Article
Care
Change
6 min read

Are we forgetting how to care?

The profound act at the heart of nursing.

Helen is a registered nurse and freelance writer, writing for audiences ranging from the general public to practitioners and scientists.

A nurse bends beside a bed and talks to a patient
Marie Curie.

Recently, at a nursing leadership programme in Oxford, attendees focused on the fundamentals of care.   Have we forgotten how to care? What can we re-learn from those who pioneered an ordinary yet profound act that affects millions? 

Anam Cara is an old Gaelic term for ‘soul friend’, a person with whom you can share your innermost self, your mind and your heart. It is a term that Tom Hill, former chief executive at Helen House Hospice in Oxford, used to describe the relationship between his staff and the thousands of children and their families who passed through their ‘big red door’ in its first twenty-five years. The hospice (or ‘loving respice’ as it became known) had been founded by Sister Frances Dominica in 1982.  

Other care in this country can also trace its religious roots. Between 1048 and 1070 in Jerusalem, the Order of St. John was founded for the purpose of helping pilgrims (“our Lords, The Sick”) who had become lost, weary, or beset by other difficulties while on their way to the Holy Land. Today, in the United Kingdom, the British Association of the Order has extended care to older people first in almshouses and later in care homes. A trustee for ten years was John Monckton, a man of ‘considerable talent, enormous integrity and deep religious conviction’; his tragic murder in 2004 led to the creation of the John Monckton Memorial Prize, which recognised and rightly celebrated commitment to care by care workers. 

Today, across the world, seen and unseen, nurses, carers and families continue to provide compassionate care. “Assisting individuals, 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” is the very essence of nursing, captured by ‘architect of nursing’, researcher and author Virginia Henderson in 1966. Meeting more than basic needs such as breathing, eating, drinking and eliminating bodily waste (which are of essential importance), Henderson recognised the role of the nurse in enabling humans to communicate with others, worship according to their faith, satisfy curiosity and sense accomplishment.  

In the desire for modernisation and professionalisation, have we lost sight of the core values and activities central to patient care?

An uncomfortable truth brought out in healthcare reports such as the Final Report of the Special Commission of Inquiry (The Garling Report) 2008, and the Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (The Francis Report) 2013 is though that this type of nursing is too often done badly or even missed, leading to pressure injury, medication errors, hospital-acquired  infection, falls, unplanned readmission, critical incidents and mortality. According to nurse scientist and scholar Professor Debra Jackson, “missed care occurs much more frequently than we might think”. She cites a systematic review in which ‘care left undone’ on the last shift ranged from 75 per cent in England, to 93 per cent in Germany, with an overall estimate of 88 per cent across 12 European countries’. 

In one offensively-titled paper, “Shitty nursing - the new normal?” (in which the authors apologise for the title but not the questions raised), real-life pen portraits are drawn of patients lying for hours on hospital trolleys, immobile through infection or injury, ignored by staff. Whilst acknowledging contextual factors for poor care, such as a shortage of nurses and resources, the authors argue that circumstances cannot be the sole cause of missed nursing care. 

A report published by the University of Adelaide, School of Nursing, has called for nurses to ‘reclaim and redefine’ the fundamentals of care. It asks whether the cause of the problem (of missed nursing care) lies “deep in the psyche of the nursing profession itself?” “Has something happened to the way modern nursing views and values caring?” it continues. “Indeed, is nursing in danger of losing its claim to care? In the desire for modernisation and professionalisation, have we lost sight of the core values and activities central to patient care? Or is this a broader social pattern where individuals are less inclined to show kindness, compassion, and care for others even if it is a necessary requirement of the job?” 

Compassion, he emphasises, is more than empathy - and way "less fluffy" but much more measurable than kindness. 

Writing in the British Medical Journal, Professor of critical care medicine Peter Brindley and Consultant in intensive care Matt Morgan wonder whether doctors also “too often default to high-tech and low-touch” when patients are dying – a time “when community and connection matter most”. They powerfully begin with a mother’s comment: “Humans are gardens to tend – not machines to fix.” 

Professor Sir Al Aynsley-Green, the first National Clinical Director for Children in Government and former Children’s Commissioner for England, and past president of the British Medical Association, suggests that we as a society need a “momentum for compassion”. Struck by the extremes of compassion witnessed during his wife’s treatment in the last years of her life, Sir Al wants to see a cultural transformation in healthcare: for compassion to be a key operating principle in NHS and care settings, led by the Chief Nurse’s Office; for every organisation to promote the importance of compassion at the professional level; for the views of patients and families to be sought regularly; for much earlier and better focus on compassion in undergraduate and postgraduate teaching programmes for all staff; for compassion to be inspected against by the Care Quality Commission; and for a willingness to encourage staff at all levels to expose poor practice as well as celebrating excellent care.  

Compassion, he emphasises, is more than empathy - and way "less fluffy" but much more measurable than kindness. “It’s putting yourself into somebody else’s shoes – and doing something about it.” Recently appointed the UK’s first Visiting Professor in Compassionate Care at Northampton University, at the age of 80, Sir Al certainly is doing something about it. He has made it his new purpose in life to “embed compassion into every aspect of care”.  

Like Sir Al, Queen Elizabeth II, the UK’s longest serving monarch, espoused compassion, in word and deed. Living a life of compassionate service, the Queen made clear that her Christian faith was her guiding principle. She speaks of Jesus Christ as ‘an inspiration,’ a ‘role model’ and ‘an anchor’. “Many will have been inspired by Jesus’ simple but powerful teaching,” she said in her Christmas Broadcast, 2000. “Love God and love thy neighbour as thyself – in other words, treat others as you would like them to treat you. His great emphasis was to give spirituality a practical purpose.”    

When nurses do unto others as they would have done unto themselves, and act as role model to colleagues, not only do patient experiences of care and their outcomes improve – but so does job satisfaction for nurses: a critical factor in nurse recruitment and retention – the biggest workforce challenge faced by healthcare organisations. Across the UK, there are currently more than 40,000 nursing vacancies, and thousands of burnt-out nurses are leaving the profession early. Whether nurses decide to stay or go is driven in part by their daily experience at work. The late Kate Granger, Consultant in medicine for older people, inspired Compassionate Care Awards in her name, envisioning that such a legacy would drive up standards in care - and surely also help retain nurses, through restoring a sense of pride, achievement and fulfilment to the nursing workforce.  

Article
Culture
Generosity
Virtues
6 min read

We need to rescue volunteering

Our use of the word now reflects unwanted obligations, rather than a deep desire to serve.

Juila is a writer and social justice advocate. 

Two small lifeboats raft together on a river rescue.
Lifeboats on the River Thames.
x.com/rnli_teddington

It’s a hot summer evening and there are 30 of us sweating in our dry suits. Tuesdays usually mean lifeboat training, but this night is a little different. An intermission from the usual intensity of a team-building exercise: racing two lifeboats across the river Thames. Allocated into teams of two rowing in a knockout tournament, we are going to be here for a while. Our cheers provide the soundtrack for the BBC radio crew recording a programme on volunteering. The mood is convivial; the competition is fierce. None of us have to be here; all of us choose to be. We are a lifeboat crew, and we are all volunteers.  

Around 25 million people in the UK do some form of volunteering. And they are celebrated during Volunteers’ Week, which has been running for 41 years. The benefits are well documented these days. The mental and physical health boost. A sense of purpose. The chance to learn new skills. A route to forging connections with other people. 

Despite this, though, the number of people volunteering has been on a twenty-year decline. One in three organisations are struggling to retain volunteers, in part due to the cost-of-living crisis making people’s time and capacity more precious than ever.  

Beyond that, our use of the word seems to have shifted to reflect unwanted obligations, rather than a deeply held desire to serve. ‘I suppose I better volunteer to put out the chairs’ we might pronounce with the deathly weight of Katniss Everdeen’s ‘I volunteer as tribute,’ glancing to the left and the right in case anyone saves us from the undesirable task. It seems the very idea of volunteering needs rescue.  

It wasn’t on my radar to be lifeboat crew, but an unexpected new job in an unfamiliar London suburb unlocked this possibility. When I considered ‘Why wouldn’t I?’, I couldn’t find a strong reason. So, one autumn evening I trekked down for my first Tuesday night at Teddington lifeboat station. It was time to fill in the paperwork: I was officially a volunteer. 

Over the months that followed, I found myself wondering why other people gave their time, energy and skills to complete the nearly 50 training modules and to be available 24/7 when someone on the water was in need. I hungered for people’s stories, to know why they kept answering the call when their beds were warm and the night was unknown. So, over the four years that I was on the crew, I asked them. I spoke with teachers and students, company directors and full-time parents. I heard stories of multiple generations on a crew, their family’s blood running orange and blue. One woman spoke of overcoming her fear of heights to scale the side of a boat; another had an unexpected tale of a dolphin attack. Each time, I had the same question: why do you do it? 

And I was struck by the fact that none of them gave an answer that fully added up. They could name parts of it: care for people, teamwork, a love of the sea. Sometimes of the reasons they started (‘Dad did it’) were not why they stayed on (‘I could make a palpable difference’). I didn’t meet anyone who didn’t enjoy being on the water. Play and peril can co-exist – and we need to have moments of joy along the way if we’re going to be in it for the long haul. But in each case, the answers always seemed to come up a little short. If I was looking for something neat and complete, I wasn’t finding it.  

This is, perhaps, the difference between volunteering and having a hobby. At some point, volunteering will cost you something. 

Back on the river, the knockout races are suddenly interrupted. A call from the coastguard: there’s a person in difficulty in the river. The mood switch is instantaneous; the action swings from contesting to collaborating to get a boat headed upstream as fast as possible. Somewhere, someone is having a very bad day. This is what we exist for.  

The RNLI was born out of a need. In the early nineteenth century, nearly 2,000 ships – and their crews – were being wrecked on British and Irish coasts every year. Sir William Hillary saw this loss firsthand from his home on the Isle of Man, joining with others to rescue as many as possible – but it wasn’t enough. People continued to perish. So, he rallied other activists and philanthropists, and in a London pub, the charity now called the Royal National Lifeboat Institution was formed. Hillary’s motto, 'with courage, nothing is impossible’, can still be found adorning lifeboat stations around the country. 

None of the lifeboat crew members that I met seemed to think of themselves as anything but ordinary. They were full of admiration in the stories of fellow crew mates, but saw themselves as entirely human, naming everyday needs and familiar comforts. Writing about courage, Andrew Davison recognised that, 

 ‘The willingness of a courageous person to forgo ease, safety, the comforts of home, and even to risk life and limb, does not spring from hatred of any of those things’.  

This is, perhaps, the difference between volunteering and having a hobby (also commendable for its health benefits, sense of purpose, opportunities for connection). At some point, volunteering will cost you something. That sacrifice is needed demonstrates the level of care; otherwise, it’s simply another act of self-actualisation in the service of the volunteer themselves. 

It’s dark on the river and the boat crew is still out. The BBC’s team has packed up for the evening. We have tidied the station, no evidence of the antics of hours earlier. We depart. Close to midnight, those of us who can, return. We bring the boat in from the water, and make it ready for the next call, which will inevitably come. One less job for those who’ve been on duty all evening. It’s the least we can do.  

In the origins of the term is a spirit of offering. The Latin voluntaries carries a sense of ‘to give of one’s free will’. This, perhaps, is where we’ve lost our way with the whole idea. For there to be a sense of duress in volunteering is to strip the generous act of its power. Where there is obligation on one side and self-interest on the other, we can find the middle ground marked by devotion, by having chosen to serve and therefore having the commitment to see it through. This is the invitation that volunteering can offer us, and that I glimpsed from people who had been volunteering on the lifeboats for decades.   

Writing to the sea-faring city of Ephesus in ancient Greece, the church leader Paul encouraged people to ‘submit to one another’, which is another way of saying sacrificially help each other. In smaller coastal communities, a lifeboat crew might be called out to save a family member. In London, a city of millions, it will always be a stranger. But either way the decision was the same: to show up. The reasons why we do it don’t always add up. There are flavours of compassion, of wanting to be useful, to be part of something bigger. But there seems to be something else as well. A dedication to meeting a need. Put another way, we might call it love. 

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