary. Most ward sisters want to lead a team that patients and their families would recommend to others. Most nurses do their best to provide compassionate care under often difficult circumstances. Most HCAs want to adhere to standards of good practice and have a clearly defined role. But the recommendations are not aimed at them – they are aimed at the minority who fail to meet these responsibilities and aspirations. And at government and those with the power to give us an NHS in which it is possible to achieve high-quality, safe and compassionate care for every patient.

ann Shuttleworth, practice and learning editor

AnAlysis: clear roleS, regUlaTioNS aNd accoUNTaBiliTy are loNg overdUe

“The recommendations are aimed at those with the power to give us an NHS in which we can achieve high-quality care for every patient”

We must ensure we focus on tissue viability for all patients in all settingsIrene Anderson

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Nursing PracticeReview

fraNciS oN... NUrSiNg

The report considered a range of themes related to nursing practice:● The decline in standards of care was

associated with inadequate staffing levels and skills, and a lack of effective leadership and support

● Candidates for entry into nursing should be assessed on their ability to provide compassionate care through work experience, aptitude testing and nationally consistent training

● Nurses’ continuing professional development should be reinforced by a revalidation system

● A specialist registered status should be created for nursing care of older people

● Ward nurse managers and named nurses should be an intrinsic part of medical ward rounds and other contacts between doctors and patients

● Healthcare support workers should have compulsory registration, common training standards and a code of conduct

Routine has been replaced by ad hoc, as and when they feel able to join. However, patient care and discharge processes have evolved over this period, resulting in increasingly frequent patient reviews and ward rounds – in some areas going from weekly to twice a day. This has increased nurses’ workloads, and it is time to recog-nise this through tools to measure patient dependency and acuity. We urgently need the necessary evidence to produce tools capable of measuring this often invisible nursing workload.

Ward rounds are the cornerstone of ward leadership, organisation of patient care and processes thereafter. A registered nurse is an essential member of a ward round – the sooner this standard of nurse advocacy is reinvigorated, the sooner patient care will improve.

coNTiNeNce: debbie yarde, chair, association for continence advice

It is sad day for the NHS when it requires 290 recom-mendations to ensure patients are treated with care and compassion. We

should all know this is a fundamental ethos of looking after the sick and vulner-able, but apparently not all of us do. While I welcome much of what is recommended, I mourn the missing recommendation that would specifically endorse the need to toilet patients.

Yet again continence fails to attract attention in its own right. There is a cata-logue of reported incidents involving patients being left in urine and faeces and, while responding to patient requests and hygiene have rightly been singled out, there is nothing to promote active conti-nence assessment and promotion within care settings for older people. This is a dis-appointing omission.

STUdeNTS: ann Hemingway, senior lecturer public health, School of Health and Social care, Bournemouth University

This report indicates yet again that organisational culture and individual attitudes are key and that those who are not open to

criticism and who don’t put patients first are giving warning signs about the stand-ards of care they offer.

The report recommends a national entry-level requirement that student nurses spend at least three months pro-viding direct patient care under the super-vision of a registered nurse. This is wel-come as it clearly focuses on ensuring those entering the profession have appro-priate attitudes.

However, the report highlights that “when concerns were raised about inappropriate pressure or bullying by staff toward trainees, these were not followed up or investigated”. Once again the culture of organisations is identified as needing to change in order to focus on what is truly important:

“The patient must be first in everything: there must be no tolerance of sub-standard care; frontline staff must be empowered with responsibility and freedom to act in this way under strong and stable leadership in stable organisations.”

NUTriTioN: liz evans, chair, National Nurse Nutrition group

Nutrition and hydration are still not being recognised as essential to patients’ recovery, as the report high-lights. Despite a plethora of

national guidance and recommendations on the importance of good nutritional

care, it is clear the message is not always getting through.

It is easy to blame nurses for not feeding patients, and the National Nurse Nutrition Group maintains they are crucial to good nutrition. However, as the report states, other health professionals must recognise the importance of nutrition and allow patients to eat and drink uninterrupted. All health professionals are capable of rec-ognising a tray of uneaten food or a cup of tea that has not been drunk and reporting this to the nurse in charge of that patient.

There is clearly still a lot of work to be done to ensure all organisations provide good nutritional care. But we do not need more guidance – steps must be taken to embed current guidance in practice to guarantee patients in hospital receive suf-ficient food and drink. Nutritional care must be taken seriously and not just seen as another tick-box exercise.

BUllyiNg: Kim Holt, Patients first, campaign to improve transparency and accountability in the NHS

Unless the pervasive bul-lying culture of the NHS is ended, it will remain dan-gerous for staff to raise con-cerns about patient care.

The experience of Helene Donnelly, a staff nurse in Stafford who gave evidence to the Francis inquiry shows how ignoring con-cerns can have huge implications for safety. Her evidence exposed the hollow-ness of the promises in the whistleblowing policy. What powerful words.

Patients First is contacted regularly by nurses who raise concerns about serious matters affecting patient care; the problem is not the raising of concerns or lack of people to do that, but the often bullying response they receive or fear receiving.

We urge ministers to immediately strengthen the law to protect whistle-blowers and arrange effective monitoring arrangements to ensure the duty of candour is discharged by all within the NHS. We need specific assurances, not warm words. We are calling for a Health Select Com-mittee inquiry into the continued bullying and victimisation of whistleblowers. NT

There is nothing to promote active continence assessment for older peopleDebbie Yarde

Other health professionals must recognise the importance of nutrition and allow patients to eat and drink uninterruptedLiz Evans


Nursing PracticeDiscussionPhilosophy of care

Author Ann Hemingway is senior lecturer public health, School of Health and Social Care, Bournemouth University. Abstract Hemingway A (2013) What is nursing care and who owns it? Nursing Times; 109: 6, 16-17.The Francis report into the failings at Mid Staffordshire, out last week, demands practical responses from all health professions if they are not to be repeated in other NHS providers. This article explores why nurses need to re-examine their philosophy of care and move beyond the notion of patient-centred care to develop a compassionate, humanising approach.

What is the role of the nurse? For many of us, the point of nursing is to care for others. This may seem a

simple objective but, for nursing in the UK, there is tension between how we define caring and how to maintain this as a pri-mary focus in an increasingly business focused, target-driven organisation like the NHS. I would argue the profession needs to go further than a focus on caring: we need to consider what the point of our practice is – what is the goal, what are we striving to achieve for each person we care for?

We need to develop a greater focus on the promotion of wellbeing through seeing illness as a life experience and rec-ognise that this goes beyond the priorities of our organisations or profession and requires us to have the patient experience as our primary consideration.

Caring for wellbeingWhat do we mean by wellbeing as a focus for care? Galvin and Todres (2012) offer a

Keywords: Compassion/Patient experience/Francis report/Wellbeing

5 talking points 1 An emphasis on

patients as consumers does not offer a value base for care

2Nurses need to go beyond the

patient-centred care concept to a compassionate, humanised approach

3How we care should be

dominated not by knowledge but an understanding of others’ feelings, experiences and stories

4Nurses need to ensure all who

work with patients have attitudes that mean they empathise, listen to and learn from others’ experiences

5Nurses need to care by “head,

hands and heart”, integrating technical and practical knowledge with understanding

view on wellbeing underpinned by a philo-sophical tradition grounded in the life-world-led perspective (Hemingway, 2011); they frame the phenomenon of human caring from the central perspective of “the world of the person” receiving care. This has many dimensions, but its guiding principles focus on vitality, movement and peace. This perspective on wellbeing considers people as having individual potential for creativity and problem solving, even during periods of vulnera-bility, such as illness. It moves away from dividing wellbeing into social, economic, political, physical and mental domains and focusing on patients as “consumers” of healthcare.

While the current emphasis on patients as consumers and the aspiration for more choice begins to put patients at the centre of care, it does not offer a comprehensive framework or value base for care. Patients can understand their own “journeys” through symptoms or long-term illness better than anyone and, in that sense, each patient is an expert. As professionals we need to acknowledge this without relin-quishing our expertise.

However, the way in which we provide care should be guided not only by tech-nical knowledge but also by our under-standing of others’ experiences, feelings and stories. Such a partnership approach will support people’s own strategies to improve health and wellbeing and do so in a dignified and respectful way.

Current issues in caringThe NHS is under stress and there is growing concern about its capacity to sus-tain a high-quality and safe service. Highly

In this article... How we define caring Why nurses should stop thinking about patients as consumers Why nurses should adopt a humanising approach to care

What is nursing care and who owns it?

In its response to the second Mid Staffordshire Foundation Trust report, the nursing profession should reflect on how it views care

NT RESPONSE

Nursing care is essential to patientsAl

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issues outlined within the Francis Report (2010) will be dealt with to the best of our ability with a caring attitude, with the experience of those we care for put at the centre. Our thoughts and actions will be dominated at all times by a desire to do things in a way that would be acceptable for ourselves, our partners, our families and our friends, with empathy.

As we educate and develop the attitudes of student nurses and healthcare assist-ants, we need to consider how best we develop their ability to “walk a mile in another’s shoes”. We need to ensure that everyone – including managers and hospital board members – who works with vulnerable sick individuals has an attitude that enables them to empathise and listen to and learn from another’s experiences.

This shift in attitude means that dan-gerous staffing levels and standards of practice must be exposed. It is the nurse’s responsibility to maintain the best stand-ards of care; this may mean that, if indi-vidual organisations ignore reports of dan-gerously low staffing levels and standards of care, then as a profession we need to consider how we share this information.

The label “whistleblower” is unhelpful when reporting dangerous and inappro-priate care or staffing levels, as it smacks of the playing field or school yard. Perhaps we need to think in terms of safeguarding within the care environment, safe-guarding safety and dignity by ensuring attitudes and actions are exemplary. We are the ones on the front line and know when things go wrong.

ReflectionOn reflection, I believe we need to articu-late our philosophy for care as nurses, which will inform our values, beliefs and actions, and we need to own it. We need to demand it of each other, our colleagues, our organisations and ourselves. NT

ReferencesFrancis R (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: The Stationery Office.Francis R (2010) Independent Inquiry into care Provided by Mid Staffordshire NHS Foundation Trust January 2005-2009 Vol 1. tinyurl.com/francis-rpt-2010Galvin K, Todres L (2012) Caring and Well-being: a Lifeworld Approach. Oxford: Routledge.Hemingway A (2011) Lifeworld-led care: is it relevant for well-being and the fifth wave of public health action? International Journal of Qualitative Studies on Health and Well-being; 6: 10364.McSherry R, Warr J (2008) An Introduction to Excellence in Practice Development in Health and Social Care. Maidenhead: Open University Press.National Voices (2012) Care Standards and Patient Feedback. www.nationalvoices.org.uk

What we must accept is that this care mat-ters just as much as the technological and curative elements of healthcare. We need to move beyond a critique of how the relational and social aspects of care are overshadowed by the technical, and so move beyond patient-centred care to focus on an authentically compassionate, humanised approach to caring (Galvin and Todres, 2012).

Nurses need to place wellbeing and individual patients – with all their com-plexities – at the centre of what we do and, crucially, we need to be able to argue our case. We must defend what is right and ensure that all those working in healthcare understand that what we do, how we act as role models, teach and assure quality of care is as essential as any technological and curative element of healthcare. Mid Staf-fordshire has shown us that when care is neglected, people’s suffering is greatly increased.

Developing the capacity to careWhile one cannot deny the great achieve-ments of medical technology and increasing specialisation, care is more than cure – and, arguably, needs to be more than patient centred. Care needs to recog-nise us all as human beings whose experi-ences affect health and wellbeing directly.

I believe nurses need to develop the “head, hand and heart” approach, which integrates practical know-how with empathic understanding and technical knowledge (Galvin and Todres, 2012) to provide humane and sensitive care. We need to teach nurses and healthcare assist-ants about caring and what attitudes they need to achieve it safely and with dignity for everyone involved.

It is laudable and essential to demand that the NHS listens to patients and fami-lies (National Voices, 2012) but, as the ini-tial Francis Report (2010) highlights, in an organisational culture that accepts bul-lying, lying, intimidation of staff and pri-oritising targets above patient health and wellbeing, we are bound to find resistance to change. So, how should we respond? Work on practice development in health and social care has shown that, unless the attitudes of staff towards those they care for and each other change, nothing else will (McSherry and Warr, 2008).

What influences our attitudes, beliefs and values? What do we see as the most important factor in what we do? If we pri-oritise treating each other as valued human beings with respect, dignity and care, then everything we do for and with those we look after will reflect that. All the

publicised failings such as those in Mid Staffordshire Foundation Trust (Francis, 2013; 2010) and in other places have shaken public trust but have not led to a clear resolution. For several years, there has been a sense that “there could be another Mid-Staffs” and that lessons from earlier failings have not been learnt and implemented.

Much of the current government’s term of office has been overshadowed by the long-awaited second Francis report. Undoubtedly, countless health profes-sionals and managers are quietly getting on with changes and innovations that are improving NHS care. What seems to be lacking is any sense of urgency to imple-ment change and innovation on a system-wide basis. Instead, “waiting for Francis” appears have had a paralysing effect.

The first section of the original Francis Report (2010) is headed Patient Experience, and illustrates how the very way that “care” is thought about and conceptualised is fragmented and misses the point. The headings within the section are:» Continence and bladder and bowel care;» Safety;» Personal and oral hygiene;» Nutrition and hydration;» Pressure area care;» Cleanliness and infection control;» Privacy and dignity; » Record keeping;» Diagnosis and treatment;» Communication;» Discharge management.

All these are fundamental aspects of nursing practice, and need to be under-taken in a dignified, safe, caring manner; however, the way individual nurses do this is controlled by our attitudes, beliefs, values and actions. We need to reflect on our beliefs and values, our guiding princi-ples and our underpinning philosophy as nurses. Without a clear articulation of these within practice and education, how can we assure the quality of our own and others’ practice?

Nursing care mattersCommenting on the culture at Mid Staf-fordshire, Francis (2010) identified that the primary issue raised by patients and fami-lies was the attitude of trust staff.

So what are attitudes, how do we develop them and how can we influence them? They emerge from our beliefs and values and are influenced by the setting in which we work and those around us – and they influence the way we behave.

Whether we label nursing care as basic, fundamental or essential is not important.

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Nursing PracticeDiscussionCompassion

Authors Maria Flynn is senior lecturer, School of Health Sciences, University of Liverpool; Dave Mercer is adjunct professor of nursing, University of Ottawa, Canada, and lecturer, School of Health Sciences, University of Liverpool. Abstract Flynn M, Mercer D (2013) Is compassion possible in a market-led NHS? Nursing Times; 109: 7, 12-14.The principle of compassionate care is increasingly seen as the core element of good nursing practice. However, recent media reports have focused on the “compassion deficit”.

We carried out a review of national and international evidence on core professional values, which showed that caring and compassion are inherent nursing values. While the development of these values is influenced by training and role modelling, the main influence is the organisation and culture in which nurses work.

This article discusses the findings of the review in relation to the national debate around compassionate care within an NHS that is being fundamentally changed. We suggest any failure in compassion is more likely to be due to government health policy and NHS organisational culture than to any shortcomings of nurses or nursing practice.

The values and behaviours expected of nurses and health and social care professionals are laid out in the NHS Constitution

(Department of Heath, 2012a) and the prin-ciples of compassion, empathy, dignity and

Keywords: Compassionate care/Compassion deficit/Healthcare culture/ Healthcare markets

respect are increasingly seen as core ele-ments of high-quality nursing care (DH, 2011; 2010). While the NHS is being radically restructured and core services are being contracted out to private care providers, many reports appearing in the media seem to focus on the supposed shortcomings of nurses and the profession.

Compassion deficitThere have been reports of institutional failings such as the culture and practices at Stafford Hospitals (Francis, 2013; 2010), and sensationalist headlines suggesting graduate nurses are “too posh to wash”.

There has also been considerable profes-sional commentary on the causes and effects of the “compassion deficit” and it has been suggested the supposed decline in care standards and increase in negative patient experiences mean that nurses need to re-establish kindness, caring and com-passion as key professional practices (Peate, 2012; McHale, 2012; Blakemore, 2011). In December 2012, the chief nursing officer and director of nursing at the Department of Health published the vision and strategy for compassion in practice (DH, 2012b), emphasising the importance of “The 6Cs” – care, compassion, competence, communi-cation, courage and commitment.

The concepts, which are central to the idea of compassionate care, are not easily defined. The professional literature shows a body of research focused on identifying how key values of compassion, empathy, dignity and respect are understood by both Al

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In this article... Results of a systematic review of core nursing values Why politics, policy and organisational culture can damage professional caring values

How nurses can assert their values and respond to challenges posed by organisational culture

While nurses have been accused by the media of lacking compassion there is little evidence of a compassion deficit in the profession

Is compassion possible in a market-led NHS?

NT RESPONSE

Newly qualified staff often enter nursing with strong compassionate values

5 key points

1Research shows compassion,

empathy, dignity and respect to be core nursing values

2Compassionate care results

from the interaction between nurses and the organisational and social contexts of nursing

3 Organisational culture, policy

and politics can exert a damaging influence on caring values

4The founding ideals of the

NHS have radically changed, with compassion not part of competitive markets

5Compassion deficit is more

likely to be due to political ideology driving health policy than shortcomings in nurses’ caring values


nurses and the public. It has been sug-gested that human and social dignity are fundamental to humanity itself (Jacobson, 2009) and that good healthcare practice is about much more than the sum of knowl-edge of disease and its treatment (Royal College of Physicians Working Party, 2005).

In the modern NHS, nurses are required to have a range of medico-technical compe-tencies alongside their inherent caring attributes and interpersonal skills (Goethals et al, 2010). It has been proposed that a com-passionate health service is one in which nurses (and other health professionals) are responsive to non-medical expectations (Hopkins et al, 2009). This is a service where nurses are able to talk and listen to their patients and attend to the small details that may not be medically important but are of concern to patients and their families.

Can compassion be measured?Compassionate care needs to be under-stood as the product of human relation-ships, professional cultures and health-care environments (Spandler and Stickley, 2011; Baillie, 2009) and in this context it is easy to see the potential for tensions to arise between nurses seeking to deliver compassionate care and the culture of evi-dence-based practice (EBP) in the NHS.

It has been suggested that the socialisa-tion of nurses in the “real world” of care delivery creates a tension between the inherent values of practitioners and the environment in which they work (Curtis et al, 2012; McSherry et al, 2012). The evidence-based practice movement has been useful in determining the effectiveness of treat-ments and interventions, but the nursing practices and kindnesses that actually make care compassionate are not neces-sarily amenable to research enquiry and cannot therefore be evidence based. Georges (2011) goes so far as to suggest the “euphemism” of evidence-based healthcare masks a depersonalisation of core nursing values, resulting in the compassion deficit.

In a climate of evidence-based health-care, outcome measures assume great sig-nificance, whether these are indices of mor-tality, morbidity, length of stay, or clinical or economic outcomes. It has even been proposed that NHS trusts and health pro-fessional groups will be required to demon-strate the mechanisms by which they measure compassion in care delivery (Jackson and Irwin, 2011), while from April 2013 the government will introduce the friends and families test as a measure of the quality of care. While there may be some consistency in the way patients, families, nurses and other care professionals

conceptualise caring values, it is debateable whether compassionate care can be appro-priately and reliably measured.

It is perhaps understandable that nurses at the front line of care delivery have become the focus of criticism about declining care standards. However, we know that the great majority are dedicated and compassionate professionals who are driven by a desire to care for people.

It was in this context that we carried out a systematic review of the evidence with the aim of uncovering any factors that influence nurses and other health profes-sionals in delivering compassionate care.

Review method Literature was eligible for inclusion if it was published between 1 January 2001 and 31 July 2012, was written in English, related to core values and behaviours as defined in the NHS Constitution (DH, 2012a), was reporting a research study or was a profes-sional discussion paper.

A total of 177 publications were retrieved. Initial screening indicated the lit-erature could be classified into three types:» Profession-specific discussion;» International research reports;» UK research reports.

Study designs and reported methods were evaluated using the Critical Appraisal Skills Programme frameworks, which iden-tified 14 international research reports and 19 UK research reports as eligible for inclu-sion. A further 30 papers were identified as appropriate discussion pieces, which helped us to interpret the findings of the research. The evidence came from a range of disciplines, including nursing, medicine and dentistry. Some studies attempted to measure compassion, and about half were concerned with the selection, education and training of compassionate nurses and health workers. The remainder explored nurses’ and patients’ experiences of com-passion, empathy, respect and dignity, and these papers are discussed here.

Key themes Tasks and routineResearch in the care settings where poor standards of care were a cause for concern reflected stories reported in the media. It was not surprising to find that the patient groups commonly associated with poor care were older people, those with mental illness and the dying. In a healthcare culture that is focused on targets, outcomes and efficiencies, the care of these vulnerable individuals costs both time and resources, so they cannot be seen to represent eco-nomic “value” in a competitive market.

In an NHS organisation under politi-cally driven human resource and financial pressures, it is perhaps inevitable that nurses’ medico-legal responsibilities, such as medicine rounds and completing nursing records, are prioritised. Interper-sonal care then becomes task focused and made into routines to meet management targets and deal with staff shortages (Woolhead et al, 2006).

Rules and hierarchyThe research included in the review also showed that where compassion in care was lacking, this was most often in organisa-tions with rigid rules and hierarchical structures (Jacobson, 2009).

Walsh and Kowenko (2002) found nurses’ and patients’ understanding of dig-nity were remarkably similar, and both rec-ognised how organisational factors con-tributed to compromised care. They also found nurses know when their care prac-tices violated privacy, dignity and respect, yet many refused to surrender their core values in difficult circumstances. Other studies also showed organisational factors, beyond individual nurse attitudes and behaviour, play a significant part in situa-tions of declining care standards (Burhans and Alligood, 2010; Hoy et al, 2007).

Organisation and fundingThe political and economic structures that organise – and fund – health services were another key theme in the review. Here, the evidence showed nurses feeling frustra-tion and disillusionment at not being able to do their job properly.

Maben et al (2006) suggested that newly qualified nurses enter the workforce with strong compassionate values and ideals, but these are “sabotaged” by organisational factors that are manifest in bureaucratic working arrangements, and adherence to covert rules to ‘”get the job done”. Woogara (2005) also identified organisational arrangements that left nurses feeling remote from management teams, feeling

fRANCiS ON… COmpASSiON

Essential ingredients for a compassionate culture include:● Acceptance that patients’ needs

come before one’s own● Recognition of the need to empathise

with patients● Willingness to give patients the help one

would want for oneself, or refer them to someone able to provide that help

Nursing Times.net

For all the latest information on the Francis report, go to nursingtimes.net/francis


Nursing PracticeDiscussion

they were not being listened to and having their complaints ignored, working to rou-tines that prioritised efficiency over care, and having to care for challenging “mixes” of patients with assorted conditions and different care needs.

Spandler and Stickley (2011) discussed “compassion fatigue” and “burnout” and that compassionate care is not about the attributes of individual nurses, or a slogan that healthcare organisations can use for a “quick fix”. They said that compassion is a quality or philosophy that should underpin all healthcare policy and practices.

Research specific to UK nursesThe research specific to nurses in the UK makes up a large part of the international evidence base about compassionate care, and accounted for 10 of the 33 studies.

Some early studies (Faithful and Hunt, 2005; Woogara, 2005) have described nurses’ and patients’ understandings of key values, while other UK research has been influential by highlighting the importance of organisational cultures in delivering compassionate care.

The substantial body of work by Baillie and collaborators (Baillie and Gallagher, 2011; Baillie, 2009; Baillie et al, 2009) has described factors that promote and sustain dignity, and also those that compromise professional values. These factors include some individual attributes of nurses, but also time constraints; the physical envi-ronment in which nurses work; high turn-over and bed occupancy rates; manage-ment pressures; NHS targets; and financial pressures. Baillie et al’s (2009) work is vital in recognising the need for a compas-sionate ethos and culture at all levels of the NHS and individual NHS organisations.

More recent UK studies (Chadwick, 2012; Curtis et al, 2012) have reinforced the idea that there is a tension between profes-sional nursing ideals and the reality of clin-ical practice, and that time and an empa-thetic organisational culture are essential to deliver compassionate nursing care.

maintaining core values and practices The research reviewed shows that nurses do hold compassion, empathy, dignity and respect as core professional values; how-ever, in a professional group as large as nursing, there will always be some people who do not deliver compassionate care. This is no different to other professions such as doctors, lawyers or teachers.

While distressing incidents suggest NHS care standards are in decline, the evi-dence does not support the argument that

there is a compassion deficit in nursing. The evidence shows the delivery of compas-sionate care is the result of the interaction between individual nurses and the organi-sational and social context of nursing. So what can nurses in the reformed NHS do to maintain professional care values?

As the largest part of the NHS work-force, nurses are in the best position to defend compassionate care. They should use the evidence to argue about the impor-tance of compassionate practice, and be confident in their expertise to resist com-promises in care delivery.

On a practical level, they could com-plete incident reports every time they are unable to care for their patients properly, so that the management of their organisa-tion is aware of the impact of rules and tar-gets on patient care. They could also record in patients’ nursing notes when time or organisational pressures have prevented them from delivering compassionate care.

Nurses can ensure that good practice is celebrated and, on the many occasions when patients and their families express gratitude, they could ask them to send their thanks in writing to the chief execu-tive of the NHS rather than just to staff within the organisation in question.

However, perhaps the most effective thing that nurses can do to safeguard com-passionate care is to work with their pro-fessional and representative bodies against any further privatisation of the NHS.

ConclusionEvidence shows that politics, policy and organisational culture can and do exert a damaging influence on professional values, but this is not surprising when the social welfare ideals on which the NHS is built are being systematically dismantled.

Compassion is not a recognised feature of competition or market forces or priva-tised service cultures. If the NHS is suf-fering from a compassion deficit, then this is more likely to be due to the political ide-ology driving current health policy, and not due to any shortcomings in the caring values of nurses. NT

● The evidence review was commissioned by the NHS NW and a full project report was submitted in August 2012. The interpretation of the evidence and the views expressed in this paper are solely those of the authors.

ReferencesBaillie L (2009) Patient dignity in an acute hospital setting: a case study. International Journal of Nursing Studies; 46: 1, 23-37.Baillie L et al (2009) Nurses’ views on dignity in care. Nursing Older People; 21: 8, 22-29.Baillie L, Gallagher A (2011) Respecting dignity in

care in diverse care settings: strategies of UK nurses. International Journal of Nursing Practice; 17: 4, 336-341.Blakemore S (2011) New health commission to tackle poor care issues. Nursing Older People; 23: 7, 6-7.Burhans LM, Alligood MR (2010) Quality nursing care in the words of nurses. Journal of Advanced Nursing; 66: 8, 1689-1697.Chadwick A (2012) A dignified approach to improving the patient experience: promoting privacy, dignity and respect through collaborative training. Nurse Education in Practice; 12: 4, 187-191.Curtis K et al (2012) Student nurse socialisation in compassionate practice: a grounded theory study. Nurse Education Today; 32: 7, 790-795.Department of Health (2012a) The NHS Constitution. London: DH. tinyurl.com/NHS-constitution-2012-DHDepartment of Health (2012b) Compassion in Practice. London: DH. tinyurl.com/compassion-practiceDepartment of Health (2011) No Health without Mental Health. London: DH. tinyurl.com/no-health-mental-health-DHDepartment of Health (2010) Equity and Excellence: Liberating the NHS. London: DH. tinyurl.com/Liberating-NHSFaithful S, Hunt G (2005) Exploring nursing values in the development of a nurse-led service. Nursing Ethics; 12: 5, 440-452.Francis R (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: The Stationery Office. tinyurl.com/HMSO-Francis2Francis R (2010) Independent Inquiry into Care Provided by Mid Staffordshire NHS Foundation Trust January 2005 – March 2009. London: DH. tinyurl.com/DH-Francis1 Georges JM (2011) Evidence of the unspeakable: biopower, compassion and nursing. Advances in Nursing Science; 34: 2, 130-135. Goethals S et al (2010) Nurses’ ethical reasoning and behaviour: a literature review. International Journal of Nursing Studies; 47: 5, 635-650.Hopkins JE et al (2009) Beyond satisfaction, what service users expect of inpatient mental health care: a literature review. Journal of Psychiatric and Mental Health Nursing; 16: 10, 927-937.Hoy B et al (2007) The elderly patient’s dignity. The core value of health. International Journal of Qualitative Studies on Health and Well-Being; 2: 30, 160-168.Jackson A, Irwin W (2011) Dignity, humanity and equality: principles of nursing practice. Nursing Standard; 25: 28, 35-37.Jacobson N (2009) Dignity violation in Health Care. Qualitative Health Research; 19: 11, 1536-1547.Maben J et al (2006) The theory-practice gap: impact of professional-bureaucratic work conflict on newly-qualified nurses. Journal of Advanced Nursing; 55: 4, 465-77.McHale JV (2012) The ageing population: is it time for an international convention of rights? British Journal of Nursing; 21: 6, 372-373.McSherry R et al (2012) The pivotal role of nurse managers, leaders and educators in enabling excellence in nursing care. Journal of Nursing Management; 20: 1, 7-19.Peate I (2012) Kindness, caring and compassion. Australian Nursing Journal; 19: 7, 16-16.Royal College of Physicians Working Party (2005) Doctors in society: medical professionalism in a changing world. Clinical Medicine; 5: 6 Suppl 1, S5-40.Spandler H, Stickley T (2011) No hope without compassion: the importance of compassion in recovery-focused mental health services. Journal of Mental Health; 20: 6, 555-566.Walsh K, Kowanko I (2002) Nurses’ and patients’ perceptions of dignity. International Journal of Nursing Practice; 8: 3, 143-151.Woogara J (2005) Patients’ privacy of the person and human rights. Nursing Ethics; 12: 3, 273-287.Woolhead G et al (2006) ‘Tu’ or ‘vous’: a European qualitative study of dignity and communication with older people in health and social care settings. Patient Education and Counselling; 61: 3, 363-371.

22 Nursing Times 19.03.13 / Vol 109 No 11 / www.nursingtimes.net

Nursing PracticeDiscussionWorkplace bullying

Author Ludwig F Lowenstein is director, Southern England Psychological Services, Allington Manor, Hampshire Abstract Lowenstein LF (2013) Bullying in nursing and ways of dealing with it. Nursing Times; 109: 11, 22-25. As with many other professions, nursing has its share of bullies who discredit the profession, while other nurses work with dedicated efficiency and good will. Bullying has an impact on the workplace environment and nurses in general; it can cause low morale and in some cases can make nurses seek employment elsewhere or even leave the profession.

This article considers recent research into bullying in the workplace, including its prevalence within the profession, causes and identification, as well as different types of bullying and its impact on victims. It also highlights research into combating, preventing and dealing with the problem.

Workplace bullying is a sig-nificant issue confronting the nursing profession, with victims described as

being part of an oppressed group. There have been cases where managers have bul-lied staff or failed to provide support for possible victims (Jackson et al, 2002). However, it is not just senior staff who carry out the bullying; often nurses have reported that both the bullies and victims are the nurses themselves (Hutchinson et al, 2006a).

Needless to say, workplace bullying occurs in numerous other occupations and is a complex phenomenon that can only be understood through looking at social,

Keywords: Whistleblowing/Behaviour/ Wellbeing

● This article has been double-blind peer reviewed

individual and organisational factors (Johnson, 2009). Johnston et al (2010) pointed out that the issue of workplace violence and bullying is something of which all organisations must be aware as it affects staff and, in the case of nurses, it can also affect patients.

Negative workplace behaviour such as bullying is a worldwide problem (Lindy and Schaefer, 2010). A Portuguese study by Sa and Fleming (2008) described nurses being bullied in the workplace: “[The] indi-vidual is persistently treated in an abusive manner over a period of time, with a feeling of not being able to counter-attack or defend him/herself against the abuse.”

Workplace bullying has attracted increased attention over the last 10-20 years due to greater awareness of the con-sequences for the victims, in this case nurses, as well as those they seek to help –the patients. The issue was highlighted recently by the report into the Mid Staf-fordshire public inquiry (Francis, 2013).

Prevalence of bullying in nursingThere have been relatively few studies that consider the incidence of workplace bul-lying in the nursing profession.

A study of clinical nurses in Taiwan by Pai and Lee (2011) reported a high number of incidents involving workplace bullying. Nurses were invited to complete a work-place violence questionnaire, which was designed to assess the frequency and types of workplace violence or bullying, including physical or verbal abuse, bul-lying or mobbing and sexual harassment. A total of 521 nurses completed the ques-tionnaire; 102 (19.6%) had been subject to

Bullying in nursing and ways of dealing with it

5 key points

1Bullying in the workplace is a

worldwide phenomenon

2It is not only senior staff

who bully; often nurses bully each other

3Bullying can often affect

nurses’ ability to provide high-quality care

4Organisational characteristics

are critical antecedents of bullying

5Policies to deal with the

possibility of bullying in the workplace and “zero tolerance” of this behaviour are needed

Bullying can have extensive effects on nurses at work but action can be taken to dealing with this destructive behaviour

In this article... Research into workplace bullying Types of bullying How to prevent and combat bullying in the workplace

Staff may feel unable to defend themselves


physical violence, 268 (51.4%) had experi-enced verbal abuse, 155 (29.8%) had been victims of bullying/mobbing and 67 (12.9%) reported having experienced sexual harassment. It was noted that working night shifts appeared to increase the likelihood of sexual harassment.

An American study by Vessey et al (2009) of nurses found that bullying was reported by a wide range of staff. Bullying occurred most frequently in medical sur-gical care (23%), critical care (18%), emer-gency areas (12%), operating room/post anaesthesia care unit (9%) and obstetric care (7%). Perpetrators included senior nurses (24%), charge nurses (17%), nurse managers (14%) and physicians (8%).

Sa and Fleming (2008) found that one in six nurses (13%) reported being bullied in the past six months.

Identifying the signs of bullying behaviourVictims of bullying tend to feel intimi-dated and often experience job dissatisfac-tion as well as physiological and psycho-logical effects (Cleary et al, 2010). Workplace bullying often takes the form of “incivility and humiliations”, which can lead to shame responses from victims (Fel-blinger, 2008).

An Australian study by Hutchinson et al (2006a) found “predatory alliances” ena-bled bullying in the work setting to be hidden. In a later study, they found that those carrying out the bullying tactics were often rewarded by being promoted (Hutchinson et al, 2009). Lewis (2006) also highlighted that managers could be tar-gets of bullying themselves by the people above them.

A Chinese research project studied bul-lying through the use of questionnaires such as the Chinese Masloch Burnout Inventory, the Negative Acts Question-naire and the Overall Job Satisfaction and General Health Questionnaire (Li and Zhang, 2010). These inventories were also used to ascertain whether the question-naire accurately measured the bullying that occurred in the nursing population in a US study (Simons et al, 2011). The study assessed the concurrent validity of the Negative Acts Questionnaire – Revised (22 items) and findings supported the use of a one-dimensional, four-item questionnaire to measure perceived bullying in nursing populations.

Causes and victims of bullyingOne of the suggested reasons for bullying is longstanding power struggles arising from conflict of values often caused by

organisational conditions and unsympa-thetic leadership styles (Strandmark and Hallberg, 2007).

Others have noted one of the causes of bullying to be discrimination towards overseas-trained nurses recruited to work in the UK, suggesting that racism can sometimes become entrenched in the nursing workplace (Allan et al, 2009). Hogh et al (2011) found that non-western immigrant health workers had a signifi-cantly higher risk of being bullied at work, particularly during their first year of employment and during their trainee period.

The reasons behind bullying can also be political, where it serves the self-interest of the perpetrators and is fre-quently due to a need for power and com-petition for promotion (Katrinli et al, 2010). A Canadian study by Laschinger et al (2010) found bullying of new graduate nurses by more experienced older nurses to be common.

A recent study by Huntington et al (2011) linked bullying to increasing pres-sures of work and organisational factors including a lack of support from manage-ment. It also found that workplace bul-lying can be embedded within informal organisational networks.

Hutchinson (2009) highlighted that bullying is not always identified for what it is because it is associated with a whole organisation. Organisational characteris-tics influence both the likelihood of bul-lying occurring as well as whether this behaviour is challenged (Hutchinson et al, 2010a). Nurses frequently find it difficult to complain about the effects of bullying. Whistleblowing can sometimes be viewed as a revenge procedure (Jackson et al, 2010), so organisations can be unaware that the bullying is even happening (John-ston et al, 2010).

Types of bullyingRacism and bullying of immigrant nurses, as documented by Allan et al (2009), sug-gests racism is entrenched in the nurses’ workplace due to an abuse of power. This can result in psychological distress and be costly to the organisation due to low morale of the nurses being bullied (Cleary et al, 2010).

Gunnarsdottir et al (2006) carried out a comparative study of the bullying of female nurses, primary school teachers and flight attendants. Repeated sexual har-assment at work was more common among flight attendants, with 31% of respondents from this group reporting they had experienced sexual harassment at work, compared with 4% of nurse respond-ents.

Hutchinson et al (2006b) noted that those who perpetrate bullying behaviour were often found in informal organisa-tional alliances, which gave them opportu-nity to assert some control over teams and to enforce rules through ritual indoctrina-tion, often destroying the self-confidence of those targeted and forcing them either to comply to survive or to resign their posi-tion. This form of bullying can also take the form of nurses being asked to do tasks below their level of competence and having areas of responsibility removed or replaced with more trivial or unpleasant tasks, something which frequently hap-pens alongside unmanageable workload levels (Sa and Fleming, 2008).

Bullying can often take the form of cyber-bullying rather than face-to-face. This behaviour should be detected, treated and steps taken to prevent it happening within organisations (Smoyak, 2011).

The impact of bullying Bullying has both a physiological and psy-chological effect on victims as well as a

fRANCIs ON… BullyINg

● In a Joint Negotiation and Consultation Committee meeting on 12 February 2009, reference was made to 30% of staff [at Mid-Staffordshire trust] having experienced or witnessed bullying by a member of management.● After reporting her concerns about senior A&E staff, staff nurse Helene Donnelly reported she was threatened by colleagues of the nurses she had raised concerns about. She alleged that the senior sister behaved in an inappropriate

and bullying manner towards her staff and junior doctors, for instance in making derogatory comments;● Dr Turner – a specialist registrar on the A&E department – reported witnessing a culture of bullying and harassment of staff, particularly the nursing staff, to the extent of witnessing nurses emerging from bed management meetings in tears in fear of losing their jobs.● Concerns raised regarding bullying at the trust were often not followed up.

Alamy

24 Nursing Times 19.03.13 / Vol 109 No 11 / www.nursingtimes.net

negative impact on organisations and patient care (Broome and Williams-Evans, 2011). Nurses who work in a culture of bul-lying are likely to experience job dissatis-faction, spend more time on leave, have decreased productivity and lower morale (Cleary et al, 2010). This threatens nurses’ wellbeing (Cleary et al, 2010; Felblinger, 2008) and frequently results in them being unable to provide high-quality care (Hunt-ington et al, 2011).

Sheridan-Leos (2008) referred to bul-lying in nursing as “lateral violence” or “an act of aggression that is perpetrated by one nurse against another”. He felt that lateral violence caused a downward spiral that was costly to individual nurses, causing job dissatisfaction and psychological dis-tress.

This finding is backed up by Hutch-inson et al (2006b), who found that bul-lying destroyed the self-confidence and self-image of those targeted and forced them eventually to resign their position or to reluctantly accept what was happening around them. In a later study, Hutchinson et al (2010b) found that bullying of nurses leads to erosion of professional compe-tence as well as increased sickness absence and employee attrition (Hutchinson et al, 2010b; Johnson, 2009). Li and Zhang (2010) also found that workplace bullying led to burnout, job dissatisfaction and health risks. It was shown to reduce self-confi-dence and decreasing work productivity by a Canadian study (Mackintosh et al, 2010a). A later study by the same authors had similar results and also highlighted mental health consequences (Mackintosh et al, 2010b).

The obvious detrimental effects bul-lying has on nurses make it essential that early intervention takes place and that staff recognise what is happening and pre-vent further bullying (Schoonbeek and Henderson, 2011). The worst outcomes of bullying are victims being subjected to annoyance, exclusion, belittlement and isolation, deprived of resources, and pre-vented from claiming their rights (Yildirim, 2009).

Combating bullying of nurses in the workplaceA number of steps can be taken to support a healthy workplace and thereby prevent bullying. The literature suggests several ways to tackle bullying within nursing including providing education, devel-oping codes of acceptable conduct and introducing a zero tolerance policy (Broome and Williams-Evans, 2011). Leaders and managers must use

a harmonious approach and work collabo-ratively to prevent any form of intimida-tion or bullying (Cleary et al, 2009).

It has been noted that nurses with a per-sonal system of resilience are better able to counteract bullying behaviour (Jackson et al, 2007). To make them more resilient, excessive workloads and a lack of autonomy should be prevented.

Whistleblowing is often seen as a nega-tive act fuelled mainly by revenge and sedi-tion; however, nurses should have the opportunity to raise concerns about patients’ care or organisational wrong-doing without fear of accusations (Jackson et al, 2010). It is important to consider con-fronting the causes of bullying as well as the actual acts (Mackintosh et al, 2010b).

Those in higher ranks in the nursing profession should be aware of signs that

could indicate a person is being bullied, such as anxiety and depression or expressing a wish to leave the profession (Quine, 2001). Nurses who feel they are bul-lied should be encouraged to speak to col-leagues and their superiors in the organi-sation rather than relying on friends and family; if these concerns are not dealt with sensitively, the victims may end up leaving the profession (Vessey et al, 2009).

RecommendationsAllegations of bullying should always be investigated and the organisation itself should take responsibility. To assist in making this a reality, policies must be in place to deal with investigations into bul-lying and “zero tolerance” of such behav-iour when it has been proven to exist. Whistleblowing should be encouraged rather than discouraged and victims of bullying must have opportunity to voice their feelings to their superiors. This could be made easier with the use of suggestion/ complaint boxes.

Nurses at all levels should be aware they are expected to use empathy with their col-leagues as part of an anti-bullying policy that everyone must be familiar with. The workplace should be seen as a place not only of physical safety but one without the emotional stress caused by bullying; every member of the team should be treated with courtesy and respect.

Anyone making a complaint should feel confident their concerns will be escalated as necessary and that solutions will be found. This means identifying and con-fronting the culprits of bullying and, after a fair hearing, disciplining them, or even dismissing them if this is warranted. Vic-tims and perpetrators should both be offered counselling.

Finally, Johnson (2009) recommended more nurse-specific research in to how nurses are treated, including bullying behaviour in the workplace, to generate a greater understanding and allow for solu-tions to be found. NT

ReferencesAllan HT et al (2009) Overseas nurses’ experiences of discrimination: a case of racist bullying? Journal of Nursing Management; 17: 898-906.Broome BS, Williams-Evans (2011) Bullying in a caring profession: reasons, results, and recommendations. Journal of Psychosocial Nursing and Mental Health Services; 49: 30-35.Cleary M et al (2010) Identifying and addressing bullying in nursing. Issues in Mental Health Nursing; 31: 331-335.Cleary M (2009) Dealing with bullying in the workplace: toward zero tolerance. Journal of Psychosocial Nursing and Mental Health Services; 47: 34-41.Felblinger DM (2008) Incivility and bullying in the

Box 1. gOT A PROBlem wITH BullyINg?

For UK nurses who feel threatened, bullied, or otherwise treated unfairly, the Department of Health offers a grievance procedure, which includes a whistleblowing service and is available 24 hours a day. The number to contact is 01215 069133.

Some lawyers specialise in unfair or wrong behaviour by any member of staff at any level.

Nursing PracticeDiscussionWorkplace bullying

Bullying can affect nurses’ ability to care

Alamy


workplace and nurses’ shame responses. Journal of Obstetric, Gynecologic & Neonatal Nursing: Clinical Scholarship for the Care of Women, Childbearing Families, & Newborns; 37: 234-242.Francis R (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: Stationery Office. tinyurl.com/HMSO-Francis2Gunnarsdottir HK et al (2006) Lifestyle harassment at work and self-assessed health of female flight attendants, nurses and teachers. Work: a Journal of Prevention, Assessment & Rehabilitation; 27: 165-172.Hogh A et al (2011) Are immigrants in the nursing industry at increased risk of bullying at work? A one-year follow-up study. Scandinavian Journal of Psychology; 52: 49-56.Huntington A et al (2011) Is anybody listening? A qualitative study of nurses’ reflections on practice. Journal of Clinical Nursing; 20: 1413-1422.Hutchinson M (2009) Restorative approaches to workplace bullying: educating nurses towards shared responsibility. Contemporary Nurse; 32: 147-155.Hutchinson M et al (2010a) Integrating individual, work group and organizational factors: testing a multidimensional model of bullying in the nursing workplace. Journal of Nursing Management; 18: 173-181.Hutchinson M et al (2010b) A typology of bullying behaviours: the experiences of Australian nurses. Journal of Clinical Nursing; 19: 2319-2328.Hutchinson M et al (2009) The worse you behave, the more you seem to be rewarded: bullying in nursing as organisational corruption. Employee Responsibilities and Rights Journal; 21: 213-229.Hutchinson M et al (2006a) Workplace bullying in nursing: towards a more critical organisational perspective. Nursing Inquiry; 13: 118-126.Hutchinson M et al (2006b) They stand you in a corner; you are not to speak: nurses tell of abusive

indoctrination in work teams dominated by bullies. Contemporary Nurse; 21: 228-238.Jackson D et al (2010) Trial and retribution: A qualitative study of whistle blowing and workplace relationships in nursing. Contemporary Nurse; 36: 34-44.Jackson D et al (2007) Personal resilience as a strategy for surviving and thriving in the face of workplace adversity: a literature review. Journal of Advanced Nursing; 60: 1-9.Jackson D et al (2002) Who would want to be a nurse? Violence in the workplace – a factor in recruitment and retention. Journal of Nursing Management; 10: 13-20.Johnson SL (2009) International perspectives on workplace bullying among nurses: a review. International Nursing Review; 56: 34-40.Johnston M et al (2010) The bullying aspect of workplace violence in nursing. JONA’s Healthcare Law, Ethics, and Regulation; 12: 36-42.Katrinli A et al (2010) Nurses’ perceptions of individual and organizational political reasons for horizontal peer bullying. Nursing Ethics; 17: 614-627.Laschinger HKS et al (2010) New graduate nurses experiences of bullying and burnout in hospital settings. Journal of Advanced Nursing; 66: 2732-2742.Lewis MA (2006) Nurse bullying: organizational considerations in the maintenance and perpetration of health care bullying cultures. Journal of Nursing Management; 14: 52-58.Li Y-X, Zhang L (2010) Relationship of workplace bullying with job burnout, job satisfaction and health in nurses. Chinese Mental Health Journal; 24: 625-628, 632.Lindy C, Schaefer F (2010) Negative workplace behaviors: an ethical dilemma for nurse managers. Journal of Nursing Management; 18: 285-292.Mackintosh J et al (2010a) Effects of workplace

bullying on how women work. Western Journal of Nursing Research; 32: 910-931.Mackintosh J et al (2010b) Workplace bullying in health care affects the meaning of work. Qualitative Health Research; 20: 1128-1141.Pai HC, Lee S (2011) Risk factors for workplace violence in clinical registered nurses in Taiwan. Journal of Clinical Nursing; 20: 1405-1412.Quine L (2001) Workplace bullying in nurses. Journal of Health Psychology; 6: 73-84.Sa L, Fleming M (2008) Bullying, burnout and mental health amongst Portuguese nurses. Issues in Mental Health Nursing; 29: 411-426.Schoonbeek S, Henderson A (2011) Shifting workplace behavior to inspire learning: a journey to building a learning culture. The Journal of Continuing Education in Nursing; 42: 43-48.Sheridan-Leos N (2008) Understanding lateral violence in nursing. Clinical Journal of Oncology Nursing; 12: 399-403.Simons SR et al (2011) A new, four-item instrument to measure workplace bullying. Research in Nursing & Health; 34: 132-140.Smoyak SA (2011) A rose is a rose is a rose: bullying in all of its disguises. Journal of Psychosocial Nursing and Mental Health Services; 49, 6-7.Strandmark KM, Hallberg LRM (2007) The origin of workplace bullying: experiences from the perspective of bully victims in the public service sector. Journal of Nursing Management; 15: 332-341.Vessey JA et al (2009) Bullying of staff registered nurses in the workplace: a preliminary study for developing personal and organizational strategies for the transformation of hostile to healthy workplace environments. Journal of Professional Nursing; 25: 299-306.Yildirim D (2009) Bullying among nurses and its effects. International Nursing Review; 56, 504-511.

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Nursing PracticeReviewWard rounds

Author Liz Lees is consultant nurse and senior clinical research fellow, Faculty of Education, Heart of England Foundation Trust, Birmingham.Abstract Lees L (2013) The nurse’s role in hospital ward rounds. Nursing Times; 109: 12, 12-14.Ward rounds are a crucial aspect of acute care, but nurses’ involvement varies. While their responsibilities on ward rounds may vary from ward to ward, nurses have a vital role to play and should make it a priority to attend. This article discusses key aspects of nurses’ responsibilities and the different stages in the ward-round process.

Ward rounds are an estab-lished, but sometimes fragmented, core activity of inpatient care during

which decisions are made and tasks allo-cated that aid the daily running of wards. They require a well-organised multidisci-plinary team to take part in the rounds, and nurses play an essential role in their smooth running. In 2012 the first inte-grated guidelines for ward rounds were published, giving best-practice recom-mendations (Royal College of Physicians and Royal College of Nursing, 2012).

A ward round is an essential organisa-tional process providing a link between patients’ admission to hospital and their discharge or transfer elsewhere. In the absence of ward rounds there would be inertia in the patient flow, particularly for unplanned (emergency) activity for which the preplanning of care is not always pos-sible (RCP, 2012a).

The emphasis on rounds and frequency

Keywords: Ward rounds/Admission/Discharge/Handover

within individual wards will vary according to patient acuity and the volume of admissions, discharge and transfers received by the area. Ward rounds provide a huge opportunity for interprofessional learning and informal continuing profes-sional development not only for junior doctors in training but also for the whole multidisciplinary team (RCP, 2012b).

Ward round or individual patient review?The traditional ward round, which took place perhaps once a week, is outdated. Rounds now take place more frequently – sometimes twice a day – to reflect the pace of patient turnover.

It is important to distinguish between ward rounds and ad-hoc individual clin-ical reviews of individual patients: unlike clinical reviews, ward rounds should involve the multidisciplinary team, while individual clinical reviews – which are additional to ward rounds – take place when the registrar or another specialist (perhaps a consultant or nurse specialist) needs to review specific investigations with the patient in question. Ward rounds have a number of characteristics, which are discussed below.

Stages of a ward roundThere are three distinct stages to ward rounds, each of which has equal importance.

Antecedents (before)Key activities before a ward round takes place are:» Establishing results of investigations;» Preparing patients – in most cases this

The nurse’s role in hospital ward rounds

5 key points

1Ward rounds provide a link

between patients’ admission to hospital and their discharge or transfer elsewhere

2 Nurses have a vital role in

ward rounds and should make it a priority to attend

3Ensuring patients/carers

are fully involved in care decisions is a nursing responsibility

4When patients are transferred

or discharged, nurses ensure information is communicated to the next stage in the pathway

5A rushed round or one with no

nurse present will have a negative effect on the team

NT RESPONSE

Ward rounds are an essential aspect of good-quality care with nurses playing a vital and central role

In this article... Why ward rounds are necessary Stages of the ward round process The nurse’s role on a ward round


simply involves letting them know the round will be taking place;

» Encouraging patients to think about any questions they may have, which may help to avoid their forgetting what is important to them;

» Chasing up any multidisciplinary per-spectives of care to discuss on the ward round.

Critical attributes (during)This refers to the key activities, and per-haps type of structure, that is integral to a ward round:» Review of unstable or deteriorating

patients;» Decision making and documenting of

care;» Review of patients going home (pre-

discharge);» Review of patients’ progress during

their inpatient stay.

Consequences (after) Once the ward round is over, a number of activities will be necessary:» Team organisation;» Progression of tasks;» Communications;» Repetition of information to the patient;» Motivation of the ward team.

Nurses’ role in ward roundsThere should be no debate about whether or not nurses should be involved in ward rounds. The only debate, perhaps, is how to reinvigorate the nurse’s role among what are often regarded as competing pri-orities such as medicine rounds, theatre lists, observations – particularly if these Al

amy

are due to take place at the same time as the ward round. However, the presence and participation of registered nurses increases their commitment to patient-centred care.

Nurses’ workload has increased over recent years, and patients in hospital beds are more acutely ill; as such, ward rounds must be taken into account alongside numerous other skilled interventions when staffing levels and patient depend-ency are being reconsidered in relation to budget setting.

The key aspects of the nurse’s role on ward rounds can be defined using the acronym ACTION:» Advocate;» Chaperone;» Transitions;» Informative;» Organiser;» Nurse-centred.

AdvocateAs members of the ward team attending the round, nurses need to know their patients. “Knowing” arises from taking a nursing handover and looking after a group of patients, so handovers and ward rounds are inextricably linked if nurses are to successfully represent those patients in their care (Jugessur and Iles, 2009). In the context of ward rounds, being an advo-cate involves:» Adequately preparing for the ward

round (safeguarding patients’ interests);» Empowering patients to ask questions

on the ward round (being included);» Communicating with the multidiscipli-

nary team after a ward round.

ChaperoneAs with any other examination or inter-vention, protecting patients’ dignity and privacy is a priority for nurses during ward rounds (Lambert, 2010). If this role is dele-gated to another team member, that person should be aware of what chaper-oning involves, which is as follows:» Preparing the patient for examination

through communication and posi-tioning;

» Taking responsibility for dignity and privacy;

» Minimising any anxiety and potential embarrassment;

» Respecting cultural wishes throughout the process.

TransitionsThe need to minimise the length of inpa-tient stays means there has never been greater emphasis on patient progress along the care pathway. Multiple hand-overs during transitions between wards or between acute, intermediate and com-munity care can lead to care being fragmented. The continuity and safe transition of information between care

Involvement may vary but nurses have a vital role to play in hospital ward rounds

frANciS oN… WArd rouNdS

● Ward rounds are an opportunity for the multidisciplinary team to review a patient’s condition and develop a coordinated plan of care, while engaging patients and/or their carers in making shared decisions about care● Ward rounds should be seen as a priority by all team members● A senior nurse should be present at every bedside patient review as part of a ward round, and the senior nursing team should be informed of all key decisions made on the ward round● No consultant ward round or visit should take place without the presence of the nurse, or an appointed deputy or other replacement, in charge of the patients to be visited● As well as improving communication and the flow of information between medical staff, nurses’ involvement in ward rounds is an important learning tool ● Senior nurses should ask student nurses to present bedside updates. This ensures students nurse are fully informed about their patients, and gives them experience while providing the senior nurse with an understanding of the student nurse’s abilities

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settings depends on the nurses who par-ticipate in the ward round, making sure all relevant information is communicated to the next stage of the pathway (Hind-marsh and Lees, 2012). This may involve the following:» Noting any ongoing investigations and

communicating these to the patient and team;

» For patient transfers, documenting any incomplete investigations/actions on a handover checklist;

» For patient discharges, documenting any relevant information on the dis-charge checklist (NHS Institute for Innovation and Improvement, 2009; Lees et al, 2006; Department of Health, 2004);

» For specialty referrals, completing a management plan indicating any next steps in the care pathway.The aim is to promote transparency

and continuity, and to reduce potential duplication or omissions of care during transitions.

InformativeNurses also play a crucial role in ensuring patients have realistic expectations of ward rounds, and receive and understand all the relevant information about their care. Where possible, patients should be actively involved in making decisions about their care rather than being passive recipients. In order to execute this process, nurses should:» Reiterate information during or after a

ward round;» Prepare the patient for the next steps in

the care pathway;» Explain anything (along the way) that

the patient may not understand;» Encourage the patient to ask questions

or express concerns;» Report back to the nursing team.

OrganiserAll team members will have their own jobs to complete during the ward round. Organising the outputs emerging from ward rounds ensures nurses can assess, progress and communicate as needed to the family, bed managers, care agencies and social-work team – depending on the complexities of patient care. The organisa-tion of activities can involve:» Delegating effectively to different team

members;» Arranging transport and medication to

take home;» Requesting specific items of equipment

that are required;» Organising care packages.

Nursing PracticeReview

Nurse-centredNurses at the bedside during ward rounds must be clinically competent to under-stand and anticipate the complexities of multifaceted patient situations, and able to view the patient and carer situation holistically rather than as a series of unre-lated tasks. Systems such as team nursing, task-allocated nursing or primary nursing may require some adaptation but for nurses to properly represent their patients, they should be one of the following: » A nurse responsible for a bay or allo-

cated number of patients, who will undertake the ward round for those patients;

» A nurse in charge of a whole ward or unit who is clinically overseeing all areas of the ward and will feed back to nurses after the ward round;

» A nurse who is not responsible for any patients but is acting in a coordinating capacity for the shift and will be respon-sible for feeding back information after the ward round to the nurses who are in those bays.In each of the above functions, having a

nurse at the bedside during ward rounds is pivotal to enable and empower the team. Although there will be some variation according to how the ward is organised and how the nursing team works, the nurse will focus on the “here and now” during the ward round, and anticipate and respond to related actions.

conclusionNurses and the multidisciplinary team are central to ward rounds. Although this article has attempted to define the core

nursing activities involved in ward rounds, nurses will delegate and/or lead the actions that arise. The energy created by a well-run ward round will resonate across a whole ward team, while a rushed round or one that has no nurse presence will have a neg-ative effect, such that related actions maybe fragmented.

In busy ward environments it is a con-stant balancing act to prioritise the jobs that need to be done within the ward rou-tine; if, however, nurses lead by example and are present on ward rounds, it is likely that discipline will be instilled in the entire team and an expected standard of practice for this core activity created. NT

referencesDepartment of Health (2004) Assisting Timely Discharge from Hospital: A Multi-disciplinary Toolkit. London: DH. Hindmarsh D, Lees L (2012) Improving the safety of patient transfer from AMU using a written checklist. Acute Medicine; 11: 1, 13-17.Jugessur T, Iles L (2009) Advocacy in mental health nursing: an integrative review of the literature. Journal of Psychiatric and Mental Health Nursing; 16: 187-195.Lambert J (2010) Chaperones: practice, policy and training. Practice Nursing; 21: 7, 347-349.Lees L et al (2006) Using post-take ward rounds to facilitate simple discharge. Nursing Times; 102: 18, 28-30.NHS Institute for Innovation and Improvement (2009) High Impact Actions for Nursing and Midwifery: The Essential Collection. Coventry: NHS Institute for Innovation adn Improvement. tinyurl.com/NHSIII-high-impact-actionsRoyal College of Physicians (2012a) Hospitals on the Edge? The time for Action. London: RCP. tinyurl.com/RCP-hospitals-on-edge Royal College of Physicians (2012b) Acute Care Toolkit 5: Teaching on the Acute Medical Unit. London: RCP. tinyurl.com/RCP-AMU-toolkitRoyal College of Physicians, Royal College Nursing (2012) Ward Rounds in Medicine: Principles for Best Practice. London: RCP/RCN. tinyurl.com/RCN-ward-rounds

CPD


Nursing PracticeDiscussionPerson-centred care

Author John Kelly is consultant lead clinical psychologist at Tees, Esk and Wear Valleys Foundation Trust.Abstract Kelly J (2013) The effect of lean systems on person-centred care. Nursing Times; 109: 12, 16-17.The drive to increase efficiency and reduce costs in the NHS has led many organisations to adopt lean management systems. However, the focus on standardisation makes it difficult to meet patients’ individual needs and denies health professionals the opportunity to exercise their skills and professional judgement.

Lean systems management stemmed from Taiichi Ohno’s lean thinking and the Toyota Pro-duction System (Ohno, 1988), but

has been adapted to various service indus-tries including healthcare. Essentially, the system seeks to minimise inventory and streamline processes.

In the NHS it involves using various lean “tools” to ensure continuous, incre-mental improvement in services to elimi-nate waste, inefficiency and variation in the provision of healthcare. The process used to achieve these outcomes often involves a detailed examination of the entire patient journey, identifying points along that journey that are “non-value adding”, such as waiting for an appoint-ment, or “value adding”, where patients receive prompt appointments.

Non-value adding elements, or their causes, are scrutinised and removed through service reconfiguration and rationalisation. Some of the final intended

Keywords: Lean/Patient-centred care/ Staff morale/Effectiveness/Systems management

effects are that the patient (more often referred to as the customer) has a minimal wait for an effective, high-quality service, processes are smooth and efficient with minimal “handoffs” (steps in the process or care pathway), and inventory is kept to a minimum.

At a time when the NHS has to save £20bn, it is perhaps unsurprising that some NHS organisations have been keen to adopt this more-for-less model. Lean is attractive because its starting point is the explicit understanding that efficiencies need to be made without extra capital or resources. However, despite this benevo-lent veneer and some might say laudable goals, the endpoint of a lean approach is that patients risk getting less for less and it may have negative effects on staff.

Lean thinking has been promoted by some as the panacea for all ills of the NHS. Jones and Mitchell (2006) state: “The lean message is 100% positive. Lean can improve safety and quality, improve staff morale and reduce costs – all at the same time. By freeing human potential, it can add value to patient care and improve quality, and create a virtuous circle rather than perpetuating vicious ones.” Paradoxi-cally, the same authors admit that: “An almost inevitable result of lean initiatives is that fewer people are needed to achieve the same (or more) results. So, potentially, people could lose their jobs.”

Effects on the workforceLean work has been described as “manage-ment by stress” (Parker and Slaughter, 1988). The relentless pursuit of Fo

tolia

The effect of lean systems on person-centred care

NT RESPONSE

Lean systems management is widely used in healthcare, but can have a negative effect on patient care and staff morale

In this article... Lean systems management and its use in healthcare Why lean does not support person-centred care Negative effects of lean systems on staff morale and person-centred care

Waiting is seen as “non-value adding”

1 “Lean can improve safety

and quality, improve staff morale and reduce costs.” Do you agree?

2Is it possible to reconcile

delivery of person-centred care with corporate efficiency targets?

3Does lean result in task-oriented

care?

4Standardisation is fundamental

to lean, but does this conflict with the principles of person-centred care?

5Does standardisation

increase efficiency and equality or result in unnecessary assessments and form filling?

5 points to discuss


“improvement” with fewer and fewer resources leads to burnout in staff trying to reconcile the delivery of high-quality, person-centred care with corporate effi-ciency targets.

This description of “management by stress” was validated by Mehri (2006), a computer simulation engineer who worked covertly at an upper-level Toyota company where lean was used. He reported his expe-rience of lean to be “unhealthy and dan-gerous” with staff being “overloaded with tasks”. Mehri stated that he was “pressed, intimidated, and overloaded to get the job done”. He summarised that “the real cost of this system can be clearly and empiri-cally seen in its adverse impact on employees – the human cost”.

More recently, Seddon (2010) said “Lean demoralises workers”, observing that “four years into its lean programme, and still experiencing serious performance prob-lems, HMRC reports chronic low morale”.

In nursing and other areas of health-care, morale is arguably already low, with the stress of repeated NHS reconfigura-tions. Additional pressure from a reces-sion-hit global economy forces managers to increasingly use lean tools to justify downbanding and sometimes cutting jobs to make the efficiency savings demanded by the government.

It is easy to see how organisational and political saving imperatives may clash with the philosophy of person-centred care; for example, increasingly demoral-ised ward staff struggle with having fewer colleagues. Kitwood (1995) observed that “Staff can only give person-centred care to others, in the long term, if their own per-sonhood is acknowledged and nurtured”. The focus of lean is ultimately impersonal and corporate.

StandardisationStandardisation is fundamental to lean. It means that “on an operational level, improvements are mainly achieved by reducing unwanted variation in processes. Variation is the degree of difference in the same process when repeated” (Joosten et al, 2009). In practice, it means inflexibility, checklists and a degree of scripted proce-dures. The argument goes that variation poses increased risk of error or omission and often constitutes “non-added value”.

However, one might argue that equity and person-centred healthcare should be about treating everyone differently. Intui-tively, it is about recognising that all people have individual needs and therefore some variation is needed. For example, as Joosten et al (2009) point out: “Surgical

procedures are never done exactly twice; psychologists never have exactly the same consult with a patient twice.”

According to Seddon (2010), standard-ising work also reduces organisations’ ability to absorb variety and may result in “failure demand” (the costly failure to do something or to do something right for a customer, which creates a level of demand). Failure demand in healthcare might be seen as readmission to hospital, or re-presentation at an outpatient clinic.

There appear to be other risks. For example, “If communications with the patient are rationed to only that which is deemed ‘essential’ this may hinder the pro-fessionals’ ability to establish a significant therapeutic relationship with the patient” (Winch and Henderson, 2009). This is of particular concern in mental health care, but may also affect the experience of gen-eral ward inpatients subjected to imper-sonal, scripted, tick-box-driven approaches. Lean’s relentless pursuit of the more obvious “added value” compo-nents of care can risk eliminating the hidden “added value” interpersonal person-centred care – the subtle (lean might say wasteful) nuances and everyday interactions that benefit patients.

Standardisation can be wasteful in itself, but is increasingly argued for in terms of providing efficiency and equality, and as a proactive defence against litiga-tion or admonishment by regulators. In practical terms, this means clinicians are subjected to ever-increasing bureaucracy in the form of sometimes unnecessary assessments, screenings and forms to be completed. This is not always for the obvious benefit of patients. Clinicians’ or nurses’ power to exercise decision making is too frequently overridden by organisa-tional policies that risk neglecting the per-sonhood of the patient in front of them.

SummaryKitwood (1997) was correct in stating: “the assumption that human services can be supplied in the same way as cars or televi-sion sets is grotesque”. Lean was born of the wholly different world of manufac-turing, not healthcare. Winch and Hend-erson (2009) state: “The uncritical adop-tion of production-line manufacturing practices (such as lean thinking) into work design processes in hospitals creates a fun-damental tension between the production of healthcare and the protection of the patient”. They note that: “There is scant evidence that re-engineering healthcare services in line with industrial models increases their efficiency.”

A truly person-centred healthcare system, in which the aim is to make all patients equal partners in their care, should acknowledge the uniqueness of individuals – clinicians and patients alike. Healthcare needs and treatments should be tailored in a way that recognises this variation and services set up to accommo-date this. The alternative is a one-size-fits-all sausage machine of healthcare that processes patients like car parts, demoral-ised staff and failure demand.

The rush to apply lean is understand-able, particularly in a time of austerity, but risks reducing clinicians to stressed automatons delivering standardised but non-person-centred care to a public who deserve better. “One of the largest interna-tional studies concluded that engineering healthcare services in line with industrial models has caused high levels of burnout, dissatisfaction and intention to leave in the nursing profession” (Aiken et al, 2001).

Ultimately, you cannot mandate a cul-ture of person-centred care, any more than a burger chain can force its employees to mean it when they cheerfully urge you to “have a nice day”. Person-centred care has to be resourced adequately and the person-hood of staff has to be carefully consid-ered. “Any organisation which claims to be providing person-centred care, but which is neglecting these [aspects], is almost cer-tainly making fraudulent claims” (Kit-wood, 1997); any organisation using lean is almost certainly at risk of cutting the person from person-centred care. NT

ReferencesAiken LH et al (2001) Nurses’ reports on hospital care in five countries. Health Affairs (Millwood); 20: 43-51.Jones D, Mitchell A (2006) Lean Thinking for the NHS. London: NHS Confederation. tinyurl.com/lean-thinking-nhsJoosten T et al (2009) Application of Lean thinking to health care: issues and observations. International Journal for Quality in Health Care; 21: 5, 341-347.Kitwood T (1995) Cultures of Care: tradition and change. In: Kitwood T, Benson S (eds) The New Culture of Dementia Care. London: Hawker Publications. Kitwood T (1997) The task of cultural transformation. In: Kitwood T (ed) Dementia Reconsidered: the Person Comes First. Buckingham: Open University Press.Mehri D (2006) The darker side of Lean: an insider’s perspective on the realities of the Toyota Production System. Academy of Management Perspectives; 20: 2, 21-43.Ohno T (1988) Toyota Production System: Beyond Large-Scale Production. New York NY: Productivity Press.Parker M, Slaughter J (1988) Choosing Sides: Unions and the Team Concept. Boston MA: South End Press.Seddon J (2010) How Lean Became Mean. Vanguard Consulting. tinyurl.com/Vanguard-LeanWinch S, Henderson AJ (2009) Making cars and making health care: a critical review. Medical Journal of Australia; 191: 28-29.

Nursing Times.net



Nursing PracticeDiscussionWorkplace culture

Author Steve Mee is senior lecturer, University of Cumbria and author of Valuing People With a Learning Disability.Abstract Mee S (2013) Is workplace culture an excuse for poor care? Nursing Times; 109; 13, 14-16.This article looks at the issue of nurses’ own responsibility for their actions. Negative behaviour can be explained by external factors, such as culture and the influence of others, or by internal ones, including a person’s own moral compass. Within the context of the Francis report, this article raises questions about how we can ensure that nurses adhere to their code of conduct.

The Francis report (Francis, 2013) describes shocking abuse and neglect of patients, with some nurses responsible for poor care.

It is difficult to comprehend how nurses can behave like this. The report suggests that culture was the problem and proposes changes to management and leadership, with an emphasis on clear guidelines and education. It advises there should be a move from a financial to a care focus.

What of the individual nurse in such a culture? Attribution theory suggests that people will attempt to explain away nega-tive actions by claiming that the cause is external to them – “It was not me, it was the culture”.

However, the code of conduct (Nursing and Midwifery Council, 2008) is clear – as nurses, we are responsible for our own behaviour. Many nurses in the Stafford hos-pitals did manage to perform their duties in a caring and professional way, although they of course did not make the headlines.

Keywords: Accountability/Code of conduct/Workplace culture

Is it possible to take personal responsi-bility and ensure that we perform in a caring way in whatever culture we work? Do nurses who are unable to take responsi-bility for their own standard of care deserve the title “nurse”?

What happened at Mid Staffordshire?The following account was reported to the Francis inquiry:

“The patient was then transferred to Ward 6 earlier than his family felt appropriate. On the ward his fluid levels were not monitored, the buzzer was placed out of reach and his colostomy bag leaked regularly. The patient required his chest to be suctioned regularly yet many nurses admitted they did not know how to carry out the procedure.

“His family tried to find out about his treatment but… a nurse refused to leave her office to speak to the family. After eight days on the ward the patient contracted MRSA and was returned to the Intensive Care Unit, where he deteriorated rapidly and died” (Francis, 2013).

This is just one example from more than 300 pages of similar stories that took place over four years. This is a sorry tale of nurses lacking knowledge, not carrying out basic monitoring and even refusing to speak to families. These can be seen as directly con-tradicting two introductory standards of conduct for nurses (NMC, 2008):» Work with others to protect and

promote the health and wellbeing of those in your care, their families and carers, and the wider community;

Is workplace culture an excuse for poor care?

5 points to discuss 1 How does

workplace culture affect how we practise?

2Why do some nurses perform

well in a particular environment while others do not?

3Can external factors be

given as a reason for lower standards of care?

4How can we follow our own

moral compass in all circumstances?

5What does the NMC code of

conduct say about personal responsibility?

NT RESPONSE

Is it ever acceptable to blame workplace culture for poor care, or should nurses take responsibility for their care regardless of this?

In this article... Why nurses should take responsibility for their own behaviour Is “I was following orders” an acceptable excuse for poor care? Why nurses fail to maintain professional standards of behaviour


» Provide a high standard of practice and care at all times.The following account must have been

unimaginably harrowing for the family: “On one occasion she attended the hospital at around 6am to find her mother in a side room calling ‘please help me, please help me’. The patient was covered in dried faeces and was completely naked. She ran down the ward to find the staff ‘chatting and laughing’. She assisted in washing her mother and it was ‘awful’. Her ‘hands were absolutely caked’ and it ‘was dried and it was up her arms and it was round her neck’ .” (Francis, 2013).

The patient died later that night. This shocking vignette makes a

mockery of the standard:» Make the care of people your first

concern, treating them as individuals and respecting their dignity (NMC, 2008).The Francis report has an astounding

number of similar stories, with instances of patients being asked to soil the bed because there was “no time to give them a bedpan”; nurses being directly rude, callous and mocking; frail people being left on com-modes for hours; buzzers being ignored or disabled; and general incompetence. There were instances of very poor hygiene, inade-quate record keeping, poor organisation, poor communication, falsifying notes and wrong administration of medication.

Culture, causal attribution and behaviourAttribution is a theory from cognitive psy-chology that attempts to understand the human tendency to attribute motivation and cause of behaviour. Heider (1958) sug-gested that there are two main types of attribution – dispositional and situational.

One makes a judgement about a behav-iour according to whether the causes are perceived as dispositional, that is within the person, or situational, which is external to the person. Heider said that one tends to perceive negative behaviour in another as dispositionally caused (they are like that) whereas one’s own negative behaviour is likely to be described as situa-tionally caused (I had no choice, the man-ager told me to do it, the ward culture was like this, I was following orders and so on). If culture is being blamed in the Stafford hospitals, then a situational attribution is being made for causality.

What of the nurses in such a culture? Davidhizar and McBride (1985) suggested that student nurses saw the tasks they had to do as externally located and stable and

their effort as internally located and unstable. This has implications for the con-fidence they will have as nurses when they rely on their inner unstable resources to challenge what they see as stable cultures.

On the other hand, Meurier et al (1998) offer some hope. They suggested that, although people generally explain unpleasant events or their role in them on external (situational) attribution and are therefore less likely to learn, nurses are more likely than is typical to blame the error on internal (dispositional) factors. This suggests a strong professional ethos and some hope for being able to care in the context of uncaring cultures.

Obedience to authorityMilgram’s famous experiment (Milgram, 1965) explored the extent to which people were prepared to hurt others simply because they were told to do so. He found that 65% of participants were prepared to inflict pain so severe that it caused a stranger to scream in pain or pass out because a man in a white coat told them to do it. Many of the participants felt extremely uncomfortable but, as far as they were aware, inflicted the pain anyway. An extract from transcripts of the experi-ment (Box 1) shows a participant giving a

situational attribution to their own nega-tive behaviour. It can be reduced to “I was only following instructions”.

One story in the Francis report (2013) described nurses’ lack of action.

“On three occasions when the patient was due to be discharged the nursing staff failed to prepare her and discharge was postponed. When her family complained, a nurse commented she was ‘just going with the flow’.” (Francis, 2013)

If part of the human condition is to follow orders and “go with the flow” then nurses can appear like mindless puppets in the health cultures imposed upon them. As nurses, we get accustomed to a steady stream of exposures and reports of neglect and abuse, with nurses at the heart of all that has gone wrong. This seems to happen in all areas of nursing and the more vulner-able the patient/client, the more callous the abuse appears to become.

The reverse side of the coinEach time there is a report, recommenda-tions similar to those proposed by Robert Francis QC are made.

However, there is one obvious point of hope. If 65% of Milgram’s participants were prepared to inflict pain on a stranger, then it is also true that 35% were not prepared to do so. What did that one third minority have that the two thirds majority did not?

First, they had a sufficient sense of right and wrong and the assertiveness to behave accordingly. It is not all despair with the Francis report either. The shocking stories will rightly take the headlines and domi-nate the discussion; however, for example, the Francis report lists 31 stories from the first quarter of 2005 and, of these, 15 are negative and 16 are positive. In other words, whatever the culture, half of the nurses managed to behave as nurses should and half did not. For example:

“Having visited A&E, the Acute Cardiac Unit, Ward 1, Ward 10 and the Shugborough Unit at Stafford Hospital, a patient cannot ‘speak highly enough’ of the care he has received in all areas. Everyone who dealt with him was passionate and caring and the staff often worked ‘above and beyond’ the call of duty. He thinks that the constant barrage of criticism is ‘counterproductive and unnecessary’.” (Francis, 2013)

This team were not just good but working “beyond the call of duty”. Simi-larly, the shocking account that opened this article began with the following:

“Following a colostomy operation at

frANCIS ON… CulTure

All those working for the NHS must adopt and demonstrate a shared culture in which the patient is the priority in everything that is done. This requires:● A common set of core values and standards shared throughout the system● Leadership at all levels from ward to the top, committed to and capable of involving all staff with those values and standards● A system that recognises and applies the values of transparency, honesty and candour● Freely available, useful, reliable and full information on attainment of the values and standards● A tool or methodology such as a cultural barometer to measure the cultural health of all parts of the system

There should be an emphasis on the culture of caring and compassion in nurse training, education and professional development. This will include a selection procedure that requires recruits to show evidence of the appropriate values, attitudes and behaviours

“Nothing beats that initial pride of qualifying and getting to wear the staff nurse belt”Elaine Maxwell p24


Nursing PracticeDiscussion

Box 1. ObedIeNCe TO AuTHOrITy fIgureS

Below is an extract from Stanley Milgram’s experiment:

Participant: “I don’t like what happened to that fellow in there [the victim]. He’s been hollering and we had to keep giving him shocks. I didn’t like that one bit. I mean he wanted to get out but he [the experimenter] just kept going, he kept throwing 450 volts. I didn’t like that.”Interviewer: “Who was actually pushing the switch?” Participant: “I was, but he kept insisting. I told him ‘No,’ but he said you got to keep going. I told him it’s time we stopped when we get up to 195 or 210 volts.”Interviewer: “Why didn’t you just stop?” Participant: “He wouldn’t let me. I wanted to stop. I kept insisting to stop, but he said ‘No’ … I figured the voltage we were giving him was quite a bit. I wanted to stop but he [the experimenter] kept insisting not to stop.”

Milgram (1965)

Stafford Hospital the patient was treated on the Intensive Care Unit where the care was ‘second to none’ and he slowly began to recover.” (Francis, 2013)

In the same hospital, nurses on one ward provided care that was “second to none” and, on another ward, nurses car-ried out serious neglect and abuse. The code of conduct (NMC, 2008) states: “As a professional, you are personally account-able for actions and omissions in your practice and must always be able to justify your decisions.” Within the same hospital culture, it seems that some were able to take that responsibility and some were not.

One vignette describes the despair of a nurse who was trying to take responsi-bility for her actions:

“[A patient] was concerned by the lack of staff. He found one nurse crying as she had worked for 12 hours without a break and at the weekend.” (Francis, 2013)

It is probably the case that many nurses of all branches feel that they work under conditions and in cultures where it is diffi-cult to truly perform the duty of care. Some of us believe that conditions are worsening, with cuts and fragmentation, to create an environment in which such scandals are more likely.

It can be instructive to consider a time in which the culture was very much worse. What did nurses do then? Strauss (1987) described the use of theoretical sampling to give a perspective when attempting to understand the meanings in a given situa-tion. Theoretical sampling involves taking an extreme example of the situation and considering what might be learned. One example is Nazi Germany.

In Nazi Germany doctors and nurses fitted in to the system and “went along with it”. It is the same human tendency in operation but under extreme conditions. In Germany in the 1930s and 1940s “going along with it” entailed knowingly giving lethal doses of barbiturates to children, performing experiments on live human beings and allowing others to starve to death. In the concentration camps, such as Auschwitz, there were particularly horrific experiments such as deliberately infecting individuals with gangrene to test different courses of treatment. These were often done without anaesthesia. Nurses took part in all of these activities and, when tried at Nuremberg, used situational attri-bution such as being under pressure for taking part in these activities.

The clichéd “I was only following orders” was used by many, including Erna

Elfriede, a nurse who was found guilty of killing 200 patients .

She said: “I was ordered to do it. When I am asked again, why I didn’t refuse, although I realised that it was an injustice, I can’t give an answer to this question. I do and did in the past have a strong feeling of guilt, but it is impossible for me to give a reason for the fact that I didn’t refuse. It simply was ordered and I had to execute orders” (Evans, 2010).

At this same time in the same culture is the story of someone who worked according to his inner moral compass. Helen Lewis (1992) was incarcerated in Auschwitz. She described how on a daily basis one of the guards, a conscripted teacher, would save some of his own food, single out a prisoner who looked frail and throw them a sandwich. Had he been caught, he would have been shot.

ConclusionThe Francis report made recommenda-tions for a change in culture and service to ensure that the events at Staffordshire Hospital are not repeated. Changing nurse training, greater transparency, mission statements making expectations clear, putting patients first in planning services and developing leadership are all critical tools of culture change.

What about us, the foot soldiers? There is not much we can do to effect these changes. As a nurse with nearly 40 years’ experience, I have become weary of scan-dals and inquiries followed by fine words and insufficient action and resources to prevent the next scandal. What can we do as individual nurses? The only access most of us have to these strategic changes is to use our vote carefully. Is our party of choice the most likely to fund and action these changes? An answer to what we can do as individuals is to be found in the code of conduct: “As a professional, you are per-sonally accountable for actions and omis-sions in your practice and must always be able to justify your decisions” (NMC, 2008).

We can all draw a personal line in the sand. “I will never ask a patient to soil the bed” is easy. “I will never shout at a patient” perhaps a little harder at the end of a long shift. “I will always respond to a request for a bedpan quickly” perhaps harder still, particularly if you attribute patients’ behaviour as dispositional and that they are just making a fuss. “I will have my own moral compass and be prepared to go against team practice if the standards are not acceptable” is even harder. “I will whistleblow if I see bad care”’ is very diffi-cult, particularly if systems are unsup-portive, as they often are in these cases.

Few of us like to stand out and be unpopular but some nurses are prepared to do so. Some did at Stafford and should be saluted. Some people did in Nazi Germany, such as the man who saved food for pris-oners at the risk of being shot. We can all decide where we stand on this continuum and draw our own line. In the end, cultures are only collection of individuals. NT

referencesDavidhizar RE, McBride A (1985) How nursing students explain their success and failure in clinical experiences. Journal of Nurse Education; 24; 7: 284-290.Evans SE (2010) Hitler’s Forgotten Victims: the Holocaust and the Disabled. Gloucester: the History Press.Francis R (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: Stationery Office. tinyurl.com/HMSO-Francis2Heider F (1958) The Psychology of Interpersonal Relations. New York, NY: WileyLewis H (1992) A Time to Speak. New York, NY: Carrol and Graf.Meurier CE et al (1998) Nurses’ responses to severity dependent errors: a study of the causal attributions made by nurses following an error. Journal of Advanced Nursing; 27: 2, 349-354.Milgram S (1965) Liberating effects of group pressure. Journal of Personality and Social Psychology; 1: 2, 127-134. Nursing and Midwifery Council (2008) The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives. www.nmc-uk.org/codeStrauss AL (1987) Qualitative Analysis for Social Scientists. Cambridge: Cambridge University Press.


Nursing PracticeReviewNursing practice

The measured tone and wide-ranging recommendations of the Francis report gave nurses reason to believe that action would be

taken across all parts of the NHS to prevent a similar situation happening again.

The government has given its initial response to the report, so what does this mean for nursing? Below, experts comment on aspects of the government response that will have the greatest effect on nurses.

STAFFING LEVELS: Jane Ball, deputy director, National Nursing Research Unit, Florence Nightingale

School of Nursing and Midwifery, King’s College LondonTalking about nurse staffing levels, a col-league in Australia asked if things are as gloomy in the UK as they seem from afar. Yes, I replied, gloomier. Recent research by King’s College London and Southampton University shows that nurse staffing is related to mortality rates. A daytime ratio of eight patients per registered nurse puts patients at risk, yet we found 40% of acute surgical and medical wards running at this level or worse.

The government clearly understands that nurse staffing is key. It says “adequate staffing levels are essential” and patients need care from “highly trained staff ”, but the policies to deliver on this rhetoric remain absent.

We regulate how many children a child-minder can care for. We set speed limits. By law, we have to wear seatbelts. But, when it comes to nurse staffing levels, there is no

Keywords: Francis report/Mid Staffordshire/Quality of care/ Patient safety

guidance or law. Instead, we must con-tinue to rely on local employers to deter-mine levels. We will continue to monitor mortality rates and advise trusts to mon-itor their staffing levels too.

Hence my despair: 40% of wards with dangerous staffing levels and a context of increasing money pressures. What impetus is there to improve nurse staffing levels? Definitely gloomy.

OLDER PEOPLE: Deidre Wild, independent consultant R&D, older people

In 2001, Help the Aged (now Age UK) and the Royal College of Nursing developed a proposal for a gerontological nursing spe-cialist role, but this was rejected by the government. Twelve years on, and despite the recent strongest evidence yet for this role, yet again it has been rejected. So how can performance be raised, before another decade passes, without this role’s geronto-logical nursing leadership?

Few nurses on the ward have time to mentor the profession’s students or newly qualified nurses into what could and should be highly skilled gerontological nursing practice. Are we, as a profession, so power-less that we must wait for the next group of prematurely deceased patients to once again shame the system into providing older people with what they most need?

Older people need proactive rather than reactive care, which includes continence promotion rather than induced inconti-nence, and remobilisation rather than being chairbound.

In this article... Key plans for nursing in the response to the Francis report How these plans could affect the profession Expert views on the proposals

The intention to put increased focus on older people in pre-registration and post-graduate nurse training is commendable but, without either a specialist career opportunity or the recognition of the spe-cialism of gerontological nursing, once again there is no investment to promote leadership in the care of older people.

This proposal is only another layer of rhetorical pledge that fails to meet what needed to be put in place yesterday for older people, let alone tomorrow.

ONE-YEAR HEALTHCARE ASSISTANT EXPERIENCE: June Girvin, pro vice-

chancellor and dean of faculty of health and life sciences, Oxford Brookes University, and member of the Council of Deans of HealthWorking as a healthcare assistant before joining a nursing degree programme may be a useful thing to do. At best, it may give a sense of the physical demands of nursing, an introduction to teamworking and an opportunity to see qualified nurses at work. However, at less than best it may establish bad or unsafe habits. A month would be enough to give a useful flavour for those who are unsure.

Nursing education standards already include compassionate care as a core com-ponent. Prospective students are already interviewed by NHS clinical staff to help ensure their values are tested. Students spend half their degree programme in uni-versity and the other half working in clin-ical areas. An HCA year would waste pre-cious time for someone who has decided

Are nurses so powerless that we must wait for more early deaths of older people to shame the system?Deidre Wild

The government’s response to the Francis report contained a number of undertakings that will have a major impact on nursing

After Francis: the government response

NT RESPONSE


nursing is their future career, and add a considerable burden to the mentoring and supervisory role of nurses.

This proposal shows a disappointing lack of understanding of modern nursing, of professional education and of the NHS workforce. Student nurses make up a tiny proportion of staff. They are continuously monitored and assessed and work under supervision. These are not the individuals who have so badly let patients down.

Rather than wasting time and money focusing on pre pre-registration students, the government and NHS England need to concentrate on getting the right numbers of qualified frontline staff, supported by their leaders to deliver high-quality care.

HCA TRAINING STANDARDS: Debbie Yarde, chair, Association for Continence AdviceAfter the powerful testimo-

nies from families of those subjected to the care in Mid Staffs, continence advisers were confounded that bladder and bowel care were not identified in the Francis report as a specific area of concern. This omission means this fundamental element of care will not be specifically included in any subsequent strategies. The proposed HCA regulations echo this.

If avoiding the issue is a fear of upset-ting Victorian sensibilities we need to move beyond this – and fast. Being able to pass urine and open your bowels is a fun-damental human need. Yes, that need is wrapped up in a requirement for privacy and dignity, but the thought that fitting a pad and then cleaning someone afterwards is enough falls woefully short of the mark.

Without a doubt, the success of the standards will be measured in some way even if efforts are made to avoid targets but, without specific reference to conti-nence, this will once again become the missed opportunity.

DUTY OF CANDOUR: Elaine Maxwell, assistant director, the Health FoundationThere is a moral imperative,

even a human right, for people to be informed of any act or omission that has

The nursing profession held its collective breath as it waited for the Francis report. Experience has shown that when something goes wrong in the NHS, nurses get most of the blame.

There have been cases of appalling practice, but the majority of nurses want to provide high-quality care.

So it was heartening that Robert Francis QC did not apportion blame. Problems at Mid Staffs were systemic, and his 290 recommendations covered all aspects of the NHS. Those related to nursing seemed constructive rather than punitive.

How disappointing, then, that the government’s initial response implicitly points the finger at nursing. Recommendations that could be brought in quickly – such as an older people’s nurse specialism – were rejected. Trusts are to decide for themselves whether to free ward sisters to spend more time on the ward and nurses more time at the bedside.

Instead, there will be a pilot scheme compelling prospective nurses to spend a year as healthcare assistants. This means an extra year on a low income, which is likely to deter many of the brightest and best (and those with families) and will have no effect until they qualify in over four years.

Nursing does have problems, but these are because nurses don’t have time to actually nurse – not because they don’t care for their patients.

Ann Shuttleworth, practice and learning editor

DROP THE BLAME AND LET NURSES NURSE

Jeremy Hunt lacks courage to look beyond the surface or beyond the symptomsMarion Colllict

Nursing Times.net

For the most comprehensive information on what the Francis report means to nursing, go to nursingtimes.net/francis

directly caused them harm. However, it is not at all clear what the introduction of a statutory duty to do so means in practice.

Criminal and civil prosecutions are already available for accountability and redress of the harm itself. A statutory duty of candour, on the other hand, requires the disclosure of errors before liability is con-sidered.

The purpose of a duty of candour is to ensure open and early disclosure of errors. Without clarity about the nature of errors covered by the duty, it will be important to ensure there are no unin-tended consequences. The impact of a criminal duty is likely to create a culture of fear and some foresee potential under-reporting (in clinical records as well as incident reports). For this reason, it is wise to be cautious of enacting a criminal duty of candour for either organisations or individuals.

Placing a civil law duty at organisa-tional level will require boards to consider systems and culture but could absolve individual practitioners from personal responsibility for disclosure, so the levels at which the duty applies will need careful consideration. In England, a contractual duty of candour for NHS organisations came into force on 1 April. This will be an opportunity to test how the service responds in practice before deciding what sort of statutory duty is required.

ROUNDING: Marion Collict, director of transformation, Luton and Dunstable University Hospital Foundation Trust

What does the government response to the Francis report tell us about Jeremy Hunt? He clearly lacks courage; courage to look beyond the surface, courage to look beyond the symptoms.

Intentional rounding is not new. The concept has taken many guises over the years but nurses have always known the importance of position change, skin checks, regular toileting and so on. The reality is that in hospital wards up and down the country, nurses are rarely able to undertake these activities routinely and delegate them to HCAs. HCAs often work unsupervised while registered nurses are distracted by many other activities keeping them away from the bedside.

An industry of paperwork has been cre-ated to provide assurance that care has been delivered and this has resulted in our tick-box culture. Nothing in the govern-ment’s proposal tackles the fundamental problem of the empty space at the patient’s

bedside – the rightful place of the nurse and the root cause of the decline in stand-ards of essential nursing care.

Nurses, now as much as ever, are com-passionate and want to nurse and care for their patients. We have created a situation that must be reversed. We must create a model of care that is sustainable, and meets the needs of patients, staff and regu-lators. This bold approach requires courage – something that Mr Hunt does not appear to have enough of. NT

Documents

Responding to Francis: nursing practice · 12 Nursing Times 12.02.13/ Vol 109 No 6 / Nursing Practice Review Nursing practice W ith a total of 290 recom-mendations, the Francis