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
Belief
Books
Culture
Morality
5 min read

Jane Austen’s satire helped her survive a dark culture

Amid folly and frailty, she allowed her characters the possibility of forgiveness

Beatrice writes on literature, religion, the arts, and the family. Her published work can be found here

A regency woman writes with a quill
Juliet Stevenson stars in Jane Austen: Rise of a Genius.
BBC.

Do Jane Austen’s heroes and heroines really get the happy endings they deserve? Not exactly, argues writer and journalist Julia Yost in her recent essay, Jane Austen’s Darkness (Wiseblood Books, 2024).  

Far from an escapist Regency fantasy, Yost paints Austen’s world as one ruled by mediocrity and hatred. While believing that ‘Marriage is the heroine’s only defense against darkness’, an institution where goodness can put up a fight against moral bankruptcy, Yost also ultimately argues that none of Austen’s heroines, with the exception of Elizabeth Bennet’s in Pride and Prejudice, manage to triumph over society’s corruption.  

Most Austen readers will be able to recite a list of her villains: Mr. Wickham, Mr. Willoughby, Henry Crawford… but Yost goes beyond this, pointing out that certain universal social malaises – greed, unregulated anger, lack of charity – infect even the supposedly nobler characters in Austen’s novels. For example, Yost interprets Emma Woodhouse’s mocking of Miss Bates, Highbury’s verbally incontinent spinster, not as a sign of immaturity, but as an expression of ‘contempt’ for a social inferior. Another character in Emma, Frank Churchill, is not simply a foolish young man trying to hide an engagement to one woman by flirting with another; he actively ‘enjoys toying with Emma’, and even ‘enjoys torturing Jane [Fairfax]’, his secret fiancée, by spending time with Emma in public. Eleanor Dashwood, Sense and Sensibility’s calm and collected heroine, is guilty of moral compromise by marrying the undeserving Edward Ferrars. Mr. Bennet, Elizabeth’s father in Pride and Prejudice, is an unreformed misanthrope. Vice runs rampant in Yost’s reading of Austen’s novels. 

Not even the truly admirable men and women of Austen’s stories are spared from suffering entirely. In Persuasion, Anne Elliot and Captain Wentworth marry under the threat of the soon-to-be-resumed Napoleonic Wars. In Pride and Prejudice, the Darcys’ marital happiness, we are told in the final chapter, is not quite enough to spread moral betterment among their family and friends: Elizabeth’s sister Kitty improves greatly, but Lady Catherine de Bourgh remains arrogant, Mr. Wickham retains his rakishness, and Lydia stays just as thoughtless.  

For Yost, showing this universal moral malady does not weaken but rather strengthens the novels’ moral gravity. ‘Austen’s satire is salubrious’, she writes, and agreeing with the Austen scholar D.W. Harding, who, in his 1940 essay ‘Regulated Hatred’, argued that laughing at vice is a ‘means for unobtrusive spiritual survival’ amidst social and natural evils. Austen’s biting condemnation, in other words, is the only way to dispel the power of human vices.  

As I was reading Jane Austen’s Darkness, I found myself agreeing with many of Yost’s observations. I’ve spent the better part of the last decade writing about why Jane Austen’s satirical tone serves to make us, the readers, more aware of our failings, so Yost finds a natural ally in me.  

Despite this, I was left feeling that something was missing. There’s a dimension of forgiveness to Austen’s narrative pattern that remains largely unspoken. To be fair to Yost, that’s not the focus of the essay. And yet, I’d be remiss not to mention that, in Austen’s novels, we can’t speak of condemnation without also speaking of repentance.  

Austen’s characters are undeniably fallible. But human frailty also allows for the possibility for repentance and, ultimately, forgiveness. 

For every example of moral failure in an Austen novel, a corresponding example of true remorse can be found. Austen tells us that, after the incident where Emma mocks Miss Bates publicly, she experiences a mixture of ‘anger against herself, mortification, and deep concern’. ‘Never had she felt so agitated, mortified, grieved, at any circumstance in her life’, we’re further told, ‘She was most forcibly struck. The truth of this representation there was no denying’. Emma’s shame pushes her to admit her mistakes to herself. Something similar happens to Elizabeth in Pride and Prejudice, when she realises how blind she has been to Mr. Darcy’s goodness and Mr. Wickham’s deception. Similarly, Yost is right that Mr. Bennet’s misanthropy ‘disables him as a moral actor’, but after his daughter Lydia’s elopement with Mr. Wickham, he begins to feel the force of guilt, knowing that this might have been prevented, had he been more involved in his own children’s upbringing. And if Fanny Price, in Mansfield Park, is passive at the risk of ceasing to be a moral agent altogether, she more than makes up for it when she sternly refuses to marry the rakish Henry Crawford, a man she neither respects nor loves.  

Austen’s characters are undeniably fallible. But human frailty also allows for the possibility for repentance and, ultimately, forgiveness. As the late philosopher and Austen devotee Alasdair Macintyre argued in After Virtue (1981), all of Austen’s heroines experience a moment when they recognise their own failings, and this newly acquired virtue of ‘self-knowledge’ allows them to repent and more consciously act as moral agents in the world. 

In turn, these true acts of repentance open up the way to mutual forgiveness. After marrying Elizabeth, Mr. Darcy, who’d claimed that he couldn’t easily ‘forget the follies and vices of others’ agrees to reconcile with his aunt Lady Catherine, welcomes Lydia into his house, and even continues to financially support Mr. Wickham for Lydia’s sake. In Persuasion, Captain Wentworth eventually forgives Lady Russell for the role she played in ending his first engagement to Anne Elliot. In Sense and Sensibility, Elinor Dashwood forgives Mr. Willoughby for abandoning her sister Marianne after he confesses how much he regrets his actions.  

Even when granted to someone we may consider undeserving, this central act of forgiveness heals broken social bonds. Perhaps, it’s even more healing than the ‘salubrious’ effect of Austen’s biting satire. There is darkness in Austen, but there is also much light. And if her novels prove that moral corruption is ubiquitous, they also make the case that, despite our corrupted nature, we’re not unsalvageable: forgiveness and redemption are always within reach of humankind.  

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