You'll find the NHS very different from American hospitals," a friend told me vaguely, "but the nurses are wonderful, much more caring. They really have time for you." Really? That was not my view after two weeks in a prestigious central London hospital. I have had ten years' experience as "the patient" - a patient with a complex autoimmune disease - and consider myself an expert on hospitals. But in London I couldn't work out which nurse was responsible for me, who was in charge of the other nurses, who could give intravenous (IV) medication and who could only take blood pressure. There was a squadron of nurses hovering around my neurological ward, yet no one I could rely on to know my diagnosis (some nurses kept offering me inappropriate drugs). People would come in, without knocking, to dump pills on my table, yet no one bothered to ask me if I was vomiting up those pills - as I was. Instead, I was repeatedly asked the same inane question, "how bad is the pain, from one to ten?"
One night nurse's actions summed up the experience. He twice brought me the wrong medication, couldn't work the IV pump ("don't you know how to use it?") and didn't know to flush my vein with saline before administrating medication; the vein, of course, collapsed. So no, I didn't like British nursing. (I was in a private room, as my visa doesn't entitle me to free treatment, but I was in an NHS hospital, staffed by NHS nurses.) And I decided to find out what lay behind the fear and neglect I felt during my stay.
Nursing officials acknowledge that there is a crisis in nursing, but they see it as a crisis of quantity, not of quality. At the Royal College of Nursing's (RCN) congress this year, General Secretary Beverly Malone proclaimed that the nursing crisis "is nowhere near sorted." Gail Adams, head of nursing at Unison, the largest nursing union, agreed: "There are large numbers of people going into nursing training; the same numbers aren't coming out." And Tom Sandford, of the RCN, said that in London especially "there are big problems with recruitment and retention and a much higher turnover - nurses staying for 18 months and then moving on."
The government claims it is getting the problem under control. The department of health recently reported that, as of September 2002, there are 367,520 nurses working in the NHS, up by 4.9 per cent on the previous year and 1.3 per cent annually since 1992. Furthermore, DoH officials say, the government has met, a year ahead of schedule, its target of 20,000 more nurses in the NHS by 2004. And, as Tony Blair announced in July, up to 50,000 new nurses have been recruited to the NHS since New Labour came to power in 1997.
But who are these nurses - and how permanent are they likely to be? Last year, for the first time, more nurses joined the register from overseas (16,155) than from Britain (14,538). For NHS trusts, foreign recruits are a quick fix. It takes three years to train a British nurse, but an overseas nurse can practice in Britain after only a three to six-month adaptation course. Some people question whether foreign nurses provide the best sort of care: Maurice Slevin, a senior oncologist and NHS reformer, notes that some foreign nurses "don't speak very good English, and when you are sick you want to converse in your own language." But the problem is not that foreign nurses are inferior to British ones. It is that many of them are footloose. If Britain can poach nurses from poor countries, other rich countries can too - the US, for example, is expecting to be 1m nurses short by 2013. Foreign recruitment is a shaky prop.
Alongside foreign nurses the other short-term solution is agency nurses. They plug the dyke but cost NHS trusts up to 30 per cent more than staff nurses - money that would be better spent on increasing staff salaries to improve retention. Many nurses do better-paid agency work on top of their hospital shifts. Agencies are popular, both among nurses and among trusts, because of their flexibility. But many trusts worry about leaning too much on temporary nurses who must quickly find their way around unfamiliar equipment and regimes.
For agency or foreign nurses to be at all effective, someone needs to supervise them. But in many cases there aren't enough senior nurses to assimilate the new additions into the hospital. A senior midwife in the sprawling Mayday hospital in Croydon told me, "many days it's only myself running the ward with a very junior midwife and 26 patients. Not only do I have to look after my patients, but I have to supervise my junior midwife, and the patient then suffers, because that empathy and compassion that you're supposed to give patients gets missed out." The supervision crisis is so acute, according to the RCN's Verity Lewis, that there aren't enough experienced nurses to mentor foreign nurses on adaptation courses. The NHS actually has to turn away some of those who apply from overseas.
But the biggest staffing problem is that nurses are leaving the NHS in droves. An October 2002 Unison study found that half of all nurses were considering quitting, often for more lucrative and less psychologically demanding careers. As one nurse put it to me: "Young people coming out of university with degrees obviously look back and say 'well hang on, if my friend can get ?35,000 after her degree in IT, why should I slog my guts out for ?17,000?' It's not on. No matter what the government does, morale is low." And although pay has risen it is still quite meagre: starting at ?16,525 for a newly qualified nurse, at ?19,585 for an experienced staff nurse, and at ?23,110 for a ward sister.
Nurses aren't just quitting for other jobs. According to an RCN study, 100,000 are due to retire in the next five years. This would cancel out the vaunted target of 80,000 more nurses. The government's solution, then, is no more than running very fast in order to stand still.
So yes, there is a problem in nursing recruitment and retention. But that's not the real crisis. The real crisis is not about quantity - it is about quality. What was profoundly wrong in my hospital was that nursing - in its most basic sense, care - was almost entirely absent. To search for the solution in money, or recruitment, or bureaucratic restructuring is to miss the point. What we are dealing with is a change in the culture of nursing - the result of a modern obsession with status and self-assertion.
Let's consider what nursing should be. Myles Harris and Janet Warren, co-authors of Come Back Miss Nightingale, write, "The purpose of nursing is to do those things for the sick that they cannot do for themselves." If a patient can't feed himself, the nurse does it for him; if he can't wash himself, the nurse helps him; if he can't administer medication, the nurse does. This definition sounds simple, but is really quite profound: if the patient can't understand his diagnosis, the nurse explains it; if he is in pain, the nurse comforts him, if he can't bear being in the hospital, the nurse tries to help him endure.
When I was in the hospital, I couldn't sleep because I was in pain and because I was terrified. I had been prescribed a heavy-duty painkiller and sedative, and had been told to ring when I needed it. Every night I would postpone the moment, dreading the uber-efficient nurse who would march in, bark at me to roll over, yank down my pants, stab me with the injection, and march out - with rarely a "goodnight." One night I had an agency nurse, who asked me what was wrong. I was so shocked at being treated kindly that I burst into tears, and after giving me a shot - "there, baby, that wasn't too bad, was it?" - the nurse pulled up a chair, took my hand and told me stories of her native Mauritius until I stopped crying and started to doze. She was gone the next day.
There is something in nursing that runs absolutely counter to the instincts of the modern world. Our age concerns itself with empowerment, personal rights; nursing, when it is done properly, is about self-abnegation. The profession requires the nurse to put him or herself second, and the patient first. A doctor friend told me of a young nurse on his ward, a nice chap, whose face was filled with ironmongery - nose, lip, tongue and eyebrow pierced. This frightened elderly patients. My friend mentioned the fact to him; perhaps he might consider a change of attire? "Piss off, man; this is my human right to self-expression," he replied. But nursing shouldn't be self-expressive. In nursing, ideally, you realise yourself through service to others.
Modern nursing has tried to stamp out the idea of a "calling." Theory, bureaucracy, and an obsession with status have replaced the old duties of corporal charity - works of bodily mercy - that bound a nurse. In the 1960s the rigid discipline and hierarchy of the Nightingale ward - elaborate uniforms, cloistered student residences, fussy matrons, many of whom had forgone marriage to follow their calling as a nurse - began to look hopelessly outdated. To attract new recruits, the thinking went, nursing had to be updated.
Feminist theory coincided with corporate thinking to kill off any remaining notions of corporal charity. Nursing, the rhetoric went, was a profession in which the male doctors dominated and oppressed the female nurses; how degrading, then, to do lowly tasks like bed-baths and feeding, to accompany the doctor on rounds and to take orders from him.
One result of the new thinking was the Salmon report of 1966. Lord Salmon was chairman of the J Lyons grocery and tea empire. He had been commissioned by a Conservative government to bring "efficiency" into the hospitals. His report, "Senior nursing staff structure," smashed the hierarchical ward system and drove nurses away from the bedside. Salmon turned the sister into the "ward manager"; the nurse's focus was henceforth on the organisation, not on the patient.
You can hear Salmon in the language of modern nursing and you could see Salmon on my ward. The "ward manager" was almost inaccessible behind the nurses' desk, where she sat all day, typing figures into a computer. When I needed my IV drip, it was up to me to get out of bed and find her, to see if she could locate a qualified nurse. On two occasions her delay was so lengthy that I received only two of my three daily doses. She could administer medication, obviously - but patient care would jeopardise her bureaucratic status.
Many modern nurses work as if in a factory, clocking out the minute their shift is complete. The night nurse twice left bang on 7am, without giving me the anti-nausea medicine to counter the extremely unpleasant drip I had just received. The day nurse assumed I had been given my medicine, but didn't bother to check. I stayed in my bed, retching, until my mother went to ask for the prescribed anti-nausea IV. Later, another nurse checked my blood pressure. Seeing that it was worryingly low, he decided that the machine was broken. He didn't look at my chart, where he might have noticed my record of low blood pressure after certain medications. He pootled off to get a new machine. But then his shift was up; and so he left. An hour later I got out of bed and tried to find someone else, who might check if my blood pressure had stabilised. I have never before felt that the provision of my care was in my own hands. What if I were too ill to get out of bed - was my constant thought - what then would have happened to me?
Too often the NHS ward structure functions so that, as a nurse gains experience, she is drawn away from her patients into bureaucracy and form-filling. The result is that healthcare assistants without nursing qualifications and students are left to do much of the hands-on nursing. A senior nurse told me: "They're doing the real work. When I started in the 1970s the nurses did the proper work."
There are now seven grades of nurses, from the A-grade healthcare assistant, to the D-grade newly qualified staff nurse, to the G-grade ward manager, with two super grades - the newly created modern matron and nurse consultant (at H and I grades). The A to C grades aren't filled by fully qualified nurses, but by healthcare assistants. Your D-grade nurse will perhaps bring pills and take blood pressure, while the more senior staff nurses, the E-grade, will - if they have taken an extra course - be able to administer IV medication. The G-grade ward manager bears little relation to the sister a patient would recognise from 30 years ago. Her place is behind the nursing station, co-ordinating rotas and compiling information on the computer. She has little direct authority over the nurses, except as a time manager. Instead, nurses work in small teams in charge of separate patients. There is no centralised clinical control - only the doctor is responsible for the patients, and, thank God, my doctors were faultless.
To an American, used to three grades of nurses - aides, vocational nurses, and registered nurses - the system is ludicrously Byzantine. Where, I asked myself, was the experienced all-rounder I was used to? Whom do you ask for help; to whom do you look if there is a problem with your care? What a falling-off from the Nightingale nurses of the 1960s, with the simple hierarchy of state-enrolled nurses and state-registered nurses, always at the bedside, with sisters looking after the ward and matrons in charge of the whole hospital. A doctor who has practised for 40 years told me of the military discipline of the old hospitals: the matron would inspect the wards in pristine white gloves, running one finger over counter tops and tray tables to catch any lingering dirt. The sister was a figure of authority in a blue cloak, who directly supervised the nurses and was responsible for every patient on the ward. When my friend, the doctor, did his rounds on the old wards and asked the sister, "how is Mr Jones?" she would run through the details of what he had eaten, whether he was off form or crotchety, how he had slept. Now the response is, "I don't know, he isn't my patient." A retired nurse recalled her first day on the wards in 1960: she was not allowed to go for coffee until she knew the name and diagnosis of every patient on the ward.
The Salmon ideals became grim reality only quite recently, when the older generation of Nightingale nurses retired or quit, and a new breed of Project 2000 nurses, trained in status, "healthcare provision," and NHS studies came in. Conceived in 1988, it was Project 2000 that codified this new model of nursing - and to solidify the status of the new nurse, it was necessary to invent "nursing studies," a university degree. Out went the old apprenticeship, where nurses learned in the hospitals, and where - after a three-month run down of anatomy, physiology and the like - young nurses were given full exposure to the sick. This exposure to the sick was deemed exploitative: what was the student during training but a source of cheap labour?
Instead, in came a course that is 50 per cent theory and 50 per cent practice - and 100 per cent indoctrination in bureaucratic circumlocution. The NMC (Nursing and Midwifery Council) requirements for pre-registration nursing programmes state: "In order to provide a knowledge base, the following should be explored using contemporary theoretical perspectives: professional, ethical and legal issues; the theory and practice of nursing; the context in which health and social care is delivered; organisation structures and processes; communication; social and life sciences... frameworks for social care and provisions of care systems." Project 2000 educators foolishly condemned a nurse's "brand loyalty" to her hospital - fostered by the apprentice system, in which a nurse would be "St Thomas's" or "Guy's" trained - and set out to destroy it. Just as the Salmon nurse would focus on the NHS organisation and not the patient, the Project 2000 nurse would be loyal only to the principles of modern nursing, as taught by her university. There can be no esprit de corps if no one belongs to a corps.
The Project 2000 evacuation to the universities started in 1988 and by 1995 all the traditional nursing schools had closed. The less academic state-enrolled nurses were phased out - either downgraded to healthcare assistants or made to sit an exam and turned into state-registered nurses. The rationale was that a degree would make nurses autonomous practitioners, the equals of doctors, ready to meet the challenges of the changing health service and 21st-century medicine. The reality was that nursing had become embedded in a power struggle, against the doctors, the NHS, even the patients - should the patients ask nurses to do anything that undermined their status. "I'm glad I trained when I did," said a newly retired nurse. "I learned real things, how the body worked; now they learn airy-fairy things like how to work with other people. That should be part of your experience, not your training."
So what are the courses? The pure distillate of PC humbug, the usual mix of victimology, identity politics and class struggle. At King's College London's ironically titled Florence Nightingale school of nursing and midwifery, students are required to study, for instance, "the social context of health and healthcare, which considers the relevance of sociology and health policy to healthcare. Integral to this course is exploration of key sociological issues, which influence healthcare such as poverty, gender, social class, ethnicity, and race... At the end of this course you will be able to begin to recognise the importance of practising in an anti-discriminatory way." Keynote lectures include "age and ageism"; "lay health and illness beliefs"; "ethnicity and healthcare"; "families and health." The list includes the ultimate society-is-to-blame seminar, which defines mental illness as "the outcome of social issues and pressures in life rather than being caused by biogenetic or psychological influences."
And what do the new courses teach you? A friend's mother, a ward sister throughout the 1960s, returned to nursing after 23 years of raising a family to retrain under the new system. "I found it frightening," she said. "They spent all our time on the structure of the NHS and responsibility for your actions within the NHS. You're responsible for your actions in life; why is it different in the NHS? And teaching about understanding that the patient is in pain! If you're a nurse you should bloody well be caring about that anyway! But they only spent an hour on drugs, which was what I needed to learn. At the end of it I was offered a job in the NHS and I thought no way, I'd be a danger to the patients, I hadn't been taught enough about the new drugs."
The endless bilge of status and power relations filters out of the university and into bedside manner and clinical practice. Bad ideas create bad practice, and Project 2000 nurses have been trained to think that certain types of care demean them. This is illustrated by my pillow story. It all started when my vein was "tissued" - my IV tube slipped out of the vein and the medicine was pumped into the tissue by mistake. It hurts like blazes, and the whole hand swells up like a Porky Pig cartoon. All you can do, a lovely older nurse told me, is keep it elevated and wait for the fluid to drain out. She brought me some pillows and arranged my hand on a little pyramid. Unfortunately a few days later, when I was in the bath, my room was cleaned - a rare occurrence - and the pillows were removed. Later that day, another nurse tissued another vein. So I went to the nurses' station to display my Porky Pig hand and ask for some extra pillows. "No, the wards only give out one per patient." I explained that it was for my swollen hand, politely refraining from mentioning that it was their fellow nurses who had necessitated the elusive pillow. "Well, you'll have to ask your nurse." Who was my nurse? "She's gone home." I went back later, when my swelling was worse, to ask again. "We don't deal with pillows." I asked to speak to whomever did; she was gone. Then I asked another nurse: "Sorry, the ward is out of pillows." Could she borrow one? "The wards are very jealous of their pillows," was her answer. Could the ward manager help me? "She doesn't deal with pillows." Well, could this nurse just look for a spare pillow? (By now my hand was blueish.) She rolled her eyes, "I won't promise anything." Forty-five minutes later I went to look for her; my hand was numb. She had gone home. This time I said I would call my doctors if that's what it took - I got my pillow.
But it's not just the patients who are the victims. Bad ideology hurts the nurses too. Some may now choose the profession for the status of a degree, but most still go into nursing to care for people, like a student nurse I spoke to. Only 21, she became quite irate when I mentioned my grudging nurses: "You mustn't be a nurse who just dumps the medication and walks off, or sits doing paperwork all the time. I hate that; I couldn't see myself doing that, but if I did I'd want someone to take my hand and give it a good smack." The villains here are ideologues, not nurses. One experienced nurse said of the move to the university: "the danger is that one loses the essence of nursing." That essence can now be found only in the goodness of individual nurses, not in the profession as a whole. It is, I believe, this dehumanisation of nursing that accounts for the retention crisis, far more so than pay - no one wants to be a cog in a huge, uncaring bureaucracy. Nurses who went into the profession in order to nurse the sick feel dissatisfied (unless they are the lucky few who have escaped into more specialist niches such as paediatrics or intensive care). But after years of "sociology and the NHS," the dissatisfied nurses can't articulate their dissatisfaction. They have been robbed of the language of compassion and had it replaced by union-speak, which picks up where university ideology leaves off, indoctrinating nurses in the dangers of "racism in the NHS" or "harassment." (RCN's Verity Lewis defines "harassment" as being isolated, excluded from meetings, and made to feel undervalued - by which token we're all victims.) Nursing will always be a high-stress job, and like any job in the public services, one that doesn't pay the highest salaries. "But at the end of the day," said a retired nurse, "why you go into the job has to be for the pride in making people better."
It is beginning to dawn, albeit dimly, even on the department of health, that the real crisis in nursing is about quality, not quantity. Recent Whitehall edicts aim to refocus nursing on patient care - but without understanding either the spirit of Nightingale-style nursing or the destructiveness of Salmon's reforms. Take "Agenda for Change" - a new pay system that aims to reward nurses for the quality of their care. According to Alastair Henderson of the NHS confederation, "it recognises clinical and caring staff, and rewards caring and emotional stress." Unison and the RCN are keen on this idea, which means that as a nurse climbs the grades from D to I, she doesn't get shunted into management but can join the growing number of senior nursing posts that are purely clinical. Henderson says: "We will see changes in the way nurses work... taking on elements of the doctors' jobs - and taking on therapists' work, there will be people who are not qualified nurses extending their skills, taking on nursing roles."
Agenda for Change is also a blanket pay rise; two thirds of all nurses will now be paid above ?20,000. But a new bonus system is no substitute for what was, in the Nightingale era, an entire culture of good nursing and compassion. And inherent within this new system is more bureaucracy; more "best practice" to measure and evaluate.
At some level the DoH recognises that Salmon's reforms "tossed the baby out with the bathwater," as my friend the retired nurse would put it. So another of its schemes aims to recapture the lost order and accountability of the Nightingale hospital - as personified in the matron. To quote from the DoH website: "the NHS reintroduced the role of the matron, one which disappeared in the late 1960s - but this time in a modern and far more important role." Three years on, there are only 2,000 of these "vitally important" matrons in the whole of Britain.
And to top it all off there's "the essence of care" - a "benchmarking, best practice" programme, which tries to codify kindness and corporal charity. "The 'essence of care' approach is fundamentally qualitative and involves the identification of patient-focused best practice in those 'softer' aspects of care which are crucial to the quality of the patient's experience... These are: principles of self-care; food and nutrition; privacy and dignity; personal and oral hygiene; continence and bladder and bowel care; pressure ulcers; record keeping; safety of clients/ patients with mental health needs and in hospital settings." In other words, feeding, changing, bed sores, bedpans - all the things that Project 2000 and Salmon taught the nurses to regard with contempt, as beneath a nurse's status. The very idea that privacy and dignity must now be regulated shows how inhuman nursing has become.
My encounter with NHS nursing was, of course, just one person's experience. But I was in a world-famous specialist hospital. And from what I have subsequently seen, read and heard, I remain sceptical that the reforms above will do much to change the culture that has destroyed British nursing.
