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Introduction

The Open University — Mon, 27 Jun 2011 09:41:32 GMT

This unit is from our archive and it is an adapted extract from Understanding Health and Social Care (K100) which is no longer in presentation. If you wish to study formally at the Open University, you may wish to explore the courses we offer in this curriculum area.

This unit considers the type of care offered in hospitals, using Leeds General Hospital as a case study. The unit looks at the people who have roles within the hospital, how they interact with each other and patients and what they consider to be 'care'. The different approaches and contributions to care by doctors and nurses are explored and patients give their perspective on the care they receive.

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Learning outcomes

The Open University — Mon, 27 Jun 2011 09:41:32 GMT

After studying this unit you should be able to:

identify the different approaches and contributions staff make to care for health in a hospital setting;
evaluate the interpersonal relationships of those working together for health in a hospital setting;
appreciate how patients might experience care for health in a hospital setting.

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1.1 Leeds General Infirmary

The Open University — Mon, 27 Jun 2011 09:41:32 GMT

To explore care in the setting of an acute hospital, I visited Leeds General Infirmary (LGI) in the winter of 1996. The hospital provides a service of medical and surgical care for local people and, because it is a specialist teaching hospital with a medical school attached, patients are referred from all over the region for specialist advice, treatment and care. The hospital occupies a bewilderingly large, sprawling site in the centre of Leeds. It is a mix of the old and the new, and at the time I first visited it staff were particularly looking forward to the opening of a new building, providing a brand-new accident and emergency service and another 14 operating theatres. Its improved facilities for heart and brain surgery, people were saying, would make this hospital one of the best in Europe. LGI was part of what was then called the United Leeds Teaching Hospitals Trust. In 1996, the trust employed over 7,000 staff and managed another six sites in Leeds and the surrounding area. It dealt with well over 1,000 inpatients, another 500 day patients and more than 7,500 outpatients every week. Like other trusts it acknowledged severe financial difficulties, its waiting lists for admission remained high and certain areas of much-needed investment were on hold.

Update: Change at Leeds

In 2002 I contacted David Lee, Head of Continuing Professional Development at Leeds, to find out about changes there since this section was written. He noted that the General Infirmary at Leeds has become part of a group now called the Leeds Teaching Hospitals NHS Trust, one of the largest in Europe. It was created in 1998 following a merger. There are eight hospital sites and over 15,000 staff serving a local population of over 250,000. As a centre for regional specialities it needs to cater for a population in excess of 4 million. David has contributed to this chunk and provided us with a view of the change going on in Hospital Trusts.

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1.2 The formation of NHS trusts

The Open University — Mon, 27 Jun 2011 09:41:32 GMT

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Some of the buildings of the Leeds Teaching Hospitals NHS Trust

Long description

Under the NHS and Community Care Act 1990, health care providers in the hospital and community sectors could for the first time bid to become self-governing trusts. Trusts are in principle free to develop their own management arrangements, to use their assets as they see fit, and to set terms and conditions for their staff. A first wave of 57 units was granted trust status in April 1991, and successive waves of successful applications in subsequent years meant that over 95 per cent of providers were trusts by 1996. Trusts bid for contracts with GP fund-holders and with health authorities to provide services for an area. They compete with directly managed units, with private and voluntary providers and with each other. They are still part of the NHS, accountable to the Secretary of State through outposts of the NHS Management Executive.

Primary Care Organisations (Trusts) have been established and are in the process of maturing their services and the ways in which they will work with the Acute Trusts to provide seamless care for patients.

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2 A day in the life of a hospital ward

The Open University — Mon, 27 Jun 2011 09:41:32 GMT

In 1996, we visited Ward 29, one of two gastroenterology wards in the medical unit, and recorded the views of patients and staff. The ward has 24 beds. Its patients were women and men, across a wide age range, suffering from digestive disorders – for example, stomach ulcers, Crohn's disease, ulcerative colitis, cancers of the digestive system or problems with liver function brought on by alcohol abuse. Because it was winter the ward had more elderly people than it would have at other times of year, and staff underlined the pressure they were under to find enough beds.

Probably everyone would agree that Jackie, the ward sister, is the linchpin of Ward 29. She qualified as a general nurse six years ago and has been working in this post for about 18 months. Hers will be the first main voice that you hear on the audio clip as she describes her morning shift. Dave, the senior registrar, speaks next. One rung below the consultant, he is the doctor who oversees day-to-day medical work on the ward. Ann, the health care assistant, is voice number three. Although she started hospital work as a domestic, she explained that she ‘always wanted to do more’. Once her children were older, she moved on to the direct care role that she describes. (Later in this part of the audio clip you will hear James, a nurse, and Susan and Jack, a patient and her husband.)

These are all real people, talking about a real day in the life of a real ward. With their permission, we have used their first names (as they indeed use them in speaking to each other). However, we have edited the clip at points where they use the full names of patients to protect patients’ confidentiality.

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Activity 1: The ward sister's day

0 hours 10 minutes

Listen to the audio clip. At this point, just jot down as you are listening the different types of people that Jackie deals with in the course of her day. If you have worked on a hospital ward yourself, or been in a hospital ward as a patient or as a visitor, see if you can add other people who might well be on the ward on any one day.

Discussion

We tend to think of a hospital ward as a place where doctors and nurses work. In fact, as you have just heard, many more people than this both work on the ward and visit it. Jackie referred to the nursing staff from the night shift who hand over to her at 7.30 am. The need to consult the pharmacist was mentioned when she was interacting with a patient and a doctor, and she talked about ‘jigging in and out’ of the more formal doctors’ round to deal with the physiotherapists, dieticians, social workers, occupational therapists. In the afternoons, she said, she spends a lot of time talking to relatives as well as sometimes going off the ward for a while for a sisters’ meeting or a meeting with her manager. There are plenty of other people she might have mentioned. She did not talk about the regular visits of the phlebotomist to take blood or her interactions with the ward clerk or the housekeeping staff. These, and the person bringing newspapers, are a very visible part of the busy ward scene. Nor did Jackie mention any kind of maintenance work. (I came up in the lift with the plumber, who was trying to find which ward had blocked drains.) Jackie did, however, mention the many phone calls that she makes, dealing with social problems, carrying out procedures that care assistants cannot do and, as you will hear later, trying to ensure that things are right for a patient returning home.

Long description

An example of one ward and one morning like this is not necessarily representative of others. But it is certainly the case that large numbers of people routinely visit acute wards in hospital. In a study of the management arrangements of 14 wards in Wales, a team of observers recorded comings and goings over a period of three days. They calculated that each day an acute ward is visited on about 125 occasions by staff who are not based on the ward (e.g. doctors, physiotherapists, porters, chaplains, phlebotomists and nurses from neighbouring wards). The demands they make upon the time of staff varies from zero for a porter collecting pathology samples to over four nurse-hours for a medical ward round:

The authors further calculated that a member of the ward staff had to stop what he or she was doing on average more than 36 times in each day. And the figure of 125 people did not even include family and friends of patients – a large number if open visiting was the norm. The pattern did vary, however, between different types of wards. A more specialised ward or a longstay ward for older people for example might have many fewer people in evidence.
(Hawley et al., 1995, p. 261)

Certainly, as Jackie's description on the audio clip makes clear, there is a lot of co-ordinating to do if care arrangements are to go smoothly.

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Activity 2: Contrasting routines of staff on the ward

0 hours 20 minutes

Listen now to the next Audio clip where two more of the staff describe their day – Dave, the senior registrar, and Ann, the health care assistant. As you listen, consider the following questions.

What are the main differences in the daily routines of the three speakers you have now heard?
Who is most available to care for a patient, and what concerns other than patient care does each of these three have?

You may find that you need to listen to all three of them once again in order to prepare your answers.

Discussion

There are different ways of approaching this, but I was struck by how very different Dave's day is from that of the other two. For Jackie and Ann, the ward is their workplace. They are there for the whole of their working time although, as Jackie says, she might leave for an hour for a meeting. A doctor, by contrast, might be in any number of places in the hospital. For a start, Dave's patients are on five wards, not one. Not only does he visit the wards, but the patients from this ward, other wards, and indeed from outside, visit him in the endoscopy department. There are of course differences between Jackie and Ann. Ann spends much of her time doing hands-on care. Jackie, you might remember from earlier, does get to do some hands-on care, and there are some procedures which Ann as a health care assistant cannot do – administering medicines for example.
Of the three, Ann is the one who is most available to care for patients. Did you notice how she emphasised the importance of talking to patients? She does other things too, for example attending to stores. Jackie, you heard earlier, does a great deal to ensure that things run smoothly on the ward. She is co-ordinating, sometimes minute by minute, she is filling the gaps, dealing with crises, offering support and advice to the nurses on her ward, as well as some of the time engaging in direct patient care tasks herself. Dave carries out technical procedures and discusses their care with patients face to face. He sees an important part of his role, however, as supervising more junior medical staff and he also teaches medical students. Although he did not mention it, he is also studying when he can in order to pass the exams which will mean he can apply for a post as consultant (see the box below).

Jackie, Dave and Ann all have responsibilities that go beyond direct patient care.

Who's who among the doctors?

Would-be doctors spend five years as students in medical school. They must then complete one year as House Officer (six months in medicine and six months in surgery) before they are registered. Then come two to three years in Senior House Officer posts and, unless they train as general practitioners at this point, three to four years as Registrar followed by perhaps four to five years as Senior Registrar before they can apply for Consultant posts. Few can hope to move out of the training grades into consultant posts before their late thirties or early forties. Moves are afoot to shorten this time by creating new specialist registrar posts and abolishing the two grades of registrar.

If two consultants have patients on a ward, counting all the junior grades, there are likely to be at least ten doctors who might visit the ward.

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Activity 3: Different approaches to care?

0 hours 30 minutes

Now play the audio clip. First, James, a qualified and experienced nurse, describes the way work is organised into what nurses call ‘primary nursing’ teams to provide greater continuity of care, and Jackie comments on this from her own point of view. You will then hear Jackie and Ann planning the details of a patient's discharge. Ann had been on a home visit with the patient. Concentrate in particular, however, on the later part of this section, where first Ann, then the others, discuss nurses and doctors and their contributions to care.

Do the speakers feel there are real differences in how they relate to patients?
Do they all value each other's work equally?

Discussion

Different people pick out different things as rewarding. James, the primary nurse, singles out an emotional problem he was able to address. Ann, the health care assistant, says that she likes patients who need a lot of physical help. Jackie talks at length about caring for the person as a whole, taking into account all their needs. Although she does not use it at this point, ‘holistic care’ is a term she and other nurses use a lot.
Ann says that she doesn't believe doctors understand what nurses actually do, although James believes that much has happened to change doctors’ narrow focus on disease. As a doctor, Dave is clear that nurses are vital. He singles out the emotional support that nurses give and reflects on the strains this brings. On the other hand, his examples seem to be about the nurse as ‘assistant’ to the doctor. On that basis, one might be inclined to agree with Ann. Notice though that the organisation of the work means that neither doctors nor nurses are well placed to observe fully the work of the other.

In the next activity you will listen to the final audio clip in this section, and hear something about how the ward feels from the receiving end. Susan is the patient. Seven years before, then in her early forties, she had a stroke and was nursed by Jackie, who at the time was a staff nurse. Susan, her husband Jack, and her grown-up children all knew that with a diagnosis of liver cancer Susan had only a short time to live. The week before our visit she had collapsed at home. She had been rushed into hospital where staff had been able to stabilise her condition. When I met her, she was cheerful and alert. She and Jack listened carefully to what I was trying to do and agreed that they would like to take part. Susan sounds lively and energetic on the clip. She and Jack were hoping that she would be back home in another week and said that they planned to ‘just take it from there’. Sadly, that was not to be. Susan did not leave Ward 29; about 10 days after my visit she lapsed into a coma and died.

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Activity 4: Patient perspectives

0 hours 20 minutes

Listen to the audio clip. Jack speaks first, describing Susan's emergency admission. Then Susan talks to a friend who came to visit. Listen to the whole clip first, and jot down your first impressions. Next, read through the questions, and then play the scene again, noting down your answers.

Jack and Susan have a great deal of praise for the care that they have received. What kinds of things do they value most?
Alongside the praise, there are also hints of ways in which things can go wrong from a patient's point of view. What criticisms, for example, do they have of doctors? Are there any criticisms of nurses or of the nursing care they receive?

Discussion

Jack couldn't praise the staff enough for the support that they gave him as he stayed by Susan's bedside. There was always someone ready to talk and he was particularly grateful for the way they would talk to his children too. Information is another need that he and Susan had. They wanted straight talking and they got it. Friendliness and informality were something Susan valued. She says that nurses have time; she feels she is a name not a number.
Neither had any direct criticisms of the present doctors, but they were aware of what can go wrong. Some doctors, Susan says, talk over your head. She feels she is well able to challenge them and deal with it, but she observes that ‘you've got to ask’. Jack points out that doctors are so busy that perhaps they don't know they are doing this.

It is hard to find any real criticism of the nurses. Susan does describe how confusing it can be with all the different people who come to your bedside – but she says she is a person who adjusts easily and is not afraid to ask. She and her visitor do complain about slowness in providing the diet supplements that she needs. Comparisons with home offer more clues to how hard it can be to adjust to the hospital. ‘You're more one to one at home’, says Susan (thinking perhaps of the fragmentation and specialisation when so many people come to attend to different things). ‘You can do things in your own time’, says Jack (thinking perhaps of the routines of the hospital day).

There are a number of published accounts of patient experiences in hospital which are more negative than the one you have been considering. Deborah Lupton, an Australian social scientist, who has gathered together and reviewed a number of published accounts, sees in them recurrent themes of helplessness and loss of control. She regards hospitals as settings where, from a patient point of view, confidence in your own knowledge and power is challenged and your sense of your self is diminished. She cites a number of accounts by people who have become ill, particularly by social scientists used to studying other settings and by doctors who become patients and are moved to observe what is happening to them. Here is just one example from Dr Oliver Sacks, a doctor who spent a long time in hospital as the result of a leg injury. Things he already knows take on a new significance from the other side of the fence:

One's own clothes are replaced by an anonymous white nightgown, one's wrist is clasped by an identification bracelet with a number. One becomes subject to institutional rules and regulations. One is no longer a free agent; one no longer has rights; one is no longer in the world at large. It is strictly analogous to becoming a prisoner, and humiliatingly reminiscent of one's first day at school. One is no longer a person – one is an inmate.
(Sacks, 1984, quoted in Lupton, 1994, p. 97)

The idea of ‘total institutions’, the depersonalisation, control and even abuse of patients that can occur are themes we take up at several points later in the unit. For the moment, I shall return to the perspectives of staff as they try to provide treatment and cure alongside good continuity of care for the patient in hospital. The next section will examine in more depth the ways of working of the doctor, the nurse and the care assistant – how they define themselves in relation to others and what effect this has on the caring that is offered.

Key points

The work of many different people must be co-ordinated to care for health in a hospital setting.
Each occupational group tends to have a different work routine and a somewhat different outlook on care.
Patients, at a time of often great anxiety, face the challenge of adjusting to hospital routines and of understanding and participating in their care.

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3.1 Doctors: the ‘Great-I-Am’

The Open University — Mon, 27 Jun 2011 09:41:32 GMT

We pin a lot of hopes on doctors. We expect them to know all that is relevant about the classification and treatment of diseases. We expect them to be able to make us better, and to give us an indication of what will happen to us next. There are strong pressures on doctors to respond to this expectation – to be knowledgeable and confident, to set themselves apart from ordinary mortals. Lesley Mackay is a researcher who, in 1989–90, carried out an extensive study involving over a hundred interviews each with doctors and nurses in five hospital settings in England and Scotland, exploring in depth how they saw themselves and their work. She coined the phrase the ‘Great-I-Am’ to try to capture the perspective of the doctors and the ways in which they related to nurses, patients and others in the hospital setting. I will quote a series of excerpts from her book (Mackay, 1993) to build up a picture of her argument about how doctors think. For many of them, she believes, life in medical school and subsequently in a hospital sets them apart from other health care workers. I will then look at Mackay's argument in the light of the material on the audio clips.

Mackay calls attention to the image of junior doctors striding purposefully to the next patient, ‘the tails of their unbuttoned white coat flapping, stethoscope prominently dangling from one pocket’ (p. 63), a reflection, she says, of an attitude that ‘only I can deal with this’. She then develops this idea:

It is easy to see how junior doctors can see themselves as being the centre of everything. The doctor arrives, decisions are taken, the action begins. Nurses, perhaps cross and impatient about any delay in the doctor's arrival, will be critical of any failure to take a speedy decision. The doctor learns to act (and it is an act, in the beginning at least) quickly and decisively. The adopted persona of decisiveness becomes convincing, and the doctor rushes onto the wards, makes the necessary decision, and rushes off again, with smaller tasks perhaps left uncommunicated or undone.
(Mackay, 1993, p. 68)

Mackay argues that accepting decision-making responsibility, as doctors do, can be a stressful responsibility that they admit is ‘scary’. It should not, but often does, mean that the doctor ignores the contribution of others, failing to listen to those who have more contact with and knowledge of the patient.

Here is another aspect:

… a continual effort is made to present a united front through which the patient is kept calm and protected. The way the performance is played is that the doctor has the leading role, the nurse acts as the assistant … The doctor can question a nurse's actions … [but] … if a nurse were to question a doctor in front of a patient, the doctor's presentation of confidence and competence would be undermined.
(pp. 112–3)

Activity 5 Thinking about doctors and caring

0 hours 30 minutes

First, summarise Mackay's argument by reference to the following questions:
1. What does Mackay mean by the ‘Great-I-Am'?
2. How does she say that the ‘Great-I-Am’ attitude is produced?
3. What results does she argue that it has?
Next, jot down your own reaction to this argument. Do you think it is accurate? Do you think it is fair to doctors?

Discussion

1. The ‘Great-I-Am’ is an expression Mackay coined to draw attention to doctors’ belief in their centrality to health care. It can mean arrogance on the part of the doctor who might refuse to listen to co-workers or to the patient. (But Mackay's account shows another side – where doctors feel that they are required to behave as if they are omniscient and always certain about a course of action, and have instilled in them a very strong sense of their own personal responsibility for outcomes and of the enormity of the consequences of error.)
2. The ‘Great-I-Am’ attitude, she argues, is also sustained in the daily organisation of work by nurses, and by the ‘golden rule’ of no disagreement in front of the patient.
3. She points out that the ‘Great-I-Am’ can give the patient confidence that the doctors know what they are doing. But it can also feed doctors’ sense of their own importance and result in devaluing the contributions of others – particularly nurses. Where nurses do not speak up and challenge there is the potential for harm to the patient.
Reading about the ‘Great-I-Am’ provoked some strong reactions in our group of course testers. Some were dismissive:

This is obsolete and of no value to the course; it's one-sided, good doctors do not have this stance, doctors are not the ‘Great-I-Am’ - they are humans!

For others, it struck a chord:

Some doctors I have come across in hospital, also GPs, when asking for information they look right through you and ignore you - you do not need to think the ‘Great-I-Am’ to help people; I have experienced doctors’ wrong opinions three times - I think the doctors should listen to what people are saying.

It would be wrong to interpret what you have read as saying that all doctors behave in a ‘Great-I-Am’ way, or that they are always ‘uncaring’. Mackay's point is that the preparation that doctors receive encourages them to be active, to decide quickly on a course of action, and to use their knowledge to get results. The model of medical activity that they learn is primarily about cure rather than care in the sense that we have been discussing it in this unit. A cure perspective -stemming from the biomedical model – can mean keeping quite distant from the person who is the site of the disease. Indeed, doctors can see this distancing as important in helping them think calmly about courses of action without getting entangled with individuals. Both James and Dave on the audio cassette indicated that they thought that doctors today are more alert to these issues than they have been in the past.

It would be unfair

Key points

Both the biomedical model and ways of working in the hospital tend to set doctors apart from others in the hospital health care team.
This can produce tensions among co-workers and can distance doctors from patients.
There is awareness of this among doctors, however, and not all behave in this way.

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3.1.1 Update: A move towards patient-centred care?

The Open University — Mon, 27 Jun 2011 09:41:32 GMT

David Lee of Leeds Teaching Hospitals NHS Trust, commenting on recent changes towards patient-centred care, said ‘The modernisation agenda stemming from the National Health Service Plan (Department of Health, 2000) is requiring major shifts in organisational and cultural thinking. The patient is increasingly being placed first and at the centre of every aspect of health care. In essence, health care and indeed ward routines are now expected to be driven by the needs of patients and users of the services, rather than by caregivers. This is closely related to the need for the Health Service, and the staff who work within it, to be responsible and accountable for the patient's experience.’ Clinical governance is the term used to encompass, among other things, ensuring quality of care, learning from mistakes and reducing risk to patients. All staff are now expected to share responsibility for clinical governance. David Lee also drew our attention to the existence of independent bodies such as the Commission for Health Improvement which are also indications of the move towards making health services responsive to the wishes of patients.

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3.2 Qualified nurses: working in the shadow of medicine?

The Open University — Mon, 27 Jun 2011 09:41:32 GMT

Dave, the senior registrar at Leeds General, made a strong statement about nurses on the audio clip:

Nursing staff are vital. I can't be there all the time. They are my eyes and ears. So they basically watch over the patients for me and will let me know of any changes either good or bad that may be important. If you are performing a procedure … it's very helpful to have an assistant there, someone who can help you with the practicalities of it and also talk to the patient… about bits and bobs to relax them.

Jackie, you might remember, said something rather different in describing what good care was to her as a nurse:

I think giving good care is listening to what the patient and the family want first and foremost … keeping [them] well informed is another thing, making sure that they feel physically as well as they can do … making sure that they know their way around … treating everybody with respect and with kindness - I think that's giving good care.

Activity 6: The role of the nurse

0 hours 15 minutes

What are the main differences between Dave's perceptions of the role of the nurse and Jackie's? How would you account for these differences?

Discussion

These two accounts are some way apart. Dave stresses ways in which the nurse can help him. He describes the nurse as an assistant to the doctor. He does not actually say that the patients are ‘his’ patients, although he seems to come close to it. What the nurse does, in this excerpt at least, is very much to play second fiddle. Even the reassurances that Dave knows he or she gives is downplayed as ‘bits and bobs’. Jackie, on the other hand, has a much wider view of what it is that nurses do. Her account is oriented to the patient and the patient's family, not to the doctor – indeed the doctor does not figure at all!

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United Leeds Teaching Hospitals Trust: nursing philosophy

Long description

David Lee comments that, since this was written, the nursing philosophy has been subsumed within the new merged organisation (Leeds Teaching Hospitals NHS Trust). However, its principles remain relevant and continue to evolve with increased emphasis upon continuing professional development (CPD), responsibility and professional accountability.

The differences stand out particularly sharply because these are short extracts. No doubt, if challenged, Jackie would acknowledge that part of the job of the nurse was to do some of the things Dave describes, and Dave too would want to add that the nurse's role was rather broader than his remarks here imply. Dave certainly makes clear that he is aware that doctors can be accused of just looking at the disease, and adds his own belief that ‘you care whichever branch of caring you are in’. But the audio clip (like the excerpts from the trust's philosophy statement) does indicate that nursing works with a different model, which emphasises care rather than cure.

The single mostly frequently used definition of nursing in textbooks and classrooms is the following:

The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to a peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible.
(Henderson, 1966, p. 3)

Jackie's description of good care very much accords with this rather more formal statement. In some ways nursing seems to be the mirror image of the biomedical model.

In place of the focus on disease, it brings the person to the fore and stresses the different goals that people might have.
In place of striving for cure, it accepts that there are other outcomes – developing or regaining independence in the context of a chronic disease or disability, for example, or aiming for a peaceful death.
In place of emphasising expertise and special techniques, it aspires to work with, rather than working on.

But:

Instead of the very clearly decisive and interventionist stance of the curer, it seems deliberately to hold back and reflect. It seems altogether a more nebulous activity.

In practice, it is probably fair to say that nursing looks both ways. Nurse education undoubtedly draws on the biomedical model with its emphasis on bodily systems and disease, but it also stresses that health and healing involve more than arresting the course of a disease by surgical or chemical means. Nursing emphasises care for the whole person, and pre-registration education brings a wide range of social sciences – including aspects of sociology, psychology, economics and social policy – into the curriculum more strongly than does medicine.

Holding a biomedical model and a broader, more holistic notion of care at the same time is not an easy matter. Nurse researcher Pam Smith, through observation on hospital wards and interviews with student nurses and qualified staff, has taken a direct look at student nurses. Her work shows that, although people come into nursing because they want to ‘care’ and initially value care very highly, caring slips down the agenda – even though no one deliberately is devaluing it (Smith, 1992). How could this happen?

First, there are the clinical placements that students do in the course of their training. As they pass through surgical, medical, gynaecological, paediatric, geriatric wards and so on, they are, in effect, moving through medical specialties. And the way in which students talked about their experience showed them shifting from an initial orientation towards people to a biomedical approach – in other words towards a medical cure model, not a nursing care one.

Second, students found the learning offered by the high-tech specialties altogether more tangible and more exciting. They were learning new and more technical procedures:

… one student, less than six months into training, compared the ‘heavy’ routine work of her first allocation to the neurological ward where she was now assigned. ‘It's unlike most other medical wards’ she said in a thrilled voice ‘because there are loads of different illnesses and multiple sclerosis and all that and people coming in for tests and lumbar punctures and things.’ In her excitement she saw neurology as exotic diseases and tests, rather than uncertainty, unpleasant symptoms and long-term suffering for patients and their families.
(Smith, 1992, pp. 54–5)

A comment from one of the nurses’ tutors conveyed, albeit for different reasons, that she too liked the medical model – because it was ‘nice and logical and it's scientific and you can do it in school beautifully’ (p. 38).

The third point in some ways is the reverse of this. When the course did deal with emotions and with interpersonal skills, it did so in a third-year module where students were encouraged to identify and explore critical incidents that they themselves had experienced and to comment on them in discussion. The informal nature of the sessions reinforced in them a sense that this was something that could not be taught. You ‘just picked it up’, they said, and they concluded that this was ‘stuff you learned as you went along’. Being caring, it seemed, resulted from experience and from coping with difficult situations.

These three points suggest that the learning experience of student nurses at the time of Smith's study was unwittingly devaluing care. Developments in nurse education have combated this in a number of ways. Student nurses spend more time in a structured educational setting and less as apprentices in hospital wards. They also now begin with a common foundation programme which emphasises health rather than disease and deliberately gives placements in community settings as well as in hospital wards.

If care tends to be devalued, cast into the shadows compared with the glamour of medicine in this way, it is important to develop concepts that can describe its contribution more clearly. Emotional labour is one such concept, designed to draw attention to the importance of offering support to patients, listening, getting involved with families, managing your own emotions and responding in helpful ways to others. While emotional labour is something people do for each other in day-to-day life, there are particular skills linked to emotional labour in the hospital and other health settings. For one thing, the nurse needs to make assessments of need and to respond appropriately to patients from different cultures and classes and at different points in the life cycle. There is skill too in organising emotional care, making the necessary time among the routines of physical care for work that can easily look and feel like doing nothing. Nicky James, a nurse researcher who has made a study of hospice nursing, argues that

care = organisation + physical labour + emotional labour

and she emphasises the centrality of emotional labour, the importance of the time to build emotional closeness and the logistical difficulties this can present in settings requiring 24-hour cover (James, 1992, p. 503).

The nursing staff on the ward in Leeds would no doubt identify with this – and Susan and Jack gave testimony to what they achieved. But often what will contribute most to the emotional well-being of a patient is something that seems on the face of it a very trivial and minor task - on a geriatric ward, for example, making sure hearing aids work and glasses are clean (Smith, 1992, p. 1). Nicky James and Pam Smith are among a number of researchers who suggest that emotional labour is a key concept in caring, which should be studied more carefully and incorporated into nurse education and into our understanding of the nature of nursing.

Activity 7: Constraints on nursing care

0 hours 15 minutes

Read the two quotations that follow. You have seen how emotional labour can be overshadowed by the glamour of cure and not be fully acknowledged in nurse education, or well understood as part of nursing. What else, do these excerpts suggest, interferes with the possibility of doing emotional labour?

A nurse has been closely watching a post-operative patient whose psychological depression had been impeding his recovery. For days he has been silently brooding, unresponsive to all efforts to make contact with him. Finally, one evening, he begins to respond to the nurse, talking about his worries and concerns for the first time. As she sits with him, listening sympathetically, using all of her interpersonal skills to support his emotional catharsis, she feels that this is one of the rare and precious moments when she is really ‘doing nursing’ in the way she was trained.
Unfortunately, just after the patient began talking, the dinner trays came up from the kitchens. It is dinner time, the food is getting cold, the other patients are hungry and restless. Organisational efficiency requires that patients be fed at a certain time. But if the nurse leaves her patient to serve dinner to the others, the patient may withdraw into his shell again. The optimal time for talking to a patient cannot be regimented, controlled, or even predicted.
(Cherniss, 1980, p. 87)

One of the characteristics of nursing work is that it is difficult to specify with any precision. This is particularly true of general hospital nursing where, at different periods, nurses have done (and do) work which could be considered the province of cleaners, dieticians, porters, clerks, secretaries, ward housekeepers, receptionists and doctors…
Traditionally, one of the most valued attributes of a nurse has been her ability to ‘cope and get the work done’. Since nurses in hospital settings are the group in continuous direct contact with patients, they tend to be the ones to cope with the absence of other staff. This is particularly true outside of office hours and at weekends, where nurses may take on secretarial or clerical tasks, run errands, or act as extension therapists.
(Beardshaw and Robinson, 1990, p. 8)

Discussion

The first quotation deals with the importance of organisational routines in the hospital, the need for a predictable pattern of events, and scheduling and co-ordination of activity. Care, on the other hand, in the context of the home and unpaid carers, is not easy to schedule and predict. It can play havoc with planned activity in a large organisation. You heard on the audio clip about one way of trying to reconcile the two - the shift to primary nursing. Organisational demands, therefore, mean that emotional labour can be devalued and sometimes actually driven out.

The second quotation continues the theme of devaluation. Caring, it seems, often amounts to coping with whatever needs to be done at the time and seems to be something that we can ‘naturally’ expect of nurses - something that is unremarkable, that goes unnoticed and unsupported. Doing other jobs can mean nurses have no time to care, and report that they are not doing ‘real nursing’. In short, then, if the doctor seems to be the ‘Great-I-Am’, the nurse seems to be the (not so) great ‘Can-Do'!

It is frequently said that nursing is ‘women's work’ and that this too contributes to its devaluation. Caring in the home is often done by women on an unpaid and unnoticed basis. An important question, therefore, is where gender fits in.

Activity 8: Images of nurses

0 hours 20 minutes

This activity is designed to start you thinking about public images of nurses and the message about nursing work that they give. Consider the two advertisements for nurses. Both these advertisements ran in the national press as part of a campaign to attract more people to nursing. They are taken, as you can see, from some time ago. What message were they giving about the nature of nursing work and nursing care?

View larger image

A 1960s recruitment advertisement

Long description

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A 1980s recruitment advertisement

Long description

Discussion

It is just as true today as it was in the 1960s, as the small print says, that most women who go into nursing marry, and that most take a break from nursing for childbearing and then return. It is also true that nurse training will help with the health care that women do in families. But it would not be surprising if nurses were annoyed at this portrayal of them. One message we might receive is that nurses are warm, attractive, caring people. Another message, conveyed by the headline and the picture is that marriage is more important for women than work, and that nursing is not really a job in its own right at all. The words say that nursing is a ‘real job’, but the context devalues it. The 1980s advertisement could also be said to devalue the work of nursing, although in a different way. By associating it with ‘women's work’ – something that comes naturally to girls – it is portrayed as a job that hardly seems to warrant formal training at all.

In the 1980s nurses campaigned against the kinds of image, in recruitment posters and in the media more generally, that portrayed them as angels or sex symbols or battle-axes (Salvage, 1985). Such images are not so prominent today, but they have not disappeared completely. And today's fictional nurses do not necessarily give what nurses themselves would see as an accurate representation of the skills and the demands of their work. Sometimes in TV soap operas it is the careful attention the nurse gives that teases out information vital to treatment. But nurses’ love lives figure in such stories more often than their skills as nurses. The recruitment posters, however, have changed. They now pay attention to the range of work and the diverse career opportunities in different fields of nursing. And at least one early 1990s campaign specifically addressed men. ‘Nursing is an Equal Opportunity Employer’ was its headline but, it went on, ‘we're very much aware that men and women aren't attracted to it in equal numbers’. It then challenged ideas that a man who nursed was ‘soppy’ or that he was there just to do the heavy work.

In some of the textbooks for nurses of a hundred years ago, describing and prescribing their place in health care, the hospital was compared to a family – the doctor as father, nurse as mother, and patient as child. The doctor made decisions, the nurse helped and respected him, and the patient followed orders, since daddy knew best (Gamarnikow, 1978)! The gender stereotypes of the time were clear – that women/nurses are naturally more nurturant, caring and motherly, and that doctors/men are calm, decisive, and scientific and rational in their approach.

Have such ideas been overturned completely? Of course, a great deal has changed in the course of a century. Although the proportion of men in nursing remains low, at about 10 per cent overall, numbers of women doctors have risen sharply in the 1990s, so that women are now about half of all entrants to medical school. Nursing is organised in the same way as medicine, as a profession that registers its members and sets conditions for entry, which has its own specialist journals and research. Yet pay differentials are considerable; nursing only became a university subject on any scale in the early 1990s; and the lack of investment in a strong programme of funded nursing research comparable with that in medicine has been a focus of enquiry and concern (Department of Health, 1992c). Has nursing ever been granted the resources and the autonomy to show what it can do? Certainly there have been nurse-led initiatives in areas where medicine has less to give – well-person clinics, care of the dying, and pain clinics, for example. We could say that in these cost-conscious days it is surprising that all this is not more developed. I am on record as arguing that medicine and nursing remain a prime example of legacies of gender-stereotyped thought and of the devaluation of the skills of caring (Davies, 1995). Others, however, point to the power that stems from being on the ward and having more knowledge of the patient under the primary nursing structure that James described on the audio clip (Hughes, 1988; Svensson, 1996).

Key points

The cure work of doctors and the care work of nurses are both important for patient care, yet nursing often seems less important.
The caring that nurses do is devalued in several ways, for example by its association with women's work.
Challenges for nurses are to re-examine the care they provide, work with others on ward towards multi-disciplinary working and to devise organisational arrangements that enable high-quality care to be given.

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3.3 More carers: still deeper in the shadows?

The Open University — Mon, 27 Jun 2011 09:41:32 GMT

What can be said of the others who work on hospital wards? There are, as you heard on the audio cassette, care assistants, there are domestic staff, and sometimes too there are nursing auxiliaries and clerical assistants whose role is to take some of the paperwork away from the nurses, to enable them to get on with the business of giving direct patient care. You have already seen that the division of labour between doctors and nurses is not always clear-cut. You will now see that there are important overlaps between nurses and those who assist them in the work of patient care. What a care assistant does, and also what a domestic or a clerical assistant does, rather like what a nurse does, can depend on who else is available, varying from ward to ward or even varying on the same ward depending on what time of day it is. This can lead to frustration all round, with the qualified nurse feeling that she is not doing the work she is trained for and wants to do, and others feeling that no one is acknowledging the skills of the work they do.

‘On the wards’, the offprint you will read for Activity 9, is an excerpt from an account by anthropologist Liz Hart of the time she spent working as one of over 200 domestic staff on the wards of a large teaching hospital in the West Midlands. Her method was open participant observation – that is to say she had permission to carry out the research, and staff and management knew that she was a researcher. But she worked shifts alongside the others, doing the same work and sharing breaks with the domestic staff.

Click view document to read: On the Wards

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Activity 9 Hidden contributors to care

0 hours 20 minutes

Patient care in a hospital is not restricted to care by doctors and nurses – it includes care provided by staff who are not professionally qualified.

Read the offprint now and try to set out the different ways in which Hart's findings support this statement.

Discussion

Hart shows that in the case of a teaching hospital domestic staff do many activities that can be classified as care.

Domestics carry out a range of tasks for patients (fetching things, finding things in the locker, helping them to drink, even sometimes lifting) in response to patient requests and in the absence of nursing staff.
Domestics converse with patients in an ordinary and everyday way which they, and some nursing commentators, claim is helpful to the patient and can be therapeutic. Relatives also sometimes turn to domestic staff for information and advice. Domestic staff can sometimes even be an ‘anchor’ in a setting where staff changes are rife.
Often domestics have long years of experience in a particular ward, and wish to and successfully do build up knowledge and relationships that mean an extension of their role.
Patient contact can be a source of job satisfaction for domestic staff, some of whom intend moving into care assistant work.

There are plenty of other examples that could be given to show that caring work is not the exclusive province of those who are qualified and registered as nurses. A great deal of care for elderly people in residential homes, for example, is carried out by care assistants. This can be true in hospital settings too. Qualified nurses plan, assess and supervise the work, delegating to others. This was clear when James described his role as a primary nurse on the audio cassette and when Ann, the care assistant, gave an account of her day. Care assistants and auxiliaries, however, are likely to have had some training for their face-to-face responsibilities for patients. Domestics are not. One of our course testers argued that Liz Hart's account was too positive -without careful training and supervision, the interventions of the staff that she describes could risk sometimes doing harm.

One of the members of the course team, Jan Walmsley, interviewed Val, a care assistant in a psychiatric setting, and then shadowed her as she worked for a day – recording what she did and what she had to say about her work. Val said that she was ‘unqualified but not untrained'; she had had a lot of experience as a care assistant, and in practice she found that she was ‘training’ the junior doctors, the student nurses and the nurses with much less experience than herself. In a hospice, the sister admitted that care assistants were the ‘backbone of the unit’ and that she was sometimes ‘a tinge jealous’ of how close some were to the patients. A staff nurse from the same hospice went further and recognised that some of the care assistants possessed skills that she herself did not. Remembering one particular incident she said:

At the time I just didn't know how to cope. And luckily the older auxiliaries were there. If Maggie hadn't been on that day I don't know what would have happened. I just didn't know what to do with this poor woman. She just completely broke down and collapsed in front of me. And I went to get Maggie, and said ‘come and help me, please’. And Maggie was very firm with her, but very sympathetic at the same time.
(Quoted in James, 1989, p. 36)

Can we ever generalise about what different grades of staff do? Can we get neat job descriptions? The answer, from workers at least, seems to be no – there is too much variation across the settings and in day-to-day resourcing. One care assistant summed it up neatly:

I think of myself as polyfilla. Filling in the gaps, doing things the nurses haven't got time for, or making it easier for the nurses, or talking to patients when no one else has got the time to talk to them. Really just anything and everything.
(Quoted in Ahmed and Kitson, 1993, p. 27)

There is considerable debate over what training should be provided for workers such as care assistants, by whom, and for how long. But over the last decade there has been growing recognition of the contribution made by non-qualified and non-clinical support workers. Substantial Department of Health funding has been made available to enable trusts and other health care organisations to develop education and training for these groups. National Vocational Qualifications (NVQs) and Scottish Vocational Qualifications (SVQs) are available to help staff in training for their important role in patient care.

Key points

Care assistants, and others who are sometimes not formally qualified or registered, carry out much hands-on care on hospital wards.
Their work can overlap with that of registered nurses, and boundaries can be hard to draw.
Although care assistants can play a key role for the patient, their training and responsibilities are not always well defined.
New opportunities are emerging, however, which enable support workers to be formally and vocationally prepared for their roles.

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References

The Open University — Mon, 27 Jun 2011 09:41:32 GMT

Care Sector Consortium (1992) Care Awards, Local Government Management Board, London.

Care Sector Consortium (1997) Review of the Care Sector Awards: Values and Principles of Good Practice and their Implementation, CCS, London.

Northern Ireland Statistics and Research Agency (1997) Northern Ireland Annual Abstract of Statistics, No. 15, HMSO, London.

The Open University (1996) K503 Learning Disability: Working as Equal People, Building Your Portfolio, The Open University, Milton Keynes.

Redman, W. (1994) Portfolio for Development: A Guide for Trainers and Managers, Kogan Page, London.

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Acknowledgements

The Open University — Mon, 27 Jun 2011 09:41:32 GMT

The content acknowledged below is Proprietary (see terms and conditions) and is used under licence.

Grateful acknowledgement is made to the following sources for permission to reproduce material within this product

Text

Mihill, C. (1997) ‘Women ‘‘forced into taking’’ antenatal tests’, Guardian, 8 February 1997, # The Guardian 1997.

Illustrations

Pages 3 and activity 6: courtesy of Leeds Teaching Hospital NHS Trust

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Jyn Meyer

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