A crisis in nursing: Six operations, six stays in hospital and six first-hand experiences of the care that doesn't

t care enough
Special Report, Day one: NHS organisation is at the top of the political agenda. But what about the vital basics that more and more patients say are being neglected?
Just over a year ago, at the RSA, I gave a talk. When I got to the lectern and took a sip of water, I could see that my hand was shaking. I'm usually a bit nervous when I give a talk, but I'm not usually so nervous that I can hardly swallow. I was nervous because the talk was supposed to sound spontaneous enough to work as a live event, but polished enough to work on the radio. But most of all, I was nervous because of what I was about to say. I had, I told the audience, recently had an operation. It was, I said, my sixth in the past eight years. The surgeon, I said, was lovely, and so was the anaesthetist, and so were the nurses. But I was surprised that the nurses were lovely, because what I'd learnt, during my six stays in hospital, was that surgeons were often lovely and so were anaesthetists, but nurses often weren't kind. The first operation, I told them, was on the day we bombed Iraq. I had just been told I had cancer and was still in shock. I was worried, I said, about losing a chunk of my breast, worried that I might get lymphedema from losing my lymph nodes and worried that the cancer might have spread. But I wasn't, I said, worried about the nursing. It had never occurred to me, I said, that the thing you should worry about when you went into hospital was the nursing. And then I told them about how, when I woke up from the operation, and was still in pain and still had tubes going in and out of me, I was told by a nurse that I had to get my own breakfast. I could, I said, work out how to clip the drips and drains on to a kind of trolley thing and use it to propel myself to the room with the table and the toast. But I couldn't work out how, when you'd just lost the lymph nodes under one arm and had drips going into the other one, you were meant to pick up and pour a giant tea pot. And that, I explained, was when I realised that

nobody seemed to care whether I got a cup of tea or not. It was useful, I explained, to learn that the nurses didn't seem to think things like food and drink had anything to do with them. And to learn that it wasn't a good idea to press your buzzer. It meant that when I had the next two operations, I knew the important thing was to keep quiet and not to make a fuss. When I told the audience about the fourth operation, which I had two years ago, I thought my voice was going to crack. It made my heart beat faster to think about it then, and it still makes my heart beat faster now. I was worried about losing a breast and worried that the chunk of flesh and blood vessels from my stomach that were going to replace it might, as the surgeon had warned me, go black and die. I was worried about having an eight-hour operation and worried that my cancer had come back. But I wasn't worried about the nursing. I had switched to this hospital because I'd been told that everything that happened in it was good. It took just a few hours for me to realise that it wasn't. It took the nurse, in fact, who told me, when I finally pressed my buzzer after waiting twoand-a-half hours for someone to check the blood vessels I'd been told had to be checked every 15 minutes, that she was "busy". And who, when she finally came back to me, an hour later, didn't seem to notice I was lying in a pool of blood. And who asked me, when I winced, what was wrong with my stomach. Who didn't, in fact, even know what operation I'd had. In that elegant room, in that Robert Adam house, I tried to explain what it feels like to be lying in a hospital bed in so much pain you can't even reach out for water, and feel that if you press your buzzer, you're going to make someone cross. I tried to explain what it feels like to hear the groans of people around you whose calls for help aren't being answered. And what it feels like to hear nurses who aren't even trying to whisper complaining about the other patients, and you. I had, I said, and was embarrassed to say this in front of an audience, and embarrassed to talk about losing a breast, never felt so abandoned, or alone. And I said that I thought it was time for nurses to start recognising that they have a choice about whether to do their job badly, or well. I was on holiday when the talk went out on Radio 4, as part of a series called Four Thought. I thought some people might get in touch, because when you write about anything to do with health and hospitals, which are things that affect everyone, people always get in touch. When I wrote a column last February, after a report was released about the care of old people, and said that it was unfair to say that nurses were ageist, since some of them seemed quite good at treating young people

badly, too, I got a huge number of emails. Even so, I was surprised. When my talk was repeated, in the PM slot during the NUJ strike last July, I got even more. And what nearly all the people who wrote the emails said was that they'd had terrible experiences of nursing, too. Julie (I can't, for legal reasons, supply surnames) said that she had been "on the receiving end of degrading treatment", which had left her "with a permanent dread of ever having need to enter hospital again". Keith said that he "was shocked by the attitude of the nursing staff" and still "shudders" when he drives by the hospital. Jo said that my experiences "mirrored" hers as "an expectant mother, a daughter of a very sick mother, a patient having emergency surgery and a mother of a daughter who had an accident". Sue said that she was "berated by the night nurse" for ringing her bell and "sobbed for 15 minutes with the relief of leaving the ward". Diana watched her father "fighting for breath" and "thrashing around in blood-stained sheets" while five or six nurses "laughed and joked about their recent holidays". Caroline was told by the midwife who was meant to be helping her through labour that she was busy "eating her biscuits". Lesley woke up from her operation for breast cancer and was given a drink "reluctantly", by a nurse who wouldn't stop reading her magazine. Bronwen, who had open heart surgery, said that there were plenty of nurses "hanging around chatting, sometimes on mobile phones", but not many who seemed to want to do "their job". Denis "woke up in something akin to corrective treatment camp" where he saw "elderly confused people being threatened in quiet corners" and patients "being verbally abused". Ruth found the nurses looking after her elderly parents "disinterested, unapproachable and cross". Emily, whose husband was in intensive care for two weeks, said that the nurses seemed to have "time enough to grumble and chat", but "were too pressed to answer a patient's call". There were a lot of emails from retired nurses. Jennifer, who spent three months in hospital after a car crash, was "shocked by the attitude of the nurses" and "left with a sense of grieving" about her profession. Maggie said she felt "angry" and "ashamed". Sheila "despaired" of the "present situation in nursing". Margaret said that she, and many of her peers, were ashamed to admit they were nurses because of "the reputation of too many unkind, selfish, disinterested and uncaring people" who should "never bear the title" of a nurse. Alison said that she had started to assess the wards her elderly mother was put on for their "level of cruelty". Claire, a nurse who became a GP, had been "horrified" to see nursing "depart from its caring role". Penny, a consultant in a hospital, said that she often had to "spend five minutes just trying to find a nurse to

inform" about the patient she'd just seen. Judy, a mental health nurse, said she was often "appalled" that "seemingly OK people could be quite so uncaring". Dominic, a GP, said that it "astonished" and "angered" him that we were spending "ever more on advanced, high-tech treatments" while "neglecting the basics". The stories in the emails are very much like the stories that seem to come out almost every week in the press. A teacher who spent nine "nightmare days" at her local hospital told the London Evening Standard that she "could never recommend" that anyone should go there, "even if someone was dying". She was, she said, "neglected", "threatened", and "abused". A businesswoman spent 1,000 hiring undercover carers to look after her mother at hers because she believed patients who didn't have "a friend or relative to come in and help look after" had "no chance". A midwife overheard a colleague telling a woman in labour to "hurry up, or I will cut you". These experiences may not be the norm. Newspapers tend not to fill their pages with stories of things that went well. And the people who respond to a newspaper column, or radio programme, talking about bad experiences of nursing are likely to be the ones who've had bad experiences of their own. But the emails, and the stories in the press, and the stories of people I've spoken to, and the reports into the care of the elderly which seem to suggest that the best thing to do when you hit 65 is invest in a noose, have convinced me that there is a problem with nursing in this country, and that that problem isn't going to go away. While I lay in that hospital bed, listening to the cries of pain, and thinking of the First World War poets, and not thinking that that was ridiculous, I made a vow. I promised that I would try to make sure that other people would have a better time in hospital than me. When I got out of hospital, and cried with relief, I wanted to forget it. But when I heard the reports of old people lying in their faeces, or with open wounds that no one had put a bandage on, or with a mouth that was red and raw and parched, because they couldn't reach the beaker of water on their bedside cabinet, I knew I couldn't. I've spent quite a lot of the past year trying to find out more about nursing, and thinking about what's gone wrong and how it can be put right. I've been pleased to hear that my Four Thought programme is being used as a teaching tool in quite a few universities and healthcare trusts, and pleased to hear from the MP Margot James that she quoted it in a debate in the House of Commons. The talk was a plea for kindness and I will always think kindness matters. But I'm also aware that problems that have come about for complicated reasons don't have simple answers.

As a columnist, I try to solve the problems of the world in 1,000 words twice a week. Nobody's going to solve the crisis in nursing in 1,000 words. But over the next four days, I'm going to try to draw together the threads of what has felt to me like quite an exhausting number of meetings, conversations and reports. I've talked to patients, doctors and nurses. I've talked to the Public Health minister Anne Milton, who used to be a nurse. I haven't, because he was rather busy with other things, talked to the Health Secretary, Andrew Lansley. Looking after someone who's ill is one of the most important things anyone can do. Let's try to honour the many brilliant nurses out there by finding a way to do it better.

Reforms in the 1990s were supposed to make nursing care better. Instead, there's a widely shared sense that this was how today's compassion deficit began. How did we come to this?
The second part of our week-long series on the crisis of caring in British nursing addresses the question of what, precisely, has gone wrong
Yesterday, Christina Patterson described how extensive first-hand experience of Britain's hospitals persuaded her that all was not well with British nursing and how subsequent research suggested that her disquiet was widely shared. Here, she tries to identify the origins of the crisis. When I asked people who worked, or had worked, in the NHS what they thought had caused the biggest changes in nursing care, nearly all of them mentioned something called Project 2000. This was a new system introduced in the early 1990s, which moved the training of nurses out of hospitals and into universities. Instead of the old apprenticeship system where nurses were attached to hospital schools, and trained on the job,

they now had to study off-site for a diploma, or degree. And now, even the diplomas are being phased out. By next year, all nurses who qualify in this country will have to get a degree. Project 2000 was designed to reflect the fact that medical treatments, and clinical care, are getting more sophisticated every day. Nurses, said its champions, needed to have a full intellectual grasp of the increasingly complex treatments they were involved in delivering. The best place, they said, to get this was in the classroom of a university. And if putting trainee nurses in universities challenged traditional views of hierarchies, and the subservience that went with them, well, that wouldn't do any harm. "Nursing," says Anne Marie Rafferty, Professor of Nursing Policy at the Florence Nightingale School of Nursing and Midwifery, "is one of the toughest academic disciplines. The curriculum is very highly regulated, and very demanding. The concentration of graduates coming up into the profession is going up. The more talent we can attract, the better that will be for the profession." But quite a few people disagree. Chloe Nightingale, who not only shares the name of the world's most famous nurse but also trained at the Nightingale school in the 1970s, contacted me after hearing the Radio 4 broadcast of a talk I gave just over a year ago about my experiences of nursing. She had, she said, found her own treatment as a patient, and that of friends and relatives in hospital, "generally appalling". It had, she said, left her "in tears of frustration". When we met, with Anne Marie Rafferty, for a coffee just down the road from where she trained, she said she could see that "there were a lot of benefits to doing a degree", but that she also had doubts. "If you look at medicine," she said, "and the most intelligent people who go into medicine, that doesn't necessarily mean that they're going to be the best hands-on doctors. They have the brain, but they don't always have the empathy. That's what concerns me, that the empathy has gone." Chloe Nightingale has one daughter who's studying to be a doctor and another studying to be a nurse. She thinks one of the big problems is that nurses are now "trying to be mini doctors". "The next thing," she said, "will be that in order to be a ward sister you'll have to have a Master's degree. Why? Nursing is not rocket science. In certain areas, yes, you do need to have a brain, and you do need to be able to think on your feet, but I really don't understand why they have to make something that's a basic instinct in some people, that's the delivery of care, into a highfalutin job that's going to rule out people who'd be bloody good nurses."

It is a view that a fair number of doctors take, too. Paul Goddard, a retired NHS consultant radiologist says, in his book The History of Medicine, Money and Politics, that he has "personally overheard nurses moaning that they are fully trained medical scientists and should not be expected to deal with patient needs such as bedpans". From "day one", he told me, "nursing lecturers tell the student nurses that they are not the handmaidens of the patients or doctors, but that they are equal professionals". And then, he said, "when they find themselves on the wards, they're surprised to discover that nobody cares about their scientific pretensions". This, he said, "is a bitter pill to swallow". Patrick Strube, a consultant in intensive care in the NHS, doesn't go quite as far as that, but he does think it's a problem that student nurses are "trained in the classroom by nurse 'educators' who haven't done any actual nursing for years". There is, he says, a "reluctance to help medical staff". Nurses "are not prepared for the consultant round" and "lack knowledge of the patients and events". You'd expect doctors to be unenthusiastic about a system that has made nurses less deferential, but some nurses also think it's gone too far. It almost looks, I said to one very senior nurse at a leading London teaching hospital, as if a whole profession has been radically shaken up just to get rid of chips on shoulders. "I agree with you," she said. "I don't think you have to downplay the caring side of things just to make yourself more equal. I worry that we've tried to solve everything with a piece of paper." It wouldn't be fair to say that Project 2000 has produced nurses who are "too posh to wash", or that their training is all about theory, and not practice. Trainee nurses do spend about half their training time on the wards, but they are supervised by "mentors" who are often too busy doing paperwork to help them turn theory into practice. Chloe Nightingale's daughter, Penny Edwardes, who is currently doing her nurse training at the Nightingale School at King's College, told me the nurses on one of her placements were known for "not being brilliant" mentors. "It sort of felt," she said, "like a bit of a waste of space. They wanted to get on with their jobs, and didn't want to have to do the mentoring. When you're first starting, it's largely observations and paperwork, and just standing around." "Students," said Anthony Ingleton, a recently retired lecturer in nursing, "are now taught less nursing, and less about the elements of fundamental care. So as universities push out cohorts of practitioners who are, in some respects, less prepared, the expertise in practice is diluted."

When Project 2000 was introduced, the system of State Enrolled Nurses, to support the State Registered Nurses, was also abolished. The SENs, who had two years training, were replaced by healthcare assistants who aren't registered, or even formally trained. Even after my six stays in hospital, and after talking to scores of people who work in the NHS, I'm not at all sure how this system is supposed to work. I certainly didn't realise that some of the people who were meant to be looking after me may have had no training at all. It wasn't clear who, if anyone, was supposed to make sure that patients were fed, or washed. And if it wasn't clear to me, it probably wasn't all that clear to anyone else. "The public," said the report Frontline Care, which drew on consultations with 300 organisations and thousands of patients, "is confused about what a nurse is." Even nurses, according to the report, are confused. No wonder patients often aren't clear who, on the ward, is meant to be doing what. Patients also aren't clear who's in charge. When I discovered that the nurse who was meant to be looking after me, after an eight-hour operation with a high risk of complications, didn't even know what operation I'd had, I asked to speak to the person in charge. The nurse I spoke to, who wasn't the one who'd been assigned to my care, didn't know who this was. She disappeared for quite a while, and then told me that, since it was a weekend, there was "no one" in charge. If nurses don't even know who's meant to be supervising their work, and who will hold them to account if it isn't up to scratch, it isn't all that surprising that it isn't always great. There is, of course, no point in hankering after a system where a dragon of a sister barked at her charges for a speck of dust on a bed pan, or a ladder in a stocking. The world has changed, and so has the work nurses do. Nurses now hover over computers because a lot of their work, like almost everyone's work, means they have to hover over computers. Nursing care involves large amounts of paperwork, and endless lists. This isn't just "red tape" that can be dropped. More complex medical care means an awful lot of things have to be checked and recorded, but it also means nurses tend to focus on the task, rather than the patient. Nurses have targets, and they have to meet those targets. But if you're the patient, as Alan Baddeley, Professor of Psychology at York, pointed out to me, it can feel as if a management consultant has "tried to make a list of all the components needed for care" and "assigned them to the minimal level of competence that might be able to achieve that task". It might, he said, "work well in car manufacturing" but it doesn't "seem to work on a ward".

The shifts, too, have changed. There used to be three shifts a day, with an overlap at lunchtime, which ward sisters encouraged nurses to use to chat to the patients. Now, and presumably in order to save money, there are usually just two. This means that many nurses work three 12-hour shifts a week. It also means that by the end of those shifts they're pretty tired. "To expect people, particularly in something like coronary care where you've got to be on the ball all the time, to have that level of concentration, and to be the same throughout the day, is," says Chloe Nightingale, "just ridiculous. No wonder mistakes get made." But 12-hour shifts, though tiring, are popular. "If you were to offer most public sector people three 12-hour shifts a week," said one Independent reader who has worked widely in the public sector, "they would snap your hands off, and immediately look for a second job. The NHS/public sector job would become one to get through with as little hassle as possible, so you could be fresh and fit for the second job (agency nursing in a private hospital?) which might be the one where better attitudes are actually demanded." Most people I've spoken to seem to think that management structures in hospitals are now so complicated that no one really knows how they work. One nurse told me that there was a "complex matrix of overlapping authority", where directors of nursing, associate directors, heads of service, operation managers, transformation teams, clinical facilitators and matrons all jostled for power. At the peak of this matrix is the chief executive of the NHS trust, but the chief executive isn't the person nurses report to, and rarely makes regular visits to the wards. What all of this seems to have led to is mass confusion and stress. Nurses feel accountable to managers they think don't understand their job. They feel weighed down by paperwork. They think doctors don't respect them, and patients don't appreciate them, and managers are constantly dreaming up new "initiatives" that they expect nurses to "cascade" down. Perhaps it's not surprising that many have, as Patrick Strube explained to me, become "institutionalised and demoralised". They feel, he says, that "their work place is unsatisfactory and maybe dangerous, but they feel unable to get their voice heard". So, he says, "they keep their heads down and hope not to get disciplined". Perhaps it's also not surprising that sickness levels for nurses are much higher than the national average. Or that nurses who see bad care around them prefer not to speak out. One who contacted me said "the real conditions in which we work and the way people are treated are woefully underreported". She would, she said, "so love" to hear that she could report her experience without feeling that her "management would find out". Another said that she and her colleagues were "worn down by being the Government's puppets".

"Our pay is better than it used to be," she said, "but we have a lot more responsibility than 15 years ago. We deal with life and death still, but a very difficult, litigious and often aggressive public, and very frightening and stressful situations, and knowing our great accountability makes us very stressed at work. It is a technical and production line role now." She hoped to leave her job soon. "I am burnt out," she said, "and I fear I have lost compassion". Nurses are struggling. Some are doing an excellent job in very difficult circumstances. Some are doing badly in systems that don't seem to give them the support, or training, they need to do their jobs well. But one thing is clear. Their leaders, and their managers, are letting them down. twitter.com/queenchristina_ Tomorrow - part 3: Culture and compassion is the crisis in nursing a symptom of a wider malaise?

How can a profession whose raison d'tre is caring attract so much criticism for its perceived callousness? Does nursing need to be managed differently? Or is the answer to develop a new culture of compassion?
Day three: It is widely agreed that something has gone wrong with nursing. But are our nurses at fault? Or is Britain suffering from a wider malaise?

Most nurses want to care. Some who contacted me after Radio 4 broadcast my talk about my experiences as a patient could hardly contain the anger they felt when they heard how some of their colleagues were letting them down. "I cannot reconcile it with what I know about my own practice, and that of my colleagues," said one staff

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nurse with over 30 years experience. "I also," he said, "have the privilege of teaching student nurses, and they sometimes shame me by their lively idealism." Another, who worked on a breast care ward, said that he often worked "with tears held back" for the "spirit and the bravery" of the patients he nursed. The management at his trust, he said, was cutting back on staff, but he tried to make sure his patients didn't suffer. The trust, he said, didn't provide food for snacks in the evening, so he and a colleague left for work early in order to "pop into the supermarket" to buy biscuits for the ward. They were, he said, in case I was worried about the money he was spending, only "own brand". Every one of the nurses I stopped and questioned, at the end of long shifts at two of London's biggest teaching hospitals, said they were "proud" to be a nurse. It's possible that the ones who wouldn't talk to me, and who just wanted, fairly understandably after a 12-hour shift, to get home and collapse, were the ones who weren't. But all of them said they were upset by reports in the press of bad patient care. "If I serve my patients," said one, who trained in the Philippines, "I think they're happy. I don't rush home. I've been a nurse for 25 years, and I never go rushing home." "I try to give my best at all times," said another. "If there was a shadow of doubt in my mind that I could give good care, I wouldn't do it," said another. "I always put empathy in it," said another. "I try to think about how would I like to be treated? You have," she said, "to treat each person as an individual." All the nurses I stopped said they thought they gave their patients good care, but they also said that this was difficult when they were shortstaffed. "I'd say that the majority of nurses are caring people," said one. "I've worked from eight till now," she said, "and I was coming out smiling." I have no doubt that each of these nurses was dedicated to their work, and I wish they'd looked after me. But it seems clear that one very big factor in compassionate care is culture. Different cultures have different approaches to care. Many of these nurses were Filipino and Caribbean. Filipino and Caribbean nurses are often trained in an environment that puts a big emphasis on the compassionate side of care. Some nurses working here and about a third of the nurses in London are from overseas train in countries where hospitals expect the non-medical aspects of care to be largely undertaken by patients' families. But the much bigger issue is with British culture, and with the culture of individual hospital trusts and wards. British culture has changed. We

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value care much less than we used to. Many of us, as the MP Margot James pointed out in the debate she tabled in October on care of the elderly, seem to be more interested in our rights than our responsibilities. Nursing takes a bigger proportion of young people out of schools than any other profession, and these people, however wellintentioned, are going to reflect the attitudes of society at large. "It is," said one lecturer in nursing who didn't want to be named, "not uncommon for a student nurse to have to be told that she should not text her friends while standing at a patient's bedside. Most of my colleagues," she said, "who teach pre-registration nursing find this is a huge problem." You can't, points out Liz Fradd, who was awarded a DBE three years ago for her services to nursing, "expect people to have a particular attitude, which we think is the right attitude, when they have no experience of, for example, elderly people being treated with dignity." Even those who go into nursing because they want to provide compassionate care often find themselves becoming "socialised", as another lecturer in nursing put it, into systems and cultures that make this difficult. "While at university," said one staff nurse, "several lecturers mentioned the adoption of the culture, and the importance of not accepting it. This," he added, "seemingly is a long-standing problem." It certainly seems to be. Audrey Emerton, a cross-bencher in the House of Lords who qualified as a nurse in the 1950s, has lived through more scandals in nursing care than she can remember. "All of them," she told me, "came up with the same findings in the end. Last year," she said, "I went back to look at the 30 recommendations to see what was common to all of them, and it came to me that it was culture." Culture isn't something you change overnight, but plenty of people are trying. Jocelyn Cornwell, at the King's Fund, has started a programme called Point of Care: a mix, she told me, of "research and writing, working with hospitals, and trying to make a difference". It draws on models that have worked successfully elsewhere, like the Schwartz Rounds developed at Massachusetts General Hospital, where "caregivers from different disciplines come together to discuss difficult emotional and social issues arising from patient care". It's also exploring the idea of "intentional rounding", where nurses don't wait for patients to press their buzzer, but visit them every hour to see what they need. The results, she says, are "encouraging". Aidan Halligan, a former deputy chief medical officer for England who's now director of education at University College London Hospitals, says that "culture management" is as important as "performance management". He has developed a "learning hospital" on the site, which replicates every aspect of the design of the main hospital, where staff are

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filmed interacting with each other. The aim, he says, is to "influence attitudes and behaviours". The learning hospital offers short training programmes for staff across the medical and nursing spectrum, including one called the ward safety checklist, which aims to improve communication between all the people involved in a patient's care. The programme, he told me, when I met him to look round, can be an emotional experience for staff with "a high level of frustration", who are "desperate to do things better". When I went back to take part in one, with consultants, junior doctors and nurses from UCH, I could see how it might make a difference. But two days after the Milly Dowler hacking scandal broke wasn't an ideal time for members of a profession under siege to open their hearts to a hack. The Patients Association, in conjunction with the Nursing Standard, called an emergency meeting last October to discuss poor nursing care. They invited 45 people from inside the NHS, and organisations which work with it, and one or two interested outsiders, like me. When the group was asked if they felt nursing was the main problem with patient care, only two or three of us put up our hands. Nicola Ranger, deputy chief nurse at UCH, was one of them. "The public has genuinely lost confidence in our profession," she told me afterwards. She was, she said, irritated by "the moan culture" among some nurses. "We need to have slightly more honest conversations with people. If you really don't like it there are other jobs out there, and I bet you within a year you'll come back and tell me, actually, I have eight weeks' holiday, I'm paid well on the whole, it's not all bad." The Patients Association, with the Nursing Standard, has launched a two-year "care campaign" to address the issue of poor patient care, and also a four-point tool it's calling the "CARE challenge". It wants patients, relatives and nurses to use the "care slogan" it has come up with as a checklist for the basics of care that patients so often say are missing. It wants nurses to remember that they should Communicate with compassion; Assist with toileting, ensuring dignity; Relieve pain effectively; and Encourage adequate nutrition. It wants to highlight the obstacles nurses face in giving basic care, and support nurses who speak out about those who fail to do it. There's certainly a lot to be said for simplicity, and if the simple measures mentioned in the slogan were adopted on a mass scale, they would surely make a difference. But compassion, and "communicating with compassion", isn't always simple. It is, says Andy Bradley, a former care assistant who contacted me after hearing my programme,"demanding" and "requires discipline and practice". He has, he told me, started an organisation called frameworks4change, which aims to put compassion "at the heart of the nurse/patient relationship".

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Bradley grew up in a care home for people with dementia run by his mother, a "compassionate life-long nurse". When he got a job as a care assistant himself, working with people with complex disabilities, he was shocked by the attitudes and behaviour of some of his colleagues. Now, he runs courses in "the compassionate practitioner" for people working in care homes, local authorities and NHS trusts. The courses are proving popular with the staff and, of course, with their patients. "The response from one of my patients," said one nurse working with dementia patients in Essex, "was that it felt like he was being cared for by a friend rather than just a technician." Bradley was recently picked by The Observer as one of its "top 50 radicals", and featured on BBC Breakfast and Radio 4's The World Tonight. He wants, he says, to change the whole culture of nursing, which is certainly aiming high. But he's confident he can do it. "As a result of these programmes," he says, "there are real and lasting changes in the care given. There's a kind of ripple effect that touches all those in the organisation." I don't doubt that compassionate care can ripple out, and even up, but I can't help thinking that cultures are usually set from the top. Liz Fradd agrees. "In any organisation," she says, "you'll find pockets of good and pockets of less good, but fundamentally the thing that really matters are the people at the top. If they're not a compassionate board, if they don't empower, encourage, support and enable staff, how can they possibly do that for their patients? If you use the John Lewis example, their internal mantra is all about the staff coming first. If you treat the staff well, they'll treat the customers well, and I think that's what we've got to get right in healthcare." Dame Liz, who helped establish the Care Quality Commission and has been doing inspection and review work for many years, has been working with Baroness Emerton and others to try to get ministers and organisations to accept that "this is not just about individuals". They have, she told me, developed a "self-assessment tool", which they're calling a "cultural barometer", to help people reflect on what the culture in their organisation is like. The work is now being developed by researchers at King's College, and has been used "in its very raw state" by the NHS Confederation in its commission on dignity. The point, she says, is, "for people to use it for their personal self-reflection, and then to build up some influence inside their organisation." What it all seems to come down to is good leaders, who set good examples, and hold the staff they're managing to account. Compassion is what we all want, but it can't, as Nicola Ranger points out, "be

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emotional with every single patient". If it's going to "come from in here", she said, tapping her heart, "that's great". But "if it doesn't let's have a code of behaviour. It's a code of behaviour that, when you walk on that ward, has got to be the standard." I think she's right. Let's, by all means, train people in compassion. But when I was in hospital I'd have settled for good care, and good manners. twitter.com/queenchristina_ Tomorrow: Part 4 - How to make a difference: A day in a hospital that shows what works Special report: A crisis in nursing * Day One: Six operations, six stays in hospital and six first-hand experiences of the care that doesn't care enough * Christina Patterson: More nurses, better paid than ever so why are standards going down? * Leading article: What can and should be done about nursing * Day Two: Reforms in the 1990s were supposed to make nursing care better. Instead, there's a widely shared sense that this was how today's compassion deficit began. How did we come to this? * Day Three: How can a profession whose raison d'tre is caring attract so much criticism for its perceived callousness? Does nursing need to be managed differently? Or is the answer to develop a new culture of compassion? * Day Four: The nurses who taught an ailing hospital how to care

The nurses who taught an ailing hospital how to care

Special report day four: There are no quick fixes to the nursing crisis but, as the latest part of our investigation shows, there are examples of how to get it right
If you want to solve a problem, it helps to know what works. It helps, for example, to know what has transformed one of the biggest NHS trusts in the country from one that has prompted terrible reports by the ombudsman to one that's now described as "exemplary". So I spent a day at Manchester Royal Infirmary, to find out. The Central Manchester University Hospitals NHS Foundation Trust, as it's not very snappily called, employs more than 11,500 people, and
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treats more than a million patients a year. There's a children's hospital. There's a dental hospital. There's a women's hospital. There's an eye hospital. What it feels like, when you wander through it, is a massive university campus, on a massive industrial estate. Some of the buildings are quite old. Some are spanking new. But all the ones I visited, one cold day in December, felt full of energy, and life. In the "command centre" of its shiny, new children's hospital, I met Gill Heaton and key members of her senior nursing team. Heaton first came here to train as a nurse in 1976. She came back 10 years ago as chief operating officer, and chief nurse. Which means she's responsible not just for every single aspect of the trust's nursing care, but for every single aspect of its "operational performance". The first thing she noticed when she took charge, she told me over a cup of tea, was the "disempowerment" of the "senior nurse force". Their "recognition" and "power base" had, she said, been "eroded". Nurses, she said, no longer had loyalty to the hospital, but to the university where they'd trained. "We're just the placement now," she explained, "and the people who went through that system didn't have that recognition of having a presence, and a status." "Ten years ago," said Cheryl Lenney, the trust's director of nursing for adults, "we could probably say the areas in the trust where we're not sure we'd want our families to be cared for." Now, she said, there wasn't anywhere in the organisation she wouldn't be happy for a relative to be treated. "We have", said Heaton, "a very simple philosophy. 'Is it good enough for me and my family?' We make it," she said, "very clear that we aspire to be the best trust in the country. But," she added, "we're not." If they're not quite the best, they're very clearly near it. Their infection control, which used to be "the absolute pits", is now used as a model for other hospitals. They're the best-performing trust for colorectal cancer. Four days before my visit, they were assessed by the NHS Litigation Authority, and were awarded a level 3, which is "exceptional". And when the Care Quality Commission visited last year, they gave such a glowing assessment that Heaton actually asked them if they were sure they were that good. The answer, apparently, was yes. "They said the thing that really strikes us about here is the quality, the care, and the consistency of delivery, but also that staff are really happy." Ten years ago, according to Heaton, there was "no consistency, no structure, and no oversight". So she set about putting all these things in place. Nurses who weren't doing their jobs well were moved into "more appropriate roles". Others were encouraged to leave. Heaton restored the nursing structure, so that there was "a clear line of accountability".

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She also set about making sure that everybody was clear what the management expected. "There is", she said, "an absolute flaw in making an assumption that people know what they're doing, and that they're doing their job, and that they're doing it well." A very big part of this has been about setting standards and looking for ways to make care better. They used, for example, schemes like "productive ward", developed by an organisation called the NHS Institute for Improvement and Innovation, to look at ways to "take time out of non-patient-facing processes, and tasks". They were trying, she said, "to put a kind of performance profile" on "quality of care". They also developed their own "patient feedback devices", and built up whole banks of "quality care round data". And in the end, they decided to draw on all the different schemes they'd tried out, to develop their own. What they came up with was the "ward accreditation" scheme, which rates each ward as gold, silver or bronze. Or, in the absence of any of these, white. "It is", said Heaton, "about mainstreaming how you work, and constantly trying to improve it. "We said that within a couple of years we want all of our wards to be gold wards. What we are saying at the outset is that for those of you who aren't, that's OK, but continuing not to be is not an option." The scheme looks according to Lisa Elliott, one of the trust's "service improvement leads" at areas like the "culture of leadership", "communication within the team", and "the ability to use the data they've collected", which staff learn over a 14-week programme, to "make decisions" and "monitor change". The culture, said Heaton, is already changing. She has even overheard nurses telling each other in the canteen that they're "going for gold". And if they're not? If they're not gold, or silver, or bronze if, in fact, they're white, which means they're doing pretty badly how do they react? "Interestingly," said Lenney, "they're devastated. I don't think", she said, "that that would have happened a year ago. We've said 'that's absolutely fine, we understand all your issues, now we are going to focus you. What is it we need to do to help you get better?'" And do they, I asked, ever hear of terrible patient experiences? "Yes," said Heaton, "we do. Where we do have complaints where we think 'Oh my God, we could have done that a lot better,' if the patients or their relatives are willing, we'll ask them to come in and talk to the wider team. We have used complaints and experiences in DVDs. Often using that visually is very powerful."

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It all sounds pretty damn good. Nurses who are constantly trying to do better. Patients who are invited in to meet the chief exec. Ward leaders who are "devastated" if they get a poor rating, and vow to do better next time. So I decided to see for myself. The first ward I visited was the renal ward. It was bright. It was clean. It was cheerful. On the wall were lists and charts. One board had the heading "Improving Quality". Another had "activity clocks", which show how much time the nurses on the ward have spent on direct patient care. All members of staff, said Emily Raybould, the ward sister, have a personal development plan. About 90 per cent of the staff, she said, were "very positive" about the data collection, and had "taken it on board". Certainly, the staff seemed happy. All the ones I spoke to said, in ways that made you think they meant it, that they loved their jobs. "I enjoy working on this ward," said one healthcare assistant, "the team is very friendly. Everybody's welcoming, and the patients are all happy." Even the patients I talked to on the gastroenterology ward, which often has patients with chronic conditions that are hard to treat, seemed happy. "The care has been absolutely brilliant," said one who'd been on the ward two weeks. "I've always been treated with respect," said another. "It's a really nice place to be." Even a patient who'd been there 15 weeks, with complications relating to lupus, had nothing but praise. "The pain management", she said, "is excellent. And the staff have smiling faces." Pamela Taylor, the ward sister, told me about some of the things she'd done to make a difficult and demoralised ward better. When she took it over, most of her staff were from overseas. Quite a few of them, she said, "needed a lot of help in acclimatising, and working at the pace and standard we expected". There were, she said, "communication issues". Clinically, they were "excellent", but it was "the other side of nursing, bedside manner, empathy, and problem-solving" that wasn't, she said, so strong. So they came up with a programme to address this, and now their ward has been given a silver rating. Next time, she's hoping for gold. "When I look back to how I provided care," said Cheryl Lenney, as she walked with me back to Gill Heaton's office, "when I first trained in the early 1980s, I probably had lots of empathy, but technically there were things I might not have done, which would then have been acceptable, but today wouldn't, and patients probably died. I defy any nurse of that generation to say that didn't happen, because it did. So I think the whole social stuff about expectations, and what we expect from healthcare now, has completely changed."

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I think she's right. I think she's right to say that patient care is safer than it used to be, and I think she's right to say that nursing is "tough" and you can get "compassioned out". She's also right that the way to make things better isn't "through fear and hierarchy", but through "setting the standards" and "setting the tone". And Gill Heaton, the inspirational leader of this inspirational nursing team, is right when she says this: "You hold," she said, "such a privileged position, because you are with patients at the most vulnerable time in their lives. They will share with you things they've never shared with anybody. You have women giving birth, you have people dying, you have everything in between. You're part and parcel of all that, and you have the opportunity, whatever's going on in their life, no matter how traumatic, to make it a bit better. If you waste that opportunity," she said, and it nearly made me cry, "you can't get it back." Nurses of the year: Raising a glass in praise of nursing excellence "The terrible reports on nursing", said the chief nursing officer for England, Chris Beasley, "can suck the life out of you. We need", she said, "to dig deep to find some of those reserves, in order for that energy not to go. We need", she said, "to listen to what people say, and we need to think about what we can do to make those changes." She was speaking three weeks ago, at the awards ceremony for the Nursing Standard Nurse of the Year. It was quite a night. The champagne flowed and so, at least at moments, at least for me, did the tears. We were there to "celebrate excellence in nursing", and there seemed to be a lot of it about. A total of 22 nurses had been nominated for awards. Some worked with children. Some worked with older people. Some worked with wounded soldiers in Afghanistan. Johanne Tomlinson, the nurse who won the overall award, has developed a care plan for ex-veterans in a prison. Simon Andrews, who won the ward sister award, has transformed a trauma unit with low morale and high sickness rates into a "gold standard ward". Lisa Brown, who won the general award, has developed a scheme to reduce the high incidence of pressure ulcers. "I was a hairdresser before," she told me. "I was working with people in their own homes, and I saw that they were quite isolated, and they needed a certain level of care. I thought", she said, "I'd like to go into nursing, and try and make a difference." Simon Andrews is her boss. "We've brought ourselves back to basics," he said. "We took ownership of our care, and patients, and improved our standards from that." And what, I asked, would he say to nurses

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who were struggling? Andrews smiled. "Take a step back," he said. "Have a good relationship with your ward manager, whether you're a healthcare assistant, or a domestic on the team. And make sure that everyone feels part of the team that's trying to make the culture change." It wouldn't, I think, have been possible to leave that ceremony and not be moved. Most of us will never have the chance to help so many people at their lowest ebb. These people do, and they do it brilliantly. "Nursing", said Natalie Ions, who won the student nurse of the year award, "was a second career for me. It wasn't until I got a part-time job as a healthcare assistant to fund myself through university that I realised I was so much more comfortable spending my days with people, rather than sitting behind a desk. "So I took the plunge, and quit my job, and went into nursing. It is the best decision I ever made," she said.

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