Editorial: Call yourself a nurse? Time to get precious

The beginning of wisdom, according to Confucius, is to call things by their right names. Language should always bear the same meaning, so that the meaning of words (names) and the duties and responsibilities which go with them are universally understood. However, when applied to the word ‘nurse’, particularly in the UK, this is clearly not the case. The evident confusion among the public, press and in some sections, the nursing profession around who or what this constitutes, has meant that ‘nurse’ appears to be a default term of reference to describe someone involved in the delivery of care in hospital and healthcare settings. The continued torpor of the profession in acknowledging, let alone challenging, this state of affairs, is to put it mildly, alarming, not least because of the currently hostile economic and cultural climate in which UK nursing finds itself. ‘The criticism of nursing has reached a tipping point’, declared the President of the Royal College of Nursing in the UK recently (Duffin 2012). A UK national broadsheet newspaper, the Independent, has published a five day series of articles, discussing the ‘Crisis in Nursing’ resulting in a ‘Ten Point Plan for Change’ (Patterson 2012). Indeed, in recent months, the profession has been shaken by a plethora of negative reportage across all sections of the media highlighting poor standards of care, often delivered without compassion, by ‘cruel’ and ‘lazy’ nurses. This drip, drip testament to ‘broken nursing’ continues to appear in the public domain with depressing regularity, reinforcing the perception that the nursing profession, if not in terminal decline, has lost its way and is in need of some supportive intervention. It is therefore then, difficult not to disagree that the image and status of nursing in the UK has (again) reached something of a nadir. Seasoned observers will hold their breath and wonder what this augers for the future. The portents are predictably familiar. The Government has set up a Nursing Care and Quality Forum designed to put the ‘care back in to nursing’ (West 2012). This has been accompanied by media calls to ‘Bring back Matron’ and mutterings within and outside nursing, about the move to all graduate status and of academic nurses ‘too posh to wash’. The profession has responded as it invariably does in these situations, with a pledge to ‘look again at nurse education’ (RCN 2012a). Yet before, we enter another round of soul searching and knee jerk responses, might it not be prudent to finally address the apparently unaskable and still unanswered question. Who exactly, are the ‘nurses’ of whom all speak? Are they in fact, nurses? – Individuals who have completed a mandatory period of education to a UK recognised standard resulting in an academic award and professional registration with a body to whom they are accountable? Or perhaps, someone who has undertaken an arbitrary induction period before becoming involved with the delivery of care? Currently, there is no statutory period or standard of preparation for unqualified healthcare workers in England, or indeed any form of registration or regulation. Let us be clear from the onset, this is not a question designed to elicit and apportion blame, or denigrate the valuable and valued, contribution of our non-qualified colleagues who, frankly, deserve a whole lot better and without which the National Health Service (NHS), with all its systemic failings, would grind to a halt. Nor is this a form of denial that the profession does not harbour registrants who simply should not be there. If we are to make a serious attempt to identify, discuss and resolve some of the extremely concerning issues that continue to beleaguer nursing in the UK, we must establish a common starting point and this requires a necessary clarity. The public report that they often cannot tell the difference between qualified and unqualified staff (COI 2010). This is compounded by nationwide inconsistencies in uniform colour or type, or indeed similarities, as is the case with scrubs. Calling for a ‘nurse’ on a hospital ward or in many other healthcare settings in the UK will elicit a response from both qualified and unqualified staff. Some will argue that a response to a call for assistance is enough and it does not matter what the qualifications or registration status of the respondent is. That may be so, but this is not and has not been the case elsewhere. The lack of clarity extends and is further compounded by the media, as the numerous twitter feeds after the recent BBC Panaroma programme on the Winterbourne View scandal testify. Even the nursing press have used the word ‘nurse’ interchangeably to encompass qualified and unqualified staff. Such is the ambiguity that one of the Independents’ Ten Point Plan for Change is the call for greater clarity around who does what in healthcare settings (Patterson 2012). The response of the professional regulatory body, the Nursing and Midwifery Council (NMC), again under scrutiny itself, is conspicuous by its silence. The title ‘nurse’ has a protected status in countries such as Australia, Canada and the United States. The rationale is simple. The public have a fundamental right to know who is looking after them; that those advising them about their care have the requisite knowledge, education and preparation, together with a licence to do so. They further have the right to be protected from unqualified, unregistered individuals no matter how well meaning that do not meet these requirements. In 2010, the Prime Minister’s Commission Report on the Future of Nursing and Midwifery in England made the protection of the title ‘nurse’ one of its ‘urgent’ recommendations. The response to this from the present government was one of quiet and possibly, convenient, dismissal. The debate in itself is not new. Calls for the protection of the title ‘nurse’ in the UK have been manifest for some time (JM Consulting 1998, Castledine 1999) and concerns around role blurring/substitution are ongoing (McKenna et al. 2007, Alcorn & Topping 2009). What has significantly changed is the economic and ideological climate, which is currently dictating the nature and direction of travel. The organisation of health care in England is undergoing fundamental restructuring, which will be underpinned by an overarching market principle. Parallel to this, the NHS is attempting to make £20 billion efficiency savings by 2015. Whilst the government maintains these savings are being reinvested in to the NHS and spending is increasing in real terms, this is being felt on the frontline with over 3500 qualified nursing posts lost since May 2010 (Gillen 2012). The task for those involved in workforce planning in the NHS now and in the future, then, is to ensure that care continues to be provided, but this must be both cost-effective and competitive. Qualified nurses are expensive to educate and employ. It is not surprising then the ratio of qualified to unqualified staff is continuing to shrink, with unqualified staff being used to replace qualified staff vacancies and conversely, qualified staff being used to fill unqualified posts (RCN 2012b). Florence Nightingale famously declared that the elements of nursing were ‘all but unknown’. What qualified nurses do is notoriously difficult to define, but in many respects successive governments of all political hues appear to have conceptualised nursing as that which is conducted by caring individuals who have mastery of a number of practical skills, most of which can be bundled up and delivered by unqualified staff, as is manifest in the principle of the ‘skills escalator’ (DOH 2007). The reductive, inherent anti intellectualism of this approach is even more difficult to counter if one does not have ownership of the franchise that nursing has become in the UK. Thus, we are where we are. Direct care of patients continues to be delivered by often poorly prepared, unregulated, unregistered staff, whose roles are continuing to be rewritten and expand. They are overseen by diminishing numbers of qualified nurses, who retain professional accountability for the delegation of duties, a role for which they are not adequately equipped. (Hasson et al. 2012). The ongoing consequences, in terms of the deskilling and deprofessionalisation of nursing in the UK, constitute a separate paper, but for the more cynically minded, the political and pecuniary capital of continued confusion among the public, of who is and who is not qualified is self-evident. If the wards appear to be staffed and manned by individuals who all look alike and answer to ‘nurse’, then the NHS remains ‘safe in our hands’. A further implication of this chimera, already felt by many on the ground, is that any transgressions committed by non-qualified, perceived to be qualified staff, automatically become a problem located within nursing and to be solved by nursing, skewing the focus back to preregistration nurse education, and hackneyed debates about a golden age of nursing, usefully bypassing scrutiny of the woefully patchy preparation, training and development of our unqualified colleagues and their registration and regulation, which the majority want and deserve (Horner 2012). Whilst welcoming the recent consultation to develop national minimum training standards and a code of conduct for unqualified staff (Skills for Health 2012) this needs to occur in tandem with compulsory registration and regulation, which their role expansion necessitates. Regrettably however, both the English government and the NMC have recently dismissed this move. Some hope may be found if we cast our eyes abroad to many of our overseas colleagues. Whilst not immune to the vagaries of fashion or finance, they can at least face future battles, with a confidence that their professional identity is of sufficient value to be recognised and enshrined in law and that this clarity extends to wider society. Such transparency can be transforming. Similar moves to reduce staffing ratios in Australia have been met with stiff opposition from a profession empowered by a sense of identity and it pleasing to see that nurses remain the most trusted profession in Australia (Roy Morgan 2012) and considered the most ethical and honest profession in the USA (Gallup 2011). Let us hope this remains the case in the UK, particularly when we cannot be certain that it is in fact ‘nurses’ who are being assessed. Protection of the title ‘nurse’ is reducible to recognition of the value of nursing knowledge and expertise and the protection of the public. If the word can be appropriated by anyone, then both are at risk. Those of us who care about what is occurring in the name of nursing and who suggest that protecting the title nurse will begin to establish some useful clarity, should no longer be content to be fobbed off with the fig leaf of semantics. Nor should we be shouted down by accusations of professional ‘preciousness’ or causing offence to our unqualified colleagues, all of which miss the point. If words should have a universal meaning, then our overseas colleagues have had no difficulty in extrapolating, legalising and owning the word ‘nurse’. If it is good enough for them and more importantly, their patients and clients, then surely it is good enough for us and ours?

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