Government Nursing Initiative: more tinkering at the edges?

In the face of a growing and alarming number of reports on poor standards of care for vulnerable patients in the NHS and the community, the Prime Minister earlier this month launched an initiative to try and tackle the problem in hospital nursing.

This is after yesterday also announcing a move back to integration of health and social services in the community.

The measures all make sense – reduce the amount of bureaucracy nurses are tied up with (devolving it down to ward clerks or other administrative posts), instituting hourly monitoring rounds, etc., etc.  These are all sensible measures in and of themselves, and along with reintegration of health and social services, are based on evidence that these measures really can improve patient care.

In addition, David Cameron has announced the launch of Nursing Quality Forum to explore further what measures can be taken to improve nursing care.  Interestingly, this is only a couple of years after the previous Prime Minister held a similar Commission on the Future of Nursing and Midwifery in England, which reported back in 2010.  Despite Cameron pledging not to tinker and  micro-manage the professions, it seems no government can resist the temptation of being seen to do something!

But this announcement does nothing to tackle two difficult issues that I feel lie at the heart of the problem. Firstly, staffing – in an NHS required to make £20 billion of savings by 2015, it is already apparent that most trusts are cutting nursing and administrative posts that would be needed to ensure the Prime Minister's new measures were properly implemented.  With recruitment freezes, and a shifting of skill mixes to reduce the proportion of RNs to care assistants on the ward, it is going to be harder and harder to achieve these goals.

Even more fundamental though is the deeper social attitude that devalues the elderly and disabled as nuisances to be kept out of sight and mind.  The recent reports of the CQC, Patients Association and EHRC all suggest that it is the attitude of staff and the culture in some hospitals, wards and care homes that is also the problem.  Where the care of the most vulnerable is seen as low status and low priority, and that those providing such care see themselves as doing the least valued roles, it inevitably affects the care that is given.  And such attitudes are transmitted from the top of the organisation, particularly in how resources are allocated.  And the values that determine such choices come from the wider society and culture – based on what we value, how we vote, how we spend, how we care for those around us in our communities.

Like it or not, as a wider society we are responsible, in part at least, for the standards of care in our hospitals.

Headline grabbing initiatives are one thing, putting in the resources and shaping the values that determine how they are deployed is something totally different. In the meantime, as nurses and as Christians we have the ability and the responsibility to shape that change one patient at a time.

Industrial Action: How should Christians Nurses respond?

Many Christian nurses and allied health professionals have been asking me how they should act in the face of a mounting industrial dispute. On 30 November, around100,000 health workers in the UK joined an estimated 2 million other public sector employees in a one day strike in protest about the government’s proposal for the future of public sector pensions. 


As the negotiations between government and unions reached a climax, we already know that Unite has rejected the latest (and possibly final) offer from the government, with the other health and professional unions likely to follow suite (including the Royal College of Nursing and Royal College of Midwives, to which most of our members will belong).

The arguments about the pensions issue are fairly well covered in an opinion piece in Prospect, needless to say that the issue of lower pensions, bigger contributions and later retirement are not unique to the public sector, – nor to this country.


Not all health sector unions joined in the day of action in November, including the BMA and RCN.  The RCN Council meets tomorrow (10 January 2012) to decide what their next steps would be, but industrial action has been mooted as a possibility.


In short, there is a real possibility that there will be ballots for nurses and midwives on industrial action over pensions in the next few months, and certainly more public protests.


So, how should Christians respond? The RCN has some guidance for members on the issue from a purely professional angle here, but I have found relatively little useful guidance on Christian websites and blogs, so here are some thoughts and pointers in relation to the current dispute.  This is not a full theological and practical shake down of the subject, but it is a humble attempt to look at the underlying principles.


The first point to make is that the removal of labour is a coercive act, and therefore should be the last course of action in any dispute.  Consider the implications for your patients, their relatives and carers, your colleagues (not just medical and nursing staff, but ancillary, administrative and managerial), employer (the trust, the NHS as a whole), and your profession if you withdraw your labour. That being said, there are precedents for Christians taking direct action, from boycotting sugar during the anti-slavery campaigns during the eighteenth century, to the bus strikes during the US Civil Rights movement.  These were not purely Christian boycotts, but Christians did join in with them.  Where the cause has been just, Christians (and others) have found it well within their conscience to take direct action and practice civil disobedience.


But are NHS pensions in the same league?  If we have good grounds to believe that some of our colleagues are going to be left far worse off, even destitute as a result of these measures, then the answer is probably a qualified ‘Yes’.  On the other hand, if everyone in the country is going to have to pay more and work longer than we expected in order to have a reasonable (or even comfortable) retirement income, are the Government proposals really a major injustice, or just learning to live with the new economic realities of the decade?  I do not offer an answer to those questions, and I myself am not going to be retiring on an NHS pension, so cannot offer a personal perspective.


The Bible has a bit to say in general about industrial relations, although most of the scriptures you will see quoted relate to slaves and their masters.  I won’t go into the arguments about whether modern workers are wage slaves, or that we have rights, and our employers responsibilities (that would be undreamt of New Testament times), let alone the ethics of slavery. Nevertheless, they do highlight some general principles.

Colossians 3:22 ‘Slaves obey your earthly masters in everything’

1 Peter 2:18 ‘Slaves, submit yourselves to your masters with all respect, not only to those who are good and considerate, but also to those who are harsh.’

1 Timothy 6:1 ‘Let all who are under a yoke as slaves regard their own masters as worthy of all honour, so that the name of God and the teachings may not be reviled’.

It is clear that Paul and Peter, in writing these messages were urging slaves not just to do their jobs, but to be exemplary, going over and above the call of duty.  The motivation for this is also clear:

Colossians 3:23-24 ‘Whatever you do, work heartily as for the Lord and not for men. Knowing that from the Lord you will receive an inheritance as your reward. You are serving the Lord Christ’.

Matthew 25:40 ‘The King will reply “I tell you the truth, whatever you did for the least of these brothers of mine, you did for me”

We serve God when we serve our employers (and more importantly, our patients) well. But we are also enjoined throughout the Bible to have a concern for justice and to stand up for those who are disadvantaged or poorly treated: Isaiah 1:17 ‘Learn to do good, seek justice, correct oppression, bring justice to the fatherless, plead the widow’s cause’.

We are also called to make peace where there is conflict – Matthew 5:9 ‘Blessed are the peacemakers’– and to act with good conscience, putting others needs ahead of our own – Philippians 2:3-4 ‘Do nothing from rivalry or conceit, but in humility count others more significant than ourselves. Let each of you look not only to his own interests but also to the interest of others.’

(Scripture references taken from BibleGateway.com)

So, in Christian workplace ethics, obedience and service are vital, putting the interests of others first, standing up for what is right, but seeking to honour our employers, and in so doing honour God. We serve God ultimately through serving the needs of our patients in obedience to our employers (NHS Trusts and GP practices, etc.).

I would suggest that based around these theological principles, when we are facing questions about industrial action there are four key questions to ask when making a decision (listed here in reverse order of priority):

1: Is the cause just – regardless of whether I will be significantly worse off or not, will my colleagues on lower pay be badly affected by these changes? Would I be perpetuating an injustice by not joining in?

2: Have the Unions and Government exhausted all other avenues to settle this dispute?  Is there room for reasonable compromise on either side that has not been taken? And can I encourage my union and my government to make further efforts?

3: Will taking industrial action adversely affect the health, wellbeing and distress of my patients? What level of service will be left if I am striking, and will the cancellation of elective operations, clinics and other procedures cause significant distress?

4: Will I be honouring God in taking this action?

There are several challenges that arise, whatever our conclusions to these questions:

1: We should take trade union membership seriously.  Get onto union committees, become a shop steward in your workplace, be active in influencing the policies of the union and its relations with the NHS in your workplace.  Christians should be right at the coalface of industrial relations, standing for justice and righteousness in the workplace.

2: Following on from that, always make sure that you vote whenever there is a ballot, even if your feelings are not strong either way.  Choosing not to vote implies a passive agreement with the decision of the majority who do vote.  But only those who cast a vote actually decide the action to be taken.

3: Recognise that your colleagues and friends will have different perspectives, so try to act with integrity, grace in pursuit of justice, rather than offering judgements on their decision. Be gracious and forgiving.

4: But be prepared to be unpopular for taking a principled stand – whether to strike or not to strike.

5: Finally, however you choose to act – never lose sight of those higher principles behind your actions and the attitude you adopt. It is God that you serve ultimately, and your conscience should be clear with him throughout.

There is no right or wrong answer about whether to join in with industrial action that may be called during this coming year, but thinking and praying through these questions and challenges may help you come to a wise decision.

CNM E-News Edition 1

Edition 1 of CNM E-News now available to download here 

News of upcoming events, prayer items, links to news and comment and more.

Next edition due February 2012

Spiritually Confused Care?

Archbishop of York, Dr John Sentamu, recently spoke of the need to remember the spiritual needs of patients in NHS care – and was promptly accused of bringing back medieval exorcism! In the following week, the Royal College of Nursing published a new online training resource to equip nurses in spiritual care, after a survey of its members two years ago showed that they felt hopelessly ill equipped to deliver a type of care that the majority considered a fundamental part of good nursing.

The GMC and BMA acknowledge the need for spiritual care, but when a seriously ill friend of mine asked the GMC if not receiving spiritual care from his consultant was in some way negligent, they could only give the vaguest of answers, despite the well-researched benefits of doing so.

The National Secular Society continue to campaign for all chaplains to be funded by religious bodies, rather than the NHS, as they do not regard spiritual or religious care (a term they seem to mistakenly use interchangeably) as being a core NHS function.

At the same time, we see a GP reprimanded for talking about Jesus to a patient, a nurse suspended for offering to pray with a patient, and countless other cases where complaints have been brought (invariably by third parties) against a health professional for talking about any issue of faith with patients, even when this has been at the patient’s own behest.

Looking at these stories in summary, you could easily conclude (possibly quite correctly) that when it comes to caring for the spiritual needs of patients, the left hand of the NHS does not know what the right is doing! There is a growing body of evidence that spirituality, faith, religious observance etc, have an impact on health (mostly good, some bad). This body of research is growing, although to be fair, most of it is very local and small scale, so even when done well it is hard to draw too many general conclusions from the findings.

At a conference earlier this month in Amsterdam we discussed these issues at length as they relate to the training and education of nurses. One of the key points was that there is a need for multi-centre studies across countries and religious and secular world views to try and get away from small scale local studies. One early multi-centre study identified that those nurses and midwives with a clear faith or belief system were the ones most willing and able to give spiritual care. While this is unsurprising, it is a nostrum that is now backed up by hard evidence from a study across centres in Wales, Netherlands, Norway and Malta.

Furthermore, spirituality is not singular – it is different for different communities and individuals. The spiritual care of a British agnostic is a different matter to that given to a French Muslim or a Maltese Catholic. And this also highlights that spiritual care (broadly speaking attending to the need for meaning, significance, purpose, hope and connection) is different from caring for religious needs (e.g. maintaining a relationship with God through prayer, religious services, reading scriptures, etc.), even if the latter may help those of faith address the former.

For Christians working in healthcare, our faith has always informed our understanding of the spiritual needs of our patients. It requires us to show compassion, and an awareness of the deepest needs of other suffering human beings. We need to have a spiritual attentiveness to, and presence with, our patients as well as a readiness to speak gently and respectfully of the faith that we have within us if asked. And we should be able to provide such care without fear.

In the UK, only Scotland and Wales have produced any standards or guidelines for good practice in spiritual care in the NHS, but in England there is not even a move in that direction. It may be a coincidence that almost every single case of a doctor or nurse facing disciplinary cases for talking about faith and spiritual issues with a patient has been in England. But I doubt it. Until the NHS in England starts taking this seriously, the current confusion in spiritual care will continue.

More training, more research, better guidelines, all will probably help, but I suspect that in a secular culture, which is still unsure of the meaning of ‘spiritual care’, misunderstandings will continue to occur. And, as many recent reports on how poorly we care for people in the NHS have shown, in a health system increasingly obsessed with measurable outcomes, budgetary controls and ‘productivity’, alongside the gradual erosion of the Christian faith from the public sphere, the human dimensions of care – compassion, kindness, the recognition of the spiritual dimensions of our humanity – will inevitably get more and more squeezed to the edges.

RCN issues guidance on dealing with assisted suicide requests from patients

In July 2009, the Royal College of Nursing announced that, after consultation with their membership, they were withdrawing their historic opposition to assisted suicide, and were moving to a ‘neutral’ position.  At the time this was heavily criticised as sending out a message of tacit support for assisted suicide. Furthermore it was based on a response from a tiny sample of the 400,000 strong membership of the RCN, so was also criticised as a major policy change with minimal mandate.

I met with Peter Carter, the General Secretary of the RCN later that summer, and expressed the concerns that many nurses were raising over this move.  He sought to reassure me that they main reason was to allow the College to produce more informed guidance for members when faced by requests from patients for assistance with ending their lives. While I still cannot see why a change in position was necessary in order to produce such guidance, I did welcome the decision to give clear professional guidelines. At the time I was told this would be out in the spring of 2010.

Now, in October 2011, the guidance has finally come out! It has proved much harder and more contentious for the RCN to navigate these complex, treacherous legal and ethical waters than it had originally anticipated. Not least because in the intervening period the Director of Public Prosecutions was ordered by the High Court to issue guidance on the grounds for prosecution in cases of assisted suicide – guidance that made it much more explicit that health professionals involved with assisting the death of a patient would face prosecution,

The guidance published today is surprisingly good.  It addresses the different legal issues – from the DPP guidelines to the Mental Capacity Act and the provision for advanced directives, to the NMC code of professional practice.  More importantly the document offer practical guidance on how to broach end of life issues with patients and their family and carers.

At the core of the policy is the following statement:

Your responsibility is to work within the law to support the patient, and their family or carer, to explore and express their thoughts about the situation. At all times you are required to act ethically and legally, and in a manner that as far as possible empowers and supports people to live well until they die. [emphases mine]

The policy makes it clear that ‘it is important to make it clear that you cannot do anything that would shorten their life, or provide information about or assist in contacting such organisations [which provide information on assisted suicide]’ for either patient, relative or carer.  But it looks frankly at the reasons why patients and their families ask for such assistance, and at how to explore sensitively the reasons for the request and the options for palliative care and other support.  It also makes it clear that the nurse should not raise the subject her/himself. Above all it stresses that nurses have a duty to work with patients and their families to address their end-of-life care needs, and not to avoid the issue.

This is important, because the subject of death is often skirted round by patient and health professional alike, for a whole host of reasons.  Health professionals’ fears of prosecution when the issue of assisted suicide is raised by patients has been used by pro-euthanasia groups to legitimise calls to legalise assisted suicide. However, the guidance makes it clear that it is possible to discuss the issue (if raised by the patient) within existing legislation and codes of professional practice. It offers very practical guidance on how to raise end of life care discussions with patients and their families or carers, which can only be of benefit if approached with care and sensitivity.

The document does explore some difficult issues, and suggests quite strongly that nurses should not discuss their own beliefs about assisted suicide with a patient or relative.  Whilst this is generally appropriate, it does limit discussion when a patient or relative asks a specific question about the health professional’s own views.  There is a danger that guidance can be too proscriptive.  There are times when it is appropriate for a professional to make their own judgement when it is appropriate to respond to such a question.

There is also a detailed exploration of the Mental Capacity Act, the Scottish Adults with Incapacity Act and their implications in the area of Advanced Directives. However, it also makes it clear that no patient can require a health professional to assist with their suicide through an advanced directive.

Overall, this is a useful document that has been worth the wait, not least because it encourages nurse not to shy away from end of life care discussions with patients, and gives practical advice about how to do this sensitively.