David Oliver: Senior nurses should stand up for nursing

In my 27 years as an NHS hospital doctor, my admiration for nurses in hands-on clinical roles has only grown. Whether staff nurses, ward sisters, charge nurses, specialist practitioners, or consultants, they’re dedicated, skilled, underpaid, and often undervalued. I can’t muster such consistent respect for their senior managers.

One advantage of medical career structures is that senior doctors can remain in clinical roles without losing status or income. It’s hard for doctors in leadership to retain credibility if they no longer practise. This flexibility to return from management gives them independence; not so in nursing. Some executive nurses still use their registration to do exemplary shifts. But, once they’ve left the bedside, they generally won’t return and would lose out if they did.

I think this is a big problem. Experiencing the job, as it is now, aids understanding. Advocacy for your profession is hard if you haven’t practised it recently. Outspoken independence is constrained by corporate responsibility. Recent policy controversies in English nursing highlight this problem.

The Department of Health ducked Francis’s recommendations on minimum safe nursing levels.¹ It belatedly asked the National Institute for Health and Care Excellence (NICE) for an independent review of the evidence,² but it stopped the work, perhaps because its implications looked inconvenient.³ The chief nurses of the Shelford Group of big teaching hospitals responded with a public letter opposing standardised safe staffing guidance.⁴

NHS England’s chief nursing officer (effectively a civil servant in a body very close to government) agreed to lead the safe staffing work instead, defending the moves in a letter to chief nurses.⁵ Against a backdrop of 90% of acute NHS hospitals being short of their own safe nursing establishment,⁶ the Care Quality Commission told hospital wards they were short of nurses.⁷ Most chief nurses have, to be fair, protected the front line by prioritising nursing numbers over finance. But now, NHS planning guidance tells hospitals to reduce their “head count” and agency spend.⁸

The government has proposed withdrawal of bursaries from nursing students⁹ and the planned creation of non-graduate nursing associates.¹⁰ Yet evidence links the nursing skill mix, training, and numbers to patient safety and quality¹¹—surely a principal concern for nurses in top jobs. Opposition? This has come from the Royal College of Nursing¹² and some lobbying groups including respected academic nursing researchers.^{13 14}

Nurses are a big and indispensable NHS workforce. Outspoken resignations from government nursing roles would set an example, as would condemnation from chief nurses of large trusts. What we’ve had instead is silence as the clinical profession they used to practise is run into the ground.