Editorials

The “professional cleansing” of nurses

BMJ 1998; 317 doi: http://dx.doi.org/10.1136/bmj.317.7170.1403 (Published 21 November 1998) Cite this as: BMJ 1998;317:1403

The systematic downgrading of nurses damages patient care

  1. Hugh McKenna, Professor of nursing
  1. School of Health Sciences, University of Ulster, Jordanstown, Co Antrim, N Ireland

    Personal view p 1463

    All readers of this editorial will be looked after by a nurse at some time in their lives. For the vast majority the experience will be a pleasant and rewarding one—unlike that outlined by Hamon (p 1463).1 My initial response to her personal view was a series of depressing questions. Why would nurses who have received a rigorous and systematic education be party to such poor quality of care? How could professionals, trained to give high quality of care, allow standards to slide so far? How could nurses go home each evening and be content with what they have done and seen in the name of modern health care? I cannot defend the poor practices reported, but there are explanations.

    Nurses make up about 70% of the NHS workforce and cost 50-60% of the total pay bill.2 Unsurprisingly, therefore, some managers question whether cost effective quality can still be assured with fewer permanent registered nurses—indeed, in Britain the NHS Executive has stated that such a strategy could produce substantial savings.3 Similar reports have been produced in the United States, with one study finding that as nursing posts became vacant half were filled with untrained healthcare assistants.4

    A look at NHS statistics during the last government's term of office supports this impression of “professional cleansing.” In 1991-2 the number of nurses qualified in general nursing in England and Wales fell by 21% and those working in care of the elderly by 33%. Contemporaneously, the number of untrained care assistants increased by 21%. In 1992-3 the number of nurses in training in England and Wales was 18 620; the following year it fell to 14 576.5 Non-nurse “experts” such as Eric Caines, the former NHS personnel director, saw this as trimming the superfluous fat from an inefficient service.6 Perhaps Dr Hamon witnessed the outcome of these efficiency savings.

    As a result of such shortsighted policies, however, there is now a shortage of nurses in the United Kingdom—and millions of pounds are being spent on recruitment. Such recruitment is not proving easy,7 and it is doubtful whether the prime minister's recently announced initiative to create “consultant nurses” will help much.8 In the late 1990s there are not as many of what Dr Hamon refers to as “altruistic young women” wanting to come into nursing. Families are smaller than they used to be and the young women who in the past may have chosen a career in nursing are now increasingly finding that they can become architects, engineers, doctors, and barristers. They would need to be very altruistic indeed to put up with the high levels of stress engendered by the modern NHS and what are perceived by many to be the unsavoury tasks that nurses perform. Furthermore, the government did not help recruitment by staging nurses' recent inadequate pay award.

    Plenty of evidence exists to suggest that the inability to provide high quality of care causes low morale among registered nurses. A recent study showed that morale has lowered consistently since the early 1990s.9 A vicious circle then occurs: low numbers of registered nurses lead to poor quality of care, which leads to high stress and low morale; this in turn leads to high sickness rates, a shortage of nurses, and poor quality of care.2 A substantial group of nurses to whom this vicious circle applies are those who are employed full time but remain on temporary contracts for years. The absence of the psychological contract represented by a permanent job causes great distress to this group. When they go to work they cannot be certain which ward they will be assigned to or whether the following week will be spent on night or day duty. Most do not know if they will have jobs in 1999 and they all know colleagues who have been laid off and subsequently offered posts at lower grades. In one health authority D grade qualified nurses were laid off and subsequently offered care assistant posts at grade B.10 This was not an isolated case and from personal experience the effect on morale is palpable. It does not provide a perception of valuing the workforce—a hallmark of quality.

    Every profession has its black sheep—individuals who go to work to do more harm than good—and the minutes of the professional conduct committees of medical and nursing statutory bodies provide the details of these isolated instances. Indications from 60 research studies point to qualified nurses providing high quality of care over a range of indicators.2 For instance, a British study carried out by management consultants Touché Ross found that nurse practitioners achieve higher levels of patient satisfaction than senior house officers or GPs.11 Qualified nurses also contribute substantially to reduced length of stay, increased clinical and cost effectiveness, reduced morbidity and mortality, and increased healthcare productivity.12

    When evidence was uncovered that junior doctors were providing less than satisfactory care, the health- care press recognised the pressures they were under and the lack of support they received. In response the government (justifiably) reduced their working hours and improved their conditions. When nurses face similar pressures (often the result of taking over junior doctors' tasks), the profession in general is blamed for changing the educational system or for being uncaring.

    Modern hospitals are becoming large intensive care units, with few low dependency patients. Compared with 10 years ago nurses have a higher workload, with mainly critically ill patients. There has not, however, been a concomitant rise in the number of ward staff. In many hospitals staffing levels are calculated using workload instruments formulated in the 1980s.

    Last night I visited an elderly woman who had had a stroke. She had been admitted to a modern unit for the care of the elderly. About 30 bed bound patients were being looked after by two staff, only one of whom was a registered nurse. The staff were literally “rushed off their feet.” This situation is not unique to Northern Ireland or indeed to the NHS. The finger of blame for poor care should not be pointed at hard pressed staff but at the system that frustrates their desire to do what they are educated to do—care. Through partnerships with and support from medical colleagues, nurses must ensure that the reasons why care is not always as good as it should be are tackled politically, strategically, and operationally.

    References