Nursing Quality and Compassion: The Future of Nursing Education

Lord MacKenzie of Culkein Excerpts

Tuesday 11th December 2012 Grand Committee

[Lord MacKenzie of Culkein]

My Lords, I am grateful to the noble Baroness, Lady Emerton, for putting down this question to the Government today.

It is apposite that we should have an opportunity to discuss the matter of care and compassion in another week when issues have again been raised about the quality of care, not least by the awful story told by Ann Clwyd MP at Prime Minister’s Questions last week. There is a very similar on the comment page of the Nursing Times of 4 December, written by a senior lecturer in the Faculty of Health and Wellbeing at the University of Cumbria. It has not been a good week for the nursing profession, not least with the release of the final report on Winterbourne View yesterday.

As a nurse, and as someone who has worked for nurses and nursing for most of my working life, I feel deeply saddened by the adverse publicity that my profession is now getting. This stuff will run and run; it will take a lot of time and hard work to mend the damage that has been done.

The question before us today is about the report of the Willis commission. The noble Lord, Lord Willis of Knaresborough, deserves our thanks for undertaking this very important piece of work. I would disagree with little, if anything, in the report. In the introduction to his report the noble Lord, Lord Willis, said that,

“there has been insufficient political or professional will”,

to implement past recommendations. He expresses the hope that that will not be the fate of his report. I sincerely share that hope. As has already been asked of the Minister, I hope that he will tell us that this time we will go down the right path.

The nursing world has in many respects changed out of recognition since the days long ago when I commenced my training. However, some things have not changed. It is not new that there are brilliant nurses, good nurses, some who are less good and some who are not suited to the profession. In my student days, when most started training at the age of 18, many of these were eased out during training.

Neither is the debate new about whether nurses are the finished article on registration. I can remember nurses who thought they had arrived and done it all on the day they completed their training. I much preferred the view that one really started to learn only after one qualified and took some measure of responsibility and accountability.

The issue of fitness to practise on registration is often discussed, but it must depend on the appropriateness and quality of education and the quality of teaching on placements followed, after graduation, by good preceptorship and clinical supervision. I have a relative who is a lecturer in a school of nursing and midwifery in a university. She tells me that they are not allowed to go into hospitals and wards to see what their students are doing, although I understand that teachers in some other universities can; indeed, I know they can because one used to appear at my bedside in uniform, complete with Barts badge to supervise what her students were doing and procedures. However, I gather that some not being allowed to supervise any work is something to do with universities and vicarious liability. That underlines my view that we need a return to clinical teaching. Pressures on ward sisters and mentors are such that there is a gap here. It is not necessarily the case, as some academics argue, that clinical teaching disrupts the natural process and flow of care.

I will touch briefly on workforce planning and commissioning. The Willis report underlines the difficulty in getting good statistics and the risks of workforce planning being left to local employers. I endorse the commission’s view that there must be a well developed UK oversight. The future cannot be left to short-termism and localism.

My union, the Confederation of Health Service Employees, supported the Project 2000 proposals to move away from apprentice-type training and into the higher and further education sector. We also supported the ending of enrolled-nurse training, as it then was; I still have the scars on my back from trying to further that argument with many enrolled nurses, including my own daughter. What we did not support was that there should be no other form of regulated training for staff that would in the future carry out much hands-on care—what I still prefer to call nursing care.

I spent many months travelling the country addressing meetings on Project 2000 and the ending of enrolled-nurse training, and advocating COHSE’s policy of an entirely new second level that did not have the problem of confusion of roles between the first and second levels as there then was. We wanted a new second-level support nurse trained to an agreed standard of about a year or so. Apart from the support of a couple of regional nursing officers, we ploughed a lone furrow. There was no real support from the leadership of the profession at that time.

The quite proper drive to enhance the status of the nursing profession has left us now with a plethora of support workers of varying training, or little or none, together with a multitude of job titles, delivering a great deal of nursing care. As the commission of the noble Lord, Lord Willis, puts it, that care is delivered with greater or lesser supervision. We need to do something now about the training of support workers. In reality, with the demographic pressures and financial pressures that there are going to be, there will be fewer degree-level nurses and more support workers. That much care is not going to be delivered by nurses themselves.

It is not part of my purpose to rubbish support workers. Many, in my experience, are excellent, but they need to be trained to an agreed standard, and they need to be regulated and registered. Some progress is being made—I have no doubt that the Minister will reinforce that—but it is not enough. I know that he has heard me on this subject before, but it is wrong and unconscionable that nurses have to accept responsibility for staff whose abilities and competencies cannot be relied upon.

There are a number of issues facing us. Some of these are cultural, although I personally find it difficult when I hear of curtains not being drawn around a bed. The noble Baroness, Lady Emerton, will well remember that we were taught to do no procedure without having first pulled the curtains around the bed and telling the patient what we were going to do. Nobody ever did anything without that ringing in their ears. It is not difficult to do, and not difficult to teach.

My final plea is that the ward sister should be supernumerary and accountable, and that senior management should be accountable because it is not always the staff at the sharp end who should carry the can. We need to get the education, the training and the skill mix right, and must not leave everything to localism. There has to be some national responsibility and accountability. I hope that nurse leaders will continue, as I know that they will, to fight to restore the image of our profession. If not, there will be more inquiries, more scandals and, perhaps, a royal commission. I hope that we do not get that.