NHS: A “Moral Vacuum” at the Heart of Nursing

There is a “moral vacuum at the heart of nursing” according to new research from the University of Birmingham. Time constraints and staff cuts have left “robotic” NHS nurses going through clinical motions rather than trusting their own moral compass in delivering care to patients. In a survey of 696 nurses, 45% said their actions were guided by following the rules rather than a decision that it was the right thing to do.

Policy Over Principles

While regulations are vital to medical care, too much reliance on tick-boxes ignores the circumstances of an individual patient and illness. Nurses must straddle the line between care and codes as they are the people who spend the most time with the patients.

Professor Kristjan Kristjansson, the University of Birmingham educational psychologist who headed the research, said that “the whole professional duty since the days of Florence Nightingale has been not only the administration of medicines correctly but creating an ethos in the hospital that puts patients at ease.”

Dealing with patients often comes from undefined but all-important insights rather than quantitative tick lists.

The study believes that this wisdom has been lost because nurses are now taught to be degree-level professionals rather than the acting arm and aid of a doctor. One nursing educator interviewed said that the desire to change nursing into hard science has taken a toll on the “intuitive artistry needed to be a good nurse”.

“Evidence-based practice can actually reduce the standard of care… It’s not anti-rational, it’s almost anti-thinking, in that I’ll go over to the shelf and get my guideline, or I’ll get my review, we seem to be getting a catalogue of them. But each time in a way it stops me thinking as a nurse.”

They Lack Support, Not Morals

The research was conducted by Birmingham University’s Jubilee Centre for Character and Virtues, which has conducted similar ethics studies across a range of vocations. Kristjansson (left) said that comparing the results was worrying and depressing.

“[Nurses] are the only professionals where reliance on their own character compass does not pick up as they gain more experience. This fact probably says a lot about the current state of nursing.”

First-year nursing students relied more heavily on their own moral reasoning but rules took over as their studies continued. As Kristjansson points out, this flies in the face of expectations

. “When you’ve been working for five years or more, usually you realise that following the rules is not the only important thing, you have to rely on your own moral compass. But the nurses didn’t.”

This lack of morals in NHS nursing is not a reflection on the nurses themselves. Of those surveyed, 83% believed the way they worked conflicted with their personal values. That conflict largely resulted from time and staff constraints that compromised the care given.

Many reported coming away from patients often feeling they didn’t do as much for them as their “hearts dictated” and that patients did not receive the care they deserved due to low staff numbers. One respondent was frustrated that “lack of attention and contact with patients is becoming part of the normal culture of nursing”. Institutional pressures such as a push to discharge patients too early were repeatedly raised as reasons why interviewees felt they couldn’t be the nurses they wanted to be.

Teaching Wisdom

Such a reliance on rulebooks may mean nurses will struggle in moral dilemmas and stressful situations like the Mid Stafford Hospital scandal.

The hospital was brought to national attention in 2008 after nurses failed to speak out about its poor care and high mortality rate. Kristjansson suggests that such cases will become more common if this mindset continues. “There won’t be any whistleblowers, people will just turn into automatons, robots at work,” he said.

The chair of the Mid Staffordshire Hospital inquiry reinforced Kristjansson’s findings. Sir Robert Francis QC called for nurse training to focus on values and compassion, to the extent that those wanting to study nursing should be interviewed and assessed for character and then trained in ethical approaches. He pointed out that NHS regulations are focused more on identifying and punishing the non-compliant few rather than educating the many to do their job well.

“It would be constructive for professional regulators to consider how they can support the practical application of the necessary virtues in everyday practice,” Francis concluded. “A culture of empowerment is likely to be more beneficial for patients than the culture of fear where that currently exists.”

But there are few signs of progress. Staff numbers are dropping, pay is static, Brexit is alienating EU nurses, stress levels are rising and nurses just don’t have the time or support to show the care and compassion they want to provide.

 

by Jo Davey

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