Being good for nothing

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It would seem that the vexed issue of the ‘problem’ of nurse education is back on the agenda, if indeed it had ever left it. Only this week on the Radio 4 Today programme, the question of whether nurses are being over-educated once more raised its ugly head. The so-called ‘too posh to wash’ argument runs as follows:

1. The mid Staffordshire enquiry and other similar analyses of the recent ‘crisis in care’ suggests (quite rightly) that nurses are neglecting the basics in caring (or not) for their patients, and that the profession needs to review its commitment to what the Chief Nurse for England has called the 5Cs of caring – compassion, competence, communication, courage and commitment.

2. Part of the reason for this gross dereliction of duty (for that is what it is) is that nurses are over-educated; that they do not need a degree in order to give a bed-bath or feed a patient. Indeed, that being in possession of an education and a degree encourages nurses to believe that their rightful place is in the office behind a computer rather than beside a bed tending to the needs of patients.

That, anyway, is the ‘logic’ behind the argument.

I would like to make a counter-intuitive suggestion: rather than over-educating our students, I would like to suggest that they are woefully under-educated; that many of them are, in fact, hardly educated at all. I am not denying that they are well trained. Some are very well trained indeed, not only in the skills required to be a safe and competent nurse, but also in how to write essays, how to pass examinations and even how to think critically. But they are not well educated, at least not in the sense that anyone who studied at university prior to the 1990s would understand the term.

We know that being able to do a particular job and being motivated to do it are two quite different things. The motivation to care for sick and vulnerable people, particularly when the care involved is hard, messy and exhausting work, derives in large part from caring about them. And caring about people, particularly those to whom we are not particularly close, attracted or related, is largely a matter of empathy and imagination. I care about my children because I love them and because they are my children, which motivates me to care for them. I care about strangers whom I encounter in hospital because I am able to imagine myself or my children in their situation.

Without this empathic imagination, we have only our training and our duty to fall back on. And when times are tough, for example when the ward is short-staffed or when we feel exhausted at the end of a long and tiring day, it is too easy to look the other way when we see a stranger in distress.

What is lacking, then, is not training but the empathy and imagination that a broad and well-rounded education provides. The problem, not only for nursing but for society generally, is that for the past twenty years or so, the mission of our universities has been less about education and more about learning outcomes, attrition rates and student satisfaction, which is not at all the same thing.

So how can we educate our students to care about as well as for their patients? How can we help them to imagine the suffering of others to the extent that they are motivated to respond to that suffering? Richard Rorty referred to this as ‘solidarity’, which he believed could be enhanced through the arts, particularly through reading novels and other fictionalised accounts of the pain and suffering of others. Solidarity can also be increased through the study of the humanities (history, the classics), through ethnography and, particularly, through what R.D. Laing referred to as existential hermeneutics. This is not an esoteric philosophical game, but a real and genuine attempt to reach out to another person in order to place ourselves in her or his position. And whilst this might come relatively easy to some, others need to be educated in the humanity of others that extends far, far beyond an understanding of their biology, their physiology and their behaviour.

I am not talking here about an objective intellectual understanding of people, but a direct subjective empathic engagement with persons. And for those of us (including myself) for whom this does not come naturally, this requires a broad education that extends well beyond the skills of nursing, well beyond the theory and research underpinning those skills, and well beyond meeting learning outcomes and demonstrating safe and effective practice. I suspect that all of the nurses and most of the care assistants who contributed to the failure of care at Mid Staffordshire and elsewhere could, if pushed to do so, demonstrate safe and effective care. What was missing was the imagination and the humanity to see the need for it. And as numerous psychological experiments have demonstrated, we are all capable of a dereliction of our duty of care which at times borders on the murderous, so there is no room for smugness or denial.

I believe that education is our last great hope, and that means the study of issues and subjects that appear to have little or no relevance to the theory and practice of nursing, such as literature and the arts, the humanities, the classics, philosophy, anthropology, the list is endless. And if there is no time and space in the current curriculum, we must find the time and space, even if it means extending our nurse education courses to four or five years. After all, it takes seven years to qualify fully as a doctor, so why not also as a nurse?

I will end by evoking an old fashioned concept: we must educate our students to be good, and as the moral philosopher and novelist Iris Murdoch tells us, good is concerned with means rather than ends, with how we act rather than simply with the technical aspects of what we do: “The Good has nothing to do with purpose, indeed it excludes the idea of purpose… The only genuine way to be good is to be good for nothing…”. So, more education rather than less, and education that addresses the means as well as the ends of nursing, the values as well as the science, the imagination as well as the facts. As educators, our challenge is to educate our students to be good for nothing.