Most people reading this book will know only too well of the scandal surrounding Mid Staffordshire NHS Foundation Trust, whereby poor care between 2005 and 2009 reportedly contributed to the avoidable deaths of many patients. The public inquiry which followed cost the taxpayer Ā£13 million, interviewed more than 160 witnesses, sifted through one million pages of evidence and resulted in 290 recommendations contained within a four-volume report that stretched over 1800 pages (Kapur, 2014). Failings were identified at every level including individuals, management, regulators of nursing, the nursing profession and nurse education (Francis, 2013). The inquiry drew on the oral accounts and written witness statements of almost 300 patients and families, before concluding that nurses at the hospital lacked the skills to care and the inherent qualities to do so with compassion. While any criticism of the profession is difficult to accept, failings in compassionate care are particularly concerning, given the defining characteristics of nursing include āto respect the dignity, autonomy and uniqueness of human beingsā (RCN, 2003, p. 3). There is no doubt that emphasis needs to be placed on care and compassion in nursing, for these are fundamental values underpinning nursing. In this respect, the public have a right to expect, when admitted to hospital or when receiving nursing care in the community, that they will be treated with the dignity and respect they deserve. With that said, there needs also to be an acknowledgement of the contextual factors impacting nursing work, for example perceived autonomy or lack thereof, involvement in decision-making, workload issues, and associated stress and burnout (Wallin, Ewald, Wikblad, Scott-Finley, & Arnetz, 2006). Without such acknowledgement, it is difficult for nurse education to conceptualise nursing in such a way as to ameliorate the factors impacting the ability of nurses to provide high-quality care, and to do so with compassion.
Nurse education needs to play its part in preparing nurses who are able to respond appropriately when nursing values are called into question. Critical thinking skills and critically reflective practice are essential tools for contemporary nursing practice and should therefore be an integral component of the nursing curriculum. This requires nurse educators to have knowledge of theories and practice in curriculum development in order to ensure nursing programmes prepare nurses who demonstrate competency in practice, alongside caring and compassionate behaviours and attitudes.
The premise on which this book rests is for a mindful consideration of pedagogy in nursing to sit alongside the measures taken by the government, by the Nursing and Midwifery Council (NMC) and by the Council of Deans of Health (CoDH) to address the issue of quality of care in nursing. This introduction begins by examining the response to the Francis Inquiry from the National Health Service (NHS), the Royal College of Nursing (RCN), the CoDH and the NMC, within the context of their impact on discourse around care, compassion, values based recruitment (VBR) and apprenticeships in nursing. The chapter introduces the notion of transformative pedagogy in nurse education as a leitmotif throughout the book.
The National Health Service
The response of the NHS to the Francis Report was immediate, with most healthcare organisations accepting the recommendations and instigating changes in the short, medium and long term. The Nuffield Trust, in research carried out within a year of the reportās publication, found the Francis Report has been taken very seriously by those working in NHS acute trusts. Furthermore, āthe welfare of patients and high quality care was uppermost in their mindsā (Nuffield Trust, 2014, p. 37). The Nuffield Trust, while recognising the limitations of the research, which provided a glimpse of activity and views of one-third of hospital trusts, nevertheless concluded that it remains to be seen whether the Francis Report will result in measurably improved care for patients and how extensive this will be across hospital trusts more generally. Critical to this is the fundamental tension between commitments to care quality, safe staffing and zero harm, on the one hand, and the relentless financial constraints facing the NHS for the foreseeable future, on the other (Nuffield Trust, 2014, p. 44).
The Royal College of Nursing
The RCN is the worldās largest nursing union and professional body, representing more than 435,000 nurses, student nurses, midwives and healthcare assistants in the UK and internationally. Governed by an elected council of 31 members, who delegate the running and management of the organisation to a Chief Executive and General Secretary, the RCN is a Royal Charter body registered with the Privy Council. Along with normal trade union activities, for example negotiating pay terms and conditions for NHS staff and staff working within independent sector organisations, the RCN, through its lobby activities, influences governments and other bodies across the UK to develop, influence and implement policy to improve the quality of patient care (RCN, 2016). With respect to the Francis Reportās recommendations concerning nurse education , in particular the call for prospective nursing students to spend up to three months working on direct patient care under the supervision of a qualified nurse, the RCN responded by stating:
we firmly believe that the 2300 hours that student nurses currently spend on clinical placements is sufficient preparation for the world of practice and patient care. Furthermore, there is no evidence that newly qualified nurses are exhibiting any behaviours that should give rise to the kinds of concerns that would warrant such a radical change to the current system. (RCN, 2013a, p. 6)
The RCN, in this respect, shared the view of the Willis Commission on the future of nurse education, who saw no major shortcomings in the way future nurses are trained (Willis, 2012). Irrespective of the RCNās confidence in the current system, stakeholders in nurse education have a duty to consider the efficacy of the current system in preparing nurses for the emotional burden of their work (Proctor, Wallbank, & Dhaliwal, 2013).
The Council of Deans of Health
The CoDH represents the UKās university faculties engaged in education and research for nurses, midwives and allied health professionals. Considered to be the voice of the professions, the CoDH operates across the UK at the heart of policy and political debate (www.ācouncilofdeans.āorg.āuk). In a discussion paper on educating the future nurse, the CoDH suggests that developing clear competencies for the newly graduated nurse is a significant opportunity to articulate the value and contribution of the profession. However, at the same time, the CoDH highlights the limitations of competency-based models and the risk of creating a formulaic, box-ticking educational culture, which stifles innovation and creativity (CoDH, 2016).
The Nursing and Midwifery Council
The NMC is the regulator of nurses, midwives and health visitors in the UK, whose primary purpose is to protect the public by setting standards of education, training, conduct and performance. The NMC holds the register for all nurses who have qualified and meet the standards. In addition, the NMC is responsible for fair and effective fitness to practice processes to investigate and deal with nurses and midwives who fall short of the standards. With respect to nurse education, the NMC responded to the first Francis Independent Inquiry in 2010 by publishing new standards for preregistration nurse education, which placed significant emphasis on care and compassion for patients. The NMCās response to the Francis Report of 2013 concentrated on issues concerning healthcare assistants and support workers, on complaints, on professional regulation and on safety (NMC, 2013).
Care and Compassion in Nursing
Since the Francis Report ācare and compassionā has become a trope, a figure of speech, used in this instance to support the speakers (undeclared) neoliberal agenda. In other words, a call to reform both the NHS and nurse education , by claiming neither is fit for the purpose in the twenty-first century. The problem with putting the words together compels the reader to attend to both concepts as psychological traits or behavioural tendencies held (or not held) by individuals: a nurse is either a caring and compassionate individual, or they are not, as the case might be. This enables the āproblemā to lie within the individual and not with organisational factors, which ultimately determine how health services are organised, managed and delivered. On the other hand, if care is viewed as physical labour, emotional labour and organisation then ācareā is more than attitude. Nurses may or may not have control over the flow, pace and indeed goals of the work they undertake. Context may determine if emotional labour compromises the capacity of nurses to undertake care in a compassionate manner. The organisation necessary for care determines whether the nurse has the positive freedom to care, whether they have the resources and infrastructure to undertake care work (James, 1992).
The current trend to engage in dialogue intrinsically coupling care with compassion has resulted in a blame culture, whereby nurse practitioners point the figure at nurse education, and nurse educators reciprocate by pointing to poor nursing practice (Bewley, 2016). Apportioning blame is a falsely reassuring response to quality issues (Baker, 2015). Blame is a comforting but counterproductive reaction when attached to quality failures. Blaming nurse education and nursing practice for quality failures supports prescriptive approaches to nurse education, evidenced by redevelopment of standards for preregistration nurse education (NMC, 2010), revalidation for qualified practitioners (NMC, 2016a) and a focus on VBR (HEE, 2016).
Compassion in nursing practice is a complex phenomenon to describe, in that it is entirely subjective with everyone, be it patients, nurses and politicians having a personal, subjective view of what constitutes compassionate nursing practice....