Good Nurse

What makes a good nurse?
A study conducted for WDGH NHS Trust

by Bournemouth University to identify nursing practice and care
within the Trust
Professor Iain Graham

Joint Head of School & Professor of Nursing Development, IHCS
Christine Partlow
Research Assistant, IHCS
Elaine Maxwell
Director of Nursing, West Dorset NHS Trust
June 2004
ISBN: 1-85899-183-8
Institute of Health and Community Studies

Bournemouth University
Contributors
Significant contributions were made to the project by: Vanessa

Read, Assistant Director of Nursing; Sally Pinnock, Assistant
Director of Nursing; and Claire Damen, Assistant Director of
Nursing, from West Dorset General Hospital (WDGH) NHS Trust.
Acknowledgements
The steering group members from WDGH NHS Trust were Elaine
Maxwell, Director of Nursing; Vanessa Read, Assistant Director of
Nursing; Sally Pinnock, Assistant Director of Nursing; and Claire
Damen, Assistant Director of Nursing. Steering group members
from Bournemouth University were Professor Iain Graham, Joint
Head of School IHCS, Professor of Nursing Development; and
Christine Partlow, Research Assistant. They would like to
acknowledge with gratitude everyone who contributed in any way
to this project.
Special thanks go to all focus group volunteers, the staff of

WDGH NHS Trust and local people served by the hospital.
Thanks also to Chris Chutter PA, staff at the Thomas Sydenham
Education Centre, Mr Pike and the catering staff at Dorset County
Hospital. Additionally, research colleagues at Bournemouth
University: Julie Childs and Sandra Allen, Lynne Humphreys,
Anita Somner, the administration staff, and everyone else who
gave their time and support to this project.
2
Contents
Page
List of Tables and Figures …………………………………….. 4
Executive summary ……………………………………………. 5
Rationale for inclusion ………………………………………… 8
Introduction and background …………………………………. 9
The evolution of British nursing ………………………………. 14
Nursing reformers ……………………………………………… 18
Poor law and voluntary hospitals …………………………….. 31
Founding the National Health Service ………………………. 34
An overview of nurse education ……………………………… 36
The modernising agenda ……………………………………… 42
Agenda for change …………………………………………….. 46
Health service development ………………………………….. 47
Analysis of key points and repeating themes ………………. 50
The project for WDGH NHS Trust …………………………… 52
Literature review ……………………………………………….. 54
Themes emerging from the literature ………………………... 65
Methodology ……………………………………………………. 67
The findings …………………………………………………….. 70
Discussion ……………………………………………………… 86
Conclusion ……………………………………………………… 96
Recommendations …………………………………………….. 97
References ……………………………………………………... 99
Appendices
Advertisement for the Dorset Evening Echo
(Dorchester) and the Blackmore Vale newspapers.. 102
Information sheet June 2002 ……………………….. 103
Questionnaire ………………………………………… 105
Consent form …………………………………………. 107
Focus group information sheet ……………………... 108
Focus group – order of events ……………………… 109
Focus group questions ………………………………. 110
3
List of Tables and Figures
Tables Page
1. What are the important activities and functions registered
nurses should be involved in? ………………………………... 70
2. Are there important things nurses should be doing that they
are not doing at the moment? ………………………………… 72
3. What stops registered nurses from doing these things? …... 73
4. What are the barriers that prevent registered nurses from
functioning effectively? ………………………………………... 74
5. Extended roles – how do these fit in? ……………………….. 75
6. What do patients most remember about nurses? ………….. 75
7. When you and others use the term ‘nurse’, who do you
think of most readily? ………………………………………….. 77
8. Sisters and charge nurses – are they nurses or something
else? …………………………………………………………….. 77
9. What are the most and least important things that nurses
do? ………………………………………………………………. 78
10. What is the impact of the modernising agenda on nurses
and training? ……………………………………………………. 78
11. Questions answered by nurses about their job at WDGH …
79
12. Other issues raised by staff during the study ……………….. 80
13. Overall views about a nurse’s role and attributes required .. 81
14. When things are not as they should be ……………………… 83
Figures
1. An illustration of the political system ………………………… 49
4
Executive Summary
The aim of the project was to identify for the Trust Board of WDGH NHS
Trust, Dorset County Hospital, the activities and functions staff and
members of the public valued most from registered nurses. A qualitative
research methodology was used and a series of focus groups took place
with various staff and public participants. The participants were self-
selected volunteers.
A potted history relating to context is provided and areas such as the

evaluation of British nursing and the role of nurse leaders, including
Nightingale, are discussed. The evolution of the health care system
within the UK is also addressed with common themes and key points
identified. For example, recognition that nurses need to be educated for
their roles and that there is tension between meeting their learning needs
and the service provision to patients. Lack of investment in nurse
education and a view that nursing is a ‘doing’ rather than a ‘thinking’
activity prevails, corrupting the ideology and philosophy of nursing.
Nurse leaders have battled with medical and hospital authority to

establish their view of standards and quality. Nursing has struggled to be
recognised as a health care profession contributing to the benefit of
society. Understanding the practice of nursing requires employers and
government to provide appropriate conditions of service, welfare,
investment and development so that the craft of nursing can flourish.
Failing to do this impairs the ability of nurses to meet the changing needs
of patients and the health care system.
The emergence of hospital systems has brought challenges and conflict

for nurses and nursing practice. In many ways hospital practice,
dominated by medical hegemony, shaped the role and position of nurses.
This raises questions about whether health/hospital care requires general
hospital workers or health practitioners and who should hold the title of
‘nurse’.
The impact of the NHS and its funding is raised but not fully explored.
This is done in other texts that discuss nursing as a nationalised industry
and the issues this raises.
Nurse education is considered by reflecting on the recommendations of

the various committees that have looked at nurse education and its role
in preparing nurses for a proper role and function. Clay (1987) wrote that
a succession of reports over the past 50 years have either been
5
misunderstood, ignored or only partially implemented. This is reflected in

the view that the difficulties which doggedly pursue nursing lie as much
within parts of the profession as they do with external factors. A general
lack of consensus and consistency continues to be a major stumbling
block for the development of appropriate education and other issues.
st
The challenge for nurses in the 21 century must be for them to find their
voice; to decide unanimously who they are, where they are going and the
education they require to meet their personal and professional goals and
the health needs of people. This must be set in a thorough understanding
of the modernisation agenda.
Reflecting on all the key points raised in the first part of this report, there
are various repeating themes that seem to reveal no real long-term
solutions. It is against this background that this study was commissioned.
The report highlights the context and methodology exploited to achieve

the findings. These findings suggest the following as areas of
consideration when exploring what makes a good nurse and what the
important activities and functions are that registered nurses should be
involved in:
• Patient care;
• Co-ordinating care;
• Creating and maintaining a safe environment;
• Teaching and promoting learning in patients, carers and others;
• An advocacy role;
• Being a role model;
• Report writing/patient assessment notes;
• Dealing with relatives;
• Working in a variety of patient care settings;
• Providing leadership for nursing practice and standards.
The findings also explore how nursing practice is affected by the

demands of today’s health care system. Many nurses find that, because
of the demands put on them, they are:
• Not giving patient care;
• Not spending time with patients;
• Not teaching;
• Not making decisions;
• Not practising autonomously;
• Not involved in budget decisions;
• Not involved in improving systems.
6
The findings also show the blocks to nursing activity in the form of:
• Bureaucracy;
• Poor system design;
• Other responsibilities;
• Technology;
• Managerial emphasis;
• Perceptions;
• The demanding reality of work places;
• Poor communication systems.
These themes are further explored in the report, highlighting barriers to

effective functioning, views about extended roles, quality measures and,
importantly, the humanistic aspect of nursing and being a nurse.
Overall three key themes emerged from the study:

• Nurses doing a range of non-nursing work (aggravated by reduced
numbers of registered nurses);
• A lost sense of the patient (and family) as people, a generalised loss
of respect in professional and other relationships (for many different
reasons);
• The loss of the one(s) in charge, few ‘captains’ remain, particularly at
ward level.
Each of these three elements has implications for patients and their care.
They also impact on the culture and capability of staff, particularly for
those working in hospital wards, to provide care.
7
Rationale for inclusion
During the process of constructing this report it became evident that a lot
of other factors and actors played their parts in shaping and developing
nursing. They affected how nurses and nursing came to be facing the
challenges they do at this time. Some of these include the history of
health care development, historical aspects relating to Florence
Nightingale and other nurse leaders and the challenges they faced, the
development of nurse education and nursing practice, the formation of
health policy and the National Health Service (NHS). In more recent
times NHS reforms and modernising agendas have played their part in
shaping nursing into the forms found today.
This report attempts to give readers a historical overview up to and

including some recent developments, as well as providing what was
required in terms of the report. It has been presented in a way that is
intended to be accessible, with links made between some of the different
important events, so that readers can gain a sense of the whole.
The report focuses on the activities and functions of registered nurses. It

is acknowledged, however, that many other people, health care workers,
administrators, support workers, professionals, specialists and managers
are also involved in the provision of care.
The range of inclusions (although there were still many omissions) meant
that depth of critique was sacrificed. No particular point of view has
intentionally been presented. All conclusions drawn were believed to be
true at the time of writing but further study and analysis could lead
authors and readers to different conclusions in the future.
It is hoped that readers will enjoy the report and find something
interesting and useful, as well as learning about issues relating directly to
this report.
8
Introduction and Background
Nursing and its various branches have developed over many years in
response to different needs being identified within the population.
Specialised needs, as identified within children’s nursing, lead to that
branch of nursing developing its own knowledge and technical base.
This report focuses on the work of hospital nurses, often seen as the
‘Cinderella workforce’, because their specialised knowledge and
technical base remain largely unrecognised and/or disregarded. In
acknowledgement of the continuing shortage of hospital nurses, it was
the intention of this project to identify the nursing roles and activities most
valued by patients/clients and staff so that they could be retained and
developed.
Context
th
Before the mid-19 century, health care was very different to today.
Following trauma, patients rarely survived. People admitted to hospital
with skin conditions like open ulcers, or people who were weak or
disabled, generally responded well to the diet and rest they were given.
Anyone who was obviously infected or terminally ill was not admitted
(Dingwell & Allen 2001). It is easy to forget that germ theory was not
understood until mid-Victorian times. People believed that sickness was
spread by bad smells, ‘miasmas’.
Cholera was a prevalent and devastating disease. In 1853, outbreaks of

cholera in Newcastle, Gateshead and London killed 10,675 people. In
1854, the Soho area of London was a filthy, smelly place and a serious
outbreak occurred here. Dr John Snow, an epidemiologist and
anaesthetist, speculated that the source of the cholera outbreak was
contaminated water from the local well. He arrived at this assessment
through careful deduction. As an experiment, he asked for the pump
handle to be removed. It was, and the spread of the disease dramatically
stopped. A few outlying cases were investigated and all led back to the
pump being the source of the infection. Dr Snow published his findings
with considerable evidence, but people remained sceptical for a long time
(Summers 1989).
In Britain before 1860 there was little public or professional recognition

that nurses needed any training. Nursing was seen as domestic service
at best, or at worst, just a way to earn a living. It was only after the
Nightingale reforms of 1860 that nursing became established as a
9
respectable career for middle-class women. These women were

expected to have a good education so that, once trained, they could
move immediately into leadership positions and spread the nursing
movement. Even after this time, hospital patients were usually poor
people. The wealthy were cared for at home well into the 1920s. This
pattern only changed as surgery developed and home conditions could
no longer support treatment and care.
Interestingly, midwifery remained the domain of women until recent

times. Obstetrics did not really develop in England as it did, for example,
in the United States. It was in 1902 that the Midwives’ Act was
successfully passed – a testament to the diligence of interested groups.
The act provided the mechanism for the organisation and registration of
midwives. However, by 1918 one in five state-registered midwives in
England still had no training (Oakley 1983). But it would be unfair to
dismiss the experience of lay midwives. There was a long tradition of
apprenticeship for midwives, and skills were acquired through
experience. The passing of the Midwives’ Act (1902) helped nurses to
gain recognition for their work and was regarded as an important
precedent by those who sought registration for nurses (Abel-Smith 1960).
The reasons why midwifery remained under the control of women for
such a long time is open to speculation. One theory relied on the
traditional belief that anything to do with menstruation and childbirth was
dirty and a danger to society. This belief is still evident even today in
some parts of the world. Childbirth was regarded as ‘women’s business’
(Oakley, 1983, p32). Men were only brought into midwifery when there
were complications. Only men were allowed to use surgical instruments
to overcome obstructed delivery. These men usually belonged to the
Barber-Surgeons Company (later to become the Royal College of
1
Surgeons ). Surgery was at that time an unrecognised and disreputable
branch of medicine. This is why surgeons are called ‘Mr’ rather than
given the honorary title of ‘Dr’. Women continued to take care of ‘normal’
births and men-midwives were called for problems. These men were to
become the obstetricians of today (Oakley 1983).
Life for most people was unbelievably difficult and it was risky for all.
Many babies and children died and many women did not survive
childbirth. All had to face disease, under-nourishment, squalor and
th
ignorance. It was not until the mid-20 century that things significantly
improved. The introduction of the first antibiotics, powerful weapons
1
Surgeons and barbers became united under Henry VIII in 1540. At that time surgery was limited and treated with
suspicion. During the 18th century, surgery began to develop its own knowledge and practice base. The surgeons
broke away from the barbers in 1745 to form the Company of Surgeons, which was granted a Royal Charter to
become The Royal College of Surgeons in 1800 (RCS 2003).
10
against infections, better housing, improved water supplies and sanitation

all helped people to be healthier and live longer. Immunisation, improved
nutrition and, more recently, technological advances mean that fewer
people now die young. The combination of these and other factors,
together with declining birth rates in the western world, have led directly
and indirectly to a shift in the age of the population and the demographic
changes we are seeing today.
Myths
Medicine has built its reputation on curing the sick. As a result, society
has become dependent on medicine and this dependency has
subsequently provided the medical profession with much of its power.
Medicine’s roots are to be found in the early Church. In 1512, the English
Church authorities passed an Act that was the first attempt to regulate
medical practice. Doctors were forbidden to treat patients who refused
confession (Oakley 1983). All doctors were men because only men could
enter university. While there, medical students studied the works of Plato,
Aristotle, Christian theology and the Hippocratic physicians of ancient
Greece (Oakley 1983). Medical education relied on astrology, theology
th
and superstition (Illich 1976). Throughout the 19 century it was believed
that sickness was spread through bad smells (even though evidence
supporting germ theory was starting to emerge towards the end of that
century). Links with science developed later. Many of medicine’s early
successes could equally have been attributed to other factors, like
improved cleanliness and sanitary conditions, and better nutrition.
Many diseases left untreated follow specific patterns of growth, peak and
decline, as was recently demonstrated by the SARS epidemic:
The main reason for the decline in infectious diseases was not
to be advances in medical science, but developments in the
system of public health. It was these developments which
provided an effective counterweight to the sorts of urban living
conditions created by the industrial revolution and within which
infectious diseases could flourish. (Ham 1999, p5)
It is worth considering that there may even be considerable risks

associated with hospitalisation (Hogg 1999, Illich 1976) and medical
intervention (Illich 1976). Risks include infections, complications and
sometimes death. This is not to decry the contributions made by
medicine; rather it is an attempt to put things into perspective. Some
authors suggest that science may not have the answers to all the
11
problems. In a review of the progress made in the treatment of cancer,

Hogg (1999) cited Lesley Doyal and Samuel Epstein (1983) to say that:
[They] have argued that the problem of the rise in cancers may
not be so much scientific as political and economic. Causes that
lie in the individual are exaggerated at the expense of
researching hazards that lie in the environment (p162).
Perhaps scientists and doctors are sometimes looking in the wrong

places for answers.
These days, where health care is necessarily controlled by economics

and escalating costs, it must surely be worth re-evaluating the nature of
health expenditure. We need to examine whether or not we are getting
the best value for money by ploughing more money into medical
research, at the expense of environmental and sociological research, all
of which influence health.
Medical progress is not straightforward and treatment is not

always beneficial. Sometimes treatment can cause more
problems for patients than the original illness. (Hogg 1999,
p162)
There must be other approaches to health and healing worth considering.
Science Our confidence in science is amazing. When we get sick we want to

believe that we will be diagnosed, treated and cured, and that science will
provide all the answers for us. This may not be the truth. The health
service is free and available to everyone; it is an ideal and a treasure and
must not be compromised. However, it is not perfect. Hogg (1999)
reminds us that:
There is little certainty in medicine and many common

treatments are not scientifically proven to be effective. Even for
routine conditions and with the most expert staff, it is not always
possible to predict with certainty the outcome of treatment.
Some people may not get better even though the prognosis was
good. Others get better when they were expected to die (p159).
There is much that is still unknown and misunderstood. Great strides

have been made but there is a wealth of knowledge still waiting to be
discovered. It is foolish to trust in science completely and it is not without
its contradictions (Chalmers 1999).
12
A medical myth A medical myth is that patients arrive at the hospital sick, they are
treated, they recover and are discharged home to continue with their
lives. This is a myth because, increasingly in the modern world, this does
not happen. Patients may or may not be treated, they may or may not
recover, and they may or may not be discharged. They then may or may
not go home and they may or may not be able to continue with their lives
as increasingly patients may need extended, often complex, aftercare.
Having unrealistic expectations gives people a false sense of security.

They may be reluctant to take steps to care for their own health, trusting
instead in ‘the system’ to take care of them when they get ill. This
optimism may lead to frustration and disappointment in the health service
when expectations, however unrealistic, are not met (Hogg 1999).
A nursing myth A popular nursing myth is that in the past hospital wards were staffed by
trained nurses. This has never been true (Salvage 1985, Dingwall &
Allen, 2001). Learners, with varying degrees of competence, have always
staffed hospital wards. The role of trained nurses was largely to oversee
and guide learners and auxiliaries. In 1985, Salvage reported that
approximately one quarter of the ward staff complement would be
learners and another quarter would be auxiliaries. From the remaining
number, some registered nurses would hold managerial positions, which
meant that less than 50% of ward staff were likely to be trained nurses.
Non-myths (truths) One thing that has changed is the nature of hospital patients. They are
frequently older, more often seriously ill, and are likely to have a complex
range of disorders. These patients are less stable and need significantly
more expert care than patients did in the past.
A second change is more subtle. In the past, nurses were very clear
about their place in the ordered hierarchy but their roles have now
changed. A range of people who work differently are replacing nurses.
Nurses are no longer sure what their place is or the extent of their
responsibilities. Many nurses have moved away from nursing, often
pressured into administrative, organisational and other non-nursing roles,
far removed from patients.
13
The evolution of British nursing
Foundations of nursing
Since the dawn of civilisation, people have responded to the care needs
of the young, the sick and the elderly. Priests and their acolytes originally
provided this service at a time when medicine and religion were closely
st
linked. During the 1 century, the rise of Christianity reinforced this trend.
Christian men and women cared for those in need. The Churches
organised women called deaconesses to provide this service (Baly 1980,
th th
The Lancet Commission 1932). The Crusades (11 -13 centuries) saw
the continued development of nursing as a service in both religious and
secular settings, caring for the sick across Europe. Later, as the religious
side of nursing became accentuated, recognition and support was only
given to those who had taken vows. This association was later identified
as one of the factors that undermined the ability of nuns to be successful
nurses. In England, the demands of the two roles eventually proved too
great and were abandoned (The Lancet Commission 1932).
th th
The 17 and 18 centuries saw a decline in nursing. Growing
populations, too few hospitals and deplorable management led to a
significant decline in standards compared with those in society. England
had lost the influence of nurses following religious orders, and nothing
significant had taken their place. In Europe this had not happened so
they fared better, but nowhere had hospital services kept up with the
advances made by society (The Lancet Commission 1932).
Kaiserswerth The growth of the Kaiserswerth movement in Germany in the early 19th
century is noteworthy because of the impact it had on nursing in ways
movement
that are recognisable today.
Nursing as a calling was at its lowest level by the beginning of

th
the 19 century, nowhere having shared in the general
development of social amenities. But in 1822 the Kaiserswerth
movement preluded real advance. Theodore Fliedner, the
Protestant clergyman of the small town of Kaiserswerth, near
Dusseldorf, visited England to obtain financial help for his poor
parish, and with his initiative the modern period opens. He
became interested in the work of prison reform, inaugurated by
2 3
John Howard and carried on by Elizabeth Fry .
On his return home, and with the co-operation of his wife

Friederike, as able and as charitable as himself, Pastor Fliedner
14
decided to institute a refuge for the care, physical and moral, of

women who had been discharged from prison. Out of this idea,
and by rapid stages, Kaiserswerth developed as an institute for
the training of a supply of nurses for the sick poor, using the
example of the Order of Deaconesses of the early Church. The
movement in this shape developed rapidly, with Caroline
Fliedner, the second wife of the founder, being also an
outstanding character.
The organisation was a religious association, but not seeking

the support either of the Church or the State. The women whom
the Fliedners enrolled took no vows, but were expected to
remain five years in the service, when they could if they wished
return to their homes or marry.
The work before the Institute was divided into four branches –
nursing, poor-relief, care of children, and succour of prisoners
and fallen women, the last heading representing the original
design.
Nursing was arranged under three heads – institutional, private,

and district – and a system of training was arrived at in which we
can recognise much that is with us today, such as a course of
preliminary training, a classification into probationers, nurses,
head-nurses, and superintendents, and a recognition of the
authority of the head-sister. The head-sister was working under
a clergyman, the Pastor, so that religious authority was present,
but without the obligation on the nurses of taking the vow and
surrendering all property to a community. This was an important
difference from conventional example, for it allowed the
Deaconess to cease from her work, when she chose, and live
an independent life (The Lancet Commission 1932, pp16-17).
th
At the start of the 19 century there was no organised nursing in this
country. Nursing was non-existent for the poor and in hospitals it was
rudimentary at best, in the hands of the unskilled.
The horrors of goal [prison] and asylum life had begun by this
time to make a strong appeal to the compassion of the public,
not on the grounds of unjust incarceration, but because of the
miserable plight of the incarcerated; but the fate of the sick poor,
especially in hospitals, aroused no such pity. An awakening of
the public conscience did not come about until some 20 years
after the Kaiserswerth example had been set. Then the need of
15
an organised supply of nurses became recognised by many, but

not in any general manner by the medical profession, who, save
for certain, notable exceptions, appear to have regarded the
quality of nursing as of secondary importance. How this could
have come about seeing the condition of things in hospitals is
difficult to understand (The Lancet Commission 1932, p18).
Standards were appalling, and nurses required courage or callousness to

cope. However, The Lancet Commission (1932) reminds us that:
It is not the failings of women placed in such circumstances that

should be wondered at, but their virtues (p20).
These women often fell through no fault of their own; they were
frequently uneducated, so were ill equipped to change conditions. At this
time, nurses’ lives were lives of great hardship and self-sacrifice.
Key points • Although caring for the sick originated through the priesthood, nuns
and other women gradually became the main carers.
• As populations increased, there were too few hospitals to keep up
with the demand and this, combined with poor management, led to a
significant fall in standards.
• Formal education for nurses did not exist. With some exceptions,
care was usually basic, given by uneducated, unskilled people. The
quality of nursing care was not considered important by the medical
profession.
• Nurses had no means of changing conditions even if they
recognised a need.
• At Kaiserswerth in Germany, nursing was gradually becoming
divided into different branches: nursing, poor-relief, care of children,
and help for prisoners and fallen women. Care was given under
three main groupings: institutional, private and district.
2
John Howard (1726-1790), High Sheriff of Bedfordshire and staunch Baptist, first became interested in prison
reform when he visited prisons in Bedfordshire. He appealed for improvements which were refused, and in 1777
undertook a journey to tour prisons across England, and later Europe, comparing the conditions he found. Through
this work, Howard became interested in the spread of infections (before germ theory was understood) and advocated
separating the sick from the well, bathing, the treatment of infected clothes, and access to medicines. As an authority
on penal reform and hygiene, Howard then turned his attention to hospitals. These, for the most part, he condemned,
vigorously supporting practical improvements to diet, cleanliness, and the use of fresh air. Howard’s records,
collected over 20 years, provided ‘the foundations for a new science of social study’ (Baly 1980, p47).
3
Elizabeth Fry (1780-1845) was an early reformer who became associated with nursing although she was best
known for her work with prison reform. Motivated by her Quaker faith, Mrs Fry visited prisoners (sinners) for them to
repent and be saved from eternal damnation. She was appalled by the atrocious conditions she found and despaired
at being able to save prisoners when they were forced to live in such conditions. Despite opposition, with a group of
sympathisers she organised improvements for female prisoners, which were recognised by reformers throughout the
world. Mrs Fry was less successful in England where the American system of large buildings with single cells was
being adopted. Her prison reform work brought Mrs Fry into contact with Pastor Fliedner and she visited
Kaiserswerth. Mrs Fry was impressed by the deaconesses and, in 1840, attempted to establish a similar system of
16
nurse training in England. However, with her ongoing commitment to prison reform, Mrs Fry was unfortunately unable
to dedicate sufficient time and energy to this new project and so it was not successful. Historians also suggest that
perhaps England in 1840 was not yet ready to engage with the idea of systematic training for nurses (Baly 1980).
17
Nursing Reformers
Florence Nightingale 1820-1919
The founder of Florence Nightingale was a well-educated, intelligent and accomplished

woman who, in the manner of the times, led what she considered to be
British nursing
an empty life. Distressed by the poverty and misery she saw as she
travelled in England and Europe, and influenced by her religious beliefs,
Miss Nightingale believed her destiny to be somehow linked with caring
for the ‘poor and miserable’ (Baly 1980, p116). In 1845, she decided she
wanted to be a nurse. She visited hospitals across the country and in
Europe, formulating her ideas. Miss Nightingale was particularly
influenced by Kaiserswerth, which she visited in 1849. It is usually
reported that Miss Nightingale received training when she returned there
shortly afterwards, although later in life she denied this, saying that:
‘The nursing was nil and the hygiene horrible’ but she was
impressed by the atmosphere of devotion…and she learned that
good nursing cannot be achieved by devotion alone (Baly, 1980,
p117).
However, following this experience, Miss Nightingale was now committed

to nursing in a large hospital. In a bid to leave home, her first
appointment was arranged. In London in 1853, Miss Nightingale was
appointed as ‘Superintendent for the Institution for the care of Sick
Gentlewomen in Distressed Circumstances’ (Baly 1980, p117).
While waiting to take up this appointment, Miss Nightingale worked with

the Sisters of Mercy in Paris where, at her own expense, she conducted
a survey using questionnaires, eliciting information from all the hospitals
across Germany, France and England, which she then collated. On her
arrival back in London, armed with all her factual information, Miss
Nightingale finally had the opportunity to put her ideas into practice. Her
reforms included proposals for lifts, piped hot water and other labour-
saving devices, described by Baly (1980, p117) as ‘exacting and
revolutionary’.
Miss Nightingale continued to visit hospitals and collect information. She

recognised the need for hospital nursing reform and urged her political
friends to support her. The following year, destiny took a hand. The
Crimean War (1854-1856) began and through reports published in The
Times, the public were able to read about the horrors of war and the lack
of hospital care for the first time. Miss Nightingale was contacted and
18
within six days (21 October 1854) she and a team of 38, non-sectarian
nurses headed for Scutari. She saw this as an opportunity to prove to the
world the benefits of good nursing.
The barracks themselves were built round a vast courtyard, and

everything was filthy and dilapidated; the courtyard was a refuse
dump, equipment and sanitation were non-existent and the
building was over a dammed-up cesspool from which came a
frightful stench; in the cellars below lived two-hundred
prostitutes and around the walls lodged a filthy rabble.
Across the Bosphorus, in great splendour lived the British

Ambassador, Lord Stratford de Redcliffe, who had orders to
equip the hospital but in fact had never even visited it until
compelled to do so by Miss Nightingale herself, and whose
excuses she countered with the famous, ‘Mr. Ambassador, I
never gave an excuse, I never take one’.
The arrival of the Nightingale party was greeted with sullen

opposition; the doctors received the news with disgust, but
because of the government backing and the power of the press
they dared not show open hostility; they simply refused the help
offered by Miss Nightingale and her nurses (Baly 1980, p119).
Miss Nightingale would not let her nurses nurse until the doctors
requested it. She had funds raised by public subscription so she and the
nurses spent their time ‘Buying equipment, stuffing mattresses, making
bandages, and cleaning the place’ (Baly 1980, p199).
th
On 9 November the situation changed. The battle of Balaclava
over in the Crimea was a disaster; stupidity and ineptitude
brought catastrophe; the harbour heaved with dead bodies, and
in the chaos and confusion the sick, the wounded and the dying
began to pour across the Bosphorus to Scutari. The hospital
filled, the doctors were overwhelmed and they turned to Miss
Nightingale.
Out came the mattresses and the bandages, and although ‘the
doctors worked like lions’ it might be two weeks before they
could see a patient; at one stage there were four miles of
patients on mattresses on the floor; there were over a thousand
cases of diarrhoea and the privies had become useless. In the
confusion it was realised that someone had the power to spend
money without army red tape; Miss Nightingale had at her
19
disposal £30,000. A visiting member of parliament Mr Augustus

Stafford, and Mr MacDonald, the administrator of ‘The Times’
Fund, were pressed into service as quartermasters and the
main requirements were bought in Constantinople. Now the
opposition collapsed (Baly 1980, pp199-120).
This had been an extraordinary effort and by the spring of 1855 Miss
Nightingale was exhausted. She had become famous, she was adored
by her charges, and it is suggested that her greatest contribution may
have been
…that she was one of the first people who regarded the British
soldier as having a dignity of his own and not ‘the scum of the
earth enlisted for drink’ [as was the popular opinion] (Baly 1980,
p120).
There continued to be many trials and challenges for Miss Nightingale.

She became ill and was expected to die, but she recovered and worked
on, continually trying to improve the conditions for soldiers. In 1856 there
was peace and Miss Nightingale returned to London. A fund had been
established to thank her for her work and this money was used to found
the first nurse training school in England, at St Thomas’ Hospital in 1860.
There was considerable opposition and so it became necessary for the
pupils to be beyond reproach. Once trained, these nurses were expected
to go out into other hospitals and set up similar training schemes (Baly
1980).
Key points • Although Miss Nightingale was a person of exceptional ability she
was still constrained by the norms of her time.
• Even with government backing, at the hospital in Crimea, Miss
Nightingale and her nurses were powerless to help with caring for
the sick in the face of opposition from the doctors.
• Miss Nightingale and her nurses were educated women who had
received nursing training.
• The British soldier was treated with dignity for the first time.
• The need for nurses to be educated was recognised as important
and the first nurse training school in England was established at St
Thomas’ Hospital in London.
• Nursing became formally recognised as a respectable occupation for
women.
Historical context The period before the first World War saw increasing unrest spread
across Britain. There was conflict in Ireland, both men’s and women’s
suffrage movements were gaining momentum and there was industrial
20
upheaval. Workers who had never before challenged employers were

forming trade unions to demand fair treatment. Women were particularly
disadvantaged but they were finding ways to be heard. People from all
walks of life were engaged in activities that challenged the status quo
(Rowbotham 1977).
Between 1880 and 1930, many people besides Florence Nightingale

were involved in nursing reforms. McGann (1992) gives interesting
accounts of eight notable reformers, three of whom are featured below.
There were protracted battles both for and against professionalisation
and nurse registration.
Eva Charlotte Luckes 1854-1919

Miss Luckes trained as a nurse at the Westminster Hospital, completing
in 1878. From there she became a night sister and then Lady
Superintendent before clashing with the authorities and resigning.
Like many matrons at the time, she tried to raise the standard of
nursing in the hospital and her reforms were regarded by the
medical staff and hospital authorities as a threat (McGann 1992,
p10).
In 1880, Miss Luckes, although still young, impressed the hospital board
with her enthusiasm, and was given the position of matron at The London
Hospital in Whitechapel, an area ‘notorious for its poverty’ (ibid). Here
Miss Luckes was challenged with reforming nursing. She quickly
identified grave shortages in the quality and quantity of nurses. With the
committee’s support, she was successful in obtaining more nurses, and
she reformed the system of training by introducing both practical and
theoretical instruction. Miss Luckes was also responsible for introducing
the first nurses’ home, which provided nurses with better food and
accommodation. She also started a private nursing service and the
hospital gained financially from this arrangement.
Miss Luckes however still had her critics. She was required to defend her
decisions on numerous occasions. Under-funding was an issue even
then, but the hospital grew as the patient population increased with many
new services being offered. Midwifery training for qualified nurses was
introduced in 1900 and it was only then, with midwives going into
people’s homes, that the full extent of the local poverty was revealed.
The hospital authorities responded appropriately and set up a fund to
provide milk for mothers and baby clothes for those in need. Miss Luckes
cared especially for the children of the poor, and she taught:
21
The nursing of children requires special care, special training

and special study. It needs infinitely more knowledge, more skill,
more observation and more patience to become a really good
children’s nurse than it does to attain an average amount of
efficiency in nursing adult patients.
It is essential for nurses to recognise that when they enter a

children’s ward, they find themselves in a new world, of which
the inhabitants are ‘little people’, with a different language,
different manners, different feelings and different thoughts
(McGann 1992, p24).
Miss Luckes, like Miss Nightingale, believed that nursing should be taken
up, not for personal gain, but to serve. (The Victorian context and the
position of women in that society should be acknowledged here.) This
shared view meant that Miss Luckes and Miss Nightingale became firm
friends. Believing that nursing should be purely vocational in nature put
Miss Luckes and Miss Nightingale into conflict with their contemporary
Mrs Fenwick (see below), who was championing registration and the
professionalisation of nursing. Registration required nurses to be
examined on theoretical knowledge before their names could be entered
on a register. It was this point that Miss Luckes and Miss Nightingale
objected to, arguing that only the training school and its matron could
know
…if a nurse was a good nurse and therefore competent. If the

certification of nurses were removed from the training schools
and vested in an independent body, such as a general nursing
council, certificates would become meaningless. The
examination could only be of the nurses theoretical knowledge
and this gave no value to the nurse’s personal characteristics
which were the difference between a good nurse and an
indifferent nurse McGann 1992, p25).
World War I (1914-1918) led to an increase in patients from the

battlefields and also an increase in applications from women wanting to
become nurses. (The war caused society to radically change and these
changes were permanent.) During this time, the activities of trained
nurses brought them into contact with other nurses from all over the
country. From their discussions, many of them realised that the
disorganised state of nursing and the disparity in training was not helping
them or their patients. Much of the training was mediocre. There followed
a public and professional swing towards registration, which was
eventually successful in 1919.
22
Key points • Miss Lukes wanted to raise the standards of nursing but experienced
opposition from the medical staff and hospital authorities who
perceived the reforms as a threat.
• She identified shortages in both the quantity and quality of the
nurses.
• Miss Lukes introduced a system of training that used both theory and
practice.
• She introduced the first nurses’ home with food provided, to improve
conditions for nurses.
• She introduced a private nursing service which benefited the hospital
financially.
• Midwifery training was introduced, which revealed the extent of local
poverty, and other services for mothers and children were
subsequently introduced.
• Miss Lukes identified the need for special training to prepare nurses
to work with children.
• Miss Lukes and Miss Nightingale were like minded in their belief that
nursing should be vocational. They challenged the fight for
registration believing that only the matron could adequately assess
the personal characteristics of each nurse, as these characteristics
were believed to make the difference between a good nurse and an
indifferent nurse. Miss Lukes and Miss Nightingale believed that
centralised registration could only measure theoretical knowledge,
and not the character of the nurse.
• WWI brought nurses together from different backgrounds and
training schools. The disparity in training, much of which was
mediocre, became evident. The result was a strong public and
professional swing towards registration as a means of developing a
standard.
Mrs Bedford Fenwick née Manson 1857-1947

Miss Ethel Gordon Manson began her nurse training when she was 21
years old. She worked first at the children’s hospital in Nottingham then
moved to Manchester where she worked for a time in surgery. When she
qualified in 1879, Miss Manson was offered the post of Sister on a
women’s medical ward in London, which she readily accepted. Miss
Manson showed an early aptitude for management. She was hard
working, popular with patients and staff, and got on well with the
physicians. The work was hard, and she worked long hours, but she
enjoyed it. In 1881, Miss Manson applied for the post of matron at St
Bartholomew’s Hospital. She was successful even though she was only
24 years old.
23
Miss Manson extended the period of nurse training to three years and
reorganised it to include both practical and theoretical instruction. She
also took paying probationers whom she felt were a good influence on
the staff and started a private nursing department. Miss Manson had high
standards and expected the same from her staff. She improved the food
for nurses, their off-duty hours and their holidays. She took a professional
interest in the health of her staff and kept reports cataloguing their
infections and illnesses. These provided Miss Manson with an illustration
of the risks associated with nursing at that time.
While Miss Manson was matron at St Bartholomew’s Hospital, she

became aware of the need for nurses to have professional
independence. There were two issues that concerned her. The first was
the lack of protection for trained nurses and patients from people who
called themselves nurses but who were untrained. The second issue
concerned the exploitation of nurses sent out to do private work. Usually,
the employing institution took the fee and Miss Manson fought for the fee
to be paid directly to the nurses. The need for nurses to have a
professional standing became her life’s work. In 1887 she married a well-
known physician, Dr Bedford Fenwick, and resigned from her position as
matron, but she continued to work for nurses and began the campaign for
registration. Shortly after her marriage, Mrs Fenwick, with 30 like-minded
matrons, founded an organisation that they called the British Nurses
Association (BNA) in 1888, as a means of organising the future of the
nursing profession.
The aim was to raise the standard of the profession as a whole

by uniting all trained nurses in membership of an association
which would support and protect their interests and provide their
registration (McGann 1992, p37).
The founders considered that the best way to protect the trained
nurse was to establish a register of trained nurses similar to the
register of doctors. They decided that the minimum qualification
for registration should be three years training in a hospital. Mrs
Fenwick was determined to set the standard of the ‘trained
nurse’ as high as that of the best nurses. She considered that
nursing was a worthwhile career and she wanted to make sure
that it had professional standing which would attract intelligent
women (McGann 1992, p38).
The BNA was well received and attracted large numbers of nurses and
physicians as members. However, there were opponents, primarily
among the medical profession and hospital managers. Criticism was
24
raised in the journal The Hospital, which had a new nursing section called
The Nursing Mirror, and was the journal read by hospital managers. The
Nursing Record, a journal ‘written by nurses for nurses’ (McGann 1992,
p39) supported the BNA and the fight for registration. This journal
attacked the critics and opponents to registration, especially Eva Luckes
(matron of The London Hospital), who had written questioning the need
for registration. (Dr and Mrs Fenwick both contributed articles to the
journal and in 1893 they became editors.)
Mrs Fenwick was active both nationally and internationally between 1892
and 1912. She met Lavinia Dock, Assistant Director of Nursing at the
John Hopkins Hospital in Baltimore, and found they were:
…Kindred spirits, sharing a dream of a nursing profession, well

organised and independent (McGann 1992, p40).
With Mrs Fenwick’s involvement, the International Council of Women

(ICW), founded by Mrs May Wright Sewell in Chicago, held a congress in
London in 1899 where:
…Distinguished nurses from America, Denmark, Holland and

the Cape Colony attended (McGann 1992, p41).
This was the first time international nurses had been able to gather
together. As a result of this meeting, the following year The International
Council of Nurses (ICN) was established:
…To promote international co-operation between nurses of all

countries and to provide them with opportunities to meet and
discuss professional issues (McGann 1992, p42).
In 1902, the Society for the State Registration of Nurses was launched.
Two Bills for nurse registration were drawn up and presented in 1906 and
1907 but they did not have government support and were unsuccessful.
In 1908, a Bill was presented to the House of Lords by the Central
Hospital Council for London (which represented the London general
hospitals):
The Bill proposed the establishment of an official directory of

nurses, to be maintained by an official registrar. No provision for
the self-governing of nurses and no minimum standard of
training was made. Mrs Fenwick called it “the Nurses’
Enslavement Bill” and urged all nurses to protest against this
piece of reactionary legislation (McGann 1992, p44).
25
This Bill was also unsuccessful at the second reading, not because of the
content, but because nurse registration still lacked government support.
Registration for nurses had already been adopted in New Zealand, South
Africa in the Cape Colony and Natal, and in ten of the United States. Mrs
Fenwick continued to pursue registration for nurses in the UK, achieving
some support as well as strong opposition from the Central Hospital
Council for London. In 1909 the Central Committee for the State
Registration of Nurses was formed to try and get a new joint Bill (with
representatives from the trained nurses’ associations) presented to
Parliament. Mrs Fenwick was one of the joint honorary secretaries.
Between 1910 and 1913 the joint Bill was introduced to the House of
Commons every year, but still lacked government support and so was not
heard. With the outbreak of war (1914-1918) presentation of this kind of
Bill was not allowed, and so the battle for registration was suspended.
The British Red Cross was given responsibility for organising nursing
services and the government was duly criticised for not preparing for a
serious shortage that could have been avoided if nursing had been given
appropriate recognition and authority through registration.
In 1916 the College of Nursing was launched to promote a standard

training for nurses. It gained support among matrons (but not Mrs
Fenwick and the professional lobby) and in 1918 the College drew up a
Bill for the registration of nurses. This Bill was condemned by Mrs
Fenwick who called it:
…An ‘employers’ Bill, because it failed to give nurses the degree

of self-government which she regarded as essential for
professional independence (McGann 1992, p48).
Heated debate between the College of Nursing and the Central

Committee for the State Registration of Nurses followed as they each
haggled for position. Eventually The Nurses Registration Act was passed
in 1919 and the General Nurses Council (GNC) was formed to maintain
the register.
Mrs Fenwick was at first optimistic, having been promised a nursing

majority of two-thirds on the council. However, when the council was
complete, the supporters of the College of Nursing outnumbered Mrs
Fenwick and her supporters. The old disputes were carried forward into
the new council and it was just a matter of time before Mrs Fenwick
became isolated and was removed from the council.
26
She continued to write and reproach nurses for not maintaining their fight
for professional independence. She criticised nurses for not paying
attention to what was happening to them:
Had the majority of nurses taken an intelligent interest in their

own affairs, acquainted themselves with the privileges granted
to them by Parliament…acted for themselves, instead of
allowing themselves to be manipulated by a company of lay
men, there would have been a very different tale to tell.
(British Journal of Nursing, Editorial, Dec 1922; cited by
McGann 1992, p50).
Mrs Fenwick continued to be a strong supporter of nurses with an

ongoing interest in their professional development, even though in her
opinion, ‘Nurses constantly demonstrated their lack of foresight and
political awareness’ (McGann 1992, p56). McGann (1992) records that
perhaps Mrs Fenwick’s greatest achievement was:
…The creation of the International Council of Nurses. She

developed the idea of a world-wide organisation of nurses from
her experience of the meetings of the International Council of
Women. At these meetings she absorbed the optimism of a new
century and the belief that women could regenerate the world.
These feelings matched her own inclinations and, with her
abilities as an orator and as a journalist, she inspired a
generation of nurses to realise their part in international peace
and progress (p56).
Key points • Miss Manson (who became Mrs Fenwick) was committed to raising
the standard of nurse training. She introduced a longer training
period with both practical and theoretical instruction.
• She improved nurses’ food, off-duty hours and holidays.
• She started a private nursing service and fought for nurses to be
paid the fee rather than the hospitals.
• She had two main areas of concern. Firstly, the need for nurses and
patients to be protected from people who called themselves nurses
but who were in fact not trained. Secondly, as above, she identified
the exploitation of nurses doing private work. Following her marriage
she committed herself to the establishment of registration and the
development of nursing as a profession.
• She founded the British Nurses Association and was influential in the
founding of the International Council of Nurses. She thus established
nursing both nationally and internationally.
27
• She wanted nurses to have self-government and professional

independence so that they could shape and determine their own
future and not be continually at the mercy of physicians and hospital
authorities. Mrs Fenwick was not well supported by the people she
was trying to protect and over time became isolated. She reproached
nurses for not taking an interest in their own affairs and for not
fighting for professional independence. The battle for registration
took 30 years and in the end the result was weak, and nurses have
been at the mercy of stronger authorities ever since.
Isla Stewart 1856-1910

Miss Stewart was born and raised in Scotland, daughter of soldier and
journalist John Hope Johnstone Stewart. She started her nurse training at
the Nightingale School for Nurses, St Thomas’ Hospital, London in 1879
aged 23. Miss Stewart was strongly influenced by the emphasis the
school put on discipline, the importance of practical nursing experience,
and the moral values displayed, which she believed helped shape the
character of the nurse.
After nine months as a probationer Miss Stewart was appointed

a sister of Alexandra Ward, a women’s surgical ward of 20 beds.
Many years later, looking back, she remarked that she was ill
equipped for the post with only nine months’ experience, ‘After I
had been a Sister for a couple of years I realised how much I
had learned as a Sister at the expense of my patients. I do not
like to remember how much my inexperience must have cost
them (McGann 1992, p59).
In 1885 Miss Stewart was invited by Sir Edmund Currie to become

matron of the smallpox camp near Dartford, Kent, established in haste to
cope with the smallpox epidemic of 1884-5. All were housed in tents, and
with unusually wet weather when she arrived, Miss Stewart described the
scene as chaotic. Despite the terrible conditions and the lack of trained
nurses, nurses were not attracted to this site, Miss Stewart reorganised
the nursing and achieved high standards, which were officially recorded.
She said of her achievements,
…Sir Edmund’s dictionary had not contained the word

‘impossible’ and he helped me to erase it from mine, for which I
have every reason to thank him (McGann 1992, p60).
In 1887 Miss Stewart took over the post of matron at the prestigious St
Bartholomew’s Hospital. This job was described as ‘the biggest
28
appointment in the nursing world’, which acclaimed the successes of the

previous matron Miss Ethel Manson when she resigned to marry Dr
Bedford Fenwick (ibid.).
Miss Stewart and Mrs Fenwick became friends and they worked together
towards establishing registration for trained nurses and many other
innovations. They shared a common interest in developing nursing
nationally and internationally.
Miss Stewart was involved in the establishment of a military nursing

service. She was a member of the Army Nursing Board, Queen
Alexandra’s Imperial Nursing Service, 1906-1910, and Principal Matron,
Territorial Force Nursing Service, 1908-1910.
Miss Stewart was also a leading educationalist. It was her achievements

over 23 years as Superintendent of St Bartholomew’s Training School for
which she was admired throughout the world. Miss Stewart developed
nurse training to meet the increasing and changing demands of medicine,
the hospital and the nursing profession. As her reputation and that of the
hospital grew, Miss Stewart was in frequent demand to speak at
conferences until her death in 1910.
The American Federation of Nurses made her an honorary

member and the French government presented her with a
special silver medal in recognition of her contribution to nurse
training in France (McGann 1992, p78).
Key points • Miss Stewart was strongly influenced by her training school, which
emphasised discipline, practical nursing and moral values to shape
the character of the nurse.
• She managed a smallpox epidemic and was acknowledged for
reorganising the nursing workforce and achieving high standards.
• With Mrs Fenwick, Miss Stewart influenced the development of
nursing nationally and internationally.
• Miss Stewart was involved in the development of the military nursing
service and became principle matron.
• Superintendent of St Bartholomew’s Training School for 23 years,
Miss Stewart was a leading educationalist who developed nurse
education to meet the changing needs and demands of the
profession. She was in frequent demand to speak at conferences
until her death.
29
Summary
These extraordinary people, with their amazing achievements, could be
an inspiration to nurses today, but nurses rarely hear about them. Nurses
do not ordinarily learn about the history of nursing and the people who
have contributed, in many different ways, to the development of their
profession.
Nursing remains predominantly female and suffers as a result. The

contributions of women tend to be ignored by historians (Achterberg
1990, Miles 1988). When men went to war it was their achievements that
were celebrated, not the roles of the wives and families who supported
them and often travelled with them onto the battlefields.
Nurses play an essential part in providing care. Neither doctors nor

hospitals could function without them. Given the opportunity, nurses have
always been creative in their approach to practice. For example, nurses
were the first people to identify a need for hospice care and to provide
this service. Hospitals and communities need nurses. They are needed to
care for the sick, and to advise so to keep people well.
30
Poor Laws and Voluntary Hospitals
The Poor Laws are a collective term for Acts of Parliament that governed
th
assistance to the poor in Britain. From the 16 century, parishes were
responsible for providing for their poor and from 1572 they levied taxation
for poor relief (Isaacs et al. 1987). However, it seems that farmers came
to exploit the Poor Law as a means to pay very low wages to workers
whose income would then be made up by the poor rate. This increased
costs and put an unnecessary burden on taxpayers. The Poor Law
Amendment Act 1834 was introduced to abolish this ‘outdoor relief’,
which meant that labourers were no longer able to claim relief on top of
their very low wages. The change solved the problem for taxpayers, but
not for the labourers who needed more money. After this Act, if anyone
wanted help they were forced to go to the workhouse (Dingwall et al.
1988).
th
The workhouses were institutions set up in 17 century Britain and
elsewhere to provide employment and shelter for paupers. The changes
in the Poor Law Amendment Act 1834 made it necessary for anyone
seeking any kind of assistance to enter a workhouse. They became
overcrowded and unhygienic and had such inhuman rules that they soon
became dreaded places (Isaacs et al. 1987).
It was not intended that the sick and the elderly would be affected by this
Act but in practice the workhouses gradually filled up with these people,
as the able-bodied, including the carers, migrated to the cities in search
of work. The economic upturn of 1844-6 was followed by a downturn, and
payment of outdoor relief had to be reintroduced because the
workhouses were now full (Dingwall et al. 1988). The Poor Law system
was not abolished until 1947.
th
Poor Law hospitals In the early 19 century, if people became sick most would be cared for
in their own homes. If they did not have homes and became destitute,
they had no choice but to enter the dreaded workhouses. The Poor Law
hospitals were the infirmaries of the workhouses. It is hard to judge the
nature of the care that people received in the workhouse. It would seem
that for some it was the elderly inmates (often sick themselves) who
provided care for no wages, but others did make the system work and
care of a reasonable standard was given (Dingwall et al. 1988).
th
Into the 20 century, these infirmaries grew and developed services with
funding from central government. The Poor Law hospitals continued to
house mainly the chronically sick and the elderly (Rivett 1998).
31
Voluntary hospitals The voluntary hospitals were originally monastic depending later on
voluntary contributions and income from investments for finance. They
were the most prestigious of the early hospitals. These hospitals had
complete autonomy. Some of the voluntary hospitals were well-
established, like the teaching hospitals in London, whereas others were
more recent developments, established to commemorate towns or
individuals (Rivett 1998).
There are few records to indicate the nature of patients and their
illnesses but it is suggested by Dingwall et al. (1988) that patients in
these hospitals during the early years were not particularly sick or poor.
This is reflected in the nature of the funding mechanisms. Contributors
would not want to be linked to hospitals perceived as killing people. They
would also likely expect favours in return for their donations and,
although the hospitals were ‘charitable’, most prospective patients would
have to pay or be sponsored for their treatment.
With the development of medicine these hospitals expanded and were

able to offer more services to greater numbers of people, but they
remained selective, focusing on the acutely ill, which meant that the Poor
Law hospitals continued to receive the elderly and people with infectious
diseases and chronic illnesses (Ham 1999).
The voluntary hospitals were well run and maintained a strict discipline.
As such they became the dominant model for the National Health Service
in 1948. All services became centralised. Medicine was always fiercely
independent and habitually opposed to government, but the centralisation
of services into hospitals gave medicine the base from which the medical
profession could further develop its authority and power. This central
base also provided the right environment for scientific study and allowed
for technological advances to take place. These same advances have
now made it possible for people to be treated at distances away from
hospitals and so there is currently a shift to try and decentralise services
back into communities. Decentralisation is also a response to
consumerism, improving patient involvement, and widening access and
choice. These changes in thinking are reflected in the new Health and
Social Care Act currently before Parliament, which could show in time a
shifting of power bases away from the big general hospitals.
Key points • Two types of hospital systems developed. The different funding
mechanisms meant that the Poor Law hospitals mainly cared for the
elderly, the chronic sick and the poor. The voluntary hospitals’
funding system meant they were able to concentrate on acute care,
the development of surgical techniques and scientific study, which
32
provided scientists and physicians with a growing power base.

These hospitals were to become the models for centralised NHS
services.
• More recently, technological advances have led to the possibility of
decentralising services again. Consultations can be conducted from
a distance and information is widely available, which means that
more conditions can be treated locally. These changes, in
combination with rising consumer expectation and choice, could
mean that decentralisation of services occurs. Decentralisation could
shift the balance of power away from the big general hospitals back
into communities.
33
Founding the National Health Service
It would be a mistake to think that the National Health Service (NHS)

came about by a process of natural evolution. It actually took years of
painstaking work by many people to achieve even small measures of
success and the result reflected what was possible rather than what
might have been desirable (Ham 1999).
As recently as 1920 when the Dawson Report was published, most of the
population were found to live in conditions described as ‘Dickensian
squalor’ (Webster 1998, p4). Some men may have had access to health
care through their employment (after the National Insurance Act 1911),
but their wives, families and elderly relatives had nothing. Working class
women were identified as particularly disadvantaged. They were
dependent, were unable to access what medical provision there was, had
too little money even for food, and their troubles were compounded by
repeated pregnancy.
The UK health services had fallen behind those of other western

societies. The next 20 years saw little improvement. The existing services
were fragmented, wasteful, inefficient and chaotic. There were two rival
hospital services, the voluntary hospitals and the private sector hospitals,
which operated in conflict and without co-ordination.
As Webster (1998, p6) reported that:
It took the second world war to shatter the inertia of the

established regime. In anticipation of likely air raid casualties
amounting to at least 300,000, with remarkable speed and
efficiency an Emergency Medical Service was set in place. The
Luftwaffe achieved in months what had defeated politicians and
planners for at least two decades.
The threat of war and large numbers of casualties motivated people to

work together at last.
Difficulties arose when plans were initiated to design the post-war health
service. The old animosities resurfaced. The different groups were
inflexible, each wanting to maintain their own positions of power. The
most successful of these were the voluntary hospitals and the medical
profession, which had gained ground but were ready to fight for more.
Three years of fierce negotiation (1942-1945) achieved little.
34
The Labour landslide victory of 1945 presented a new opportunity.

Labour had long been committed to providing a government-operated,
comprehensive health service for its citizens. Aneurin Bevan was
appointed Minister of Health with the huge responsibility for housing and
health. Bevan was a young ex-coal miner from South Wales. As a
backbencher he had acquired a reputation as a maverick. Many people
doubted his abilities, especially in such an important role, but Bevan
quickly dispelled their doubts and proved to be a gifted and talented
politician. Against resistance he used pragmatism and common sense to
forge ahead. Instead of revisiting old battlegrounds, Bevan proceeded
into new territory by choosing nationalisation as an alternative route to
success. He regained control over the policy-making process (which had
previously been given away though repeated, unfruitful negotiations with
the voluntary hospitals and the medical profession, who wanted that
control for themselves) and translated policy into legislation within a year
(Webster 1998).
Once the plan was revealed it took a further two years to work out the
detail of how the health service would be administered and run. Each of
the groups still battled to try and maintain as much authority as possible,
but in the end there was a smooth transition and the National Health
th
Service was introduced on 5 July 1948.
Key points • In 1920 most of the population were living in squalor. Some men had
access to health care but their wives, children and the elderly did
not. Working class women were identified as particularly
disadvantaged.
• UK health services had fallen behind those of other western
societies.
• The two rival hospital systems operated in conflict and without co-
operation.
• One particularly talented and gifted politician, Aneurin Bevan, was
able to take the idea through to fruition.
• The process was challenging and the resulting NHS service
represented what was possible rather than what might have been
desirable.
35
An overview of nurse education
The history of nurse education has always been one of compromise; the
aspirations of nurses to raise the status of their work, set against the
need for large numbers of nurses to do the work. Mrs Fenwick argued (at
th
the beginning of the 20 century) that nursing wanted to attract ‘the pick
of the basket, not the leavings’ (cited by Abel-Smith 1960, p123). But
each time standards were raised, improvements were undermined. The
relentless demand for more nurses to do more work has continued.
The Lancet Commission 1932

The Lancet Commission on Nursing was published in 1932. The work
was commissioned (due to the initiative of one female member) in
December 1930 to investigate the reasons why there was a shortage of
nurses, trained and untrained, throughout the country, and to offer
suggestions for making nursing ‘more attractive to women suitable for
this necessary work’ (The Lancet Commission 1932, p7).
The language suggests that nursing was seen as an appropriate

occupation for ‘suitable women’, although suitable was not clarified, and
that nursing work was ‘necessary’. The word necessary is defined in two
separate dictionaries as ‘indispensable’, and ‘absolutely needed to
accomplish a desired result’. The doctors recognised that they needed
nurses if they were to accomplish their goals.
Data were collected using questionnaires distributed to all the General

Nursing Council approved training schools and a sample of hospitals not
so approved. Subsequent questionnaires were completed by selected
groups of trained nurses, probationers and two different age groups of
girls. The commission only claimed to report the views of female nurses
in England and Wales. It was decided that there was not adequate
information to draw conclusions on the conditions for male nurses or for
those nurses working in Scotland and Ireland.
By the middle of 1931, the impact of the great depression was beginning
to be felt and people were attracted into work that offered food and
accommodation. This change relieved some of the acute nursing
shortages but the commission believed that if nursing numbers were to
be maintained, and future shortages were to be avoided, the
recommendations had to be made.
36
The recommendations of 1932 included aspects such as allowing nurses

to live off the hospital site. This is not really relevant today, but other
aspects are more pertinent. The commission referred to nurses’ pay and
their lack of freedom. A modern interpretation could suggest that an
appropriate salary is still important to attract and keep registered nurses.
Freedom could refer to aspects within and outside the work environment.
These freedoms could be things like the freedom for nurses to be
creative when caring for and managing patients or it could mean being
able to manage a family or maintain important social contacts as well as
working. One-dimensional nurses will not stay happy or effective for long.
The commission also recommended that the workload between nurses

and ward-maids be redistributed. This would then relieve nurses of tasks
that did not relate to patients. Again it may be possible to draw
comparisons with today’s nurses – it may not be domestic work that they
become engulfed in but paperwork. It may be appropriate for someone
else to do this important work so nurses can be free to concentrate on
caring for patients.
The post-war years

In the years after World War II, nursing and teaching were seen as ways
for young women to improve their lives. Nursing provided young women
with a means to earn a living, move away from home and create a life for
themselves. This development boosted nursing numbers for a time but
there remained a shortfall. The expansion of higher education in the post
war years had given women many new employment opportunities.
To encourage more recruits to take up nursing, it was proposed by The

Wood Report (1948) that nurse training should be taken out of the control
of the hospitals and put into the hands of powerful regional committees. It
was believed that under the control of the hospitals, the need to staff the
hospital wards would always serve to undermine the education of, and
therefore the needs of, the nurses (Abel-Smith 1960, Clay 1987). The
Wood Report also recommended that more married nurses, part-time
staff, and male nurses and male orderlies (but not enrolled nurses) be
employed (Clay 1987). The reasons for the exclusion of enrolled nurses
in this recommendation are not clear.
The government gave serious attention to the recommendations and in

1949 the Nurses Act achieved some success, but the matrons retained
their power and nurse training stayed in the hands of the hospitals. It was
opposition from the Royal College of Nursing and the General Nursing
Council that prevented these early reforms, not government intervention
(Clay 1987).
37
The recruitment of nursing staff remained problematic. In the years

following the founding of the NHS, the recruitment of nurses was in
competition with other occupations. Sufficient nursing numbers depended
on a supply of young, unmarried students and a core of unmarried
qualified staff. It was recognised that:
If the nurses were rushed, it was hard [for them] to give good
care and to supervise the clinical training of students (Rivett
1998, p186).
Advances in treatment compounded the demand and the difficulties.
In 1961 the Royal College of Nursing commissioned a complete

reappraisal of nurse education. The outcome of the review (The Platt
Report 1964) recommended that nurses should be educated along two
different pathways. The recommendations were that student nurses
should meet an educational entry standard of five ‘O’ levels and have two
years’ academic study before gaining clinical experience. Student nurses
should also take an examination at the end of their education. Enrolled
nurses should have less academic focus; they would instead follow an
apprenticeship type of training with more emphasis on clinical
experience. These were standards recommended to try and improve the
quality and uniformity of nurse education (Rivett 1998).
Over the same period, discussions were taking place to improve the
working hours and conditions for nurses. The recommendations would
also make it possible for married women to become nurses.
Improvements in nurses’ pay did not follow these discussions and it was
only much later that this was achieved.
The Platt Report (1964) had similar objectives to those of The Wood
Report (1948) some years earlier, but had even less impact. According to
Clay (1987) this latest report was quickly killed off by people who
prioritised staffing the wards and maintaining the status quo over nurse
education.
The enlightened reformers Sir Robert Wood and Sir Harry Platt
proposed:
Real educational change that would give both students and

patients the deal to which they were entitled (Clay 1987, p73).
But they were perceived as the villains rather than the heroes of nurse
education.
38
Just six years later in 1970 the Briggs Committee was set up, against
background of industrial unrest, to again address how best to educate
nurses and midwives. The Briggs Report was published in 1972, and
Professor Briggs was of the opinion that gradual change could no longer
be tolerated. He recommended radical proposals for structural reform,
with only small changes to education (which Clay (1987) said were still
unrealised). However, the structural reforms led to the Nurses, Midwives
and Health Visitors Act 1979, which created the UKCC statutory body,
with responsibility:
To establish and improve standards of training and professional

conduct for nurses, midwives and health visitors (Clay 1987,
p73).
The creation of the UKCC was a sweeping change. Old structures gave
way to new and presented the opportunity for educational reform. The
development of Project 2000 followed in 1986.
White (1988) referred to the ongoing ambiguity surrounding the education

of nurses. She identified that entry gates to nursing in the UK are
constantly being modified. When entry requirements are raised, changes
only last until the next nursing shortage, which leads to entry gates being
lowered again to boost nursing numbers. It could be argued that quality is
repeatedly sacrificed in favour of quantity. Paradoxically this is happening
again now, at a time when nurses are expected to function at levels that
require them to have higher education and more, to be effective. The
juggling act with numbers may have led to some of the disparity found
within the nursing profession. Some nurses are educated to PhD level
while others do not recognise any need for higher education (Clay 1987).
Nurses remain a diverse group with different goals and aspirations. The
professional bodies should perhaps be taking the lead to determine
standards and clarity for nurses and patients so that the best interests of
both can be protected. Other professions have successfully achieved
this.
Over many years the education of nurses has remained a challenge. In

1987, Clay wrote:
A succession of reports over the past 50 years have either been

misunderstood, ignored, or only partially implemented. Crystal
clear, far sighted recommendations such as those in the Wood
Report (1947) were watered down, not primarily by the
government but by the profession itself – or sections of it –
39
anxious to preserve the system, nervous of radical change and

determined to move only as far as they were pushed (p70).
This view illustrates that the difficulties which doggedly pursue nursing lie
as much within parts of the profession as they do with external factors.
The general lack of consensus and consistency within nursing continues
to be a major stumbling block for the development of appropriate
education and many other issues.
Clay (1987) cites Dr Harry Judge, who was involved with the
development of Project 2000, as saying when interviewed in 1985:
I do believe that when nurses say what they want in terms of the
education they require they will get it, until they do, they won’t
(p70).
People may think that nursing is currently at a cross-road, but Clay

(1987) reminds us that nursing seems to be ever at a cross-road unable
to get beyond it, choosing instead to bear the burden and continue to live
‘The subservient role under the patriarchal system rather than taking a
new road that can lead beyond patriarchy’ (p117).
st
The challenge for nurses in the 21 century must surely be for nurses to
find one voice, to decide unanimously who they are, where they want to
go, and the education they require to achieve their personal and
professional goals and meet the health needs of the people.
Key points • In 1930 a commission was launched to investigate the reasons why
there was a nursing shortage throughout the country.
• The recommendations made in 1932 included more freedom for
nurses with improved pay and conditions.
• In 1948 the Wood Report recommended that nurse training should
be taken out of the control of hospitals, fearing that the need to staff
the wards would always dominate local decisions and undermine the
development of nursing. The matrons, the Royal College of Nursing
and the General Nursing Council, not the government, defeated this
move.
• As other roles and professions have opened up to women, nursing
numbers have continued to fall.
• Each time nurse education has been improved and entry gates
raised, the need to staff the wards has undermined these
improvements and entry gates have been modified.
• The creation of the UKCC in 1986 offered the potential for real
reform with Project 2000.
40
• Ambiguity persists and quality of nurse training is repeatedly

sacrificed in favour of quantity (the production of nursing numbers).
• Nurses remain a diverse group with little parity, which further defeats
efforts to raise the profile of nursing.
41
The modernising agenda
The modernising agenda for the NHS arguably began in January 1988
when Mrs Thatcher announced that the NHS was to be reformed. The
announcement was made against the backdrop of attempts to avoid
financial crisis in the NHS. New words entered the vocabulary of the
British people, such as hospital Trusts and GP fund-holding, internal
markets, competing for contracts and the purchaser/provider divide.
Health services became pseudo businesses. This was a good idea
except for the fact that people are not commodities and they should not
be treated as if they are.
However, White (1986) perceived the changes and the Griffiths reforms
as an opportunity for nurses. Where general mangers were in charge of
budgets White believed there were opportunities for nurses. She
encouraged nurses to concentrate on developing quality assurance tools
and for nurses to become re-focused on their ideological claim to be
there for their patients. White called for nurses to re-establish patients at
the centre of care, instead of bowing to the agendas of the service. In
1992, The Health of the Nation (DOH 1992) was the first document to
have a real health focus.
The newly elected labour government of 1997 produced The New NHS:
Modern, Dependable (DOH 1997). It promised a modern and dependable
health service, giving high quality treatment and care wherever it was
needed: at home, in the community and in hospital. The internal market
was scrapped and replaced by the concept of integrated care. Nurse-led
services were endorsed and NHS Direct was created. There was talk of
multi-agency health centres and of professionals working in partnership.
In this document there was recognition that:
Old centralised command and control systems…stifled

innovation and put the needs of institutions ahead of the needs
of patients (DOH 1997, p10).
The New NHS: Modern, Dependable (DOH 1997) was designed to drive
change in the NHS, by recognising the need to develop quality and
efficiency, and introduced standards. This approach was called ‘The ‘third
way’ of running the NHS – a system based on partnership…driven by
performance’ (p10).
42
This document spells out the need for high quality treatment and care.
The vision of this document relies on nurses to make it happen, to make
it become a reality; it gives nurses permission, it practically begs them, to
become involved.
In Making a Difference (DOH 1999), the forward was written by The Rt

Hon Frank Dobson MP, the Secretary of State for Health in 1999. He
said:
Wherever I go in our country most people have nothing but

praise for nurses, midwives and health visitors. Their jobs are
very demanding (DOH 1999, p2).
He promised to see that nurses, midwives and health visitors would be

properly rewarded and looked after. This goal was to be achieved by
improving recruitment, education and training, introducing family friendly
policies, and the development of career pathways. It was as a result of
these proposals that the roles of consultant nurse, consultant midwife
and consultant health visitor, were created.
In The NHS Plan (DoH 2000), the government identified that the NHS
was the public service most valued by British people. The government
supported the fundamental principles of the NHS as being, ‘A universal
service for all based on clinical need not the ability to pay’, and that the
NHS would provide, ‘A comprehensive range of services’ (DoH 2000,
p3). To achieve this, the government promised more money and the
modernisation of the health service.
An organisation could be described as a place where individuals are

systematically united to achieve some end. The hospital could fit into this
description. But most importantly, organisations are made up of people
with values and belief systems that have often been formed over many
years. These values and systems give rise to the activities and functions
of different groups within organisations and form a cultural web (Johnson
& Scholes 1999). A cultural web is a powerful thing constructed of many
taken-for-granted aspects relating to rituals and routines, stories and
symbols, controls and rewards, and reinforced by the traditional holders
of power. A document like The NHS Plan (DoH 2000) challenges many of
these aspects. It calls for people to work differently, for different rituals
and routines to be created and for new stories and symbols to replace
the old ones. This document also challenges the traditional holders of
power to surrender their hold and allow other people and other groups to
thrive.
43
For the objectives of The NHS Plan (DoH 2000) to be achieved, nurses
and others within NHS organisations are required to work differently than
in the past. This means that the culture must change but this will not be
achieved without considerable negotiation as people try to hold on to
their traditional power bases.
The new roles for nurses outlined in The NHS Plan (DoH 2000) are:
Chief Nursing Officer’s 10 key roles for nurses:

• To order diagnostic investigations such as pathology tests
and x-rays.
• To make and receive referrals direct, say, to a therapist or a
pain consultant.
• To admit and discharge patients for specified conditions
and within agreed protocols.
• To manage patient caseloads, say for diabetes and
rheumatology.
• To run clinics, say, for ophthalmology or dermatology.
• To prescribe medicines and treatments.
(DOH 2000, p83)
The supporters of this document may say that it is at least a start. The
critics may say that it does not go far enough. Statements like those in
the document give nurses a legitimate claim to work differently, but
presented in this hesitant way, unsupported by any real government
monitoring, they fail to give nurses the necessary authority or power.
Cultural change will not come easily or quickly.
The NHS Plan (DoH 2000) has been the driving force for the current
reforms in the NHS, and the new Health and Social Care Act, currently
before Parliament, is set to be the driver for even more radical changes.
The NHS Plan – an action guide for nurses, midwives and health visitors
(DoH 2001) contains a message from the Chief Nursing Officer, Sarah
Mullally. This document highlights the things patients want nurses,
midwives and health visitors to be involved in. These are:
• Improving the quality of care;

• More staff more time – see Improving Working Lives Standard,
nurses actively working to improve conditions for staff in their Trust
www.doh.gov.uk/iwl/;
• Strong nursing and midwifery leadership from all levels of staff;
• Working in new ways – innovative nursing practice;
• Clean and pleasant environment for patients and staff;
44
• Involving patients – forming new relationships with patients, allowing

patients to have more say in their treatment and more influence over
the way the NHS works, shaping care around their needs and
convenience;
• Prioritising cancer, coronary heart disease and mental health
www.doh.gov.uk/cancer/cancerplan.htm
www.doh.gov.uk/nsf/coronary.htm
www.doh.gov.uk/nsf/mentalhealth.htm;
• Older people – developing services that promote independence.
Inclusive partnerships with them and their carers, and anticipating
their needs while in hospital – food, drink, hygiene, skin care,
maintaining continence. Be aware that older people are often
reluctant to ask for help. www.doh.gov.uk/olderpeople.
Key points • The modernising agenda was proposed to try and avoid a financial
crisis within the NHS.
• Managing the money and budgets became the focus of attention.
• Business culture dominates.
• Bold attempts to challenge traditional roles and ways of working.
• Patient/user involvement.
45
Agenda for change
Agenda for change refers to the new salary framework that came into
effect from April 2004. It is a system of pay and conditions that aims to
reward NHS staff fairly for the roles they perform while at work. It affects
all NHS staff, nursing, allied health professionals and service support
staff. Medical staff have made separate arrangements but they will also
experience changes in pay and conditions.
Under this system pay is linked to responsibility, accountability,

competency, ability, knowledge and skills. These elements are contained
within the National Service Frameworks. More information and detail
about the agenda for change can be found on the web at:
www.rcn.org.uk/agendaforchange
The agenda for change is also about transforming centralised services

that have been in place since the introduction of the NHS in 1948.
Centralised services meant that, as technology developed, it could be
incorporated into existing systems. However, technology has now moved
on. It has become even more sophisticated and is not large and
cumbersome anymore. In fact technological applications are increasingly
small and portable. This means that services can now be decentralised,
moved back again into communities, making it easier and more
convenient for staff, and easier and more convenient for patients to
access care.
The changes are designed to support the new Health and Social Care
Act currently before Parliament.
46
Health Service Development
The development of health services and health policy is not accidental or

evolutionary. It comes about in part due to the efforts of dedicated and
committed people, but these people are acting under conditions over
which they have little or no control. Any resulting policies are therefore
the end product of long negotiations and bargaining among many people
with differing agendas.
th
The second half of the 18 century saw the beginning of the industrial
revolution. People began moving from farms and villages into the towns
for work. The factories with their power-driven machines were reshaping
the economy and the way people lived. Where people had once lived in
small open communities they were now forced to live in overcrowded and
increasingly squalid conditions in the towns. These places provided the
perfect conditions for the spread of infectious diseases such as cholera,
which was spread through water contaminated by infected sewage. In
cities across the land outbreaks of cholera erupted regularly, with
devastating consequences and loss of life.
The public health movement led by Edwin Chadwick and his supporters
identified the need for clean water and effective sewage disposal to
tackle cholera in particular and other infectious diseases. The Public
Health Act 1848 aimed to establish the construction of systems to provide
clean water and effective sewage disposal. It appeared to be a
straightforward plan to implement such a policy, but this was not the
case. The Act was opposed by people who made money out of the
insanitary conditions and by taxpayers who were anxious about the costs
being passed on to them. It took considerable jostling before the Act was
eventually passed and several more years and subsequent legislation
before effective changes were made. The most significant of these was
the Public Health Act of 1872, which called for the appointment of a
medical officer of health to specifically tackle infectious diseases and to
campaign for better health (Ham 1999).
Struggles like this, apparently straightforward but instead infused with

difficulty, are commonplace in history. They serve to illustrate the
negotiation and re-negotiation process of the positions of interested
parties, each striving to keep their own area of authority and power,
which are not unique to health care.
Government, groups or individuals may initiate the formation of policy. It

necessitates the gathering of ideas and discourse with interested parties
47
who may be apparent or who may show their interest and point of view in
a variety of ways. The signing of petitions, the formation of pressure
groups and strike action are all ways ordinary people can make their
views heard by the elected government who will be wanting to extend
their time in power. (No position is value free; everyone has their own
personal and/or public slant on a proposal.) One person or a panel of
people may be appointed to lead the process, which may take a
considerable time or be brief depending on the issues and people
involved. Because of the nature of the process, policies are usually a
compromise position, negotiated and re-negotiated with interested parties
and powerful groups.
Nurses are increasingly encouraged to become politically minded and be

active in the debate rather than, as they have been criticised for, just
accepting policies produced by others (Clifford 2000, Conn & Armer
1996, Des Jardin 2001, Northway 1996, Nottingham & O’Neill 1996).
Nurses should be aware of and be involved in national and international
issues, but they should also become involved in local issues. Nurses can
develop a strong voice, using their positions to advantage on at least two
fronts. Firstly, nurses hold a unique and highly regarded position with
patients and families. They are the ones who know how they should be
functioning to serve their patients best. Nurses have not been articulate
in the past but they owe it to their patients and themselves to become so
in the future. Secondly, nurses need to be involved in professional
debates, or their roles and activities will continue to be determined (and
perhaps undermined) by others.
Policy formation is a far from perfect system but it may be considered to

be comparatively sound in the UK, providing everyone with the
opportunity to contribute and be heard. Whether their views will be taken
into account can be debated but opportunities exist. It can also be argued
that some policies when implemented have unanticipated consequences.
These consequences may be useful or they create more problems
requiring further legislation.
Policies are a necessary part of the constitution. They are needed to

provide proposals and plans of action, which then provide a forum for
further debate. Following agreement, they can be implemented. Ham
(1999, p100) cites Easton who gave this simple illustration of a political
system:
48
Environment Environment
Demands The Political System Decisions

Inputs Supports & Actions Outputs
Environment Environment
Figure 1. An illustration of the political system
This illustration is useful even though it is recognised to be a very simple

representation of a complex political system. For more detail see Ham
1999, Chapter 5.
49
Analysis of key points and repeating

themes
Factors relating to nurses and nursing

Throughout the history of nursing, many similar themes keep recurring:
• Education for nurses is generally not valued as illustrated by the lack

of support from employers (service needs versus nurse education).
• Educational standards are not consistent over time (entry gates and
final qualifications vary – driven by service needs).
• Nurses lack real authority in workplaces.
• Falling numbers of nurses, nurses replaced by non-nurses, lack of
quality and quantity of nurses (nursing shortage/falling standards?).
• Nurses are a diverse group. Different sub-groups have different
aspirations and abilities. Parity is needed so that the title ‘nurse’
means the same to everyone (public and professionals/nurses and
non-nurses). Mechanisms must be found to achieve parity. Lack of
parity inhibits the development of nurses and nursing.
• Nurses are needed to work at high levels of skill in a range of
workplaces. Hospital settings dominate the thinking of planners (and
many professionals).
• The challenge of accurate assessment of learning.
• Nursing as a predominantly female occupation, issues of
socialisation and gender;
• Ethical issues related to care.
All of these points continue to pose concerns. In the last hundred years,
much has been achieved but many of the same fundamental issues
remain unresolved. The current government has responded with
sweeping proposals, but local hospitals and communities interpret the
proposals within the existing frameworks.
Worrying trends
th
As populations increased in the mid-19 century there were too few
places to care for people who needed some kind of hospital care. Poor
management of the demand led to falling standards. Today we are
seeing similar patterns developing even though the causes and solutions
may be different. Today’s challenges include increased demand and also
the increased usage of resources for a number of commendable reasons.
Users include a range of survivors, people who in the past would have
50
died as a result of their cancer, heart disease, diabetes or trauma. These

people, and others who live longer than in the past, may develop chronic
conditions which again boost the numbers of people needing treatment
and care in hospitals and community settings.
Solutions include the introduction of a range of workers who are not

registered nurses. Fewer people year on year are choosing nursing as a
career. The increased demand on services, combined with fewer
registered nurses to look after them, is a worrying and potentially
dangerous trend for patients. This is because good patient outcomes are
directly linked to the numbers of qualified nurses looking after them.
Once you go beyond a certain point, balance becomes unsustainable,
and standards and safety inevitably fall.
51
The Project for WDGH NHS Trust
This study was commissioned by Mrs Elaine Maxwell, Director of

Nursing, Dorset County Hospital, West Dorset General Hospital (WDGH)
NHS Trust, Dorchester.
Background to this study
Nursing shortage Against the background of a worsening national and international

shortage of nurses, the Board of WDGH NHS Trust requested this study
to identify the work that registered nurses should be engaged in, the
aspects of their role most valued by patients, and the health care teams
that nurses work alongside. The Board wanted to identify these activities
and functions so that they could support the necessary education and
training requirements of nurses to help build a strong nursing workforce
for the future, in ways most valued by patients and carers.
Who are the Over the last few years, the nature of hospital patients has changed.
Patients are frequently older, more often seriously ill, and they are likely
patients?
to have a complex range of disorders in addition to the condition for
which they are currently being treated. This means that today’s patients
are often less stable and need significantly more care than patients in the
past.
Implications for It is apparent that the daily challenges facing hospital nurses are far
greater than the challenges of the past. Nurses tend to respond in two
nurses and nursing
significant ways: they either stay on hospital wards as essentially
generalists or they leave the wards to become specialists. Nurses who
stayed on the wards have become divided again into those who continue
to practice hands-on care and those who have become managers of the
complex system. Both aspects are needed but there exists increasing
tensions between the different demands currently being put on nurses.
When nurses are few in number they tend to be drawn into activities that
many say they do not want to perform, in particular, administrative roles.
Many nurses still claim that they want to be working with patients, to be
giving them the time and care they need, but that administrative duties
and other activities increasingly prevent them from performing this
primary function of nursing.
Implications for Nurses, whether they are performing nursing functions or not, need to be
in charge of, and responsible for, the overall care patients receive. If
patient care
nurses are drawn into other activities, for whatever reason, and they are
52
no longer able to perform this crucial role, then patient care will suffer.
But nurses should not be expected to carry out this important function on
their own. Mechanisms must be in place to support and enable nurses to
fulfil it.
53
Literature Review
Literature related to this study
Who are the nurses? There is a tendency to think of nurses as a homogenous group, with
shared values and goals. The reality is more challenging as registered
nurses form a complex group both within the profession and outside in
organisational structures. White (1988) identified three main groups of
nurses:
• The mangers – who want to control the nursing staff and budgets.
The managers support the existing structures that maintain their
positions in the hierarchy.
• The generalists – who are in their jobs mainly to earn a living. There
is nothing wrong with this but again it is in their interests to support
the existing systems and resist change.
• The professionally minded – this group may include specialists.
These nurses look to higher education and specialist knowledge to
develop practice. They tend to challenge existing structures and
working practices, so come into conflict with the other two groups.
Nurses are individuals with some common ground, but with many
different aspirations as well. They often have to function within well-
established peer groups, which exert strong pressures to conform.
Nurses are not a uniform group; they do not have a clear focus and so
lack the strength they could have if consensus was possible.
What do nurses do? As described previously, nurses fall into three main groups: the
managers, the generalists, and the professionals including some
specialists. Arguably, all three groups should undertake nursing practice,
but frequently it is the last two groups that have most contact with
patients and the care they receive. Care has to be managed, standards
of care maintained, the education and support of staff co-ordinated –
these are all activities nurses should be involved in. Nurses also carry the
responsibility for the care given to patients in their area. This is
particularly true for sisters and charge nurses but the team of nurses
supporting these people carry a share of the responsibility.
In recent years, nursing practice has become blurred with the practice of
medicine. In some areas the use of technology and the tasking of
procedures have begun to take priority and status away from nursing
care. A shift in emphasis like this can make care a dehumanising activity
for the nurse as well as the patient, instead of the therapeutic relationship
it should be (Dean 1998).
54
Nursing care remains hard to define although many people have tried
(Webb 1992). One way to identify nursing care is to look from the position
of the patient. Virginia Henderson’s 1960s definition of nursing (cited by
Clark 1998, p39) still stands firm today:
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 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. This part of her function
she initiates and controls, of this she is the master.
Nursing work is about meeting the needs of patients until they can do it
for themselves. Nursing work may not be glamorous but it is always
important (Lawler 1991). Here is one nurse’s description of nursing
activity (RCN 1992, p10):
I was a student nurse and I was being taught by the enrolled

nurse how to pass a nasogastric tube on a patient. The lady we
were working on was quite poorly. She had lung cancer and had
had fluid drained from her pleural cavity twice that week. It was
very painful and nauseating for her. She couldn’t keep anything
down, and she retched a lot. The nasogastric tube was to let us
drain off some of the foul bile stained fluid that she brought up
each time she was sick.
The enrolled nurse explained to her exactly what we were going

to do, and how much better she would feel. He was quite clear
about how unpleasant the tube could be when it was going over
the back of her throat. He then explained it again to me, and she
watched like a hawk, holding the tube he had given her in her
hand. After all the preparation, he proceeded to put the tube up
to her nose, and lifted her two hands and wrapped them around
his. ‘At any time when you want, you can stop this,’ he said. So
she did, three seconds later. The second time, he was just as
patient. Eventually, with tears pouring down her face, she
pushed at his hand to ‘help’ the tube going right down her throat.
After she was all tidied up and settled, and some of the bile had
been drained off, we all held hands for a second, and he made
her laugh by inviting her to help with the intubation of any other
patient who might need it. (Staff Nurse)
55
The nursing task was to pass a nasogastric tube. What makes the task
described special are the nursing ingredients of knowledge,
understanding, sincerity, patience and humour. Such elements could be
called the art of nursing.
st
Nursing care in the 21 century should still be about achieving these
same fundamental ends. In 1995, Sibbald published ‘A senario from the
future’ (cited by Clark 1998, p41), which brings a possible future nursing
reality to life:
The computer hums gently to life as community health specialist

Rachel Muhammat logs into NurseNet. She asks a research
partner, a cyberware specialist in London, England, for the
results from a trial on neurological side effects of ocular
biochips. Rachel, as part of a 61-member research team in 23
countries, is studying six clients with the chips. Then it’s down to
local business. Rachel e-mails information on air contaminant
syndrome to a client down the street whose son is susceptible to
the condition, and tells her about a support group in
Philadelphia. She contacts a Quigong specialist to see if he can
teach the boy breathing exercises, and schedules an
appointment with an environmental nurse specialist. Moments
before her 9.45 appointment, Rachel gets into her El-van and
programmes it to an address 2km away. Her patient, Mr Chan
lost both legs in a subway accident and needs to be prepared
for a bionic double leg transplant. Together they assess his
needs and put together a team of health workers. The surgeon,
physiotherapist, acupuncturist and home care helpers are
contacted. Rachel talks to Mr Chan about the transplant and
they hook up to his virtual reality computer to see and talk to
another client who has undergone the same procedure. Before
leaving, Mr Chan grasps her hand and thanks her for helping
him. Rachel hugs him and urges him to e-mail her if he has any
more questions.
What do nurses not Many nurses want to give patients ‘individualised holistic care’ (Tonuma
& Winbolt 2000, p214), as championed by nurses for patients in the
do?
1970s and 1980s (Pembrey 1980). But nurses find their daily reality to be
very different. Hospital ward work in particular seems to have been
reduced to a series of rituals and routines provided by a range of different
people, from technicians to various assistants, which makes care
unsatisfactory for both patients and nurses. Relationships between the
different groups can become stretched to the point of hostility (Marsden
1995, Snell 2000), which benefits no-one.
56
In ward situations, nurses seem to have been manoeuvred into isolated

positions where they carry all the responsibility but have little or no
authority. A multitude of administrative and other tasks, while undeniably
important, seem to have taken nurses away from their fundamental role
of providing care.
What are the The medically dominated culture found within hospitals can be
reductionist, turning people into conditions or disorders, rather than
barriers?
treating patients as human beings with a health problem. The managerial
focus concentrates efforts on cost reduction and minimalist approaches.
These different tensions serve to undermine the activities of nurses.
Nurses claim to be people-centred, but many nursing roles have become

blurred, their expertise eroded and their skills undermined. Nurses have
become marginalised, which reduces their authority and power.
Redfern (1996) reminds us that authority and power are similar but not
the same. In hospitals many people are given authority (the ‘right’ and
responsibility) to make decisions, but they are not also given the power.
Other people can then overrule their decisions and nothing is achieved. If
this happens repeatedly it can seriously undermine enthusiasm and
effectiveness. Power may also be given through job titles but real power
is associated with knowledge and influence. Nurses need to build their
power bases by developing knowledge and influence in the organisation.
However, many nurses remain uncomfortable with notions of power
(Keighley 1996). Nurses seem to believe that power will undermine their
fundamental values and beliefs, when really the opposite may be true.
Many specialist nurses, nurse practitioners and others, recognise that

without power they remain in subservient, unsatisfactory positions that
make nonsense of their expertise. Marsden (1995, p949) reports that,
From a job satisfaction point of view, experienced nurses,

particularly in specialised areas, spend a good deal of time
teaching new medical staff and it seems paradoxical that they
can instruct and supervise doctors undertaking care and
treatments that they are unable [not allowed] to carry out
themselves.
This scenario may have changed in some areas, but many nurses are
familiar with experiences like the one described.
So where do feelings of powerlessness really come from? Benner (1984)

registered alarm when she heard that nurses believed their caring
57
qualities were the source of their powerlessness. She retaliated by

insisting that feminine qualities were just as important as those usually
associated with male sources of power: competitiveness, domination and
control. Benner (1984, p207) pointed out,
The disparagement of feminine perspectives on power is based

upon the misguided assumption that feminine values have kept
women and nursing subservient, rather than recognising that
society’s devaluing of and discrimination against women are the
sources of the problem. The former view – the misguided
assumption – blames the victim and promises that
discrimination will stop when women abandon what they value
and learn to play the power games like men do.
It is sad to note that some nurses do adopt masculine approaches to gain

power, but Benner (1984) offers a glimpse of an alternative view. From
the results of her study Benner reported that nurses developed their
power by empowering patients, helping patients take control of their own
situations. Through their caring, nurses were able to develop respectful
relationships with patients, which released them both from the tyranny of
the organisation.
Nurses remain reluctant to stand up for what they claim they believe in.
Crouch (2003, p22) says that,
As a result people don’t take nurses seriously when they make

constructive suggestions about patient care. Too often we are
tokenistic, and other people begin to expect us to be tokenistic.
Crouch encourages nurses to take opportunities and become involved:
Nurses have great opportunities in the present climate to lift

their eyes up from the here and now and look at the bigger
picture – we need to get out and make an impact. (2003, p24).
For nurses to have a strategic influence, they have to put themselves into
positions where they will be heard, for example as part of the
management team, and then they must commit to the challenge.
Too often, Trust chief executives and chairs still look to nurses
for quick fixes to fill the gaps left by junior doctors or GPs, but
that’s hardly going to inspire nurses to feel valued and part of
the team, they need to be part of system changes (Crouch
2003, p25).
58
Roberts (2000, p71) explains that,
Powerless groups have difficulty taking control of their own

destiny because internalised beliefs about their own inferiority
lead to a cycle of self-hatred and inability to unite to challenge
the inequality of power. Empowerment of these groups involves
the development of a more positive self-image through
understanding of the cycle.
Roberts (2000) encourages nurses to understand the real sources of

their oppression (society’s devaluing of and discrimination against
women) and for them to develop positive identities instead.
What do sisters and Most nurses are promoted into the role of sister or charge nurse with little
or no training. This role requires good clinical and management skills, but
charge nurses do?
good people skills and leadership qualities are also needed. Girvin (1996,
p20) cites Hempstead who claimed that,
Nurses are prisoners of their own past, steeped in tradition,

comfortable in hierarchical structures and management in a
conventional, controlled environment.
Nurses were socialised not to take risks but to maintain the status quo. A
nurse’s authority, when needed, came from association with medical
colleagues, rather than his or her own standing.
Girvin (1996) stresses how important it is for nurses to learn the skills to
become effective leaders so that they can influence and refocus care on
the welfare of patients, rather than, as currently happens, on
management agendas.
The role of the sister and charge nurse is essentially to be ‘in charge’.
This person must supervise and know what is going on and what is
happening to whom. They are responsible for every person, patients and
staff, for all the care given while they are on duty and for giving a
complete and detailed hand-over to the next person in charge (Armstrong
1981, Pembrey 1980).
The sister or charge nurse must also provide support for everyone while
on duty. Nurses need support to do their work properly, as do other care
staff including the medical team. A good sister or charge nurse will also
be the one person the consultant can turn to in times of crisis. When
consultants feels vulnerable, they have few people they can confidently
confide in (Armstrong 1981). This is an important role for the sister once
confidentiality is established.
59
A good working relationship with the medical team is essential for good
patient outcomes. Nurses need to develop their own authority, as this
example from the Royal College of Nursing (1992, p46) shows:
When you develop a good working relationship with your

medical colleagues, you know you can rely on them in a crisis,
and they know you won’t bother them with trivial details when
they are busy. Having said that, there are some people at some
times who constantly do not respond. There was a big X-ray
meeting on Mondays where the juniors presented cases and
you just did not disturb that meeting. On one occasion when I
bleeped the houseman out of there, he came so fast that he was
out of breath. He knew that he was needed badly, and he was
right. (Ward Sister)
However, to become a good ward sister or charge nurse, he or she

needs a good team of people they can rely on. The ward sister or charge
nurse should also be ‘part’ of a team, giving support to those below
(receiving authority from them), while also receiving support and authority
from above (from senior nurses, assistant matrons and matrons).
Authority refers to the right to make binding decisions (Obholzer cited by
Redfern, 1996). Without real authority and the corresponding power,
sisters and charge nurses cannot be effective. They cannot be expected
to function effectively if they are left in isolation.
The health outcome Nurses say they want to give patient care but are prevented from doing
so by other, predominantly administrative responsibilities. However, there
of insufficient
is much evidence to support the need for registered nurses to be the
numbers of ones giving patient care. Registered nurses have more knowledge than
registered nurses less educated colleagues and as a result they are more able to analyse
issues, think critically, evaluate situations and solve problems as they
working with patients
arise (Swindells & Willmott 2003). This means that patients receive more
responsive, high quality care, with lower mortality rates, as demonstrated
by the magnet hospitals in the United States (Aiken 1998, Eckardt 1998).
These hospitals were called magnet hospitals because of the way they
were able to attract and keep nursing staff (Buchan 1997). When nurses
were allowed to work in rewarding ways, ways that satisfied them and
allowed them to give the best possible care to patients, nurses became
committed to the hospitals and stayed. One of the key features of the
success of the magnet hospitals was the ability to recruit and maintain
adequate nursing staff levels and therefore build a mature workforce. The
higher levels of nurses in the workforce were directly linked to lower
mortality rates (Aiken 1998).
60
Cost implications of The cost implications of employing more (or fewer) registered nurses
could sometimes be considered a matter of ‘weighting’. Nursing costs
having more
measured only from the front of the equation will make their replacement
registered nurses in by other, cheaper workers appear cost effective. However, taking into
hospitals account costs acquired further down the line in the patient journey from
infections, complications, re-admission, even death, these equations look
less convincing.
In the UK, Pembrey (1984 cited by Clay 1987), the Royal Mardsen
Hospital in London (Clay 1987), and the Magnet hospitals in the United
States, support the belief that, for the best patient outcomes, qualified
nurses should be looking after patients. They support this position using
cost-effectiveness as evidence. They report that having more registered
nurses reduces costs in the longer term by reducing the numbers and
types of complications (even death) experienced by patients.
This real example taken from the Royal College of Nursing (1992, p47)
illustrates the kind of difficulties that can occur if there are not enough
registered nurses on duty:
As a senior night sister I was called to the receiving room of

casualty. The staff nurse and casualty officer were with a patient
in the resuscitation room, leaving a nursing auxiliary in main
casualty. She was experienced in the department and trying to
sort out an order of priority for a group of youths who had come
in together from a knife fight. One was bleeding profusely from
facial lacerations, other had various lacerations to hand and
arms. One was fairly quiet and only had a nick in the skin in the
area of his stomach. As he was quiet and with little apparent
bleeding she had placed him last in line. Although experienced,
she did not have the depth of knowledge to know that the very
quietness of the man was ominous and that the nick was the
entry point of a stiletto stab wound that needed rapid surgical
exploration. Within the hour the young man had been to the
theatre and had his spleen removed. Any delay could have
resulted in his bleeding to death quietly and cleanly, possibly
unnoticed in the fracas that was going on. (Night Sister)
This example is not unique; many nurses are able to relate similar
stories. It serves to illustrate the importance of having enough suitably
qualified staff to safely cope with the patients they are responsible for. If
there are too few nurses, even when they are appropriately trained and
experienced, they may not be able to provide the care needed if they are
stretched too thinly, and patients may die. As Aiken (1998) reported,
61
higher levels of nurses in the workforce are directly linked to lower

mortality rates. Employing more registered nurses provides the
opportunity to build a reliable and committed workforce, which is then
able to provide high quality care. The long-term effect of this is to reduce
costs and build the reputation of the organisation.
In The Future Health Worker (2003, pi), Kendall & Lissauer acknowledge
that under investment in the NHS, compared with other European
countries, means that ‘too many health workers have to struggle to
provide care in difficult and challenging circumstances’. They predict that
although these pressures are likely to increase in the future, health
workers need to keep care patient-centred. Patient-centred care is
defined below:
Patient-centred care for hospital inpatients

• Respect for patients’ values, preferences, and expressed needs
(including impact of illness and treatment on quality of life,
involvement in decision-making, dignity and autonomy)
• Co-ordination and integration of care (including clinical care, ancillary
and support services and ‘front-line’ care);
• Information, communication, and education (including clinical status,
progress and prognosis, processes of care, facilitation of autonomy,
self-care and health promotion);
• Physical comfort (including pain management, help with activities of
daily living, surroundings and hospital environment);
• Emotional support and alleviation of fear and anxiety (including
clinical status, treatment and prognosis, impact of illness on self and
family and financial impact of illness);
• Involvement of family and friends (including social and emotional
support, involvement in decision-making, support for care-giving,
impact on family dynamics and functioning);
• Transition and continuity (including information about medication and
danger signals to look out for after leaving hospital, co-ordination
and discharge planning, clinical, social, physical and financial
support).
(Gerteis et al. 1993 cited by Kendall & Lissauer 2003, p11)
Kendall & Lissauer (2003) refer to the work of the US Institute of

Medicine’s Quality of Health Care in America project which identified the
need for a patient-centred approach to care achieve improvements and
meet the needs of patients in the future. These findings are equally
valuable to British health care and the NHS as they are to the American
health care system. The elements the project identified as important are
illustrated here:
62
st
Establishing aims for the 21 century health care system
• Safe – avoiding injuries to patients from the care that is intended to
help them;
• Effective – providing services based on scientific knowledge to all
who could benefit, and refraining from providing services to those not
likely to benefit (avoiding under-use and overuse respectively);
• Patient-centred – providing care that is respectful of and responsive
to individual patient preferences, needs and values, and ensuring
that patient values guide all clinical decisions;
• Timely – reducing waits and sometimes harmful delays for both
those who receive and those who give care;
• Efficient – avoiding waste, including waste of equipment, supplies,
ideas and energy;
• Equitable – providing care that does not vary in quality because of
personal characteristics such as gender, ethnicity, geographic
location and socio-economic status.
(Institute of Medicine 2001, cited by Kendall & Lissauer 2003, p12)
Health care workers need to understand the importance of remaining

patient-focused to work in patient-centred ways. All of the elements
described above are fundamental and there is nothing revolutionary
about any of the recommendations. They are all features that health
workers would hope to find for themselves and their families if they
should ever need to access the NHS, but pressures and challenges of
recent years have led to a loss of focus. Now is the time for health
st
workers to re-identify and value these fundamentals of care for the 21
century.
Do nurses need There is a common perception that nursing is easy and anyone can do it
– it is even supposed to be a ‘natural’ activity for some. The facts do not
educating?
support this view. Swindells & Willmott (2003) conducted a study that
compared the abilities of graduate nurses with those of diploma educated
nurses. They found that in the areas of cognitive ability, reflective practice
and professional practice the graduates all performed better than the
diplomates.
Nurses are the acknowledged detectors of complications – doctors rely

on nurses to do this for them. They have the knowledge and ability to put
together early indications of deterioration in a patient’s condition and take
appropriate action. Aiken et al. (2003, p1617) found that:
In hospitals with higher proportions of nurses educated at the

baccalaureate level or higher, surgical patients experienced
lower mortality and failure-to-rescue rates.
63
Nursing is a highly complex activity, which remains under-rated. As a

result, nursing is commonly regarded as a marginal occupation, with the
education of nurses perceived as low priority. Exceptions to this
perception include nurses who, although they are highly educated,
remain aware of how much there is still to know, as illustrated by this
example from the Royal College of Nursing (1992, p48):
As students, we worked alone on night duty with only our

common sense and a small amount of knowledge to help.
Patients survived sometimes in spite of, not because of us.
Then we became trained and built up experience. I found myself
thinking, after I had acquired the diploma in nursing why did they
not tell me that before? We study and realise that some of our
experiences lack validity. We examined the mistakes we made
through lack of knowledge and the inadequacies of our training.
We have become more supportive to our patients and our
juniors as we gain insight and confidence. This professional
development takes time and it takes a professional commitment.
Reason, knowledge and understanding give commitment. If
nursing is simple, why do I have two degrees and five nursing
qualifications and still feel that I am scratching the surface?
(Nurse Manager)
Benner (1984) supported higher education for nurses. She recognised

the complexity of nursing practice and that time alone
(experience) is not enough. Time must also be combined with knowledge
and reflection for nurses to develop their expertise and give patients the
care they deserve.
64
Themes emerging from the literature
Who are the nurses Who are the nurses?

The people called nurses should be registered nurses, who make up a
and what do they
fairly uniform group of people, who hold similar values and practice to
do? similar standards of competency. This is not the reality. Registered
nurses are not a homogenous group. The reality is that registered nurses
form a diverse group of people with very different values and abilities.
The repeated adjustment of entry requirements and the trend for care
workers to call themselves nurses aggravates this problem.
Nurses need to develop strategies to regulate standards of education and

practice so that they can develop into a more unified group able to give
st
21 century standards of care.
What do nurses do?

Registered nurses may perform a range of activities. They may be:
• Managing large, busy communal areas or hospital wards;
• Giving direct care in specialist areas or areas with a specific focus;
• Giving individual, one-to-one care in the home or private setting for
individuals and/or families.
Barriers to care Nurses report many barriers that prevent them from giving quality care to
patients. The barriers include:
giving
• Reduced numbers of registered nurses to care for patients;
• Increased nursing and non-nursing work loads, fed by the
expectation that nurses can and should spread themselves to do
everything: administrative duties, deal with human resource issues,
advanced/extended practice providing treatment and care
traditionally given by doctors;
• Lack of authority and nurses’ concerns and difficulties not listened to
or not addressed;
• In hospitals, the dominant managerial culture seems to prefer
monetary unit cost as the determinant, rather than quality outcomes
– a short-term focus.
Leadership in Leadership in hospitals, particularly on the ward, seems largely missing:

• Role models lost during the 1980s’ reforms need to be reinvented;
hospitals
• Strong leaders as sisters and charge nurses are needed to actively
supervise and manage complex work areas;
• There is a need for sisters and charge nurses, people with real
authority, skilled and able to do the job; experts in the field, expert at
managing people and using conflict resolution skills;
65
• Leaders need to demonstrate and inspire professional identity and

high standards of care;
• Structures and people in the hierarchy need to support leaders and
leadership development.
st
Quality registered Quality and 21 century standards cannot be achieved without
investment in people, education and practice. Investment is needed to:
nurses giving quality
• Keep experienced nurses in ward areas;
care • Keep the experienced nurses who can then develop the learners in
the field;
• Produce ‘quality’ staff rather than just increasing ‘numbers’ if patient
outcome disasters are to be avoided. (Not a short-term measure but
investment works out cheaper, with better results in the long-term.)
st
Patient/carer The 21 century brings with it a new public culture. People increasingly
know what they want from the health service and will use political and
involvement
other pressures to achieve their objectives. The NHS must cultivate
involvement and develop strategies to improve standards and give the
public what they want.
Education for nurses Education is linked to improved nursing practice and patient outcome.
Advanced education for nurses produces even better results. Small
investments in education reap large rewards for patients. Closer links and
improved relationships between service areas and educational
establishments could lead to more creative environments and greater
scope for teaching and learning.
66
Methodology
The study objective
• To identify the activities and functions that registered nurses

employed by West Dorset NHS Trust should be involved in.
The informants were the staff of West Dorset NHS Trust and local people
served by Dorset County Hospital. The study was approved by the local
ethical authority and guided by the steering group.
Study design
Recruitment of staff Staff were invited to take part in the project by responding to ‘information
packs’ distributed across the Trust with salary slips (total number: 2,850).
The information packs contained background information and a
description of the project, a contact questionnaire and a pre-paid address
sticker. An information article was also published in the staff newspaper
Headlines at the same time. Staff were asked to respond using either
approach and thus volunteer to be contacted by the researcher at
Bournemouth University. This contact between the staff member and the
researcher formed the initial consent to take part in the project. A formal
consent was obtained later. Everyone who responded remained a
volunteer and was able to withdraw from the project at any time if they
wished.
The researcher used the contact details to reach the volunteer and place
them into a focus group. The original intention was that people could be
placed into groups where every member had one purpose and a common
identity through self-selection. In the event, through people’s limited
availability, this was not possible and so mixed groups were formed.
However, care was taken to arrange groups where people felt
themselves to be with peers, and were not therefore overwhelmed by
other perhaps more senior members within the Trust. It was an important
consideration that everyone should feel comfortable and thus able to
contribute fully to the discussion.
There were 18 groups available for self-selection, and 17 of these were

used. The groups chosen by the volunteers are listed below with the
number of people who self-selected into each indicated in parentheses:
• Administration/secretarial (10)
• Allied health professional (12)
• Consultants (3)
67
• Directorate (1)
• Doctor (4)
• Executive (1)
• Experienced nurse (43)
• Leadership role (4)
• Manager (9)
• Mental health professional (3)
• Newly qualified nurse (7)
• Non-executive (2)
• Nursing support staff (10)
• Other (details given) (2)
• Pharmacy (2)
• Service support staff (6)
• Speciality (12)
Volunteers
There were 131 volunteers forming 4.6% of the staff at West Dorset NHS
Trust. From these, 59 staff (45%) were able to take part in focus groups.
To maintain anonymity, people are referred to as either nurses or non-
nurses. The project was designed to consider the activities and functions
of registered nurses and so any reference to nurses includes all
registered nurses, newly qualified staff and more experienced nurses
who may also be managers, specialists and midwives. References to
non-nurses include health care support workers (although they have
nursing roles, they cannot be called nurses for the purpose of this study),
non-nurse managers, administrators, ward clerks, allied health
professionals, physiotherapists, therapists, pharmacists, radiographers,
service support staff, consultants, doctors, executives and non-
executives.
Focus groups
Focus groups were used to try and give staff at West Dorset NHS Trust
the greatest opportunity to take part. Specific dates were selected in
conjunction with the availability of rooms in the Thomas Sydenham
Education Centre. The aim was to hold up to three focus groups on each
of those days: one in the morning, one in the afternoon and one in the
evening, to give participants a choice. A total of ten focus groups were
held: five in the morning, four in the afternoon and one in the evening. All
were well attended. Staff were enthusiastic and contributed thoughtfully
to the discussions.
Limitations to focus group attendance

Many more people wanted to take part in the focus groups but there were
difficulties with availability. Some people found it hard to get away from
68
ward and clinic situations, others worked different shift patterns, and
some had commitments to patients and families that prevented them
from taking part. There were also unexpected emergencies and problems
that prevented people from attending.
Recruitment of the An advertisement (see Appendix 1), aimed at attracting and recruiting
local people to the project, was placed in two newspapers available
public
across Dorset and Wiltshire: The Blackmore Vale and The [Dorchester]
Echo. Distribution included the towns of Dorchester, Weymouth, Bridport,
Sherborne and many villages. Five people responded to these
advertisements with four indicating that they wanted to take part in the
project.
The disappointingly small number of people responding to the

advertisement was taken as an issue to the steering group. The
members of the steering group made sound suggestions (lessons
learned for the future) but in the event it was decided to follow up the four
volunteers. One person could not be reached but three people were
contacted and took part in individual tape-recorded interviews.
Many of the staff participating in the focus groups had either been
patients themselves or had close family members as patients in hospital
in the recent past. As a result, staff could give their views as both staff
working for the organisation, and as members of the public.
All contributions were valued and much appreciated by those involved in

the production of this project.
Managing the data Data were collected by tape-recording the focus groups (staff
contribution) and by tape-recording the individual interviews (public
contribution). The tapes were then transcribed and analysed. The volume
of data collected was organised into tables, providing clear and easy
access to the emerging themes and issues raised.
69
Findings
The findings have been presented in tables to show easily and clearly the
issues raised and the emerging themes. Some of the points made were
aspirations rather than facts. None of the findings was intended to be in
any way critical. Participants were simply highlighting issues they
identified as important.
Different people conducted the focus groups, so some variations

occurred. Some of the questions were not given to every group. A lot of
interesting and useful information was collected. To clarify what nurses
should be doing, see Table 1.
Table 1: What are the important activities and functions registered nurses should be involved in?
Themes Main points
Patient care (1) - Giving hands-on holistic patient care

- Assessing needs/making relevant referrals
- Care-planning
- Spending time with patients/listening
- Identifying anxieties/problem solving on patient’s behalf
- Giving medication/infusions/dressings
- Taking ECGs/bloods (screening)/cannulation (out-of-hours)
- Admissions/history taking (out-of-hours)
- 24 hour carers/one constant
- Patient as a person not a diagnosis
- Nursing focus
- Using special nursing skills/multiple layers of skills
- Supporting medical team; providing extra detail about patient;
reporting subtle changes
- Stabilising influence (in roller-coaster of treatment, the one there for
them, to help them through)
Co-ordinating care (2) - Conduit of care/pulling all the different specialists and treatments
together at the appropriate times/central person
- Forward planning
- Discharges (planning)
Creating and maintaining a - Clean and dry environment, patients able to eat appropriate food
safe environment (3) - Safety measures (security, cot sides, special mattresses, isolation,
barrier nursing)/comfort
- Appropriate equipment used/well maintained/properly trained staff
(competent and compassionate)
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- Staff appropriately qualified and trained

- Infection control (high standards)
- Oversee whole ward/maintain high standards
Education (4) - Working alongside nursing colleagues
- Providing more formal teaching
- Mentor and preceptor for nurse learners
- Educating other groups
Advocacy role (5) - Providing support in challenging circumstances (for staff, patients
and relatives)
- Explaining treatment and choices
- Making sure patient voice heard
- Defending patient choice
Role model (6) - Practice in ways that inspire and give confidence (staff, patients,
relatives), staff wanting to copy standards of behaviour, trustworthy
Legal documents/report - To see that all appropriate forms/referrals/letters/records are
writing/paperwork (7) completed to the right standard
- Audit information
- Admissions/discharges/care plans/diets/phone
Relatives (8) - Keeping relatives informed
- Providing information
- Giving support
Working in a variety of - Nurse-led centres – decision-making, autonomous practice
different patient care - Specialist roles – decision-making, autonomous practice
settings (9)
- With GPs, in schools etc.
Leadership (10) - Person in charge of patients and their care should be a registered
nurse
- Nurses should be making decisions about treatment and care
- Nurses should be involved in professional issues, leadership
Themes 1 and 2 refer to the direct care that registered nurses should be
involved in. Themes 3, 5, 6, 7, 8, 9 and 10 refer to issues of responsibility
and accountability. Theme 4 refers to registered nurses’ responsibility to
support colleagues and provide education. Table 2 tries to identify what
areas of practice nurses have given up.
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Table 2: Are there important things nurses should be doing that they are not doing at the
moment?
Themes Main points
Not giving patient care (11) - Delivering the system instead of delivering patient care
- Other work perceived as more important, takes priority
- Not using nursing skills in patient care (touching, rolling without pain,
doing the private things)
- Task focus not patient focus
Not spending time with - Not a priority
patients (11) - Not letting patients talk
- Not able to listen or explain things
- Can’t anticipate needs
Not teaching, supervising/ - Not teaching, supervising nurses (HCSW) learning new skills
supporting nurse - Not supporting/de-briefing following traumatic events
colleagues (12)
- Not role modelling
Not making decisions (11) - Only able to take some decisions in some areas
Not practising - Only functioning autonomously in some areas
autonomously
Not involved in budget/ - Decisions about staffing, skills mix, equipment
expenditure decisions (12) - No voice
Not involved in improving - Screening services
systems (13) - Systems for patients (e.g. one-stop medications)
- Making best use of satellite hospitals
- Presenting patient point of view
This situation does vary however. Different areas across the Trust have
different organisational cultures. Some areas allow nurses to have more
authority and others give nurses less authority. This is not a criticism but
an attempt to highlight problems. It would seem that nurses on the wards
have a largely dependent function.
The themes from Table 1 and Table 2 can also be grouped into:
• Issues of direct care: 1, 2, 5, 8, 11, 12
• Issues of governance and control systems: 3, 7, 13
• Issues around the preparation and support of others: 4, 6, 9
• Issues of accountability: 10, 11, 12
All the issues in Table 1 have been identified as important. Tables 2, 3

and 4 illustrate problems currently experienced by registered nurses
which prevent them from functioning as they would like, with patients at
the focus of care. Tables 3 and 4 try to identify what it is that prevents
nurses from doing the things they should be doing.
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Table 3: What stops registered nurses from doing these things?

Themes Main points
Bureaucracy (1) - Lengthy negotiation to obtain treatment or equipment for patients

when it should be straightforward (exhausting)
- Conflict between professional decisions and local policies
- Constant fighting with managers (different priorities)
Poor systems/poor design - Systems too rigid and narrow to allow effective use
(2) - Protocols and procedures lack flexibility
- Identifying a problem but not having a system to resolve it
- Having to tackle every problem from the beginning point every time
- No opportunities for staff to be together to discuss problems and sort
out solutions/improve systems
Other responsibilities (3) - Running the organisation instead of giving care
- Doing non-nursing work (lots of ‘paperwork’), administration, writing
letters, audit information/chasing results/provision of adequate staff
numbers and skill mix/patient admissions/dealing with discharge
difficulties). Believe nursing care important but so is paperwork –
legal documents, patient safety, litigation
- Responsible for the education and support of other groups of staff
not just nurses
- Some groups constantly changing so becomes a treadmill of
responsibility for nurses
- Filling the gaps when other staff not available (as messengers), out-
of-hours nurses perform all roles
- Picking up work left by others
- Doing what no-one else will do
- Running errands (often ‘has to be a nurse’ – unclear why)
- Serving food (some believe this a positive exercise/others negative)
Technical emphasis (4) - Technical/equipment skills valued over nursing skills
- Completing charts and ticking boxes
Managerial emphasis - Managerial requirements given priority over nursing
Perceptions - The belief that nurses have to take responsibility for things other
than nursing
- Nurses have always filled the gaps – they and others expect nurses
to continue to do this
- Believing nurses are not allowed to do certain things (a belief which
may be false)
- Needing permission to perform as they would like
- Belief that nurses have to do the paperwork
- Lack of trust in nurses
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Reality of the work place - High turnover of complex patients

- Staff shortages/lost continuity/bank and agency staff filling gaps-not
familiar with area, treatments, routines (extra pressure)
- HCSW expected to work to different levels in different areas
- Technicians fragmenting the care of patients
- Dealing with difficult relatives
- ‘Fire-fighting’
Incomplete hand-over/has - Only told about allocated patients not the whole ward
to be quick/communication - Little detail given at hand-over
systems
Table 4: What are the barriers that prevent registered nurses from functioning effectively?
Themes Main points
Loss of hand-over time and - Fragmented report – only hear about allocated patients (not the
overlap whole ward, not very much detail)
- Lost opportunities for teaching, team-building
Staff shortages - Ward work unrelenting/hard physically, mentally, emotionally
Burden of paperwork (5) - Many different sources, overwhelming
Other people’s work - Supporting many other people and other roles in different ways –
filling the gaps left by others
Loss of focus (6) - Nurses unsure about what their focus should be (many demands all
have validity)
Lack appreciation/respect - Between/across different groups of workers (on occasions)
- Some groups reject/ignore advice given by experienced others
- Verbal instructions later denied
- Telling patients they can go home but not telling nurse
- Nurse as hand-maiden
- Nurses blamed when things go wrong
Organisational culture - Different areas across the Trust have different organisational
cultures. Some areas allow nurses to have more authority and others
give nurses less authority
- Lack of belief/faith in nurses’ abilities
- Lack awareness of nurses’ potential
- Deference to physicians
- Dependent function (on wards)
Perceptions - Lack of self belief by nurses
- The need for permission (nursing belief)
- Lack personal and professional authority
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The themes from Table 3 and Table 4 could be grouped into:

• Direct care: 4
• Governance and control systems: 1, 2, 3, 4, 5
• Supporting other staff: 3
• Accountability: 6
These blocks and barriers must be addressed because they are having a
huge negative impact on staff capability and morale, and quality patient
care. Table 5 looks at the issue of extended roles for nurses (these views
sometimes include specialist roles).
Table 5: Extended roles – how do these fit in?

Themes Main points
Open to different - Generally good, if have the time to do the work and if its done as part
interpretations of the nursing role and not as ‘added on’ tasks
- Usually employs technical skills
Opinions for: - Increased knowledge and expertise/autonomy/accountability
- Using nurses’ abilities to good effect
- Senior roles and specialist roles (more prestige)
- Increased job satisfaction (opportunity to do roles as aspire to – this
view was voiced as particularly true for specialist nurses)
- Better for patients
Opinions against: - Other people’s jobs off-loaded on to nurses
- Often task orientated
- Nurses filling gaps left by others
Table 6 tries to clarify issues from the patient’s perspective. Many staff,
nurses and non-nurses had experience as patients themselves, and
experience of close relatives and friends as patients, so they were able to
give comments from the patient’s point of view even though they were
also staff.
Table 6: What do patients most remember about nurses? What do they most value?
Themes Main points
Quality time (1) - Nurses listening, answering questions/explaining, giving time

- Seeing the same person daily/nightly (continuity/a familiar face)
- Helping with problems, provision made for pet/home concerns
Quality care (2) - Being clean, dry, fed
- Nurses giving strength, reassurance, explanation
- Nurses being kind
- Being treated with respect
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- Making the family feel like partners in the care of a child

- High quality care given by highly skilled nurses
- Knowing whether they have been cared for by nurses or others
- That Sister is ‘in charge’ (gives confidence)
Overwhelming experience - Feeling a fish-out-of-water, frightened, everyone rushing around
(3) - Not wanting to be a burden – not asking for/not getting pain relief,
help, etc.
- Being told things would happen but they did not
- Being told someone would come back but they did not
- Not knowing who different people are (uniforms confusing)
- Being asked the same questions over and over
- Being left alone, not told what is happening
- Discharged inappropriately
Conflict (4) - Being told different things by different people
- Operations cancelled
- Not being washed (one example given was of a patient who had not
been washed for five days)
Watching and listening (5) - Patients able to quickly assess the different personalities of staff
- Listening to talk/observing what is happening to other people
Nursing station (5) - Nurses ‘busy’ but apparently standing/sitting at the nurses’ station
Reassurance (5) - The first five minutes are most important: how they are greeted/are
they bombarded with questions?
- Knowing that someone is in charge
- That someone knows what is happening to them
- The sense that staff are competent and compassionate
Table 6 highlights many of the personal attributes registered nurses,

sisters and charge nurses should have in themes 1 and 2.
As reported in theme 3 it is easy (and understandable to some extent) for

nurses to forget what an overwhelming and frightening environment the
ward can be when they are so familiar with the ward and its challenges.
However, staff must not forget and they must remain vigilant. Nurses
must also stay aware of the issues in theme 4 and improve systems to
overcome these unacceptable problems.
Theme 5 reflects the importance of a welcoming environment. Many

organisations currently place a great emphasis on hospitality issues, and
in various examples given, it would seem that the NHS has fallen far
below expectations on this issue. This could be an on-going, in-house
educational priority, to highlight the special nature of WDGH NHS Trust
and its employees. Tables 7 and 8 are attempts to clarify certain terms.
76
Table 7: When you and others use the term ‘nurse’ who do you think of most readily?
Themes Main points – perceptions
Nurse - The most usual expectation is that this person is a registered nurse
Health care support - The most usual care giver (may also be called nurses)
workers
Sister/charge nurse - A nurse, the one ‘in-charge’ who may or may not give hands-on care
Problems - Uniforms were reported as confusing – patients, doctors and others
who make up the care teams reported being unable to tell who is
who/who is giving the patient care/who is ‘in-charge’. Who are the
nurses, who are they speaking to/who will be answering their
questions?
Table 8: Sisters and charge nurses – are they nurses or something else?
Themes Main points
Role - Difficult balance

- Many responsibilities
- Challenge stereotypes
- Develop own style
- Managing/developing own staff
- Loss of control: beds admission/discharges: cleanliness left to
contractors
- Constant interruptions
- Too many patients to deal with (when complex situations develop, it
was reported that sometimes it’s impossible to get round to
everybody even once on a shift)
- Staffing shortages, having to ‘make do’ with bank and agency staff
- Should be good role model/leader
- Should be positively influencing the environment/developing
systems/patient pathways
- Should be developing junior staff to support them in the role
- Staff (and patients) remember (and talk about) ‘good’ sisters/charge
nurses
As nurses Partly personality dependent (partly other things, situation etc.) – if
valued, more likely to keep aspects of nursing in the role/others may
have different focus (different situation) and more administrative role
As managers Administrative work, organising, co-ordinating
Uniform Important for patients and other staff to know who this person is
Table 8 highlights many of the difficulties experienced in this senior role;

but this is a senior role which is crucial to effective patient care. The
service exists to care for patients. Their needs must take priority. The
sister or charge nurse needs to be the ‘captain of the ship’, the one
77
responsible for all the care given (and not given). Anxieties expressed in
Tables 6 and 14 reflect the failings of this person, and the failure of
systems to support and enable the effective implementation of this
important role.
It is acknowledged that sisters and charge nurses cannot be expected to

be effective in isolation. They need to be leaders of the ward culture, as
well as part of an effective team. There should be real support given from
above (Matrons, Assistant Directors of Nursing, Director of Nursing) and
from below (the registered nurses and other staff) to enable them to deal
with the complex problems within their areas. Sisters and charge nurses
need to be proactive in this development; patient care depends on them,
they are the ones who carry the responsibility.
Table 9 tries to clarify the most important things registered nurses should
do – and possibly suggests things that could be delegated to others to
perform, and systems that need to be improved or changed.
Table 9: What are the most and least important things that nurses do?
Most important duties Least important duties
Provide a safe, secure environment Administration: paperwork

Listen to patients Negotiate (do battle with) the system
Effective communication Struggle for staff cover
Professionalism – working to best ability Clean up behind others
Negotiating care – giving advice Administration: off-duty, staff records
Turning up for work!
Table 10 identifies perceptions about the modernising agenda.
Table 10: What is the impact of the modernising agenda on nurses and nursing?
Themes Main points
Housekeepers - Good addition, highly valued, some control given back to ward
sisters/charge nurse
Using registered nurses - Special roles, different roles
more effectively
Working in new ways - Can be difficult to achieve, volume of work, needing to keep on top
of things
- More machines
- Loss of skills
- More assessment
- Higher standards
- More data collection
- Keep the good but recognise that change is needed
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Patient involvement - Welcome move, need to know what patients think, what they want
- Service to be more responsive
Nurse expectations - Non-traditional expectations
- Nurses who want to be managers
- More opportunities
- Nurses/nursing to determine own future
Tables 11 and 12 aim to highlight issues important for the recruitment

and retention of nurses in the Trust. It includes significant comments,
suggestions and observations made by staff who took part in the focus
groups.
Table 11: Questions answered by nurses about their job at WDGH

Questions Main points
What do you enjoy about - Patient contact, real people, caring for them and family
nursing? - Different every day
- Helping with patient’s/family’s problems
What keeps you in your - Enjoyment, security, confidence in doing a good job, job satisfaction,
job? comfortable in role
- Team working, team spirit, nice people
- Challenge, excitement, learning new things
- Seeing people get well or have peaceful death
Why do you stay working at - Live locally, family close by, nice area
WDGH? - Like the building, art, gardens, proud of hospital, friendly colleagues,
good social life
- Like local people/nice patients
- Nice size (not too big), offers variety
- (Some people) feel well supported by line managers
- Loyalty to Trust
- Consolidation before possibly moving on
Why would you leave - Expensive area to live – pay is an issue
WDGH? - Retirement
- Take up new challenge
- Lack of opportunities for advancement, poor prospects, few rewards
- Frustration when complete courses but unable to implement change,
roles lack authority
- Lack of support and too much responsibility for newly-qualified
nurses
- On-going hassles
- Not feeling valued/feeling abandoned/organisation taking advantage
of goodwill
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- Unable to meet personal standards of care (due to factors beyond

personal control)
- Inadequate cover giving rise to dangerous situations.
- Too much pressure
- When treated badly by seniors
- Fear of academic study, too much responsibility (consider leaving
nursing)
- Dealing with difficult/aggressive relatives
Table 12 identifies other issues from the focus groups not specifically
related to this study but considered sufficiently important by staff for them
to be raised in this forum for discussion.
Table 12: Other issues raised by staff during the focus groups
Themes Main points
Leadership - Highlighted the importance of the person in charge being the right
person with the right personality
- Recognising that strong leadership creates a strong team
- Practitioners need to meet on a regular basis to discuss issues and
thrash out difficulties
Staff shortages All areas across the Trust have too few workers, nurses, doctors,
administrators, radiographers, messengers. No slack in the system. Too
few staff on duty at the weekend
Lack of support Nurses, (newly-qualified nurses in particular), HCSW, junior doctors –
concerns not being heard
Working extra hours without Nurses and administrators in particular (largely administrative type of
payment work) done in own time
Lack of effective career Nurses, HCSW, administrators. People with real talent not identified and
structure nurtured, get frustrated and leave. Their talent is then lost to the
organisation. Lack of pay parity for equivalent work across roles. Many
staff not paid for the level of work they give.
Special helpers - Handyman/engineer (rehabilitation areas in particular) to help adapt
equipment for better use (by patients/clients and staff)
- Social workers (on wards) needed to help with complex discharges
(financial aid/funding issues/special expertise)
- Observer person – someone (perhaps in training/shadowing) who is
able to identify where efforts are being duplicated/help to streamline
activities. (People are too bogged down/actively fire-fighting so
unable to identify different ways of doing things)
Recruitment Lots of obstacles. Convoluted system. Slow. In-house moves could be
stream-lined (many aspects not necessary/unnecessary duplication)
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Unrealistic expectations - Many patients expect a hotel service which cannot be supplied
- Health/disease/responsibility, not perceived as the individual’s
problem/the system there to put things right
Government interventions - TV for every bed makes giving care and keeping areas clean more
difficult for staff
- Targets mean unequal access to money for funding services
- Money targeted to ‘treatment’ (easy to count/short term effect)
instead of prevention (hard to count/long term investment)
Menus Do not necessarily reflect healthy eating, health promotion, source of
amusement
Nurse education – some - Entry gate too high
staff perceptions as - Learners lack the right attitude (many not interested in basic care)
reported
- Lack commitment (some just do not turn up for work)
- Too little clinical experience when qualified
These issues were considered important by the staff attending the focus
groups. They need to be acknowledged and addressed within the Trust.
Tables 13 and 14 reflect the views and experiences of people served by

this and other hospitals.
Table 13: Overall views about a nurse’s role and attributes required
Themes Main points
Role of the registered nurse - To give care as role permits, but to always supervise care being
given
- The ones responsible for care being given correctly – which includes
patient’s bathing, taking to toilet, able to access food/water, able to
eat properly, teeth clean – as well as dressings, medication and
technical aspects of the role
- To remember the patient in a room on his/her own and go in to them
frequently (reported as very frightening to be left in a room alone for
long periods)
- To prioritise nursing work over other work, e.g. a nurse dealing with
one patients domestic problems (perceived as low priority) instead of
giving pain relieving care to other patient(s) (perceived as high
priority)
- To keep clear and legible records
- Oversee and be responsible for all care given to patients
- Work with and educate colleagues
- Develop protocols
- Improve systems (patient care/record keeping/in wards and out-
patient departments)
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Personal qualities: - Good communicator

Good nurses, good sisters, - To be kind, to keep patients and relatives informed, to make them
charge nurses and good feel ‘human’ not just a ‘case’/insignificant
care staff
- To develop an aura to inspire confidence
- Clear thinking, lateral thinking, organised
- Knowledgeable, confident
- Able to speak up in meetings, able to deal with difficult ward issues
and people, including monitoring the performance of all staff (nurses,
physicians, consultants, others) – able to take issues to sister/charge
nurse/able go higher when appropriate
- Not using terms of endearment unless invited to do so – patients in
very vulnerable position, made worse by being called ‘love’/’dear’ –
shows lack of respect
- Good with patients, able to be sympathetic, reassuring, kind
- Hard working
Good image: - Distinguishable uniforms (patients want to know who is who)
To give reassurance and - Clean hands, tidy short nails
confidence in care
- Tidy hair, worn up if long
- Well fitting dresses/trousers and tops
- To look like a ‘health professional’. Looking as though he/she takes
care of self so can be trusted to look after patient, relative, friend,
should look good, smell healthy
- To have clean and tidy shoes and tights
- Involvement of someone like Richard Branson to sell nursing as a
career (we all need nurses at some stage in our lives)
Role of sister or charge - Must have a clear overview
nurse: - If ‘job sharing’ should be sharing the role and information
Perceived as crucial to (mechanism built in to role) and not become two separate part time
good organisation and care roles
- Should know/meet/talk to all the patients every day and know what is
Need able, supportive staff
happening to each one
nurses, to help them to do
- To give care as role permits, help out nurses, work with them and
their ward jobs effectively
patients, educating, guiding
- Provide a welcoming environment
Also need support from
- Supervising over all
above to enable them to
make necessary changes
- Support consultant/medical teams (aide memoir, confidante – can be
a powerful and rewarding relationship)
and be effective
- Ability to discipline nurses and other staff when necessary
- To support nurses and other staff as needed
- Ensure good, detailed, hand-over – the more care is broken up, the
greater the risk of communication breakdown – the person in charge
is the one to hold it all together with the aid of capable staff nurses
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- Able to speak up in meetings, able to deal with difficult ward issues

and difficult people
- Responsible for monitoring the performance of all staff (nurses,
physicians, consultants, others) and able to deal with the issues
- To develop protocols, improve systems (is all the paperwork really
necessary?)
- The ones responsible for all care being given correctly – which
includes for patients: bathing, escorting to toilet, able to access
food/water, and able to eat appropriately (should be monitoring
patient’s nutrition); for nurses: should be working with nurses to
make sure these things done/educating/overseeing
- To oversee and be responsible for all care given to all patients
- To be a good ‘captain of the ship’
Table 14. When things are not as they should be…

Things nurses are not doing - Nurses have lost sight of the whole picture
that they should be doing – - Lost sight of/ value of the basic things – these are important to
where this happens … patients/important to get right
- Food/water must be where patients can reach it – nurses should be
responsible for seeing that it is
- If unable to do everything themselves nurses should be teaching and
supervising others, taking responsibility for the care given to patients
even if not doing it themselves
- Working with computers instead of with patient and relatives/friends
- Not treating people with respect, terms of address/treating them as
‘cases’ not as sensitive human beings
Changed perceptions - Nursing work not seen as important/not glamorous – but it is very
important to patients
- Changed perceptions of self – nurses as managers/technicians/busy
doing ‘other things’ but should not lose sight of (or the importance of)
their nursing focus
- Role models lost (unforeseen casualties of 1980’s sweeping
reforms) and managerial/business focus replacing patient focus
Changed focus - Focus changed from patient-centredness to managerial
responsibilities/business speak (organisational focus/numbers/tick
boxes)
These people wanted to stress that usually they found care to be good
but that sometimes things did go wrong. When this happened, it was a
source of distress for them, their relatives and friends. From the research
perspective, the staff of the Trust and the public were invited to give their
views so that improvements could be made. To have received only
83
compliments would have been comfortable but not useful, so all views,
including criticisms, were welcomed.
Although many experiences were good, the most important deficits were
identified as:
• Nurses doing non-nursing work (aggravated by reduced numbers of
registered nurses);
• A lost sense of the patient and family as ‘people’ (a loss of respect in
relationships for many different reasons);
• The loss of the one(s) in-charge, the ‘captain(s)’ – particularly at
ward level.
Each of these three elements has massive implications for patients and
their care. They also have an impact on the culture and capability of staff
to provide care, particularly for those working in wards.
21st Century Treatment Forum

st
The need for a 21 century treatment forum was an issue raised through
the process of this project. It was considered important by a participant
who had regular contact with members of the medical profession and
other professionals. She had witnessed and been part of difficult
treatment decisions, difficulties that arose through advanced technology
st
and new treatment options. This issue was raised because, in the 21
century, life-preserving treatment can be available in situations where it
may not be the best option for the patient. In the current climate these
decisions were seen as predominantly medical/physician dilemmas, but
other health professionals would necessarily need to be involved in
complex treatment decisions in the future.
It was proposed that the issue of whether active treatment was the most
appropriate action was a dilemma likely to become more commonplace
as technology and other advances continue to be made. The need for a
forum, where professionals can thrash out treatment options in private
(and therefore confidentially) before meeting with families, was identified.
The view was raised that, while the rights and wishes of families would
always be honoured, the rights of patients and the most appropriate
treatment option(s) for them should always take priority.
When patients were able to speak for themselves and make their own
treatment decisions, it was believed that there would be no need for
discussion. Where this was not possible, doctors in particular voiced the
need for help from professional colleagues. Clarke (2000) suggests that
hospital ethics committees and legal specialists should be involved with
84
difficult cases. It was proposed that a place easily accessible by all care
professionals should be established in the local area for this purpose.
The need to get decisions right was seen as paramount. Appropriate
treatment choices would benefit doctors, health care teams, the
organisation and most importantly patients and their families. The
development of some kind of accessible forum was thought to be the
best way to tackle this difficult issue.
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Discussion
Issues raised
What are the Staff working for the Trust were able to readily identify activities and
functions they thought nurses should be involved in. Table 1 covers an
important activities
extensive range of activities including direct (hands-on) care as well as
and functions lots of managerial and organisational aspects.
registered nurses
White (1988) identified three types of nurses who showed different
should be involved
preferences across this range of activity. The nurses in the study clearly
in? identified the need for all of these functions but many of them reported
that the demands of managerial and organisational activities took them
away from direct nursing and meaningful contact with patients and
families.
Members of the public had very clear requirements about what they
wanted from nurses (see Table 13); for nurses to be giving care but more
importantly for them to be supervising all aspects of care and setting the
standards on the wards. While many experiences reported were good,
some were not (see Table 14), with examples of poor care, poor
management and supervision, and poor interpersonal skills, which
caused distress.
Gertis et al. (1993 cited by Kendall & Lissauer 2003, p11) highlighted
respect, co-ordination and integration, information, communication and
education, physical comfort, emotional support, involvement of family and
friends, transition and continuity as being the main aspects of patient-
centred care that nurses should be providing.
It would be convenient to blame nurses for the failings but that would not
be fair. History has shown that nursing is a complex activity. Lots of
powerful groups have an interest in controlling nurses and nursing
expenditure, while maintaining their own positions of power within
organisations. Nurses are required to do, and be responsible for, a range
of activities, but they frequently have little or no authority to make
changes that would enable them to do their work effectively.
Nurses should be the ones designing and controlling nursing agendas

but they are frequently excluded from decision-making arenas. Benner
(1984) and others have persistently encouraged nurses to find their
identity and authority through their ability to focus on patient-centred
st
care. 21 century service users demand high quality care and nurses say
86
they want to give such care. If nurses really believe in this goal and
remain focused on this objective, they must be able to find a way through
traditional bureaucratic mechanisms to find a new place for pursuing their
ideals for patients.
Who are the nurses? For this study it was necessary to focus on the work of registered nurses
within the organisation, but it was also respectfully acknowledged that
other groups contribute significantly to the nursing care patients receive.
Through the course of the study it quickly became evident that, as

described in the literature, registered nurses within WDGH NHS Trust
were not a uniform group. The three types of nurses described by White
(1988) were evident, with each group showing different motivations and
different approaches. Differences in terms of values and orientation mean
that consensus views are not possible.
The specialist nurses were largely a self-contained group that managed

their own clients and workloads. Many had moved into these roles so that
they could practice high levels of skill with more freedom than was
currently possible in ward situations. The specialists found their work
rewarding but on some occasions they could feel isolated and distant
from the organisation. There did not appear to be mechanisms in place to
encourage them to feel part of the greater whole of the organisation.
They were also subject to many barriers within hospital systems.
Specialist nurses reported spending precious hours ‘negotiating the
system’ to gain legitimate equipment and/or medication for their clients.
In a recent study conducted by Graham & Keen (2003), a different group
of specialist nurses reported similar difficulties. These barriers frustrated
specialist nurses’ efforts and diffused their enthusiasm, thus wasting
energy and expertise that could have been better channelled towards
patient care.
Many of the generalist nurses saw their roles more as jobs they enjoyed,
which provided them with a salary and a measure of security. These
aspirations were viewed as equally valid. The generalist nurses were
concerned for their patients and they performed to the best of their ability,
but they had busy lives and other commitments, preventing them from
becoming too involved with issues in the workplace.
There were also many nurses who became managers. As with the
specialist nurses, some of them had moved into management roles to
have more control over their working lives. Some of the management
roles were in ward situations, some were not. Ward management roles
were roles like ward sister or charge nurse. Other management roles
87
involved higher levels of service management or different types of service

development management. Sisters and charge nurses were seen as
crucial to the effective running of the ward (by nurses, doctors, members
of the public, physiotherapists, administrators and others), but how
sisters and charge nurses performed this important role seemed to be
dependent on personality and attitude. As a result, there were many
different interpretations of the role. Whether sisters and charge nurses
received preparation and support in their roles was not asked and was
not evident. For them to be effective it would seem that both preparation
and support would be necessary.
When considering nursing roles it is important to remember that nurses

are not a static workforce. At different times nurses may focus their
attention on different aspects of their lives. Although for some, home and
child-care may take priority at the moment, at a different time they may
want to change roles, take up educational opportunities or even opt out
altogether for a while. All of these choices are positive and can be viewed
as plus factors for nursing. Nursing as a profession continues to offer
flexibility and opportunity for those who want it.
Many nurses and others considered nursing to be a professional role.

Some conformed to White’s (1988) description of professional nurses as
those who looked to higher education and specialist knowledge to
develop their practice, while others did not. Many nurses working across
the Trust were, however, able to identify with White’s (1988) description
of the three groups of nurses. Within the Trust, nurses were working as
specialists, generalists and managers. Constraints reported within ward
situations could make life difficult and challenging for nurses who did
identify with White’s (1988) description of the professional nurse. They
reported wanting to use professional knowledge and education within
ward situations and beyond, but that organisational structures and
traditional ways of working prevented this.
Aiken (2003) and Swindells & Wilmot (2003) highlighted the advantages
of having educated nurses looking after patients. The examples from the
magnet hospitals and examples given by the Royal College of Nursing
support this and research conducted by Swindells & Willmott (2003,
p1102) endorsed this view. They found that nurses educated to graduate
level were able to perform, in terms of cognitive ability, reflective practice
ability and professional practice, even better than diploma educated
nurses, making them more effective in their practice while working for
patients. Post-graduate education was found to enhance decision-making
abilities and clinical skills development even more, making the whole
treatment process safer for patients. However, there must be
88
opportunities for nurses to use their knowledge and skills. If opportunities

do not exist, as in many ward situations, nurses may become
disheartened and move to other areas where they can be more
autonomous, or perhaps they may leave the organisation altogether.
It is important to retain skilled and educated nurses at ward level. These

nurses are much needed to supervise and educate staff, while using their
talents to benefit patient care. It would appear that many nurses and
other health professionals find ward situations difficult and challenging
places to work in at this time (Kendall & Lissauer 2003). Nurses, and
others, seemed to be under constant pressure. They want to give high
quality care but are constantly being drawn into other work away from
patients.
What prevents Nurses reported that bureaucracy, poor systems and non-nursing
responsibilities were the main causes for being unable to care for
nurses from working
patients. The volume of work seemed to be a real issue. There is much
this way? research to support the notion that adequate numbers of registered
nurses are essential to provide safe, quality care (Aiken 1998, Buchan
1997, Clay 1987, Eckardt 1998, Kendall & Lissauer 2003, Lawler 1991,
Pembrey 1984 cited by Clay 1987, RCN 1992). Nurses reported that they
spent much of their time ‘fire-fighting’ and dealing with non-nursing crises
of different types. This was unsatisfactory and patient care inevitably
suffered.
Nurses regretted the loss of hand-over time, which is now non-existent in

many circumstances, and the accompanying advantages. Losses
include: the detail about patients and their care, knowledge of the whole
complement of the ward (now nurses just hear about their allocated
patients), the loss of team building and ward culture development, and
crucially the loss of informal education, which was an integral part of the
detailed hand-over. These things just don’t happen now and the service
suffers greatly as a result. Cost-cutting measures have come at a high
price.
Nurses seemed to have no way of communicating what was important to

them (high quality care) and no way of influencing people within
organisations to make this possible. Nurses should be in positions where
they can influence and implement necessary changes.
What do patients When staff commented on what patients wanted from nurses, they told
stories of their own personal experiences, stories of fear and of feelings
want from nurses?
of being overwhelmed while in hospital. There were also issues of
conflict. Patients were told different things by different people, and that
89
certain things would happen but they did not happen. All of this
undermines patients’ confidence and makes them afraid. There were also
reports of neglect, unacceptable at any time.
Kendall & Lissauer (2003, p12) cite the Institute of Medicine (2001) which
st
identified that the 21 century health care system should be safe,
effective, patient-centred, timely, efficient and equitable.
Members of the public expressed traditional values when referring to

what they wanted from nurses. They wanted nurses to be kind, to
address them respectfully, and to be inspiring both through how they
looked and how they behaved. These are simple values easily achieved
but readily forgotten. Competence to do the job was expected and taken
for granted.
The ward sister role was seen as crucial (Armstrong 1981, Pembury
1980, RCN 1992). The public wanted to know that this person, (someone
specific and identifiable) was in-charge, and that he or she would be
responsible for their safety and well-being throughout their stay.
Health care seems to have become locked into special jargon, the
perception of commodities rather than people, with much of it adopted
from the business sector. But all that patients really want is to be treated
well and reliably looked after while they are in hospital. How is it possible
that such simple, understandable and important goals have so often
become lost?
Different groups of Some historical perceptions are still held by some doctors and managers
in particular. They continue to believe that nurses can ‘fill the gaps’ and
staff within the Trust
hold the system together as they have always done. Many nurses
and their different themselves also wanted to be able to perform this function, recognising
perceptions that if they did not hold things together patient care would suffer. But as
Girvin (1996) found, many nurses remain prisoners of their past. The
traditional socialisation of nurses has moulded them into roles as dutiful
followers. This socialisation has left many nurses ill-prepared to rise to
the particular leadership challenges they face today.
As a group, nurses are skilled and resourceful. With the needs of patients
in mind, nurses at WDGH acknowledged that doctors needed blood and
other results to make important treatment decisions, families needed to
be informed, medication had to be ordered and arrangements for
discharge must be made. Nurses at WDGH found themselves caught up
in all of these functions; important functions but ones which often take
lots of time, taking them away from patients and preventing them from
90
giving care, which they recognised should be their primary role. Many
nurses reported this type of scenario and that the overly demanding
environment prevented them from working effectively and receiving the
job satisfaction normally associated with their work. Nurses reported
overall feelings of being pulled in too many directions, unable to do any of
them well.
Nurses are used to responding to the needs of the environment. They are
not accustomed to standing back and looking for other alternatives. They
need to begin to do this. They have to learn how to form their own ideas.
They can then take these ideas to doctors and managers to gain their
support for implementing change. Everyone in health care wants the
same outcomes. They want quality, patient-centred care. This can only
be achieved when teams listen to and support each other.
The adoption of the business culture into health care has had a
significant impact. Resources are finite and must be effectively managed
but there are many contentious issues, and cost-cutting for its own sake
is not necessarily the best measure. Everything is open to different
interpretations and should be discussed fully. There is the perception that
replacing registered nurses with other less educated workers is a cost-
effective measure. The perception is that you will get ‘like for like’ but for
less cost. The reality is very different. Aiken (1998, 2003), the magnet
hospitals in the United States, Pembrey (cited by Clay 1987) and the
Royal Marsden hospital in London all report that having higher numbers
of registered nurses leads to fewer complications, fewer re-admissions
and fewer deaths. These all are important factors to take into account
when considering costs. Hospital-acquired infection alone contributes
hugely to the NHS bill, as do costs for re-admission, complications and
death, where costs are perhaps less quantifiable but of enormous
consequence to patients.
The modernising According to Kendall & Lissauer (2003), and in common with other
people working in health care organisations, staff at WDGH NHS Trust
agenda
did not have particularly clear ideas about the Government’s modernising
agenda. (To help staff gain access to information about the modernising
agenda and agenda for change, some details have been included in this
report.) Staff rightly identified that roles need to change and that nurses
need to be working in new ways. Extended roles were seen as a good
thing unless they were used as a way of giving junior doctor
responsibilities to nurses without providing extra nurses to do the nursing
work as well.
91
Members of the public could see the potential of having extensive de-
centralised services available to them out in the community. This was
seen as a positive development.
Kendall & Lissauer (2003, p5) report that:
Professional organisations, trades unions and Government all

agree that further changes to working practices will be required
in the years ahead. Yet there is little agreement about what the
overall shape of the future health workforce should look like.
The British Medical Association has called for a hugely

expanded role for nurses…but it does not envisage non-
professionally qualified workers taking on more responsibility as
nurses’ roles expand.
Clearly there are incompatible demands identified here. The same

number of nurses cannot continue to take on extended roles if they are
also responsible for nursing care. If nursing care is to be no longer given
by nurses then sufficient numbers of appropriately educated individuals
must be developed to step into this role, or patient safety will be
sacrificed. Difficult decisions have to be made and appropriate numbers
of suitably qualified staff have to be prepared for the future.
How should nurses Nurses need to be working more effectively within the Trust. This is what
both doctors and nurses want. Doctors want nurses to expand their roles
be working in
but organisational structures do not support this. Higher education is one
WDGH NHS Trust? aspect of preparing nurses to work more effectively but learning must be
supported by education within ward situations as well. Also, a different
group of people perhaps needs to be prepared to take over some of the
nursing responsibilities. Organisational structures and systems need to
be developed to allow this to happen.
Substituting nurses for other less educated health workers may look like
a bargain. There is the perception that you get ‘like for like’ but according
to the research, as previously stated, this is not the case. Qualified
nurses, through education, knowledge, experience and constructive
reflection, are able to perform in ways unachievable by their less
educated colleagues. The more education and experience nurses have
(hence the notion of lifelong learning for all professionals), the better they
are able to perform. One of the classic nursing texts, From Novice to
Expert (Benner, 1984), clearly illustrates this extraordinary development
process.
92
Nurses need to be the ones to spearhead the pursuit of improved quality

of care and improved standards. They can do this from their philosophical
position of being patient centred. This approach is in contrast to the
existing popular culture within hospitals, which focuses on fulfilling the
needs of the service.
In deciding the future service of the Trust, the Trust Board needs to
decide how it wishes to invest in the future. By reducing the number of
nurses looking after patients and replacing them with substitute less-
educated workers may save money initially but research has shown that
this approach, as a cost-cutting measure, does not add up. Patients are
more likely to suffer complications following treatment, which will cost the
organisation more money to put right. These costs are shown in terms of
more emergencies, repeated surgery, more hospital care perhaps
requiring intensive care, and even death.
Recruitment and Staff predominantly reported being satisfied with their work. Most gave
examples of good relationships with colleagues and real pleasure being
retention of staff
able to work with patients and other members of the public. They were
within the Trust happy with the environment, the clean building and beautiful grounds, but
there were areas of concern that should not be overlooked.
Health care support workers, administrators and those working in

different hospital departments, all reported that there were insufficient
staff numbers to properly do the work required of them. They
experienced feelings of disorganisation in their work and reported
episodes of ‘fighting the system’ instead of having systems to help them
do their work effectively. Poor systems were usually reported to be the
sources of problems, rather than individuals.
There were a few episodes of disrespect between individuals, which had

caused unnecessary distress. Some people also experienced confusion
in their roles, with a lack of uniformity across the Trust about what they
were ‘allowed’ to do in the course of their work. This issue was a real
stumbling block, and appeared to be based on perceptions and
assumptions about what people could do rather than their abilities. This
approach held people back, stopped them from being creative, and
produced anxiety instead of rewards.
Different groups also raised the problems they had in gaining promotion
and/or recognition for the level of work done. Systems seemed to be
designed to keep people in the same place financially. They were often
allowed to do more, but their efforts went un-rewarded. This made people
feel unhappy and in some cases seek employment elsewhere. The
93
tragedy of this is disappointment for the individual, and excellent people

are continually being lost from the organisation. Can the organisation
afford to let this happen?
Other issues raised
• The recruitment process for staff in WDGH was seen as

unnecessarily laborious and long-winded. There were perceptions
that delays were a mechanism to reduce costs, where reality
demanded that staff be replaced as quickly as possible to maintain
levels of care. Some sisters and charge nurses reported that they felt
unnecessarily encumbered with human resource responsibilities that
should be done by people employed in the human resource
department.
• It was reported that while some sisters and charge nurses were
undoubtedly very good, highly effective and supportive of staff and
patients, some were not. Again it would be easy to blame individuals
for their failings but as already discussed these people rarely receive
preparation for their roles. Success seemed to be more reliant on
personality and luck rather than good systems. It may be that
through necessity some people are appointed when they do not
have the necessary skills, which serves a purpose in the short term
at the expense of the individual. It may be preferable to keep a
position vacant when appropriate people cannot be found rather than
masking the problem by appointing someone who is unable to do the
job effectively. Better systems could be developed to prepare people
in advance so that when positions become vacant, a ready supply of
suitable applicants is available.
• The lack of support for learners and staff in all roles and at all levels
appeared to be a problem across the Trust. This issue should be
addressed because many people, with appropriate support and
education, are then able to do well. If this need is not addressed staff
could leave, develop illness, or become bitter and ineffective if left to
cope on their own.
Recurring themes
Throughout the history of nursing three recurring themes remain:
• The education of nurses is not recognised as important. Service
organisations do not adequately support nurses in education. Many
nurses themselves do not recognise the advantages of education for
their own personal and professional development. Professional
94
colleagues do not usually recognise the advantages of having

educated nurses and the ways in which these nurses could help
provide better services for patients.
• The lack of recognition for nurses’ abilities leads to a lack of real

authority. Even in these marginally enlightened times, the majority of
senior nurses, many of whom hold leadership positions within
organisations, do not have sufficient authority to make any kind of
change within their work environment. They are required to take their
concerns to a higher authority every time. Evidence from this and
similar studies confirms that higher authorities rarely take the
concerns of nurses seriously so senior nurses have to be persistent
in the extreme to achieve anything. This is a waste of their time,
energy and commitment.
• Because nurses are not valued or rewarded in financial or other

ways, there are few incentives for people to choose nursing as a
career so shortages are inevitable. Nursing roles are also being
eroded. Other less educated care workers do not usually have
sufficient knowledge or experience to keep patients safe. Hospitals
are dangerous places. When people are sick they may die.
Registered nurses are needed to establish and maintain standards in
hospitals. They are needed to set an example, to teach learners, to
oversee the care patients receive and to keep patients safe. Only the
nurses have sufficient knowledge and experience to do this. There
must be continuity and stability in the workforce. If there are too few
nurses able to provide this, patient safety will be put at risk.
Professional issues need serious attention if a nursing crisis and

subsequent impacts on patient care are to be avoided.
95
Conclusion
While much about the Trust appeared to be good and working effectively,
there were areas of concern. Nurses (and other staff) seemed to be
struggling to cope with the many and extensive demands placed on
them. Staff were feeling overwhelmed.
There appeared to be many complex reasons for this, including staff

shortages across the Trust, fragmented care-giving, too few ‘captains’
leading teams, and many poor systems. Nurses seemed to be at the
brunt of the difficulties. None of the reported issues could easily be fixed
but they could be improved. Staff need to be aware that their concerns
are being heard and will be addressed.
The challenge for the Trust at WDGH is perhaps to recognise that difficult
decisions have to be made. If important issues are left unattended, the
Trust runs the risk of losing many of its staff, perhaps the best staff.
People who have good qualifications and experience are able to go
elsewhere. However, many staff also expressed tremendous loyalty to
the organisation, to colleagues and to patients. Loyalty is a special quality
that should not be squandered. Once lost it is difficult to rebuild and
replace.
96
Recommendations
Systems to value While a lot of loyalty and commitment exists within the Trust, many staff
were suffering from the complex effects of changes that have taken place
staff
within the NHS over the last ten years and more. It is not surprising if
some have become battle-weary.
All staff need to be adequately rewarded for the work they do. Agenda for
change aims to rectify financial aspects of this discrepancy, but for some
time the reality is likely to be more upheaval and uncertainty. All staff
across the Trust need to be supported through this difficult time and
beyond, or the service and patients will suffer.
Financial gain is not the only way to reward staff. To give their best,
people need to feel valued and many staff across the Trust did not feel
valued by the organisation.
Leadership positions Ward sisters and charge nurses need to be given and be able to take real
authority to manage their clinical areas. They need to be supported from
below by registered nurses, and from above by matrons and managers.
They need real authority to take decisions and make the changes they
need to in their clinical areas.
Clinical nurse specialists and consultant nurses have less linear but
equally important roles to provide leadership and service development.
They should be able to do this without spending time arguing with those
who hold the real authority within the organisation.
It is assumed that nurses are given senior roles because they are
considered to be experienced and trustworthy. But these same people
are not usually given the authority they need to function. This behaviour
tells senior nurses that although they are in senior positions they are not
really trusted after all. This is an impossible situation. Senior people
cannot do their work effectively without the corresponding authority.
Recruitment Recruitment systems need to be improved to make it easier for staff to

move within the organisation. The process of bringing in new people
must also be speeded up. Staff report that they already struggle to meet
daily variations in staffing numbers – being without staff makes managing
care and patient safety almost impossible.
97
Education and Education is important if nurses and others are to function more
effectively. Research has shown that education equips nurses to work
leadership
more effectively. However, education is not the responsibility of one
development individual or organisation. Education needs to be provided from a variety
of sources, both university and hospital based. Education needs to be
supported in the workplace by nursing and other colleagues, and through
mechanisms of continuing professional development, so that learners at
all levels can reach their full potential. The concept of lifelong learning
was introduced for exactly this purpose. Learning is not about short
episodes, it is about the development of an organisational culture that
values staff, a culture that gives them opportunities to develop and
contribute to the overall values and goals of the organisation. All staff
would benefit from the development of a more open and supportive
educational culture.
Some nurses do not necessarily have a clear identity at the moment.

There are lots of different types of nursing roles and this can be
confusing for learners especially, in the early days. In an interprofessional
world, each professional needs to hold core values about their own
profession to recognise and appreciate what other professions have to
offer. Curriculum development could perhaps address this issue. There
should also be the development of strong nursing role models across the
organisation through the development of sisters and charge nurses.
For nursing to change and take an active partnership role in caring for
patients, nurses need to recognise the recurring difficulties they suffer
and address those difficulties. Many of the same problems have
burdened nurses and their development for at least a hundred years.
There are fundamental flaws in the organisation of nurses and nursing.
Nurses have to find new ways to resolve recurring problems and
difficulties, which should be approached from the perspective of providing
high-quality care for patients.
Only nurses can make real and lasting changes to their profession. They
need to be aware of the problems, aware of what has been tried before
and failed, to find new and lasting solutions. Only nurses can shape their
profession in ways nurses themselves have declared they want to work.
Nurses want to be able to give high-quality patient care, and they want to
contribute meaningfully to the development of services. Only they can
make that difference. Personal and professional development can help
them to this. They will then be in much stronger positions to bring about
lasting change to the nursing profession.
98
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increased value to practice. British Journal of Nursing. 12 (18), 1096-
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THE LANCET COMMISSION. (1932) The Lancet Commission on
Nursing. London: The Lancet Ltd.
TONUMA, M & WINBOLT, M. (2000) From rituals to reason: Creating an
environment that allows nurses to nurse. International Journal of Nursing
Practice. 6, 214-218.
WEBB, C. (1992) What is nursing? British Journal of Nursing. 1 (11),
567-568.
WEBSTER, C. (1998) The National Health Service: A Political History.
Buckingham: Open University Press.
WHITE, R. (1986) From matron to manager: the political construction of
reality. Political Issues in Nursing: Past, Present and Future, Volume 2.
In: R. WHITE (ed.) Political Issues in Nursing: Past, Present and Future,
Volume 3. Chichester: John Wiley & Sons, 45-68.
WHITE, R. (1988) The influence of nursing on the politics of health. In: R.
WHITE (ed.) Political Issues in Nursing: Past, Present and Future,
Volume 3. Chichester: John Wiley & Sons, 15-31.
101
Appendix 1
Advertisement for the Dorset Evening Echo

(Dorchester) and the Blackmore Vale
newspapers
(Bournemouth University Logo) (WDGH NHS Trust Logo)

Have you got an opinion on this subject?
Bournemouth University and Dorset County Hospital are looking for

volunteers to take part in a group discussion.
We want to find out what you value in our hospital nurses
If you live in the local area and are served by Dorset County Hospital you
can help us by attending one discussion group for just two hours.
Reasonable travelling and/or caring expenses will be met (following
application).
If you are over 18 and interested in taking part, please write in giving your
name and address (for the postal information sheet), your telephone
number (with dial code) and email (if you have one) so that we can
contact you, to the address below. If you are chosen from the replies
(random selection method used) you will be contacted during the next
few months.
Contact person: C. Partlow

IHCS Bournemouth University
st
1 floor Royal London House
Christchurch Road
Bournemouth BH1 3LT
102
Appendix 2
Information sheet June 2002

You are being invited to take part in a research project. Here is some
information to help you to decide whether or not to take part. Please take
time to read the following information carefully and discuss it with friends
and relatives. Take time to decide whether or not you wish to take part.
Thank you for reading this.
What should nursing practice and care

in WDGH NHS Trust be?
Background to the study and brief overview of the project

Nursing has changed a lot in recent years. The old models of nursing
have become eroded and new roles are taking their place. Many of the
changes have been beneficial, but so many changes have given rise to a
loss of focus about what nursing really is and what it is that nurses are
trying to achieve.
The aim of this study is to re-identify what activities and functions people
most value from registered nurses. Your views will then be used to inform
the Dorset County Hospital Trust Board to help them plan the
professional development of registered nurses and to channel the scarce
nursing resource in the most effective ways. The study will be in two
stages:
§ Stage One: Local people served by Dorset County Hospital will need
to respond to local advertising (and be prepared to complete a small
questionnaire later). For hospital employees Stage One will be this
initial contact and they are asked to complete the enclosed
questionnaire if they are interested in becoming involved.
§ Stage Two: Local people and employees will be invited to attend one
of a series of focus groups (to be held on the hospital site) to try and
establish what they most value or think is most valuable about
nursing, nursing practice and care.
The questionnaire asks general demographic details, and WDGH

employees are asked to select the group they most readily identify with.
That will be the group they become part of for this study. Up to ten people
will be randomly selected from each group to take part in one, 2-hour
focus group, which will be part of a series of focus groups to be held over
the next few months on the WDGH hospital site.
103
For effective communication focus groups need to be quite small, no

more than ten people, so if more than ten returns are obtained from one
group then a random selection of ten names will be made. They will then
be contacted to check on their availability. So if you have responded and
have not been contacted it will be because you were not randomly
selected from the replies but your group will be represented.
To include as many people as possible reasonable travel and/or care

expenses will be met by WDGH NHS Trust. (An invoice will be given to
you at the focus group to be processed later by the accounts department
at WDGH). Trust employees may also apply but they will need to obtain
prior approval from the Director of Nursing.
This study is a collaborative investigation between WDGH NHS Trust and

Bournemouth University but only researchers at Bournemouth University
will have access to information collected. This process will ensure that all
data collected will remain anonymous. A report will be presented at the
end of the study.
104
Appendix 3
Questionnaire
Employees of WDGH please complete all questions where applicable
(and return to the researcher at Bournemouth University). Members of
the public please complete questions 2, 3 and 4 (before the focus group
starts).
What should nursing practice and care in

West Dorset General Hospitals NHS Trust be?
If you are interested in taking part in a focus group to discuss issues

around the practice and care provided by registered nurses at WDGH
please provide the information below. All of this information will remain
strictly confidential.
The information is for demographic profiling (all groups) and contact

purposes and group selection (for employees of WDGH). It may also be
used anonymously as part of the report. All the details will be held in a
secure place by the researcher and destroyed when the study is
completed.
Employees of WDGH NHS Trust please to complete question 1:

1. In order to contact you please provide:
Your name:
Telephone number with dial code

(please include the best times to reach you)
At work:
At home:
Email (if you have regular access to this service):
All groups please complete questions 2, 3 and 4:

2. Your age:
3. Are you male or female:
4. Your title/job/profession:
105
Employees of WDGH NHS Trust to complete questions 5, 6 and 7 please

(where applicable):
5. Self-selection into groups:
This information will be used to identify which focus group you will be
invited to attend. This question is about the role you feel you fulfil within
your work area rather than your actual title or job description.
Please self-select into the group you most readily identify with (please
choose one):
Newly qualified nurse Experienced nurse

Nursing support staff Directorate
Speciality Doctor
Consultant Mental health professional
Leadership role Manager
Executive Non-Executive
Allied health professional Administration/Secretarial
Pharmacy Chaplain
Service support staff Other (please specify):
6. Number of years qualified – please answer this question only if

you have a registered clinical health professional qualification.
7. For nurses only:

Have you always worked in the NHS in Dorset as a registered
nurse? Yes/No
For employees of WDGH NHS Trust only:

When completed, please return this form to the researcher at
Bournemouth University using the pre-paid sticker provided. This return
will imply your consent to be contacted by the researcher for the purpose
of organising focus groups.
106
Appendix 4
Consent Form
Consent form to be signed by all participants before the focus group starts.
Title of the Project:
What should nursing practice and care in WDGH NHS Trust be?
This is a collaborative study between West Dorset General Hospital NHS Trust and Bournemouth
University.
Name of the Researcher(s):

Professor Iain Graham, Christine Partlow, Teresa Keane, Farnaz Heidari
Please initial each point 1-8:

1. I confirm that I have read and understood the information sheet dated June 2002 for the above
project.
2. I understand that my participation is voluntary and that I am free to withdraw at any time without my
care or legal rights being affected.
3. I am willing that my words as part of the (anonymous) focus group be tape-recorded and
transcribed later for analysis.
4. I am willing for the researcher to make (anonymous) field notes.
5. I expect that all data collected will be stored in a secure place and made anonymous for the final
report.
6. I agree that all discussions within this room remain confidential and will not be referred to or
discussed again elsewhere.
7. I am over 18 years of age.
8. I agree to take part in the study.
Name of the participant Date Signature
Name of the person taking consent Date Signature

(if different from the researcher)
Name of the researcher Date Signature
One copy to be kept by the participant and one copy to be kept by the researcher.
107
Appendix 5
Focus group information sheet
This research project is a collaboration between WDGH NHS Trust and Bournemouth University.
What should nursing practice and care

in WDGH NHS Trust be?
What is a focus group?

A focus group is a research method used to explore a particular topic from a range of perspectives. The
facilitator of the group has a number of prepared trigger questions that are designed to encourage
discussion between the members of the focus group about their views and ideas on the subject. What
individuals say during the sessions is considered to be confidential by the other members. The sessions
are usually tape-recorded to assist the research staff but the tapes are kept securely and only used by
the researchers. Members should not be concerned about their views being attributed to them as any
data from the focus groups which is given in the research findings will be reported anonymously.
Who will be there?

The focus group should be made up of no more than 10 individuals. The membership will be people who
are considered peers, for example all experienced nurses, or all doctors (wherever possible depending
upon peoples availability). Two members of the research team will facilitate the focus group, one taking
a lead role.
How long will it take?

After consent and introductions the focus group should take about 90 minutes depending upon the
fullness of the discussion during the session.
What do I need to do as a member of the focus group?

Come prepared to share your views on what you believe to be the most valuable aspects of the role
performed by registered nurses. This could include things nurses are already actively engaged in or it
could also be areas of work you would like to see developed. Think a little about your role and how your
role relates to the/other registered nurses. How do you feel about current issues and what do you see as
important for the future.
Light refreshments will be provided.
Taken from the format developed by Professor Kate Galvin and Holly Crossen-White, Institute of Health
and Community Studies, Bournemouth University.
108
Appendix 6
Focus group – order of events
1. Welcome, thanks and introductions

You have been invited here to assist with research commissioned by the Director of Nursing for WDGH
NHS Trust to share your views about what you consider to be most valuable about the role of the
registered nurse both currently and in the future. This information will help the Trust Board to develop
nurses’ education and skills in the most appropriate ways.
We will be discussing your thoughts and opinions, the things you most value and want to keep as
nursing activities as well as things that perhaps they don’t do that you feel they should be doing as
registered nurses. We also want you to consider who are the nurses and where extended roles may fit
both now and in the future.
There are no right or wrong answers just different points of view. Please feel comfortable to share your
view even if it differs from what others have said. We are interested in a range of opinions and we are
just as interested in negative things as positive things. In this type of research all your views are helpful.
2. Ground rules
Before we begin we would like to suggest things that make discussions more productive.
• Only one person to speak at a time – we are tape-recording and this will help us to capture all of
your comments. Tapes will be held securely and destroyed when the study is completed.
• We will use first names only for the discussion – but there will be no names used in the report.
Confidentiality will be protected.
• My role is to ask questions and listen. We want you to feel free to talk with one another. We will ask
questions and move the discussion through the questions. There is a tendency in these discussions
for some people to talk a lot and for some to not say very much but it is important to hear from all of
you. If this happens, my colleague or I may invite your opinion if you are not saying very much and
equally if some are sharing a lot we may ask you to let others share their thoughts.
3. Beginning
Consent forms to be signed, claim forms (and pre-paid labels) to be distributed, turn off mobile phones if
possible, name badges (first name only), start tapes. Let’s go round and find out a little bit about each
other. Please tell us your first name (and your role where mixed group).
4. Questions
5. Ending/Close
• Is there anything that you feel has been missed out in our discussions?
• Is there anything you would like to add?
• To conclude the focus group can you please give one sentence which describes what it was
like to be part of this focus group?
109
Appendix 7
Focus group questions

1. What is nursing (the activity)?
2. What is it that nurses do (the function)?
3. What should nurses be doing (that they are not doing at the
moment)?
4. What stops them (from doing those things)?
5. What do patients most remember about nursing?
6. Who are the nurses?
7. Where do expanded roles fit in?
8. Sisters/charge nurses - are they nurses or something different?
9. What would you say are the three most important things nurses do?
10. What would you say are the least important things nurses do?
Questions 11 and 12 for people who may have a view about these issues
– in particular doctors whose own roles have changed and are continuing
to change, also managers and others – to be offered but not pursued – at
the researcher’s discretion.
11. In view of the modernisation agenda and inevitable changes what

impact do you think that will have on nursing?
12. How do you think that agenda will affect the things nurses do?
For nurses only:

13. What do you enjoy about nursing?
14. What keeps you in your job?
15. Why do you stay working at WDGH?
16. Why would you leave WDGH?
110

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What makes a good nurse?

A study conducted for WDGH NHS Trust

Professor Iain Graham

Institute of Health and Community Studies

Significant contributions were made to the project by: Vanessa

Special thanks go to all focus group volunteers, the staff of

List of Tables and Figures

A potted history relating to context is provided and areas such as the

Nurse leaders have battled with medical and hospital authority to

The emergence of hospital systems has brought challenges and conflict

Nurse education is considered by reflecting on the recommendations of

misunderstood, ignored or only partially implemented. This is reflected in

The report highlights the context and methodology exploited to achieve

The findings also explore how nursing practice is affected by the

These themes are further explored in the report, highlighting barriers to

Overall three key themes emerged from the study:

Rationale for inclusion

This report attempts to give readers a historical overview up to and

The report focuses on the activities and functions of registered nurses. It

Introduction and Background

Cholera was a prevalent and devastating disease. In 1853, outbreaks of

In Britain before 1860 there was little public or professional recognition

respectable career for middle-class women. These women were

Interestingly, midwifery remained the domain of women until recent

against infections, better housing, improved water supplies and sanitation

It is worth considering that there may even be considerable risks

problems. In a review of the progress made in the treatment of cancer,

Perhaps scientists and doctors are sometimes looking in the wrong

These days, where health care is necessarily controlled by economics

Medical progress is not straightforward and treatment is not

There must be other approaches to health and healing worth considering.

Science Our confidence in science is amazing. When we get sick we want to

There is little certainty in medicine and many common

There is much that is still unknown and misunderstood. Great strides

Having unrealistic expectations gives people a false sense of security.

The evolution of British nursing

Nursing as a calling was at its lowest level by the beginning of

On his return home, and with the co-operation of his wife

decided to institute a refuge for the care, physical and moral, of

The organisation was a religious association, but not seeking

Nursing was arranged under three heads – institutional, private,

an organised supply of nurses became recognised by many, but

Standards were appalling, and nurses required courage or callousness to

It is not the failings of women placed in such circumstances that

Florence Nightingale 1820-1919

The founder of Florence Nightingale was a well-educated, intelligent and accomplished

However, following this experience, Miss Nightingale was now committed

While waiting to take up this appointment, Miss Nightingale worked with

Miss Nightingale continued to visit hospitals and collect information. She

The barracks themselves were built round a vast courtyard, and

Across the Bosphorus, in great splendour lived the British

The arrival of the Nightingale party was greeted with sullen

disposal £30,000. A visiting member of parliament Mr Augustus

There continued to be many trials and challenges for Miss Nightingale.

upheaval. Workers who had never before challenged employers were

Between 1880 and 1930, many people besides Florence Nightingale

Eva Charlotte Luckes 1854-1919

The nursing of children requires special care, special training

It is essential for nurses to recognise that when they enter a

…if a nurse was a good nurse and therefore competent. If the