The UK Government, supported by the Royal College of Nursing (RCN), has stated its proposal to measure nursing care for compassion. The paper will consider the implications of this statement in order to contribute to future debate about the direction of UK nursing, and by extension to nursing, medicine and healthcare worldwide.

BACKGROUND AND CONTEXT

In June 2008, the UK Secretary of State for Health announced that the quality of compassion and care would now be measured in the National Health Service:

It is important that we measure not only the effectiveness and safety of patient care but also how compassionately that care is given. It is often said that the NHS is data-rich and information poor. One of the challenges of the next few years will be to find better ways of converting that data into intelligence that can improve patient care.1

The RCN issued a statement welcoming the government comments and approach.2

The government’s position was expanded in the House of Commons, when a member of parliament described the cold and bureaucratic treatment of his constituent, who had cancer, and wanted to know what hope there was for a more “human and humane service.”3 In response, the Secretary of State for Health stated that patients

… also have a right to ensure that they are treated with dignity, respect and compassion. Those things can be measured. The press were talking about the size of a nurse’s smile, but the Royal College of Nursing supports us on this because although safety and effectiveness can be measured, compassion and dignity are equally important to patients’ experience. We can measure those factors through patient surveys and ensure that the quality of care improves for everybody.4

Clearly, both the government and the profession acknowledged a lack of compassion by some staff in the National Health Service. Evidence for this had been highlighted by the Healthcare Commission earlier that year.5 This found that 7 per cent of health service complaints referred specifically to nursing issues, including attitudes of staff.

This was not new. A decade earlier, numerous reports and studies had demonstrated that many patients perceived a lack of compassion in their care.6^–8 A seminal study on the quality of surgeons for the Royal College of Surgeons that did not intend to collect data on nursing care had nonetheless received unsolicited comments:

… patients have chosen to add a large volume of free-text criticism of nursing care on the surgical wards surveyed. Although a few patients chose to write a praising account of the nurses, the following are representative of 144 written criticisms of nursing attitude, communication and standard of care.9

The 1990s marked a period of major change in how patients perceived the quality of their nursing care, coinciding with the effects of profound changes in nursing policy, education and practice from the late 1970s.10 Before this, virtually every survey contained unsolicited comments on the kindness and helpfulness of nursing staff. Overall satisfaction with hospital inpatient care was consistently high and this was particularly true of nursing care.11 Moreover, patients’ views of nurses collected by social scientists in the 1960s and 1970s—for example, by Cartwright—consistently showed that patients were extremely satisfied with their nursing care.12

Whether the quality of nursing care can be measured by such social science methods, as the government appears to believe, is questionable, as the social scientist Fitzpatrick argues.13 Collecting data regarding patient satisfaction brings problems, because patients are reluctant to express criticism of the National Health Service (NHS) or health professionals. Hence, measurement has to take these normative effects into consideration when findings are analysed.

Notwithstanding methodological issues, there is a deeper question. For it seems that behind both the government’s and the RCN’s statements is an assumption that “compassionate care” is a given requirement of nursing that is amenable to measurement. But is it? In response to the government, the NHS Confederation admitted that compassion and care needed to be put back into healthcare and that nursing quality should be measured but that “it will be difficult to measure and benchmark compassion”.14 So what is compassion? And what is its relationship to care? These questions will be addressed with reference to nursing.

CONTEMPORARY UNDERSTANDINGS OF CARE AND COMPASSION

The term care in nursing has traditionally been understood as an axiom, the normative moral practice of compassionate help for the stranger in need. This seems to be the understanding that the government, RCN and NHS Confederation presuppose. But this very specific understanding differs from other contemporary positions. Heidegger uses the term care (Sorge) to describe existential anxiety or concern of the self in temporary being in the world.15 More recently, Noddings, developing the philosophical approaches of Buber, Gilligan and Mayeroff, argues that care is not derived from individual virtue, but is relational, feminine and emotional.16^–19 She supports Gilligan’s ethics of attachment and relationality, Mayeroff’s view that caring is self-actualisation, and Buber’s I and Thou conception, but she rejects Buber’s theistic framework.

Like Gilligan, Noddings espouses a view of feminine morality differentiated from what she perceives to be the more masculine and rational Kantian duty ethic. Noddings suggests that the moral impetus to care is an engrossed subjective experience and not a moral norm. It is neither generalisable nor universalisable and depends on an affirmative response in the cared-for. From this perspective, “compassion” is an emotional response dependent on reciprocation, and not a virtue to be cultivated as an aspect of individual character. This feminine ethic of care is not intended to provide a moral basis for the nurse to help the unresponsive, indifferent or even hostile and unsympathetic stranger. Not normative, and derived from the feminine nature, it is problematic for the male nurse too.

These contemporary approaches to care are by their nature not measurable, so cannot respond to the government’s call. Nevertheless, it seems doubtful that the secretary of state for health is referring to concepts of care as defined by either Heidegger or Noddings. So what is the basis for the traditional understanding of compassionate care that the government seems to presume?

THE TRADITIONAL UNDERSTANDING OF CARE: COMPASSION—THE VIRTUE THAT UNDERPINS THE PRACTICE OF CARE FOR THE STRANGER

The traditional view of care is of a practice that depends on the cultivation of the virtue of compassion in the carer.20 21 From this perspective, compassion is suffering together with another: more than an emotion or feeling it is a whole praxis. As a virtue, compassion has a moral and intellectual component that is universalisable. Compassion is a virtue that the individual cultivates as part of his or her character. It involves a strengthening of virtuous intention and practices and a deepening of the disposition to do the morally right thing even when no one is watching. There is congruence between the interior and exterior dimensions of moral acts. Compassion is not an abstract theoretical idea but is lived out in the practice of the carer.

Historically, it was this imperative, the development of the compassionate character as the impetus for the practice of care, that provided the nursing profession with its ethos until its rejection in the 1970s. As Nightingale22 reiterated, it is what the nurse is inside that counts; “the rest is only the outward shell or envelope”. She was clear: “If the Nurse has not practised the “heroic virtues” who has?” Until the 1960s, numerous writers on nursing espoused very similar conceptions of care, as the development of virtue alongside scientific practice.23 Nurse training involved becoming kind and compassionate, as well as becoming technically competent; nursing was both art and science.

This ethos is clearly shown in the writings of Evelyn Pearce, a General Nursing Council member and examiner, who wrote the classic nursing textbook that was regularly updated from 1937 to 1971 and was used in the training of generations of student nurses.24 She emphasised the importance of the nurse developing a moral character leading to devoted service of the patient: “Great patience is required in the exercise of the kindness, compassion, and unselfishness which contact with sick people demands.”25 Jarvis, an educationalist, presupposes this traditional understanding when he describes nurse training as a process of induction. The nurse educator is a guardian of a tradition about the meaning of nursing. In Jarvis’s view, education involves the education of character, and the character of the nurse is as important as the knowledge that she possesses.26

This approach, the cultivation of the compassionate character, was rooted and grounded in the Judaeo-Christian framework of moral values underpinned by the narrative encapsulated in the Good Samaritan. Nightingale explicitly stressed the importance of such values in her letters to probationers.22 Pearce, similarly, is clear that the ethos of nursing is derived theologically: “A nurse is privileged to be an integral part of God’s design in the world of service … The inspiration of Christian nursing is a history of love.”25 The same tradition gave rise to a very specific and practical way of care, described recently by the secular sociologist, Bauman, as being “my brother’s keeper”.27

Because this approach is not empirically testable, the nurse’s character could not be empirically measured. Rather, to test the quality of nursing care was to make a moral judgement on the character of the carer, and such judgements could only occur from within the tradition of kindness. Nightingale argued firmly that the art of care was not amenable to testing or certifiable by examination. The nurse was caring for living people, “living bodies and no less living minds”, and was not like a plumber or carpenter.28 As she wrote, “It is what she is in herself, and what comes out of herself, out of what she is—that exercises a moral or religious influence over her patients. No set form of words is of any use.”22 Pearce, too, is clear that compassionate care is not expressed so much in words as in actions: in firm touch, a gentle and courteous manner and kindness. “Kindness cannot be over-estimated. It endows the character with qualities which make it rich and warm as the sentiments of the heart temper the efficiency of the work of head and hands.”25

REDEFINED UNDERSTANDINGS OF “CARE” IN NURSING

As Pearce recognised with sadness, from the end of the 1960s onwards the vocational values of this model, and particularly its underpinning moral framework, were rejected by nursing leaders. “People shrink from the word vocation instead of profession, but it is in vocation that full expression of oneself can be found … because in vocation the good of man and not any personal pleasure or profit-seeking is the motive.”25 Writers on nursing were anxious to remove the quasi-religious base for care.29 As a consequence, as occurred in the USA earlier, student nurses who often entered training with a presumption of this framework of values underwent a professional socialisation and doctrinal conversion that repudiated such values.30

North American nursing began to influence UK nursing. Writers on nursing in both the USA and the UK sought to restate conceptions of nursing care and caring devoid of quasi-religious foundations in similar ways to Noddings.16 Even though some nursing writers—for example, McFarlane in the UK and Benner in the USA—were personally very sympathetic to the Judaeo-Christian framework,31 32 the new frameworks that they espoused publicly were supported by reference to secular philosophies. McFarlane draws on Mayeroff,33 19 while Benner and Wrubel draw on Heidegger.34 15 The originating Good Samaritan framework is not made explicit.

But not all nursing writers agree that these newly developed positions are supportable, either philosophically or pragmatically. Allmark, for example, in a critique of “ethics of care”, and with reference to Noddings, suggests that “care” in itself has no intrinsic moral content.35 It is a neutral term to denote what is important to the individual. As he points out, even a torturer “cares”. His view is that “caring” approaches such as espoused by Noddings,16 and drawn on by nursing writers, are “hopelessly vague”. They cannot tell what constitutes the right things or the right way. He is critical of these nursing writers who, he argues, assume “wrongly that caring is good”. Allmark’s critique shows that these nursing writers are being disingenuous, in not articulating or fostering an understanding of care underpinned by the virtue of compassion as defined by their own Judaeo-Christian moral framework. They seem to assume this framework of values as if it were simply a fact of nature, which Allmark argues it is not—his argument corroborated by government concerns. Moreover, if care itself has no moral content, is not “good” in itself, the type of measurement that the UK government proposes is irrelevant.

Other nursing writers argue that an emphasis on caring is detrimental to nursing.36 37 Paley argues that the conception of “caring” as an ideology or essence of the profession is a “slave morality” that prevents nursing becoming a noble—that is, properly scientific—profession. He sees “care” being used as a paradigm to attack the “medical–scientific model” of nursing and so prevent its real development. According to Paley, drawing on Nietzsche’s Darwinian perspective, “the system of values which privileges compassion, and other slave-revolt “virtues”, over self-affirmation, risk taking, aestheticism, and experimentalism” is moral servitude. For Paley, then, the government’s proposal to measure compassionate care is both impossible and mistaken.

THE MCDONALDISATION OF CARE

Both philosophically and practically, compassionate care is no longer axiomatic in UK nursing. In 2006, Salvage, an influential nursing writer and editor, responded angrily to criticisms in the press of nurses as incompetent, sulky and uninterested.38 But, ironically, in 2004 Salvage had argued that the concept of vocational care should be rehabilitated.39 The “Good Samaritan” commitment was not well articulated or understood, suggested Salvage, but was a kind of love in action. And she referred explicitly to Nightingale’s view of care as “an act of charity”. So Salvage acknowledged that conceptions of care are rooted in a moral framework, although she disagreed with that framework. Even though Salvage still wants to secularise this idea of vocation, she cannot help but place it in its Judaeo-Christian context—even as she rejects it.

Arguably, even as modern plural society cannot countenance Judaeo-Christian values, or consider their relevance, so modern UK nursing is increasingly subject to the utilitarian model of healthcare in the UK.40 A market-driven and bureaucratised approach has overtaken the values of care. Outcomes, measurement and technical rationality predominate. Many nurses are so tied to this rationalisation and its structures that they are unable to critique it or counter its claims.41

According to Bauman, the traditional approach to care, as “my brother’s keeper”, has fallen apart and is disappearing in the face of bureaucratisation and commodification, “the cost and effects balance sheet”. The moral basis of care cannot be assumed or taken for granted, as so many contemporary nursing writers have tried to do, in a society in which “competitiveness, cost effects, calculations, profitability and other free market commandments rule supreme …”.27

Where does this lead? Ritzer suggests that bureaucratisation, which inhibits human interaction and thinking, leads to an increasingly rationalised world affecting all aspects of every day life. He uses the fast-food outlet, McDonald’s, as a case model to demonstrate his arguments: “… McDonaldization … is the process by which the principles of the fast-food restaurant are coming to dominate more and more sectors of American society as well as the rest of the world.”42 Ritzer’s thesis suggests that there are five dominant themes: efficiency, calculability, predictability, increased control and the replacement of human by non-human technology. From this perspective, he argues, the human employee is not required to think but merely to follow instructions.

With this model, all that can be measured are appearances and outcomes. If adopted as proposed by both government and the RCN, nurses will be expected to demonstrate the appearance of compassionate care as a façade. It asks nurses only to practice techniques such as the art of smiling, or the saying of warm words, in order that measures can be ticked and audited and data thereby gathered.

But genuine compassionate care is not merely a technique. It arises from virtue, an intention and practised disposition of the carer, seen but also unseen, amenable to testing only from within the values of the same tradition. To try to test this humane quality of kindness is to miss the point.

CONCLUSIONS

While it may now not be possible to return to a traditional Judaeo-Christian framework in a modern supposedly secular and plural society, it is disingenuous to claim its values. It should be clearly accepted that new models of care have different underpinning values. Without the tradition and its essence, which is immeasurable, unquantifiable, and often unobservable, all that is left is appearance, and a rhetoric echoing an earlier era. And if appearances of compassionate care are imposed on nurses by government as a technique, the nurse will be required to become merely an actor.

The appearance of compassionate care will be nothing but a façade, a pale imitation, even a parody, of the former understanding of care as arising out of virtuous character. Like the smile on the face of the Cheshire cat, this vestige of care lingers on in the mind, conveniently perhaps for politicians and the nursing leadership. But conceptions of care divorced from virtue, such as those the government proposes, make nursing practice philosophically incoherent and artificial, requiring nurses merely to pretend. Perhaps the media understand this in their criticisms of these government proposals as “measuring the nurse’s smile”. For all that can be measured is what is visible and commodifiable: the “have a nice day” nurse. This McDonaldised approach is not the same as a heartfelt nurse’s care.i