For the past 50 years, May 12 – Florence Nightingale’s birthday – has been celebrated around the world as “International Nurses Day”. But who exactly is celebrating nursing in 2015, when nurses appear to be under constant criticism and their morale is at an all-time low?
Certainly in the US, nursing is held in high esteem by the public: nurses rank as the “most trusted” group of staff, and have done so every year since Gallup started polling the public in 1976. But this is in stark contrast to how nursing appears to be valued by many in the UK.
Formal analysis of media coverage of nursing suggests that the British public’s perception of nurses as “angels” or of “sisters of mercy” has been replaced with something much more murky.
There is an implied distrust of nurses which goes beyond isolated views relating to specific examples of the misconduct or poor care. It is a generalised anxiety about whether nursing itself, not just individual members of the profession, has “lost its way”.
Commission after commission and the occasional forum has been set up to examine the “problems” in nursing, and consider what needs to be done to address them. The Department of Health said in response to the Francis Inquiry into poor levels of care in the Mid Staffordshire NHS Foundation Trust, that the government has been “tough on insisting on compassionate care in our hospitals”. This language is a far cry from a celebration of nursing in Britain and seems to imply that nurses need to be coerced to do something they might otherwise be unable or unwilling to do.
But research suggests that it isn’t the quality of recruits into nursing, the level of education, or the values that registered nurses hold, that are problems. On the contrary, there is international evidence that hospitals employing more nurses with degree-level qualification have lower mortality rates.
Research undertaken in the UK found that student nurses go into the profession with strong values and high ideals. They have a determination to provide high-quality, holistic care and to always have time for patients and their families.
But after just 15 months in the job, almost a third of these same nurses are described as having “crushed ideals” and more than half have “compromised ideals” – compromising one or more ideals on a daily basis. They felt they were unable to practice nursing in the way they or their patients expected.
Other research suggests that problems in England stem from having relatively low levels of registered nurses, too few degree-educated nurses and too little time to deliver complete care. The international RN4Cast study allows cross-country comparisons of the environments and experiences of hospital nurses.
England’s league table positions do not look good. Out of 12, the country was rated 10th on quality of work environment, 10th on the proportion of the workforce who are registered nurses (44% of staff providing nursing care on NHS wards have had no nursing education), and 11th on a scale of “burn-out”.
A survey in England found that 86% of registered nurses reported leaving necessary care undone on their last shift due to lack of time. This issue – lack of time – is arguably the biggest challenge facing the delivery of nursing care.
Time available to provide care depends on staffing levels, which has been a matter for increasing debate and concern. The Francis Inquiry revealed how decisions about nurse staffing at the Mid Staffordshire Trust had been made without due attention being paid to the risks. The consequences for patients and the staff working in these under-resourced environments were graphically described. Inadequate staffing had increased the risk of poor care and patients dying as a result of the treatment they receive rather than their original condition.
The risk of registered nurses reporting that they have left care tasks undone due to lack of time is significantly reduced on the best-staffed shifts (with six patients or fewer per registered nurse). For every additional patient per registered nurse, there is a 7% increased risk of death following common surgery.
Our work to explore the barriers and enablers to fundamental care aims to make explicit the challenges and identify root causes of problems that prevent nurses putting their skills and education to use. This goes beyond staffing levels – but ensuring that we have the right staff with the right skills in place is a key part of it.
We hope that by applying this research to practice, NHS care will not just meet Florence Nightingale’s first principle that: “Hospital shall do the sick no harm” but will be of a consistently high standard. So that as her birthday is marked in the future, both nurses and the public can feel proud not just of the heritage of nursing, but of its modern-day form.