The nursing profession is facing exceptionally difficult times. Deep cuts to frontline services, continued attacks on terms and conditions and an unrelenting degree of media scrutiny are all taking their toll on the profession. There is also, of course, the publication of the seminal Francis report, which gives nursing – and indeed anyone working in healthcare – a lot to think about.
The Francis report presents a watershed moment in the history of our health service, and a major opportunity for the nursing profession. Francis rightly recognised that nurses are at the very heart of patient-centred care. As such, he made a number of crucial proposals which – if implemented – will enable nursing staff to deliver the standards of care that patients deserve.
Despite what some commentators have said in the past few months, nurses have not become a fundamentally less caring group of people. It is the environments in which nursing staff work and the culture of their organisations that can create unrealistic expectations and pressures, impacting on the care they provide. Indeed, if Mid Staffordshire tells us anything, it is that a toxic culture can pollute good people; it can force staff to focus more on targets and less on patients – to devastating effect.
Investing in nursing is a big part of the solution. We need nurses in the right numbers, with the right training and skills. We need nurses who know that, when they raise concerns, they will be heard and real action will be taken.
Francis shone a light on what happens when we do not recognise the role of nurses as fundamental to the delivery of acute care. Crucially, some NHS organisations need to stop viewing nurses as just ‘a pair of hands’ and properly recognise and respect their skills as expert leaders in the patient’s journey.
We also need to ensure nurses’ skills are appropriately developed, to complement the overarching standards which Francis recommends. The RCN’s Principles of Nursing Practice lie at the very heart of this vision, setting out a framework for the provision of excellence in nursing care.
Robert Francis’ report highlighted that inadequate staffing levels contributed to the care failings at Mid Staffordshire. Importantly, he recommended stronger guidance for setting safe staffing levels, built into the new regulatory arrangements.
Francis recommends that NICE develop evidence-based tools for establishing what each service is likely to require as a minimum in terms of staff numbers and skills mix. If implemented, there is no denying that this measure would be an improvement on the status quo.
However, the move does not go far enough. The proposal falls short of the protection that mandatory staffing levels will provide for patients – something that cannot be guaranteed in the current system. This is something that the RCN has longed called for, and we intend to keep making the case for mandatory safe staffing in order to protect patients and support staff.
Francis also made recommendations to improve the support available to those who wish to speak out when they see poor care. The RCN knows that significant numbers of nurses would fear reprisals if they raised the alarm. This might include victimisation at work or negative implications for their career prospects. This just isn’t right. We need to support, not punish, individuals who chose to raise concerns and ‘blow the whistle’. The NHS cannot continue to surround itself in the veil of secrecy alluded to by Robert Francis; the costs of doing so are simply just too great.
We need also to invest in every member of the nursing team. There are an estimated half a million health care assistants (HCAs) working in the independent sector and around 300,000 in the NHS. In our modern healthcare landscape, HCAs deliver essential patient care to millions. Yet depressingly, for many HCAs, training is minimal and can be as little as an hour.
The RCN has long called for the regulation and training of HCAs, and are very encouraged that Francis dismissed the Government’s proposal for a system of voluntary registration. Instead, he recommended a mandatory system of registration and training, which will give these individuals and patients the protection they need. The ball is now firmly in the court of the Government to make this key proposal a reality.
Francis makes some important recommendations for leadership and training at every level of our profession, rightly identifying the benefit of nurse leaders in the management of the NHS. NHS organisations too often ignore the professional voice of nursing, which has a detrimental and often dangerous impact on patient care.
Robert Francis delivered a seminal report which has the potential to change how we deliver care in the NHS forever. Whether it is HCA regulation or mandatory safe staffing levels, the time for change is now.
Dr Peter Carter is chief executive and general secretary of the Royal College of Nursing