Have NHS Pressures Caused UK Nurses to Lose Their Moral Compass?

A new research report, launched on September 28 by the Jubilee Centre for Character and Virtues, reveals that NHS pressures are hindering ethical practice and caring among UK nurses. The new research reveals that eight in ten nurses face barriers to working in a caring and compassionate manner, and that staff reductions, time pressures and ‘pen-pushing’ are leading to moral disengagement and compromising professional practice.

 The study, Virtuous Practice in Nursing, provides a moral snapshot of the profession at a time of unrivalled pressure on the NHS. It reveals that experienced nurses face serious challenges staying true to their moral character and values due to the demands on their time. The factors preventing nurses from ‘living out their own character’ on the wards include staff shortages, time constraints, bed management and administrative tasks, all of which stop them spending the time with patients they feel is required for good professional care.

More specifically, many nurses reported that they felt that conflicting demands on their time left them feeling as though they were not able to offer care in as compassionate way as they would like to, and that shortages in nursing numbers negatively affected their ability to care for patients.

The context and nature of the study

Motivated by the negative media coverage of the current state of nursing and the well-known 2013 Francis Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, this research project explored the ethical dimensions of contemporary nursing education and practice in the UK. The findings are drawn from survey and interview data from 696 participants across three-cohorts: first-year undergraduates in nursing, final-year students about to enter employment at the end of initial training, and established professionals who had been in practice for five years or more, as well as from interviews with educators from UK Schools of Nursing.

The Jubilee Centre has conducted a large body of work with students and professionals in a range of professions (lawyers, teachers, medical doctors) in recent years. As the Principal Investigator on this project, the present author was particularly struck by the finding that nurses stand out among all the experienced professionals we have surveyed. They are the only professionals where reliance on their own character compass does not pick up as they gain more experience. More specifically, we looked at the extent to which nurses rely on virtue-based reasoning (e.g. justifications about what is the compassionate thing to do) when facing ethical dilemmas in the workplace. While students entering nursing education rely heavily on such reasoning, during the course of their studies those considerations are overtaken by rule-and-code-based reasoning, and this trend continues among experienced nurses.

From the point of view of virtue ethics, which is gradually becoming the moral theory of choice in nursing ethics, this is a worrying trend. The tenets of professional ethics theory seem to be becoming increasingly irrelevant to actual nursing practice.

But there are some positives

We identified several positive findings about the profession. In particular, student nurses consistently name moral motivators like care and compassion as the principal reasons for joining the profession. Both student nurses and established professionals view the job as a vocation. Moreover, despite significant institutional pressures, nurses feel they can work autonomously and feel supported by colleagues. They also believe it is possible to maintain a level of emotional engagement with patients and their profession, which is encouraging given the motivational role of compassion and care in recruiting the nurses of the future.

The report recommends that moral role modelling is placed at the heart of nursing education. In the absence of adequate role modelling, the tendency will be to ‘go by the book’, circumventing individual reflection and responsibility and doing uncritically whatever the rules or standards of practice say.

In publishing this report, the Jubilee Centre calls for a greater emphasis on ethical theory in the education of student nurses, helping trainees to relate values and virtues to practice. The Centre also recommends a ‘robust approach’ to character evaluation at interview stage to assess the suitability of candidates for nursing, and to monitor the development of their character throughout the programme.

Food for thought

 This report shows that, given the challenges of nursing in the UK today, there is an increased pressure on nurses to get each decision right, under constraints of time and resources. To choose the option that is the best clinical one for patients, but also ethically correct, requires careful deliberation and the capacity to exhibit professional wisdom. The ability of the nurse to make such decisions on behalf of patients goes right to the core of what it means to be a nurse, whose first responsibility is to the patient. This study highlights ways in which shortcomings in the working and learning environments limit trained nurses’ and nursing students’ development of core values for nursing practice. It offers practical recommendations for improvement and paves the way for a fuller discussion of issues that are likely to be with us for quite some time.

Professor Kristján Kristjánsson was the Principal Investigator on the project ‘Virtuous Practice in Nursing’ report. The report was co-authored by  Jinu Varghese, James Arthur, Francisco Moller and Matt Ferkany. The full report can be viewed here

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