The National Health Service (NHS) in England has been rocked by the findings of the Francis report – an independent public enquiry into appalling standards of care at the Mid Staffordshire NHS Foundation Trust. The range of problems in this large public hospital is reported more completely elsewhere (Francis 2013), but include failings in the most essential aspects of nursing care: for example, patients left to lie in excrement for lengthy periods, a widespread lack of recognition of patient dignity and privacy, failing to hydrate and feed patients adequately and a pervasive lack of compassion. This was compounded by a management culture that valued financially driven care targets over genuine patient care, the lack of a ‘caring and compassionate’ culture and also management styles that discouraged staff from expressing concerns about poor standards of care. This situation persisted for several years, thereby highlighting problems in the statutory monitoring systems for care in the NHS. In other words, this simply should not have happened – but it did – and has put the quality of nursing care and nurse education under the spotlight.
The Francis report is a lengthy account of the harrowing experiences of patients and relatives, which concludes with extensive recommendations (the executive summary of the report runs to 114 pages). Much of the report – correctly – focuses on particular NHS systems and relates specifically to a UK audience. However, the situation in Mid Staffordshire and the Francis report has wider messages for nursing care provision, patient care, professional regulation and nurse education, especially, recruitment and the structure of nursing registration programmes. One of the debates in the media and amongst politicians in response to the poor care exposed by Francis was how nurses are trained – particularly, the supposed deficiencies related to graduate nurses. The argument is that nurses trained to degree level focus on theory at the expense of practical skills and lack the compassion of nurses trained through less academic or ‘traditional’ means.
This view is flawed. First, it regards the past in some kind of nostalgic haze where nurses could do no wrong and care was always of a high standard – a notion dispelled by a conversation with any nurse older than 50 years. Second, it assumes less time at the bedside than in the past; however, UK graduate nurses engage in 50% ‘hands on’ experience in the same way as nurses who trained in the past. Third, it is wrong evidentially: nurses who are graduates deliver better care than those who are not (Aiken et al. 2003). It is, therefore, important that nurse educators resist temptations to reduce the academic level of nurse education and use the evidence at our disposal to resist such pressure. The Francis report must not be used to undermine the fact that a graduate nursing workforce is a good thing for the quality of care and not something to be embarrassed about.
What Francis did was highlight the importance of nursing skill mix and staffing numbers in relation to standards of care. Although low staffing is never an excuse for the appalling lack of care described in the Francis report, it was a factor. Again, the evidence is clear: the better the nurse/patient ratio and the higher the skill mix, the higher the quality of patient care (Curry et al. 2005). Often, deficiencies in care are not because nurses ‘lack compassion’ or lack the necessary skills – it is because they are over-stretched and struggle to provide the rudiments of care to inappropriately large groups of patients.
One of the most concerning elements of the Francis report was the inability of the hospital managers to listen to concerns from patients, families and some staff. The essence of Francis was that this was fuelled by the hospital management being driven by the achievement of targets – set centrally by the Department of Health – that were paper- based indicators of ‘quality care’ and ‘success’. These were inextricably linked to financial imperatives, which created a culture where, if the numbers look right, then it was assumed that the hospital was providing quality care. This was demonstrably not the case in Mid Staffordshire – but created an impression that things were going well. Indeed, the fact that the hospital had the coveted ‘Foundation Trust’ status, an alleged mark of quality and efficiency, makes the situation even worse. The lesson here is the importance of keeping close links between managers, clinician and patients. It also raises the issue that many of the managers in UK health care do not have a clinical background. This seems a key problem; it was suggested by Francis that prospective nurses complete a period of care work prior to application to nursing college. It may be more appropriate that hospital managers are required to do the same before working in clinical settings.
There has been a strong Department of Health in England steer towards requiring prospective nursing students to complete a period – up to one year – of health care work experience before application to nursing college. However, the suggestion that this would enhance the quality of nursing recruits is highly questionable. There is no evidence that this would have any effect; nevertheless, many UK nursing schools are exploring this idea. The ‘knee-jerk’, anecdotal acceptance of the value of such an approach is a cause for concern. It is based on the assumption that 12 months’ work as a Health Care Assistant (HCA) will equip a prospective nursing student with the compassionate caring skills for nursing. This is a bizarre assumption; many of the poor care examples in the Mid Staffordshire case involved HCAs. Furthermore, no one has examined whether the nurses implicated in poor care at Mid Staffordshire had previously been HCAs, an exercise that seems sensible, given the premise that HCA work before nursing is beneficial. In addition, the proposal that pre-education nurses work alongside completely unregulated HCAs is a potential recipe for disaster. It would be extremely difficult to ensure that they received the right kind of experience, and how this would instil a caring attitude is unexplained by its proponents. It would also inspire more confidence if the recommendation by Francis for the regulation of UK HCAs had not been dismissed by the English Health Department. And finally on this idea – the costs of implementing such a scheme could be enormous. The Council of Nursing Deans in the UK estimates that the annual cost of this could be around £766 million per year – a huge amount for a resource-starved NHS to spend on a scheme of unproven worth (Council of Deans of Health, 2013).
Francis also highlighted the potential problems around the measurement of care quality and hospital ‘success’. It is vitally important that methods to measure quality and bestow quality ‘markers’ on hospitals do just that, and do not simply rely on audit and paper- based evidence of quality care. Nurses can and should play a role in the development and monitoring of these systems, and where they are deficient, raise the alarm. Another lesson from Francis is that nurses who raise the alarm about poor care should be protected. The issue of ‘whistleblowing’ (reporting instances of poor care) is a sensitive one – with examples of nurses being disciplined and even dismissed by their employers for reporting poor care to the press. It is important that hospitals have proper systems for staff to report concerns and that staff use these in the first instance. Defending a decision to go to the press is easier against a history of failing to receive acknowledgement and action through the correct channels. Francis also remarked on the potential role the nursing regulator could have in the future. At the moment, the UK Nursing and Midwifery Council is charged with policing the ‘fitness to practise’ of individual nurses – not institutional instances of poor nursing care. Perhaps this should be reviewed. Additionally, the role of nursing regulators in addressing deficiencies in the management of nursing care not just its delivery needs attention; it may be the case that nurses who are managers escape sanction at the expense of hands-on clinical staff.
Within Francis and among the political clamour surrounding it was concern about the apparent lack of caring and compassion within ‘modern nursing’. It seems that every media commentator had a view and experience of this. Let us be clear – the vast majority of nurses are caring, compassionate and skilled practitioners, striving to do a difficult job in difficult situations – starved of resources and faced with the shifting demands of a politically charged healthcare system constantly in flux. There will be examples of poor care and these should not be tolerated. However, to use an incident like Mid Staffordshire to castigate the values and skills of a whole profession is misguided. It alienates nurses when they are the very people needed to drive up the essential care standards that patients deserve.
The Francis report may be a watershed moment in UK health care. There is the opportunity to respond positively to the appalling situation in this hospital. Some of the issues in this editorial are examples of this. However, despite the potential for change, two issues remain uppermost in my mind as a result of this report and the situation in Mid Staffordshire – one is how the press and politicians use such situations for their own agenda. Related to this is how uncoordinated the immediate nursing response was. Finally, if we are to take example from the impact of other high-profile enquiries into such matters as child protection, we must also, unfortunately, prepare for a similar situation happening again.