In 2020, we saw windows plastered with rainbows, flooding hospitals with donations and NHS workers often described as heroes. Although it has been linked to increased risks faced by health workers during the pandemic, ideas of self-sacrifice in nursing are not new. In fact, they have long underlined the nature of the role.
With the professionalization of nursing work in the 19th century, in a society where a woman’s role was defined by nursing, nurses were considered married to the work. Like military or convent life, nurses were expected to not only suffer without complaining, but to embrace it as part of your life service.
As written by E Glover, in a letter to the Nursing Journal, published in 1903:
A good nurse can never be compensated by money, She must be paid … but her work must be something better, something higher, and I can add purer and holier than the ordinary trade of today.
Women’s and workers’ rights have come a long way since then. Yet bedridden nurses’ role, work autonomy, and even salaries are still defined by the idea that they, as naturally compassionate individuals, must be willing to sacrifice parts of themselves to provide care to others.
“Bedside nursing” refers to direct patient care and includes registered, associate and assistant nurses across a range of settings. The majority work day and night shift patterns and are not paid above band six (at which level you can earn a maximum of £ 39,027 once you have more than five years of experience). In addition, you move to management or become a specialist practitioner.
Over my 15 years working on the bed, I have seen hundreds of ward staff experience burnout. My doctoral research on ward-based care distribution shows how bed nurses are particularly vulnerable to distress and burnout. Such tension is only exacerbated by heroic tales.
The lasting ideal of nursing as a calling
The historical distribution of employment by gender and class underlies a hierarchy of labor within modern health care systems. Despite providing the most patient care and being at most risk, bedridden nurses have the lowest clinical pay bands.
Medicine has long been considered a professional specialization. Nursing, conversely, was seen as a calling. It is rooted in the idea that caring is altruistic, and that caring is an attitude – not a skill.
Following this traditional demarcation between healing and care, the persistent efforts of regulators and unions to strengthen nursing as a skilled profession have unfortunately led to a greater devaluation of direct patient care and bed nursing.
With diagnostic and life-enhancing treatments at the forefront, the fundamentals of healthcare – observation, hygiene, nutrition and comfort – are framed as the basic principles and therefore the least valuable. It is defined by a pay structure that effectively rewards staff financially for moving away from bed care and to a nine-to-five role, despite having the greatest direct impact on patient care outcomes.
This rejection does not reflect the necessity or demands of bed nursing. It’s physically and emotionally strenuous work, and it comes at a price. Cross-labor force studies show that nurses across the board are undoubtedly more prone to post-traumatic stress disorder, anxiety, depression, alcohol dependence, self-harm, and suicidal ideation.
While research has shown a link between increases in mental health disorders among staff and highlights in COVID surveys, it has less to do with the trauma of COVID-specific care than it does with the increased adverse impact of overdose and under-resources.
This was most felt outside the COVID critical care departments where resources were pooled, something I saw firsthand.
How rationing care causes distress to patients and staff
During the first wave, I was redeployed to a COVID high-dependency unit, where I cared for patients who were critically ill. It left me shocked, stressed and upset. But nothing prepared me for my return to an exhausted and overloaded oncology ward for the second wave.
Patients were neglected because we could not adequately meet their needs. It was there – and not at COVID wards – that I felt unsafe, that I saw more drug errors, longer waiting times, inadequate levels of basic care and limited life-saving interventions.
When distress is unlimited and resources are limited, patients suffer humiliation, harm and neglect. How bed nurses prioritize who gets their time and attention is at the heart of my research. I have found that the process of refusing care to some to provide to others – which experts refer to as care “rationing” – has a serious detrimental effect on bed nurses.
Healthcare zoning is a human rights issue and not being able to provide good care is a significant cause of distress. Unlike policy and macro-level rationing, where institutions are ultimately held accountable for the effective neglect in which the rationing results, care rationing shifts the moral responsibility to the caregiver.
Nurses have to bear the burden of deciding who feeds their meals while it is still hot, who lies in dirty sheets and who is left alone to die. To try to mitigate these injustices, they come in early and stay late. They skip meals, they work through breaks, and they burn out.
I am currently working with the International Public Policy Observatory on a rapid evidence review, which demonstrates how poor mental health among NHS staff places an overwhelming operational burden on the service. This comes at a considerable financial cost.
While statistics on nurses’ mental well-being and its wider impact draw much-needed attention to the topic, surveys and reporting cannot do justice to the reality of the work on an understaffed, understaffed and overcrowded acute NHS department. They cannot adequately cope with the physical, emotional, and mental stress that bedridden patients endure.
As long as the role itself is devalued and as long as bed nurses are kept to an impossible standard, it will not change.
On Friday, June 17, The Conversation’s partner organization, the International Public Policy Observatory, presents an online opportunity to launch its rapid evidence review on NHS staff wellness and mental health. Speakers will include Dr Steve Boorman CBE and Professor Dame Carol Black. Sign up here for this free event.