130 years ago, Florence Nightingale received the Royal Red Cross from Queen Victoria in recognition of her special devotion in nursing sick and wounded servicemen. If she were alive today, she would be in awe of the phenomenal advancements in the field of medicine that have taken place in the century following her death. But what would she make of Health Secretary Jeremy Hunt telling MPs that thousands died needlessly at 14 hospitals? And what would she make of the collapse of the Liverpool Care Pathway following a government-commissioned review which heard that hospital staff drugged patients and deprived them of fluids in their last weeks of life? Nightingale’s writings contain rhetoric that reflect not only her skill as a medical practitioner, but also the premium she used to put on compassion. She will be writhing in her grave to learn that, in the 21st century, despite the revolution in modern medicine, we demonstrably fail the most vulnerable members of our society.
I’m sure the vast majority of nurses go to work with Nightingale-like fervour, determined to provide compassionate, high-quality care to their patients. So what goes wrong? It must be that they are under so much pressure from management to achieve goals and targets that they unconsciously allow patient welfare to slide further and further down on their list of priorities.
A tick-box culture is often portrayed as pointless, onerous, bean-counting bureaucracy gone mad. But targets and tick-box checklists have their place and should not be universally denounced as the root of all the problems facing organisations such as the police, the NHS and schools. Checklists ensure that important, routine tasks are not overlooked. They have obvious benefits in the working lives of people like surgeons and pilots. Would you be happy to allow a surgeon to dispense with a procedure that ensures he or she removes the correct limb or kidney? How would you feel if take-off procedures and checklists were left to a pilot’s discretion?
However, not every human activity or transaction can be reduced to mechanically ticking off items on a list. Problems occur when either the threat of litigation or the perceived need for empirical measurement of success leads managers down the garden path of analysing performance quantitatively and not qualitatively.
There are many ways of illustrating these problems. Let’s take our education system, where obsession with passing tests has gradually eroded the quality and breadth of teaching. League tables focus the attention of teachers on a narrow section of students. There is no point concentrating on the brightest ones because they already satisfy the targets. The average students may also be overlooked if they are likely to fall fairly safely within the A to C bracket. All the attention falls on those students who could be improved from a D up to a C. As a result, a school may look better statistically, despite the fact that the overall quality of teaching may have actually deteriorated.
A short while ago, it was discovered that probation officers spent only a quarter of their time dealing directly with offenders. The rest of their time was spent doing admin. They clearly became so preoccupied with ticking boxes and attending to other paperwork that they scarcely had time to do anything else. A tick-box culture can creep through an organisation like poison in the veins, reducing people to automatons and compromising their judgement and integrity.
Just as in Florence Nightingale’s time, a nurse should regularly speak to all the patients and, if she suspects anything is not right, she should respond appropriately according to her skill and judgement, whether the boxes say she should or not. There may be a place for limited, judicious use of tick-box protocols in hospitals, but care, in the wider sense of the word, cannot and should not be measured that way. Procedures must allow for treatment to be tailored to the individual patient and the management ethos must encourage and promote qualities such as empathy, sincerity and thoroughness.
Florence Nightingale once wrote that “the very first requirement in a hospital is that it should do the sick no harm”. A cultural shift must be achieved soon, or none of us will be happy to leave anyone we love alone in a NHS hospital.
