Compassion fatigue and the NHS

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Guest post by Tara Nipe. This is a reprint of a post written by Tara for her blog, A Nurse’s countdown to the 2014 Victorian election, with a little ranting thrown in. Among many other things, Tara is a clinical nurse specialist on a mixed medical specialty unit at the Alfred in Melbourne,  one of Victoria’s most acute hospitals. She has been a workplace delegate for the Australian Nursing Federation (Vic branch) since 1992.

In case you hadn’t noticed, nursing standards and so-called ‘compassion fatigue’ have been at the centre of an ongoing ruckus in Britain and the issue has blown up again with the release last week of the Francis Report, an inquiry into neglect and mistreatment at Stafford Hospital which led to the deaths of over 1000 patients. NHS nurses in general have been accused of being ‘uncaring’. Here Tara looks at the various NHS scandals and asks what, if any, difference exists in Australia.

Tara Nipe

On Friday I read a tweet from  Jane Cummings, England’s Chief Nursing Officer, about creating a culture than encourages compassion in nurses. It linked to her article in The Telegraph, about the distressing findings of the Francis report.

For several years the papers have covered story after story of failures in NHS care, often centring on nursing care or, more accurately, lack of care – and the issues at Stafford are mirrored in hospitals and aged care centres across England. Indeed, five more trusts are now scheduled for investigation.

Just this week there’s the story of litigation against the University Hospitals Bristol Foundation trust, following the deaths of seven children and hospital-acquired disability of three others. Reading summaries of the breaches of care (which included multiple episodes of alarms being switched off, repeated failures to recognise deterioration and leaving children covered in vomit and in soiled nappies) one wonders how it’s possible for such inhumanity from anyone, let alone professionals whose job is to provide care.

Descriptions of other medical and nursing breaches are equally horrifying – patients who undeniably died as a result of being denied fluids, fasted for over a week because of repeatedly delayed surgery, failure to provide pain relief, refusal to provide assistance with toileting or linen changes.

A graphic which is bring shared on Facebook to defend NHS health workers.

This lack of compassion is most often attributed to nursing and medical education – this article by Yvonne Roberts is typical, mentioning that

a solid and sustained grounding during training would help… For the most part, training for health professionals gives cursory attention to ethics, psychology and simulated patient exercises, while managerial bonding adventures are not enough to remind us that behind the targets behaviour, sometimes aberrant, also requires accounting.

I’ve read a lot about how the NHS needs cultural change, calls over and over for a return to hospital-based training instead of a degree (university educated nurses are deemed ‘too posh to wash‘), and/or an emphasis on personal qualities like compassion over academic ability when selecting student nurses.

That the NHS is in trouble isn’t news, but things are rapidly getting worse and it’s a situation Australians should be watching with care. Though there are certainly differences,  I find it hard to believe that Australia’s health care culture is so markedly different from England’s as to account for this, yet (with rare exceptions) there are no stories like these in our papers. We have the same stereotypes about Gen Y fecklessness. We have the same bemoaning about electronic connection instead of direct interaction. The last Victorian hospital-based nursing education program closed in 1990, yet over twenty years of university-educated nurses hasn’t led to a compassion abyss.

So if it’s not the people, not the switch in education, what’s the difference?

Though there are similarities, there are significant differences between the NHS and Australia’s public hospitals. Unlike Medicare, NHS services vary from Trust to Trust – not only in term of facilities, but even which medications are able to be prescribed. So unlike here, where decisions about subsidised medications are made by the PBS Advisory Committee and then made available to all who meet prescribing guidelines,expensive drugs can be further restricted by trusts. As I discovered at a 2011 palliative care conference in Manchester, that includes chemotherapy drugs, so that patients in neighbouring suburbs but different trusts may have very disparate treatment options and the borders between Trusts seem far more rigid, so that a Not For Resuscitation order from one trust may not be recognised when that patient is transported across the boundary of a second trust.

The training systems are also different – instead of the (potentially articulating) enrolled nurse, registered nurse and midwife options, in the UK there are four streams (adult, pediatric, mental health, learning disabilities) with little crossover. Because there are no diploma-level nurses, less technical duties (the essential care on which all nursing and midwifery is based) often devolve to under-qualified, unregulated health care assistants; though Australian acute care hospitals employ HCAs, Victoria restricts their employment to rehabilitation, aged care and private hospitals. This was one of the three key elements of our recent EBA campaign, as I’ve explained previously.

Unlike most discussions about this NHS issue, the article I referenced above opens its concluding paragraph with ‘Cut frontline staff and collaboration splinters’.

And I believe that’s at the heart of this problem. Others have written more comprehensively than I about the link between workload, burnout and compassion fatigue. For a snapshot of the tensions overworked nurses face, you can’t go past this account of a week in the life of an NHS nurse.

For Victorian nurses, the key difference between our public hospital system and the NHS, though, is ratios. We have legally mandated minimum staffing – though the ratios are now twelve years old and inadequately reflect the increase in patient acuity between 2000 and now, they still provide essential protection for nurses and midwives – and patients. Even in states and territories without ratios, it cannot happen here, as it has at University College Hospital, for example, for forty-one postpartum women and their babies to be cared for by only three midwives and a handful of aides.

It worries me that the issues with care provision in the UK are repeatedly rooted in local culture and individual responsibility, instead of being seen as a symptom of a system-wide problem.

I love my work and I take enormous satisfaction in knowing that my patients receive excellent nursing care – not just by me, but by my colleagues. When I was a very junior student complaining about a bad shift, a friend asked if my care had  made a positive difference to anyone. I replied that I had. “What more,” she asked, “can you ask for in a day?” I can say that I have made a positive difference every single shift of my career.

Yet I can’t give the care I’d like to. I can’t remember the last time I gave all my patients a face-back-and-hands wash at the end of an evening shift – something that used to be routine. When I assist a patient with a meal it’s often a few mouthfuls, off to fix an IV, a couple of mouthfuls, answer the phone…

Last week I hadn’t slept well before my shift. When I got to work it was chaotic – the PM shift hadn’t been able to finish everything, we had admissions coming, a couple of significantly unwell patients and I had a dozen things that needed doing immediately, but only two of us to do them. When one of my patients buzzed for a pan I turned her on my own, though I would have been better to get my colleague to assist – but she was caught up and my patient’s need was pressing. I was tempted to leave her to be incontinent – I knew she’d overshoot the pan and would need a linen change anyway.

I got her a pan, with a somewhat forced smile, risked my back turning her alone and washed her and changed the bed when not all the urine made it into the pan. But I can easily see how, faced with that level of work every day, with more than eight patients, without support and without over two decades of experience, I could have made a different decision.

[On Twitter] I responded to the tweet I opened this blog post with: “Compassion fatigue signals burnout; that it’s endemic in the NHS indicates chronic under-staffing.” The conversation that followed included responses from another nurse that “we have learned with staff burnout its [sic] the totality of life often and work is only one facet” and “we hear sad stories nurses feeling torn we have a range of support but its [sic] always about choices” plus a link to a “great self audit tool for energy to avoid burnout”.

I agree that nurses, midwives and other health professionals have a responsibility to balance their lives, to take care of themselves and thus their patients, to recognise burnout and take steps to combat it. I also think that’s an ideal that for many is hard to meet, particularly when burnout’s already set in.

I also have significant concerns that placing so much of the responsibility of the problem on individuals abrogates the wider responsibility of the institution. Without inquiring beyond the failure of individuals nothing will change. Despite an already near-critical nursing shortage in the UK, the article I linked to at the top of this post is titled Nurses who don’t care about patients must leave the NHS.

The best nurses take steps to get out before they’re burned out – it’s the reason I returned to study, after working with a nurse who was crispy with burnout but had no options and no energy to look at anything except trudging through each day. Without significant change there won’t be any compassionate nurses left in the NHS.

Previously on Nurse Uncut: Nurses in the Olympics opening ceremony

3 COMMENTS

  1. I have been reading those articles and it makes me so upset and at times angry to read the comments posted by non-health/medical/nursing people who, thanks to these articles, brand all nurses to be lacking in compassion because all they do is nothing but sit on their ass all day.

    I think one of the biggest problems we face as health care professionals is that the majority of the community do not even know what our job is. Nursing, for example, is so under-estimated by the community/society in general until they come in contact with nurses and realise we actually are educated health professionals. I really think it would be nice if somehow they can be shown who we really are and what we face on a daily basis to know WHY we sometimes don’t seem to ‘care’ enough and all we do is rally for this and that.

    The swearing/screaming/yelling/abuse etc that we face on a daily basis should be broadcast. That is never shown to the public. Ambulance officers have been graced in newspapers about things they get abused about, police officers have enough TV shows to showcase their work, Drs get all the glory in medical shows, what about the backbone of the health care system? Why can’t we, as nurses, show our community what we have to face while trying to care for them? They should seriously consider having shows which showcase a shift of a nurse. Ward nurse, ED nurse, paed nurse, ICU nurse etc. Show them the amount of showers, bed pans and family disputes ward nurses have to deal with, show how many times ED nurses are abused, screamed and spat at for trying to help, how the paeds nurse gets abused by parents because they may not have children and are therefore not educated enough to talk etc.

    Why can’t we show the world the crap we have to put up with? Show them what the government pays us, then expects us to do, the sometimes unrealistic targets set, otherwise cut our funding, we lack resources, we lack staff, but we put in 110% to make things work, we try to care whilst doing our mountains of paperwork thanks to auditors. The unrealistic expectations of such which takes us AWAY from patient care. We need their help to convince the government we need more staff, we need more funding. It isn’t because we want to have less work, it is because we want to care about their loved ones and family members. Without the time, who can care for their patients properly? We are doing all of this because:
    – more pay = ability to retain staff = more people to care for their loved ones.
    – more staff per pt ratio = better and safer care for patients
    – more educators = train the new staff = better skills to care and detect sick pts
    – more funding = better resources (eg. new machines) = better quality care

    What we all fight for is not only for us nurses, but for the community we look after. They deserve the best care and we nurses are fighting for them to get the care they deserve. If the community realises this, they might actually help pressure the government to deliver these because the people of Australia deserve better care. If the government doesn’t agree, does it mean the current Government is denying the better care the people of Australia can receive? Then why vote for them!

    Enough rambling. I don’t think I make very good sense at 2am in the morning after a shift today.

  2. This is an interesting review by Tara, but I disagree and reckon her summary is symptomatic of the poisonous culture that has evolved in UK nursing where everyone recognises the problem but blames individual cases of negligence on ‘the system’. This is a lawyer’s dream… At the end of the day, system failures, pressure, fatigue and absence of resources at best mitigate the responsibility an individual nurses holds in regards to the choices they make, but it never absolves them. The Francis report identifies countless cases where nurses withheld analgesia, food and other basic necessities not because they were time pressured or simply overwhelmed with their workload, but because they simply didn’t give a stuff. Over and over again the press (and UK parliament) has identified similar cultures of disinterest across the UK. And over and over again everyone has identified that at the level of the individual nurse, all seem to be saying “yes there’s a problem, but it’s not my fault”. All choices to give or withhold care are made at the level of the individual, not the institution, and when nurses in the UK eventually recognise that, then cultural change will come about.

  3. Thank you for your response, Dan.

    The first point I’d make is that, as an Australian nurse who’s never practiced in the UK, I think my perspective’s minimally skewed by any “poisonous culture” in British nursing – a culture that I’ve seen no sign of in any coverage of either the Francis report nor NHS nursing in general. Indeed, as I wrote, the attitude expressed by CNO Cummings of individual blame is typical. I’d be delighted to see some acknowledgement of the role systems have to play in these outcomes.

    I do apologise if, in my indignation at all the accountability being placed on individuals, it looked as though I absolved the nurses involved of any responsibility. I do most certainly agree that individual nurses continue to have a duty of care to their patients, and that there are clear and repeated breaches of that duty detailed in the Francis report and associated press coverage – breaches I described as “horrifying”and “inhumane.”

    Perhaps I am mistaken, and it’s not the workload that has caused what is quite clearly a cripplingly broad issue across the NHS nursing and midwifery professions – however untenable it may seem to a nurse working with legally-enforceable ratios, skill mix and (usually) adequate support systems.

    What I would be very interested in hearing about, Dan, is the source of this cultural apathy to which you attribute neglegent care, if it’s not the product of systemic pressures.

    I ruled out the Gen Y stereotype and the switch from hospital training as factors, as they haven’t caused a deterioration in the Australian delivery of care. I also discussed the absence of an all-nurse/midwife workforce, but it’s only in Victoria that this is the case – every other state and territory in Australia utilises patient aides (however titled) in the direct provision of acute public hospital patient care, yet egregious cases of neglect are rare, let alone the maleficence you describe.

    There is no question that there is a deep, wide, contagious and highly troubling problem with Britain’s nursing and midwifery workforces. There are many professional, dedicated, educated, compassionate practitioners – my concern is that they, being consciencious professionals, will leave when they can no longer provide quality care; alternatively, their standards will slide and they, too, will become disinterested and burned out.

    Whatever the issue, attributing blame to individuals is easy, and comforting – it allows the rest of us to distance ourselves, to think we’re neither part of the problem nor at risk of becoming One of Them. It also means we don’t need to identify or address the root cause/s – but without doing so we have no hope of fixing a problem that threatens to get even worse. This is an issue that ought to be a high priority for the Nursing and Midwifery Council, the Chief Nursing Officer, the National Health Service and Unison. That it doesn’t seem to be worries me at least as much as the events that triggered the Francis report.

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