Are we forgetting how to care?

The profound act at the heart of nursing.

Helen Cowan

Helen is a registered nurse and freelance writer, writing for audiences ranging from the general public to practitioners and scientists.

A nurse bends beside a bed and talks to a patient

Marie Curie.

Recently, at a nursing leadership programme in Oxford, attendees focused on the fundamentals of care. Have we forgotten how to care? What can we re-learn from those who pioneered an ordinary yet profound act that affects millions?

Anam Cara is an old Gaelic term for ‘soul friend’, a person with whom you can share your innermost self, your mind and your heart. It is a term that Tom Hill, former chief executive at Helen House Hospice in Oxford, used to describe the relationship between his staff and the thousands of children and their families who passed through their ‘big red door’ in its first twenty-five years. The hospice (or ‘loving respice’ as it became known) had been founded by Sister Frances Dominica in 1982.

Other care in this country can also trace its religious roots. Between 1048 and 1070 in Jerusalem, the Order of St. John was founded for the purpose of helping pilgrims (“our Lords, The Sick”) who had become lost, weary, or beset by other difficulties while on their way to the Holy Land. Today, in the United Kingdom, the British Association of the Order has extended care to older people first in almshouses and later in care homes. A trustee for ten years was John Monckton, a man of ‘considerable talent, enormous integrity and deep religious conviction’; his tragic murder in 2004 led to the creation of the John Monckton Memorial Prize, which recognised and rightly celebrated commitment to care by care workers.

Today, across the world, seen and unseen, nurses, carers and families continue to provide compassionate care. “Assisting individuals, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge” is the very essence of nursing, captured by ‘architect of nursing’, researcher and author Virginia Henderson in 1966. Meeting more than basic needs such as breathing, eating, drinking and eliminating bodily waste (which are of essential importance), Henderson recognised the role of the nurse in enabling humans to communicate with others, worship according to their faith, satisfy curiosity and sense accomplishment.

In the desire for modernisation and professionalisation, have we lost sight of the core values and activities central to patient care?

An uncomfortable truth brought out in healthcare reports such as the Final Report of the Special Commission of Inquiry (The Garling Report) 2008, and the Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (The Francis Report) 2013 is though that this type of nursing is too often done badly or even missed, leading to pressure injury, medication errors, hospital-acquired infection, falls, unplanned readmission, critical incidents and mortality. According to nurse scientist and scholar Professor Debra Jackson, “missed care occurs much more frequently than we might think”. She cites a systematic review in which ‘care left undone’ on the last shift ranged from 75 per cent in England, to 93 per cent in Germany, with an overall estimate of 88 per cent across 12 European countries’.

In one offensively-titled paper, “Shitty nursing - the new normal?” (in which the authors apologise for the title but not the questions raised), real-life pen portraits are drawn of patients lying for hours on hospital trolleys, immobile through infection or injury, ignored by staff. Whilst acknowledging contextual factors for poor care, such as a shortage of nurses and resources, the authors argue that circumstances cannot be the sole cause of missed nursing care.

A report published by the University of Adelaide, School of Nursing, has called for nurses to ‘reclaim and redefine’ the fundamentals of care. It asks whether the cause of the problem (of missed nursing care) lies “deep in the psyche of the nursing profession itself?” “Has something happened to the way modern nursing views and values caring?” it continues. “Indeed, is nursing in danger of losing its claim to care? In the desire for modernisation and professionalisation, have we lost sight of the core values and activities central to patient care? Or is this a broader social pattern where individuals are less inclined to show kindness, compassion, and care for others even if it is a necessary requirement of the job?”

Compassion, he emphasises, is more than empathy - and way "less fluffy" but much more measurable than kindness.

Writing in the British Medical Journal, Professor of critical care medicine Peter Brindley and Consultant in intensive care Matt Morgan wonder whether doctors also “too often default to high-tech and low-touch” when patients are dying – a time “when community and connection matter most”. They powerfully begin with a mother’s comment: “Humans are gardens to tend – not machines to fix.”

Professor Sir Al Aynsley-Green, the first National Clinical Director for Children in Government and former Children’s Commissioner for England, and past president of the British Medical Association, suggests that we as a society need a “momentum for compassion”. Struck by the extremes of compassion witnessed during his wife’s treatment in the last years of her life, Sir Al wants to see a cultural transformation in healthcare: for compassion to be a key operating principle in NHS and care settings, led by the Chief Nurse’s Office; for every organisation to promote the importance of compassion at the professional level; for the views of patients and families to be sought regularly; for much earlier and better focus on compassion in undergraduate and postgraduate teaching programmes for all staff; for compassion to be inspected against by the Care Quality Commission; and for a willingness to encourage staff at all levels to expose poor practice as well as celebrating excellent care.

Compassion, he emphasises, is more than empathy - and way "less fluffy" but much more measurable than kindness. “It’s putting yourself into somebody else’s shoes – and doing something about it.” Recently appointed the UK’s first Visiting Professor in Compassionate Care at Northampton University, at the age of 80, Sir Al certainly is doing something about it. He has made it his new purpose in life to “embed compassion into every aspect of care”.

Like Sir Al, Queen Elizabeth II, the UK’s longest serving monarch, espoused compassion, in word and deed. Living a life of compassionate service, the Queen made clear that her Christian faith was her guiding principle. She speaks of Jesus Christ as ‘an inspiration,’ a ‘role model’ and ‘an anchor’. “Many will have been inspired by Jesus’ simple but powerful teaching,” she said in her Christmas Broadcast, 2000. “Love God and love thy neighbour as thyself – in other words, treat others as you would like them to treat you. His great emphasis was to give spirituality a practical purpose.”

When nurses do unto others as they would have done unto themselves, and act as role model to colleagues, not only do patient experiences of care and their outcomes improve – but so does job satisfaction for nurses: a critical factor in nurse recruitment and retention – the biggest workforce challenge faced by healthcare organisations. Across the UK, there are currently more than 40,000 nursing vacancies, and thousands of burnt-out nurses are leaving the profession early. Whether nurses decide to stay or go is driven in part by their daily experience at work. The late Kate Granger, Consultant in medicine for older people, inspired Compassionate Care Awards in her name, envisioning that such a legacy would drive up standards in care - and surely also help retain nurses, through restoring a sense of pride, achievement and fulfilment to the nursing workforce.

Review

Books

Culture

22 March 2024

6 min read

The beliefs that made Jane Austen and her world

A ‘fashionable goodness’ lay at the heart of the author and her writing.

Beatrice Scudeler

Beatrice writes on literature, religion, the arts, and the family. Her published work can be found here.

A woman in 18th century clothes sits within a windowsill reading a book

Anne Hathaway as Jane Austen in Becoming Jane.

‘There just wasn’t a comprehensive book on Jane Austen’s faith’, Brenda Cox told me when I chatted to her recently, ‘That’s why I decided to write one’. She’s right. There are a handful of books that treat Austen’s Anglican faith seriously, even extensively. Irene Collins’ two books on Austen, Jane Austen and the Clergy (1994) and Jane Austen: The Parson’s Daughter (1998), as well as Laura Mooneyham White’s Jane Austen’s Anglicanism (2011) are excellent examples. But they’re also very academic. On the other hand, Cox’s new book Fashionable Goodness: Christianity in Jane Austen’s England (2022) achieves something truly remarkable: it’s both highly accessible – assuming no prior knowledge of Austen’s life, of theology, or of Regency history – and highly insightful. It’s a true labour of love (Cox told me she spent years on reading and research), and it shows. Before I say anything else about Fashionable Goodness, let me urge you to read it. If you want to understand the way Austen and her characters saw the world around them, this is the book to pick up.

I’ve spent the last ten odd years reading, thinking, and writing about Austen, and yet Cox has made me see her novels in a new light. What she does best is to help us immerse ourselves into the daily life of Regency people, detailing in the first part of her book how the Church of England functioned in Austen’s times. She explains the difference between a vicar, a rector, and a curate; what tithes were; what exams a young man had to pass to become an ordained priest. As I was reading Cox’s book, Austen’s characters gradually came alive in my imagination like never before. Learning more about how they lived their faith day to day helped me to better grasp their motivations and their behaviour. For example, how many readers (myself included!) have been left confused by the passage in Persuasion where Anne judges her cousin Mr. Elliot for his habits of ‘Sunday traveling’? It only starts to make sense once we know that traveling on a Sunday would have likely meant missing church attendance, of which Austen disapproved. Similarly, in Mansfield Park Mary Crawford’s scoffing remark that Edmund Bertram will become ‘a celebrated preacher in some great society of Methodists’ will mean little to us unless we know that in the early 19th century Methodists were often treated suspiciously and looked down upon as overly emotional and ‘enthusiastic’. To my surprise, even my opinion of Austen’s most notoriously silly clergyman, Pride and Prejudice’s Mr. Collins, improved. Cox points out that Mr. Collins writes at least some of his own sermons, at a time when many clergymen would simply pick ready-written sermons out of a sermon book; he is also resident in his own parish of Hunsford after marrying Charlotte Lucas, when non-residence – the practice of a priest delegating all duties to a curate and living away from the parish – was common. Mr. Collins may be irritating and obsequious to a fault, but if we judge him by the standards of his own time, not of ours, he emerges as quite a respectable man after all.

Far from being in ignorance of these changes in religious sensibility, Austen observed them, and they gave her hope.

And that is something else that Cox does brilliantly: she shows us that the past is indeed a foreign country, with different moral standards. Instead of trying to find ways in which we’re similar to the people of Austen’s England, Cox helps us to realise that the values and assumptions of Austen’s England are radically different from ours. Even our language is different. Focusing on what she identifies as key ‘faith words’, Cox shows us that we cannot understand just how deeply English society was steeped in the Christian faith, unless we recognise the religious significance that many words had in Austen’s times. For example, when Elinor Dashwood cries to her sister Marianne, ‘Exert yourself’ in Sense and Sensibility, she doesn’t simply mean that Marianne should be less emotionally affected by Willoughby’s betrayal. Rather, she’s reminding Marianne of her religious duty of ‘exertion’, meaning not giving in to despair. Or, when Anne Elliot engages in ‘An interval of meditation, serious and grateful’ after her engagement to Captain Wentworth in Persuasion, we should not understand Anne’s ‘serious meditation’ as mere reflection; Austen would have expected her readers to know that, in this passage, Anne is examining her conscience and specifically praying. Even the word ‘manners’, often mentioned in Mansfield Park, had a deeper meaning than simply social graces, pointing to a person’s religious principles. Cox encourages us to notice these differences, and to let the past change our way of seeing the world through its alienness.

Lastly, Cox also presents an England whose religious sensibilities were changing fast. The Church of England faced pressure to address its problems. Pluralism, the practice of one clergyman serving several parishes, meant that some members of the clergy were very well off, while others struggled to make a living. In turn, this encouraged non-residence – especially if the parishes were far from each other – and led to the non-resident parishes to be neglected. But at the same time, the Church of England was also being infused with newly found religious fervour. The Evangelical and Methodist movements, still officially part of the Anglican Church at this point, were spreading at a rapid pace thanks to figures like George Whitfield and the Wesley brothers, championing many worthy causes in the name of the Christian faith. The abolitionist movement heralded by Wilberforce, Clarkson, and Hannah More was gaining momentum just as Austen was beginning to write novels. By the time Sense and Sensibility, her first, was published, the slave trade had been abolished in England. Sunday schools were opening up which would educate thousands and thousands of children in the 19th century; the prison reform movement was gaining popularity, as were efforts to combat animal cruelty and ensure better conditions for factory workers. Goodness, as Cox puts it, was becoming fashionable in England.

What about Austen herself? Cox tells us that she mentions reading the works of abolitionists with pleasure in her letters, as well as remarking on the newly emerging Evangelical movement with somewhat like cautious admiration. Far from being in ignorance of these changes in religious sensibility, Austen observed them, and they gave her hope. As Cox quotes in the final chapter of Fashionable Goodness, in an 1814 letter to her friend Martha Lloyd, Austen describes England as ‘a Nation in spite of much Evil improving in Religion’. Austen was confident that faithful Christians could rise to the challenges placed before them, and this confidence is reflected in her heroines and heroes, whose storylines trace their growth in virtue. It’s perhaps not a coincidence that 1814 is also the year Austen started working on Mansfield Park, a novel whose heroine, Fanny Price, is famously the most ardent in her moral principles. Fanny’s ‘goodness’, however – which the narrator often explicitly mentions – is no longer fashionable. Contemporary readers of Austen tend to dislike her seriousness and her outspoken religiosity. But perhaps, if we join Brenda Cox in immersing ourselves in the alien country that is Regency England, we can learn to judge the ‘goodness’ of Austen’s characters by different standards from our own. Perhaps we can free ourselves of our prejudices, and appreciate earnest characters like Fanny, as well as witty ones, like Emma Woodhouse or Elizabeth Bennet. Perhaps we too, like Austen herself, will gain hope that ‘goodness’ can be made fashionable once more in our time.