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"open door policy of nurse recruitment",  "A cart-horse could jump through the NMC's net!", "hiding behind the skirts of the truth".

My fall from grace in nursing was a slow process, as it often is for those of us who didn't call a spade a shovel. You might first be sent to the equivalent of nursing Siberia - the staff room where everyone speaks to everyone, but not to you. This usually accompanies a stint on bed-pan alley, and subtle innuendos that your name has a thick line ruled through it. Oh my dear hearts of today, you may as well swallow the whistle and choke on it, rather than blow it!

My fall from the 36D bosom of nursing led to me being a gypsy of sorts, as nursing agencies peddled my services to a variety of private shit-holes ... Oops! ... that should be 'private nursing homes and hospitals', which 'offer unparalleled care to our dearly beloved residents'. It was whilst I was doing a drug round at one of these (very) unparallel shit-holes that I first met Mary - a nurse doing her NMC pre-registration course for overseas nurses, as it was then. Mary wasn't her real name, just as they are not when speaking to someone in an Indian call centre. She asked me, "Can I do one?", dispense a medication, that is. The prescribed dose was 100mg, and the liquid strength was 50mg in 5ml - the simplest of calculations for any nurse. As I watched Mary slowly pour 10mls into a medicine pot - hovering over the 5ml mark! - I began to have certain doubts! "Is this right?", she asked, handing me the pot. "Very nearly", I replied, somewhat kindly, "but perhaps we can just take 2ml out". Whatever her slight 'failings', she had a gentle heart of 24 carat gold, and that made me worried for her, and is why I remember her. More of Mary, soon. 

As I came to the end of my nursing travels, and having had my nursing procedures hovered over by ("Can I watch?, you do it differently here") 'nurses', the subject of fake certificates became of interest. Here are the results of my most recent research into this topic:

The idea that any average Joe or Joanne can buy a fake nursing degree and practise in the UK is likely to be false. Joe or Joanne would need some nursing experience before buying the degree and accompanying certificates that would allow them to practise as a registered nurse. The seven nurses recently arrested in California had nursing experience. A report in (June 6, 2014), sated: 'Seven people have plead guilty to charges of forgery for using fake transcripts to become licensed as Registered Nurses. All were arrested as a result of a multi-agency probe initiated by the Board of Registered Nursing (BRN) that involved the Division of Investigation (DOI), the U.S. Immigration and Customs Enforcement (ICE), Homeland Security Investigations (HSI) and the Internal Revenue Service (IRS) ... BRN licensing staff were instrumental in assisting with identifying the individuals involved and verifying they did not attend the nursing schools listed on applications for licensure. "Protecting patient safety is the Board’s top priority," said Louise Bailey, Executive Officer of the Board of Registered Nursing. "A nurse without the proper education could be dangerous to a patient". (In my experience, nurses with so-called 'proper education', and a lack of being able to convert it to good practice, have been a danger to patients).

They may have had a nursing degree and falsified their transcripts to show that they'd had all the requisite theory/clinical experiences. They may have partly gone through Nursing school. They may have been care assistants with a lot of clinical/theoretical knowledge, and I have known many of them. The end result is that they somehow managed to convince the nursing authorities that they met all the requirements for initial registration, and passed the required (NCLEX) exam. Although this is a difficult exam, enough study material exists that would allow someone to pass it. All seven people were sentenced on June 27, 2014. There are investigations into another 100 plus cases.

A question is: if people are willing to run the gauntlet of a very tough American regime, involving HSI, with severe penalties for offenders, how much more likely is it that they will come to the UK?, with its chocolate fireguard of a nurse regulatory organisation that performs No Meaningful Checks (NMC).

We are not talking about fake online degrees and transcripts from bogus colleges. My research identifies some of the premier league of forgery experts, who use the most advanced technology to replicate degrees, birth certificates, and driving and marriage licenses:

('Over the years we have developed a true expertise in developing the highest quality custom replicated documents. Our expert printers have the experience and equipment to get the job done to the highest level of quality. Customer service and relationship building is another pillar in our philosophy, in that we strive to provide the most optimal level of customer service with the hopes that the customer will come back for future printing, copying and replicating business. (We supply) Replicated, Fake Degrees/Diplomas from most post-secondary institutions from around the world (we have over 3000 templates on file) all designed to look 100% identical to the original' (Their Polish passports look extremely 'real').


( 'Obtaining a Fake Marriage Certificate takes very little time, just click on the 'order now' tab on this site and fill out the easy request form to get the authentic marriage certificate you want! We have two types of marriage certificates for your needs that can be customized for almost any country, state and province. They are: The Platinum/Official Marriage Certificate: This certificate looks 100% authentic and is designed to match up equally with originals. It is created by using embossed seals, identical water markings, identical security grade transcript paper, raised ink crests and the correct card stock weight to correspond with institution specifications'.

( 'Letter of Recommendation - $25.00 each. Letter of Enrolment Verification - $25.00 each'.


( We create and customize detailed fake diplomas and college, university, and high school documents to meet any specific requirements that you may have, no matter how detailed the document might be. We are able to produce extremely genuine documents for any application from a real college degree, a completely customized college transcript, or a fictitious high school diploma. We will gladly make any type of document you may need. All of them are available at a reasonable price and we will provide them for you within a reasonable time frame'.


( 'We are unique producer of quality fake documents. We offer only original high-quality fake passports, driver's licenses, ID cards, stamps and other products for following countries: Australia, Belgium, Mexico, Spain, Brazil, Canada, Finland, France, Ireland, Portugal, Sweden, Germany, Italy, Netherlands, UK, USA, and so many other countries. We are the best producers of quality documents, with over 1 million of our documents circulating over the world. We offer only original high-quality real and fake passports, driver’s licenses, ID cards, Visas, Birth certificate, stamps etc.'. (Over 1 million!).  


( 'Many universities, and colleges use either embossing or gold seal. It can be multiple colors as well. Some schools combine different methods to make it look as good as possible, eg. thermographic plus gold foil, or gold foil embossed. Other schools stick with their tradition for many decades, eg. University of London using relief type embossing. For relief type embossing and in case we don't have the die sets ready, it may take up to three weeks to get it done'. (They also offer an A-Z of UK 'degrees', from: Aberystwyth University, American Intercontinental University, Anglia Ruskin University (Cambridge), Anglia Ruskin University (Chelmsford),Aston University, Bangor University, Belfast Royal Hospitals, Birmingham City University (UCE), Boston University, Bournemouth University, British College of Osteopathic Medicine, British School of Osteopathy, Brunel University ... (Lincoln University 'degrees' look particularly authentic).


( 'Realistic fake diplomas, degrees, and transcripts with authentic seals from the college or university of your choice shipped quick and starting under $60! At we also offer genuine looking GED certificates and General Equivalency score sheets at prices our competitors cannot beat! Our novelty college and university diplomas are printed on premium heavyweight ivory paper stock, and they are also available with metallic gold, raised foil, and replica school seals! Our fake transcripts and GED score sheets are printed on genuine anti-tamper security paper, and are available with embossed registrar seals, and we have over one hundred fake degrees and majors on file for you to select from to complete your college or university transcript'.


('Fake College Degrees and Transcripts offers quality diploma replication and fake college degrees and transcripts, Our quality cannot be match because we use the same exact printing equipment as every major university including the same transcripts security paper. What ever the reason your looking for a fake diploma, novelty degree or university transcripts, choose us. We are not only the best quality, but we can match the same design to 100% accuracy, with no difference in quality and authenticity of our fake degrees. 100% exact as the original. If you look at our samples page you will notice the effort we put into creating a quality degree, everything from raised lettering to embossed foil seals. Our fake degrees are truly amazing. We even use the same exact registrar signatures as the date of graduation you request. Remember that using these for job interviews and other professional matters are illegal in many countries. Be careful of how you use these products ... However our products are guaranteed not to be exposed, so there is no fear in using them. They have passed rigorous scrutiny from many experts in the field and passed with flying colors. You have no fear in buying one from us ... Our largest market is in the Asian Region where our products are seen as great novelty items or as great show pieces. The laws in these countries are less stringent against novelty item so they can purchase them without and fear of recrimination from the authorities ... For added authenticity, our fake diplomas are printed on high-quality parchment paper to match the original documents. Original seals of the school are also raised embossed on the diploma. We use the school real seal and not replacement seal that other faked diploma website offers ... We also use customized safe-security paper on each of our fake transcripts in order to match the original. Why bother with generic looking fake diploma, why not go for the real deal and get yourself fake degrees that have been painstakingly created with the utmost care and even if subjected to close examination our fake diplomas will pass any quality check, so why take a risk with low quality alternatives, when we are here to create authentic fake university diplomas for you! As a matter of fact, we operate much of the same printing and embossing equipment actual universities use to print their own diplomas. Through our years of experience in the diploma printing business, we have also amassed the largest stock of real college & university diploma templates found anywhere. When printing replica diplomas for our customers, in many cases, We uses the exact color and weight parchment and printing techniques that the specific college or university of your choice would use to print their own diplomas. In addition to producing the most authentic quality replica diplomas available, Underground Documents also produces extremely realistic, replica transcripts that can be customized to your exact specifications. Our replica academic transcripts include and allow you to customize everything from classes, grades, and grade point average (GPA) to your graduation date, dates of attendance, student ID number and much more'.

Thus, a choice of entry into UK nursing is offered: use forged documents to enter a UK university and enrol on its nursing degree course. UK universities use derisory checks, if a document looks kosher, that will do, just cough up the cash. You do not have to be particularly academic, either, just keep stumping up the cash. ( 'Every year we deliver over 10,000 custom written pieces of work to students, just like you, who are looking for a little extra help to boost their grade. With the cost of university study increasing in the UK, we know how important it is to make the most of your studies and get the grade you need to kick-start your career ... Our passionate team is dedicated to improving your university learning experience by helping you achieve more with your essays, dissertations and coursework. We offer a wide range of services, including our premier custom essay and dissertation writing services, a comprehensive marking service and a wide variety of other services to help you succeed in your studies. We know it’s vital that your order is delivered on time and to the correct standard, which is where our Aftercare team come in. Our Aftercare quality checkers need to eat, sleep and breathe quality – we won’t tolerate anything but the best. This commitment to quality is why we’ve been the UK's leading writing service for over a decade. All orders are written ‘on request’, which means we guarantee it will be 100% original. In fact, we promise that if your essay is plagiarised, we will give you £5,000 in compensation'.

Alternatively, for those choosing the fast-track and less expensive route, just go and knock on the NMC door. There will always be room in their stable if their various tests on an applicants bona fides are anything to go by.

 1. Pass an eligibility assessment. Translation = Does the information on your forged documents meet our criteria? Of course it does! 

 2. Take a competence test. Translation = Take a computer-based, multi-choice test at a centre in your own country. Anyone with some nursing experience and a little revision will almost certainly pass this test. Anyone who could pass the tests taken by the seven arrested nurses would sail through this.

3. Take the objective-structured clinical examination (OSCE) at the University of Northampton. Translation = In the simulated environment perform a task that you have probably done many times before (most 'foreign' nursing is more hands-on), to a level 'based on current UK pre-registration standards'! This takes the proverbial! The reason why many UK nurse students can not get their first hospital job is because managers can not waste money bringing them up to an up-and-ready level of competence, which their university course did not provide.4. Identification check. Applicants are required to attend a face to face identification check at our office in London. At the ID interview you must produce the original versions of the documents you sent photocopies of. We will undertake final checks on your previous registration, and take a photograph for our records. Translation = Show us the original fake5. English language requirements. All applicants also meet our English language requirements, with an international English language test (IELTS) score of 7.0. The seven nurses who were arrested spoke competent English. Applicants know the height of the bar they have to jump over.

Although many newly qualified UK nurses can not get their first hospital job (I have monitored ten Hospital Trusts' vacancy boards for 6 months, and 80% of them require applicants to have 'previous experience'), the NMC actively assist foreign nurses to work in the NHS! Don't tell UKIP! 'We have been working closely with UK Immigration and Visas (formally the UK Border Agency) to ensure that there are appropriate provisions in place for applicants taking the Test of Competence: Part 2 – the Objective Structure Clinical Examination (OSCE).

 For those sponsored by an employer, it is anticipated the sponsorship will formally start from the date of the scheduled OSCE, with arrival permitted up to 14 days ahead of that date. The sponsor may choose to continue to offer sponsorship in cases where the individual needs to re-sit the OSCE. For those without sponsorship who wish to travel to the UK to take the examination, a visitor visa provision is being put in place. This will allow nurses and midwives to enter the UK on a six-month visitor visa specifically to take the OSCE'. What cost advantages accrue to a sponsoring employer? Who are they? Is it in their interests to insist on rigorous, American-style certificate validation processes? Why are three-quarters of hospital Trusts recruiting from overseas, when their job vacancy adverts clearly debar newly qualified nurses, without the necessary experience, from applying? Answer: There is no shortage of nurses, just a shortage of adequately trained ones. Those who ignore this fact are hiding behind the skirts of the truth. This situation is mirrored in America and Australia, where many newly qualified nurses can not find work.

 That the NMC testing system is fat on words but anorexic in effect is suggested by their advice to employers who find that foreign nurse the NMC have registered are not competent - report them to us! It's like a supermarket saying to customers, if you find our beef products contain horse meat, just let us know, it must have slipped through our very fine net! A cart-horse could jump through the NMC's net!

 The situation with EU nurses is even more Brian Rixish. There is either 'automatic recognition', or acquired rights. The NMC assess your training programme directly against the relevant United Kingdom (UK) educational requirements. To do this we need a complete transcript of your training, which must show the number of hours of theoretical and clinical study, and number of deliveries if you are a midwife. Certifying copies of your documents: We accept documents that have been certified by: A legal practitioner (solicitor, lawyer). A notary public. The competent authority in your country of training.  An official who is authorised to certify documents from an embassy or consulate. A police officer. A justice of the peace. The office of mayor (when authorised to do so). The certifying authority must confirm they have seen the original document. They must state their full name, profession and stamp and sign the document. We cannot accept faxes and subsequent photocopies of certified documents'. All this can be expertly forged, faxes are superfluous, as most forgery vendors offer a bespoke service -  anyone's signature or stamp of office. It is quite meaningless to have applicants turn up at the Post Office and have passport, birth, and marriage certificates checked, for these documents can be genuine.

The NMC have not been given the resources of their American counterparts. They will not phone a police station in Poland or Bulgaria and ask questions (in Polish or Bulgarian), about nursing applicants. The nurse training programmes in some EU countries are not equivalent to UK levels, which are, themselves, not high enough to guarantee students a job. The level of nursing technologies employed in these countries is inferior. This is the word on the street, away from the cloud-cuckoo tower of the NMC, away from government which declares the NMC is independent of them, but which gives them so little resources that their pitiful defence of UK nursing is in this way directly controlled by government. It is as if an open door policy of nurse recruitment is the aim of the British government, which sends ten troops to guard a border fort against an army of thousands, and only wants these troops to offer meaningless words and useless drills. The British equivalent of the American Homeland Security Service are not asked to investigate potential fraud relating to fake nursing certificates. What does that tell us? By way of answer, it can be explained that the top council members of the NMC are appointed by the Privy Council, that is, by the British Establishment. The NMC are nothing but a branch of the British government. They protect the government and not the public.

That the RCN now remonstrates against the use of off-the-peg foreign nurses, and highlights that it costs £70,000 to train a UK nurse, is laudable, but less so when it refuses to investigate exactly how many of these nursing students get a full time, long term NHS job. It is as if they do not want to bring attention to the poor cost effectiveness and training outcomes of the nurse lecturer industry, which many of their members feed off. If you attack Jack, my dears, you must also attack Jill, or else you will find yourselves falling arse over heels down the slope of the government's hill, which they are busily greasing for you. Governments are starting to muse over the advantages of one year nursing courses in specialist areas, to create a cheap form of nurse specialist, i.e. surgery/A&E nurses, rather than fund a three year degree course based on the 'Jack of all trades and the master of none' principle. A salient question to the RCN 'top brass' is: Why do you complain about the increased use of overseas nurses by the NHS, when you are starkly silent about the NMC's complicity in their recruitment? Is it merely a coincidence that most of the NMC's ruling committee are RCN members?

The number of 'fake' nurses in the UK would fill Wembley Stadium. I came to this conclusion as I recently lay on a hospital ward, ignored by the nurses I repeatedly requested assistance from. It was then that I thought of Mary, who I had once observed holding the hand of an elderly lady patient who was dying. This was after her shift had ended. She explained: "I can't bear anyone ending this life without a hand to hold". Remembering Mary, I came to this conclusion: I could not give 'Jack Shit' whether the person caring for me had forged documents or not, for I would rather be cared for by someone with a fake certificate and genuine heart than someone with a genuine certificate and a fake heart. Most of us would make this choice, I think, especially as the seven arrested nurses were probably more competent than most UK nursing graduates, and may also have had, like Mary, 24 carat hearts.

lenin nightingale 2014

 Is it Becoming Illegal To Care?

Would somebody please care to develop this or add to? Thanks

Is it becoming illegal to care?

Consider the headlines- whistleblowers unsupported or there are false accusations against them, a couple in USA charged for daring to give feed to the homeless, homeless people moved from a New York street and also in the UK, mal-treatment of some people with mental illness UK, USA, Romania..

Reasons? Are they a threat? Is it against the affluent image of the town or country? Do politicians aiming for neoliberalism - “each responsible for themselves”- urge us to harbour mal-feelings towards the so called “non contributors?”

The number of “non contributors” in all countries, is increasing due to the increasing wealth of the businessmen who pull the puppet strings of politicians.

Remember the street children killed in Brazil (amnesty 2013) ,shot in a hail of gunfire by the police. These were the real people. So much more worth than police and politicians.

 Link to history- does caring actually exist naturally or is it an aim to survive?

Suggested reading- Huxley  A Brave New World, Golding W Lord Of The Flies

Suggested viewing Soylent Green


Zero Hours

This piece is written by  a home carer, who wishes to remain anonymous. Names are unimportant. The piece is written from the heart. Too often it is demanded that articles be clogged with references which hides the voice of the person.

Zero hours and non-payment of the minimum wage , by way of non-payment of travel time Well that seems to sum up the majority of home care providers in the UK right now. Over the past year I have heard a lot of people talk about these subjects. Politicians, journalists, leading world thinkers.

 Mainly zero hours as it would appear no one seems prepared to address national minimum wage laws. No one seems to have the answer.

 I’ve heard people talk statistics, budgets , profit margins and targets. But I see these problems from a different level – ground level. I have worked in homecare for almost 20 years and have seen a decline in the quality of care being provided, as huge private equity firms have been able to take control of the sector, and drive down the cost of care to almost unattainable levels. I have witnessed huge staff turnover caused by poor terms and conditions and also abuse and neglect of those receiving care as it has become acceptable to employ people with little or no experience to cope with the increasing demand.

 When I talk zero hours and non-payment of travel time I talk about people I have met, people let down by our fundamentally broken system of care. Experienced staff forced to leave because they simply can’t afford to stay. Those receiving care accepting undignified substandard care and the lack of continuity that means they never know who is coming into their home to provide the most intimate personal care.

 I could stand here and quote statistics and budgets but I can’t – I don’t understand them. What I do understand is people, what I do understand is care.

 That is why I wanted to share an experience I had that I think sums up the problems within the current home care system. An experience that essentially continues to drive me.

 I met a lovely man I’m going to call George. George had very complex needs and was unable to carry out even the simplest of tasks without support. I only met George occasionally, when his regular carer was off. They had been together a long time , George and his family were confident in her ability to provide him with quality care.

 Suddenly Georges carer started losing hours , those hours being replaced by 15/20 minute calls , 10 -15 miles away. She was paying more for petrol than she was able to earn. The last time we spoke she was broken , struggling to provide for her family. Then she simply left.

 Her crime and the reason she was being punished this way, she dared to challenge that organisation about the quality of care they were providing.

 I started to pick up a few more calls at Georges house , immediately I was concerned about the quality of care being provided. There was no continuity George had different carers daily. Often people didn’t turn up and on several occasions George was left in bed for up to 20 hours. Times they did arrive they often forgot to give him food , drinks, medication. And more often than not they would forget to open the blinds , turn the TV and heating on. George simply couldn’t do these things alone. I and Georges family repeatedly reported concerns. I begged them to give staff details of his needs, but nothing changed. I asked to be George’s carer but they said no !

 I started to drive by George’s house about 1030 every day, if the blinds were closed I would call the office explain I was aware of the problems in his house and could I just pop in and check on him. Usually he was sitting staring at the walls no tv or heating on. Sometimes he hadn’t had any food or drinks, many times he had no medication. Each time I reported what I had found and begged them to make sure it didn’t happen again.

 This continued for several weeks until I called in and requested to go in and check as I had done many times before. I was told no, I couldn’t go in and it was none of my business anymore. I felt the fight being kicked out of me- what more could I do?

 Just a few weeks later someone called in sick and I was asked to cover a lunch call at George’s house. I arrived at the same time as his son. By now George’s family were so concerned at the quality of care being provided they had started to take it in turns to take time out of work around lunch time each day , just to make sure he had been cared for.

 As we walked in to the house I was struck by how cold it was. It was January and there was snow outside , there was no heating on and all of the internal doors were wide open.

 What I saw next will stay with me forever. George was sitting visibly shaking, he was wearing a t-shirt, his skin was grey from the cold. George was wet , a doubly incontinent man , staff had failed to provide him with a pad.

 The blinds were shut, the TV was off the lights were off. George hadn’t had anything to eat or drink , he hadn’t had any medication.

 Cold, wet, hungry, alone in the dark – just waiting for someone to help.

 I was angry, upset, annoyed , with the person who had left him to suffer like this, with the organisation who had failed to listen to my concerns, with the system of care that is so underfunded and undervalued this so called care has become accepted by many.

 Mostly I was upset angry and annoyed with myself. I allowed that organisation to knock the fight out of me – essentially I allowed that situation to continue.

 However guilty I may have felt and still feel , I know that wasn’t my fault.

 There were 3 key point which lead to Georges suffering,

Zero hour contracts and their use by way of punishment and reward.

Unpaid travel time, Georges carer simply couldn’t afford to stay.

The lack of regulations for employing care staff which mean its acceptable to employ anyone to care for our most vulnerable.

I made a promise that day , I promised George and his family I was going to fight ot ensure this never happened again.

I only hope that by sharing my experience I can get the support of others to help me keep my promise.

Culture and Care

Culture  may define to some degree how  a person behaves and the attitudes that they have (Durkheim). For example, nurses from some countries may display  a more positive attitude towards older people than from other countries. This may be demonstrated in such aspects as respect or dignity. There are NMC cases which involved such as calling an old person names; is it possible that cultural factors influenced  the nurse ? This is not to excuse the behaviour, but to heighten awareness of factors involved so as to address the situation.

There is  a high use of overseas nurses within all fields in the UK, but especially within the private sector. Duell (in Dimon 2013), discusses that many nurses from overseas complain less. Of course, this may depend on which country they are from. Many countries, discourage the questioning of doctors or more senior staff. How then can we expect such staff to immediately adapt to the UK? There are also differences regarding such aspects as pain control (RCN 2003 ). Of course,  countries may lack the resources and methods that other countries have. Indeed, some people are still expected to have a stiff upper lip and carry on despite pain. This article will explore the difficulties that nurses from other countries may face when adapting to work within the UK.

Culture may be influenced   within one country by such factors as   affluent areas and   poor areas . There are also cultural  differences between countries. Obvious differences include religion or tradition . There are present UK campaigns against female genital mutilation  within some parts of Africa for example (

It is indicated that the wealthy have less empathy, which may be hastened by the work ethic- you earn what you get, and their aim to justify their wealthy position (Goleman 2013).

Physical restraint of individuals is used in some other countries to a greater degree than the UK. For example, in some regions of South Africa, there is no community care, so  a mentally ill person may be chained to the wall while the relatives have to go to work to earn money to eat. In Somalia, mentally ill patients may be put in a cage with hyenas (Hooper 2013). Therefore, nurses from such countries may well regard restraint as the norm.

Culture also affects expectations of care. Some patients may well accept  queuing for a bath with other patients . Some individuals in some countries, as in parts of Africa, still believe in witch doctors and that evil spirits cause  mental and physical ill-health.

An analysis of NMC cases indicates  that some nurses who are convicted at professional conduct hearings may well be from overseas. However, the NMC does not keep  a record of overseas status, unlike the GMC. Such a record would help to monitor the situation. Indeed, nurses from different regions within Africa have been known to refuse to work with or communicate with one another, due to tribal differences.

Finding actual cases of poor care of patients in the UK which may be determined by culture is not easy. There are some newspaper reports that  state  the nurse was from overseas, there are also cases that involve UK trained nurses who abuse patients.

 The following does refer to nursing in  Nigeria, but again it may not refer to all nurses;

“Picture this scenario:  a nurse is beating a sick patient in bed. Reason : Madam Nurse was provoked by the patient’s groans. A deadlier scenario:   a weak but desperate asthmatic patient is in a struggle with a nurse who wants to strangulate him. This triggers an attack and the patient frantically reaches for his inhaler, only for the nurse to smash that life instrument on the ground, breaking but not totally destroying it, before the patient manages to get it out of sheer willpower. This may seem stronger than fiction, but these two events happened only recently. Welcome to the deadly world of Nigerian nursing” (Kowale 2012).

The author questions why, despite the Nigerian Code stating “the nurse must provide care in such a manner as to maintain the integrity of the profession”, such attitudes prevail. Such an example as this indicates that there are people of conscience within all countries.

 Simulsesli (2012) further analyses the work of Jewkes  et al 1998, asking why abuse of midwifery patients occurs in Zambia. He concludes there are many underlying sociological factors, but they can be challenged by, for example, positive role models, effective complaints procedures, and improved working conditions.

I argue also, there are political factors which fuel the work ethic belief that some people are more deserving than others, because they work.

Indeed, such attitudes prevailed within the UK, and other Western countries, many years ago, as evidenced within workhouse records or by such authors as Barbara Robb. Pregnant mothers were still hit by midwives, until the 1970s in London, according to Jewkes et al 1998 . Is it possible that within the UK, and other Western countries, there is  a return to this era, with such examples as patients in some hospitals and care homes  being tormented and ridiculed.

Of course, I am not saying do not employ staff from overseas from different  cultures. There are some excellent staff from overseas . What I am suggesting is that they should be  better prepared by a more robust adaptation programme for example,  a cultural adaptation course. We consider cultural differences of patients- so why not staff?


Dimon C (2013) The Commodity of Care Cloister House Press

Free updates

Durkheim E Ethics and the Sociology of Morals Prometheus books

Goleman D (2013) New York Times Rich People Just Care Less October 5

Hooper R (2013) Where Hyenas are Used to Treat Mental Illness 17 .10 bbcnews

Jewkes R, Abrahams N, Mvo V (1998) Why do Nurses Abuse Patients? Reflections From South African Obstetric Services  Soc Sci Med v47 n11 p1781-1795

Kolawole K (2012) Nigeria: Ethical Issues in Nursing Practice 6 December

RCN(2003) “We Need Respect”: Experiences of Internationally Recruited Nurses  In The UK 1st March

Sumulesli A (2012) Why do Zambian  Nurses Abuse Patients? Zambian 22 August


Carol Dimon c 2014



Roll up! Roll up!! Buy your fake certificate in anything.

A high number of nurses from overseas are employed within the UK, despite 20000  UK student nurses’ education being  paid for by the government  a year. Most of the overseas nurses  are employed within the private sector . Many private nursing home companies , and  NHS trusts, have set contracts with agencies who provide these nurses. Blog evidence provides such comments as “ I am newly qualified, but could not be given a job by the hospital, because they have to take so many nurses from overseas”. HEE explains that whilst some newly qualified nurses are needed, nurses who are more  experienced  are  needed. Do nurses from overseas necessarily have compatible training and experience of UK nurses ?

 Fake certificates are very easy to obtain from such countries as the Philippines, Bulgaria, and India. Indeed, one may purchase one whilst living in the UK. Recto is the key to unlocking a scam of huge potential significance to nursing in the UK and elsewhere. Recto is  street near  Manila University  where  fake traders provide false passport, marriage certificates, and any fake academic qualification from around the world, forged to an expert quality. This practice also is reported to occur in Eastern Europe.  .

 These certificates are extremely hard to detect even if the NMC now propose that overseas nurses “attend NMC headquarters with their certificate”. India, in particular, is attempting to tackle this problem , and has closed many  fake Universities – some of which were operating from car parks! Possessing an approved list of Universities may help, but not stop the problem. In some cases, corrupt individuals at valid Universities have sold certificates. The GMC does have an approved list of Universities for Doctors  in the UK, but the NMC do not answer this question.

One recommendation is for all approved nurses courses to require students to have their finger prints taken . Blog comments in foreign language from nurses with fake certificates working in the USA, provides comments such as “today I nearly killed  a patient”.

 Certificates of all levels, including PHD , in all fields, may also be fake. Students  may not have a  degree at all, but come to the UK to do  a higher degree. It is also possible to pay somebody to write the essay or dissertation for you , another worldwide business.

A  nursing degree offers skills in essay writing, along with practical skills . Countries do not provide  equivalent courses. Indeed, there are also differences in course content between UK Universities .

 Overseas nurses may not have access to the same up to date equipment, or  have been trained in the use of patient care plans, or treatments. Such regulations pertaining to  human rights and deprivation of liberty will  differ between countries, as  also  will attitudes towards such as pain control. So, despite NMC adaptation training in the UK offering a test or training based on individual needs, it will not necessarily address such differences .

 People with fake certificates obtain full references and course descriptions, announcing that they have had full training.

 An additional problem of some overseas nurses is the inability to speak or understand English.  The example of the nurse who brought  a bowl of cornflakes when asked for  a kylie sums it up. Why should cabinets on hospital wards have to display signs to enable  overseas nurses to understand what is stored in them ?  Such problems with communication would be more serious regarding medication,  for example. Yet, the NMC declare that it is against human rights legislation  to address this issue, other than requiring overseas nurses  outside  the EU to complete an IELTS in their own country.  If you wish to work as  a nurse in Bulgaria, you must undertake  a 6 months  intensive course in the Bulgarian language; why does not a similar standard apply in the UK?

 There is no wonder the NMC do not keep records of  the origin of training of the nurses convicted at hearings, yet they do for such as sexual orientation. The GMC meanwhile do keep such records.

 Do people and organisations fail to act because they fear public panic, human rights accusations, or do they support the fact  that overseas nurses are cheaper and complain less? (Dimon 2013). If nurses, or any other professional, come to the UK from overseas they must be individually assessed and adequately prepared and trained.

 Through neglect of this issue, we are failing   to protect educational standards in all fields,  and, in areas such as nursing, we are exploiting  overseas nurses . Does this negate the value of all qualifications?

 Carol Dimon, Lenin Nightingale  c

Dimon C (2013) The Commodity of Care Cloister House Press free updates


Link to Lenin on twitter.

Poor care IS poor care

 Poor care in nursing- or any other care professions- in all establishments, has always existed (Dimon 2013) and will always be a potential problem that all staff need to know how to address. This is due to several factors including socio-political, neoliberalism, attitudes, low staffing and poor resources. Poor care exists on  a continuum from unintentional to intentional. This is evidenced by blogs, research, NMC or coroner cases. Unintentional refers to errors such as drug errors, or well meaning staff who oppose the rights of the patient  for outcomes determined by the professional. Intentional includes such as physical abuse- slapping, or verbal-swearing. The occurrence of this does vary between types of care. For example in specialist units such as ICU, there may be  clinical errors rather than  such as, leaving patients in wet beds or shouting at them. Reasons for this may be various, such as the higher attention paid to ICU patients, rather than continuing care of vulnerable patients including old people or mentally ill. There are of course, higher staff levels on specialist units with more qualified staff. Of course such units may face short staffing, if people are sick for example, but they are usually given the priority when moving staff from other units.

This is all regardless of who owns the establishments. However, there is evidence of deliberate shorter staff levels within private equity owned care homes (Fernandez 2012) . Indeed there is also  a higher use of overseas staff within the private sector who are cheaper and complain less (Duell in Dimon 2013)

The training of overseas staff when arriving in the UK, is another factor. Indications are that it is inadequate (Dimon 2013) and cultural attitudes do of course differ (Jewkes et al 1996). Whilst this is an early reference, few authors write about this issue but it is supported by several blogs. There are a few articles highlighting further attitude differences, such as (RCN ) attitudes to pain relief between cultures (2003 in Dimon 2013) . Also attitudes towards older people , or restraint are addressed within other articles.

Mee (2013) discusses well, the issue that nurses need to take responsibility for their own actions , describing the situation of two adjacent wards, being very different regarding quality of care. This situation has been described to the authors, by several care assistants, who also are aware of possible reasons why.  He also discusses attitudes of staff, and the willingness, or ability to oppose authority. Mee begins to do what is required- an analysis of the actual major incidents and why they occurred- not a whitewash of short staffing.

The excuse of “short staffing” is used as a smoke screen for poor care; primarily triggered by the RCN who aim to maintain nurse and HCA members, and avoid upsetting the profession.  “We must only write about good care” they declare.

Of course we cannot dispute in anyway, that low staffing (which may occur unplanned), DOES cause poor care by for example, omitted aspects of care such as baths. It does not excuse however, swearing at a dying patient who was incontinent in bed (just one reported case). Nor does it excuse locking patients  in  a care home, in a “dungeon” (Gregory 2013).

There are so many factors involved. We really need to look at the issue of why we fail to accept that poor care in essence, does occur, even without short staffing. This tells us  a lot about the issue. Is it fear of admitting? Loss of professional reputation? Loss of business? Guilt? Or is it the difficulty of the aspects- that so differs between cultures  regarding expectations and acceptance? This has vast implications if people will address it- far wider than the issue of care or the NHS hospital ward.

This is  a plea to focus upon “poor care” as the issue- and not “low staffing”.

Lenin Nightingale. Carol Dimon



 Dimon C (2013) The commodity of care Cloister House Press

Fernandez E (2012) Low staffing and poor Quality of Care at Nations For Profit Nursing Homes  UCSF Nov 29

Gregory A (2013) 7 workers 'arrested' after dungeon found in care home. 23.10

Jewkes R, Abrahams N, Mvo Z (1998) Why do nurses abuse patients? Soc Sci and Med v47n11 p1781-1795


Mee S (2013) Is workplace culture an excuse for poor care? Nursing Times 109;14-16 5 April

                                                      SOME ASPECTS OF THE RCN


i. This article will discuss key elements of RCN policy, those relating to nursing entrants requiring a degree, and a support of relatively high ratios of trained staff to care assistants. The RCN's links to UK and international institutions that seek to influence nursing policy will then be considered. 

ii. Analogies will be made to 'Animal Farm' - a novel written in 1945 by George Orwell that depicts events leading to the Russian Revolution of 1917, and events following it - as such, a brief synopsis of this novel is given: Major, a boar who lives on Manor farm, has a dream, and calls a meeting in the barn to tell the other animals of it. He has dreamt of a 'golden' future in which animals will not be oppressed by humans. He teaches them a song that expresses his vision, called 'Beasts of England' - 'Beasts of England, beasts of Ireland, Beasts of every land and clime, Hearken to my joyful tiding Of the golden future time'.  After Major's death, the animals defeat the farmer, and run him off the farm. Three young pigs - Snowball, Napoleon, and Squealer - assume leadership of the animals, one of whom, Boxer, a cart-horse, particularly dedicates himself to the cause of 'animalism', and adopts his maxims, “I will work harder”, and 'Napoleon is always right'. Under the new regime the pigs alone make all of the decisions - for the good of every animal - and any animal who opposes Napoleon’s leadership will meet instant death at the teeth of the farm's dogs. But Napoleon begins to act more and more like the displaced farmer, sleeping in a bed, drinking whisky, and trading with other farmers. Squealer, Napoleon’s propagandist, justifies every action to the other animals, in terms of Napolian has their best interests at heart, despite the fact that the other animals are hungry and overworked. Then, Boxer is missing. Squealer explains that he has died after having been taken to hospital, praising  Napolian with his last breath. In fact, Napoleon had sold Boxer to a glue factory in order to get money for whisky. Years pass, and the pigs become more and more like humans, carrying whips, and wearing clothes. The original principles of their revolution, written on the side of the barn, become reduced to a single phrase - “all animals are equal, but some animals are more equal than others”. Napoleon invites a human farmer to dinner, and tells him that they should unite against both the animal and human working class. The animal workers look at this party through the window, and can not tell which are the pigs and which are the humans. Animal Farm has become a society in which the powerful determine who gets what rights. The workers  exist only to serve the aims of their leadership, to provide them with glory, and to support their luxurious lifestyle. The pigs abuse language to control the workers - their propaganda aimed at drowning out dissenting opinion. How many 'voices' critical of RCN policy are given expression in such RCN publications as the Nursing Standard, Nursing Management ('FOR NURSING LEADERS EVERYWHERE'); Nurse Researcher; Nursing Older People; Mental Health Practice; Primary Health Care, Nursing children and Young People, and Emergency Nurse? Do RCN members have influence within the Nursing Times? 

iii.The views of 'ordinary' nurses, students, and care assistants will be considered, so as to provide a 'counter voice' to those of high-ranking RCN members who purport to represent them. Themes emerging from a study of 150 blog entries made between September 2011 and September 2013 will be given by way of representing these 'counter voices', which are taken from both the NHS and the private care home sector, as the former seems to dominate debate at the expense of the latter, despite it accounting for the majority of elderly care, and its costly 'care' devastating the lives of many families.


iv. Do nurses require a degree? One argument that they do gives credence to the role of nursing assistants in providing the 'basics of care', whilst pointing out that they will not be able to recognise such things as skin condition or facial paralysis. This is not necessarily the case: I have worked with nursing assistants who were particularly good at such observation, and newly qualified nurses who were not, unsurprisingly so, given their frequent contact with a simulation dummy.


v. Moreover, the skills of nursing assistants are being increased and recognised in a number of American States, so the demarcation between the nurse and assistant becomes blurred. This is obviously a threat to the RCN, who mostly represent the more equal, yet their protestations are only valid if they can prove the nursing assistant is inferior to the 'degree nurse' in making an initial observation which requires further investigation. To object to a person other than a nurse being responsible solely on the grounds of them not being a nurse is done so to protect a vested interest, not the patient.


vi. Graduates of the 'Florida State Nursing Assistant Progam' would argue that they were well prepared to identify signs and symptoms that may indicate further investigation. Such facilities as the Erwin Technical Centre ( offer 165 hours of instruction: 'The Nursing Assistant Program combines classroom theory and over 20 hours of clinical experience that prepares students to take the Florida State Certification Exam and to pursue an entry level position in a nursing home. All nursing assistants working in long term care in Florida must be certified by the State of Florida'. They state: 'Nursing Assistants are an important liaison between the residents and nurses. Nursing Assistants are trained to notice changes in residents and report pertinent information to the nurses in charge so adjustments in care can be made. In addition, nursing assistants help residents perform activities of daily living such as bathing, grooming, eating, and toileting. Nursing Assistants are the eyes, ears, and hands of medical professionals keeping residents comfortable, clean, and fed. The courses are held over either two days a week for two months, or two evenings a week for four months. Graduates are informed that: 'The U.S. Department of Labor lists Nursing Assisting as one of the fastest growing occupations, and the need is expected to grow by 18% over the next six years'. This reflects the current emphasis on budgetary constraint, a 'tide' which it will be useless to swim against, and one which will inevitably encroach further on roles traditionally performed by the nurse.

vii. Florida nursing assistant graduates are given a career pathway: 'Nursing Assistants often advance to become patient care technicians by acquiring additional training in phlebotomy and EKG’s. Also, Nursing Assisting is an excellent launching pad for people pursuing careers in other health care arenas'. Nursing assistant courses stress the importance of a compassionate attitude to would-be entrants. They also stress the importance of education: Vision Statement: "Erwin Technical Center will: Empower students to take ownership of their education; educate students to be highly-trained, productive members of society; and provide an environment for the achievement of higher education, focusing on technology, job preparation and personal growth".

viii. The average pay in 2010 of Florida nursing assistant graduates was £7.15p per hour as of currency exchange rates applying 0ctober 22, 2013. The annual rate of pay for a patient care technician in the USA as of May 2013 was $15,866 - $42,644 for those with between one and four years experience ( median rate was $26,240 ( This equates to £16, 240 per annum. The highest rate ($42,644) equates to £26,380 per annum. Newly qualified nurses in the UK typically start at £21, 000 per anum (nursing.nhscareers.nhs.), which roughly equates with the starting salary for a qualified teacher (point M1): £21,588 (ibid.). Generally, a patient care technician would, on average, expect to earn 80% of the wages of a newly qualified nurse, with nursing assistants expecting 66%. Obviously, as the newly qualified nurse progresses through pay scales, the relative 'affordability' on nursing assistants and nursing technicians increases. According to figures from NHS Employers, average pay in the NHS in 2012 – including basic pay plus additions such as overtime – was £30,564 for a nurse, £109,651 for a consultant, £47,702 for a manager and £36,130 for a qualified paramedic.

ix. This is the 'economic tide' which the RCN, in its call for high nurse to nurse assistant ratios, is trying to hold back. It is claimed that £500 million of  wage costs are  equivalent  to 15,000 nurses (Donnelly, 2013). It follows that a great deal more staff could be 'afforded' if care was given by a different balance of nurses, nursing assistants, and nursing technicians. The danger here is that a more 'economical balance' of staff would not necessarily bring about a higher staff to patient ratio, because the logic inherent in running the NHS as a business might result in the same number of staff being employed, with a lesser number of nurses. 

x. There should be a statutory minimum staff to patient ratio, and, if there is not, then all calls for good patient care are hollow. These minimum staff ratios should apply to both the NHS and private care homes, with any nurse in charge of the latter having a statutory duty to report ongoing staff shortages to the CQC, who would be given the power to send agency staff to the care home. Such 'interference' in the 'market' is, however, unlikely, given that the main political parties of the UK are wedded to it.

xi. The poor care given at Orchid View Care Home, where one nurse and two assistants were expected to give good care to 30 patients, is one example of the business needs of an organisation riding roughshod over the needs of patients (Rush 2013). Private equity firms, which borrow large amounts of money to fund their acquisition of care home groups (, seek to maximise profits by running on minimum staffing levels, which are comprised of a high percentage of foreign nurses and nursing assistants, who are considered more 'flexible' and 'cheaper' than their UK counterparts (ibid.). The 'training' received by overseas nursing assistants in the UK is of a derisory nature, stipulated by the NMC. As one European recruitment agency states: 'Looking to Employ Care Staff? We may be able to help. The carers we source from the ten east Europe EU countries such as Hungary, Poland, Romania, Czech Republic, Slovakia, Bulgaria etc. ... are hard working reliable individuals looking for work as a carer, they may not have care experience but will undergo the normal 2-5 days training as required by care home providers' ( The NMC merely rubber stamps EU migration of labour policy.

xii. Why is it not a statutory requirement for all NHS wards and private nursing homes, who care for elderly, chronically ill patients,  to have to provide a staff/patient ratio of 1:5; one nurse and five nursing assistants to care for 30 patients? What is the stance of the RCN on this matter? Within the private care sector it is one that 'recognises the business goals' of care providers (whoownscarehomes). There seems to be an obvious conflict of interests here; a desire to increase membership of the RCN, which is set against the needs of patients. That is, the RCN, as Napoleon, collude with business interests. Squealer (any RCN spokesperson) explains to poorly paid and overworked foreign nurses and assistants that Napoleon (the RCN) has their best interests at heart, and, in return for their subscription fees, will negotiate the terms of their slavery. Of course, in the worst possible example of adulterated English, the private equity firms will be called 'leading players' or 'stakeholders', or other such absurdities that do not necessitate thought - to repeat: The pigs abuse language to control the workers - their propaganda aimed at drowning out dissenting opinion. This is not to say Napoleon is the root of all evil, for he merely serves a greater elite, as will be explained.

xiii. Private equity firms give a guaranteed 'return' to their investors, regardless of profit or loss considerations, this return being stripped from fee income. The question of who these 'investors' are is highly problematic, being clouded in secrecy. A sceptic might suggest that the UK government could claw back some care costs by investing in private equity firms, but, surely, such a level of deceit could not be perpetrated on the British electorate? - not without at least a 45 minute warning.

xiv. It is not a case that poor nursing care is solely the result of 'economic' staffing levels. To add to the apocrypha of the uncaring nurse and knowledgeable nurse, on a recent visit to a NHS ward a colleague was told by a patient that she had told a nurse that her catheter was "leaking", to be curtly informed that "it could not be". Nursing is thus reduced to the level of a 'Carry On' film.

xv. This is an example of 'care' in the public domain of an NHS ward (and yes, many examples of good care can be given), but what of care in the 'private' world of the care home?  There are numerous reports of poor care: 'Seven care workers arrested after 'dungeon' found at care home. The unheated, locked room at Veilstone Care Home contained only a blow-up mattress, light bulb and CCTV camera' (Gregory, 2013). 'Concerns have been raised in the wake of a series of scathing inspections at residential homes for the elderly across north and west Cumbria. Malnourished, unwashed, dehydrated, unclean and poorly staffed were just some of the issues raised by the Care Quality Commission at nine homes in six months' ( Parsons,  2013). A respondent writing: 'The CQC needs to look at a whole picture working in a care home is not just caring. There is laundry, cleaning ... just let us do the job we are paid to do "CARE" (ibid.). 'Staff at a care home which has been closed down by health inspectors gave elderly residents sleeping tablets when they didn't need them. The revelations come as health watchdog the Care Quality Commission today announced it had cancelled the registration of the home with immediate effect due to its poor standards. Inspectors found: One resident struggling to eat soup with their fingers for 15 minutes (Howell, 2013). Will the government extend its proposed legislation to criminalize neglect of the elderly in the NHS to cover private sector care homes? If not, why not?

xvi. What relevance has this to the NHS? It is its future. Foundation Trusts will be hived off to private equity companies, or other forms of business, in an insidious process which seeks to hide privatisation from public view: Virgin Care run more than 100 NHS services, from radiology departments to GP clinics, all run under the NHS logo. The van comes to take Boxer away. The animals rush to the yard in time to see it leave. They  wave goodbye to Boxer, but Benjamin is very agitated, and tells them to read the letters on the van, which describes it as being owned by the local horse-slaughterer. The animals try to warn Boxer, who tries to kick his way out of the van, but he has no strength left after his heroic efforts on Animal Farm. Three days later, Squealer announces that Boxer died in hospital. He makes a moving speech in praise of Boxer, explaining the sign on the van by saying that the veterinary surgeon bought the van from the horse-slaughterer, and had not yet replaced the sign. 'Nurses of England, Nurses of Ireland, Nurses of every land and clime, Hearken to my joyful tiding Of the golden Virgin time'. 

xvii. To return to the question of who should do what in nursing: Providers of training, such as the Erwin Technical Centre, do not see themselves as imparting a scant level of training, one not fit for purpose. It could be argued that the level of clinical skills attained by students undertaking a three year 'generalist' degree, culminating in a chosen speciality, are not always of a level that enables them to 'hit the ground running' as a newly qualified nurse; a reason cited by employers for preferring experienced nurses.

xviii. The training of nurse assistants and technicians could be highly focused to specific areas of nursing, eradicating the superfluous content of much of the nursing degree. A constant theme of blog entries is that patients are not concerned with a nurses aptitude to discuss philosophical nuances of care. Of course,  some nurses will need to know the 'science behind the condition', but not all; as not all doctors need to be brain surgeons.

xix. Such courses can be offered in all areas of nursing as an entry level to nursing itself, with nursing assistant graduates who become patient care technicians being eligible to apply for a shortened degree course, which credits previous learning experience; the number of these 'degree' nurses to be matched to the number of job vacancies which hospitals have to offer.

xx. What of the the 'voices' of nursing assistants? Themes that arise from blog entries are: A lack of recognition of their skills. Being overworked because nurses are busy doing drug rounds and care plans, etc., so can not assist with routine care. Not having a clear pathway to a career in nursing that credits their experience and skills.

xxi. What of the voices of nursing students? Themes that arise from blog entries are: Many feel inadequately prepared in clinical skills. Too emotionally immature to cope with the demands of nursing (young students). Mature students have difficulty fitting in academic work with family commitments. Trusts give few jobs to qualifying students. The NHS has an uncertain future. Poor public perception of nursing students inflamed by the media. Training should return to more traditional methods. Patients want students who care and are not bothered if they are not academic geniuses. Staff morale is low in some schools of nursing.

xxii. These issues are inter-dependent. The NHS Future Forum, the advisory panel set up by the Government to examine the NHS, says there is “almost universal concern” about the “huge variations in quality” of education and training for nurses and midwives across the country. This is strongly reflected in student blog posts. There is also a variation in the content of  training, with the NMC allowing universities to chose the components of their nursing degrees. This is analogous to ordering a new car, to be told that the ones made Friday differ from those made Monday. In the same way, employers are faced with a variable (nurse graduate) product, which contributes to Trusts giving few jobs to qualifying students. 

xxiii. 'The NHS Future Forum reported that NHS hospital managers are failing to take responsibility for the poor quality of some nurses. It also accuses nurse training schools of failing to recruit the right type of student to ensure patients receive a good standard of care. The report adds to growing concerns that nurses’ training has become too academic to prepare students properly for the realities of the job and makes them less willing to carry out practical care. Prof. Steve Field, a GP and chairman of the forum, said that nurses needed to be “more than a set of GCSE and A-level results”. Patients’ groups who had argued that nurses’ training had become too academic welcomed the report' (Adams, Smith, 2012).

xxiv. Let us now look more closely at the aims of the RCN as an organisation, and the groups it is affiliated to. The RCN in June and July of 2013 advertised for a Parliamentary Officer, stating: 'With a membership of over 410,000, the RCN is the largest professional association and union of nursing staff and students in the UK. We’re proud to be a leading player in the development of nursing policy and practice, with an influential voice at home and abroad. We have a vacancy for a full time Parliamentary Officer based in the RCN’s multi award winning External Affairs and Member Communications team. Working to influence UK parliamentary audiences, as Parliamentary Officer you will monitor and analyse UK parliamentary activity, identifying where issues will impact upon, and provide opportunities for, the RCN. Sharing information with colleagues and key RCN staff, you will also be responsible for providing briefings and information for parliamentary stakeholders. ...  You will have the ability to spot opportunities to promote nursing within the parliamentary system, and ensure that key RCN staff are aware of political developments'.

xxv. Thus, the RCN, as a 'leading player', seeks to influence government, so as to further its own ends. Their Parliamentary Officer must 'spot opportunities to promote nursing (aka the RCN) within the parliamentary system. This is nothing remarkable; the UK parliamentary system is riddled with lobbyists, and many unions will have a vast flotilla of staff paid out of their members' subscriptions that are far removed from the 'front line' of representation. This imperative to influence, in the case of the RCN, is not confined to the UK: 'RCN membership of international organisations enables us to exchange information and share best practice amongst a much larger audience than we would be able to reach on our own. Through membership of international alliances the RCN works collectively to influence decision-makers in governments and institutions across the world to improve the health of communities' (, 2013). Some of the RCN's partners are:

xxvi. The International Council of Nurses.'The International Council of Nurses is a federation of over 130 national nurses' associations (NNAs), representing nurses around the globe. ... The International Council of Nurses (ICN) believes that profession-led nursing.  ... The title of “Nurse” should be protected by law and applied to and used only by those legally authorised to represent themselves as nurses and to practice nursing. ... Reserving the title “Nurse” for those who meet the legal standard enhances public protection by allowing the public to distinguish legally qualified nurses from other care providers' ( Again, there is nothing remarkable about the RCN allying itself to an organisation which seeks to define what nursing is and exclude others from it, as the medieval guilds sought to protect their trades. Yet, it is a stance that is anathema to corporate capitalism, which eulogises the virtues of a multi-tasking 'flexible' and cheap (zero hours contracted) workforce. As all three main political parties in the UK openly support the dominant role of corporate capitalism in the economy, as utility providers, etc., with substantial regulation of them being as unlikely as their re-nationalisation. It would be a uphill struggle to oppose this creed.  I would suggest that the RCN is not so blind to its self interest as to do this; it would be as a martyr not renouncing their faith in the warmth of the flames.

xxvii. The European Federation of Nurses Associations ( ''The European Federation of Nurses Associations (EFN) represents the nursing profession and its interests to the European Union institutions. It focuses mainly on nurse education, the mobility and protection of health care professionals, and EU health policies. EFN is the independent voice of the nursing profession in Europe, representing more than a million nurses from national nurses' associations in 30 countries. ... As European citizens, this means having the right to choose where to receive medical treatment across the EU, and to be reimbursed for it. The EFN believes that this Directive, aiming to clarify citizens’ rights to access healthcare in another EU Member State, and to facilitate their access to healthcare services, guarantees the principles of universality, access to quality care, equity and solidarity. Therefore, if a patient is to receive medical treatment in another EU country, he/she will have the same rights as a citizen of that country, and the treatment will be subject to the same rules and standards. ... The EFN believes that a transparent system for automatic recognition is needed to deal with the migration of professionals in a practical and efficient way and to ensure that a certain level of health protection for patients and consumers of health care in the EU is maintained. ... ENSA goes for a new governance structure to actively lead the nursing students’ movement ... The European Nursing Students Association (ENSA) elected five new board members ... The new board, coming from Norway, Greece, Sweden, Turkey and Germany opted to work closely with the EFN to make nurses and nursing stronger in the EU. ... The EFN General Secretary therefore believes that more students should join ENSA, so that it covers at least one student from each EU Member State'. (My italics).

xxviii. This association, I suggest, is highly problematic to the RCN. I will address the question of whether the RCN should be the national nurses' association anon. Their affiliation to an organisation which believes in 'medical tourism' is not remarkable, as this relates to medical tourists from affluent countries who will be treated as private patients, and will pay their medical costs, typically for dental treatment, cosmetic surgery, or fertility treatment. They are not to be confused with health tourists, whose intent to pay for treatment is not certain. Governments see 'medical tourism' as a lucrative source of revenue. The RCN's affiliation to an organisation that supports migration of professionals might be a cause of concern to some. There is most definitely a shortage of people engaged in caring in the NHS. There are widespread shortages because NHS trusts freeze vacant posts in a bid to save money. Trusts routinely freeze posts whenever staff retire or move elsewhere, creating widespread shortages. Is the answer an increase in the number of nurses, or in the number of nursing assistants?  A majority of patients would probably opt for the latter, as would those in charge of budgets, though it is not certain that there will be increases in staff of any kind; staff will be told to adopt Boxer's maxims, “I will work harder”, and 'Napoleon is always right', but their fate is the glue factory. When the government state that every NHS ward will have to make public the number of nurses on a ward on all shifts, so that these numbers can be compared with recommended minimums, a great sleight of hand is being dealt, for the majority of 'physical' care given in any elderly care setting is by the 'Boxers' (nursing assistants) of this world, not by  nurses busy dispensing drugs or filling in care plans.

xxix.  As for student nurses, blog after blog reports of the majority of newly qualified nurses not being given jobs, with those that are being offered half time hours on fixed term 6 month contracts, which are unlikely to be renewed. This is cheaper than employing experienced staff, and is a continuous process of repeated 6 month preceptorships; rather like employment schemes that take on a new batch of trainees every time the old batch is about to qualify for a permanent (higher waged) job. There is not a shortage of nurses in the UK, but, rather, a shortage of jobs for them, for both those who are newly qualified and those on part time contracts who would like full time work.

xxx. It may seem of little importance that the RCN is affiliated to a group that supports migration of professionals if there are no nursing posts for them in the NHS. This may not always be the case, for such as Bulgarian nurses may agree to work for the minimum wage; and with reports of some Bulgarian nurses earning as little as £200 per month, the prospect of the minimum wage may be alluring to both them and potential employers. An important point is missed if it is claimed that such rates of pay are disallowed under NHS pay agreements, which will cease when the privatisation process is complete.

xxxi. A vision of the future is provided by those hospitals that fail to achieve 'Foundation Trust' status, which must find an alternative solution, one of which is to operate under private enterprise management, as in the example of Hinchingbrooke Health Care NHS Trust, run by the Circle Partnership. Currently, staff employed by the organisation remain as NHS employees, and are paid NHS rates. This may not always be the case, for what is exampled here is a vision of  the evolution of the health service as entertained by the private sector mouthpiece, Camclegg Miliband.

xxxii. The dismantling of the NHS is introduced so gradually so as to alarm by degrees, not to shock into opposition. It is as if nails are being driven into the NHS coffin one by one, and, when the final one is in place, those running the PHS (privatised health service) will call for pay 'flexibility', and the right to set their own levels of pay; to be 'competitive'; to give the tax payer 'best value', etc., which will herald a migration of professionals. Nurses trained in the UK will be as scarce as Saville Row suits; foreign manufactured 'off the peg' ones will be the norm. Either this route, or that of the nursing assistant as patient technician, beckons, one in which the RCN and other unions will seek to recruit membership, from whoever is doing the caring, called by whatever name, for, unless we are to witness a heroic and principled 'last stand', the lure of membership subscriptions will be king. Workers will look on at the party between workers' 'representatives' and big business through the window, and will not be able to tell one from the other; they only exist to serve the aims of their leadership, to provide them with glory (a seat at the table), and to support their luxurious conference and committee-attending lifestyle.

xxxiii. There will be wholesale transfer of hospitals to the private sector. Hurrah! some may say, let us put the NHS under the management of efficient and successful private companies. It may surprise them to learn that Circle made a pre-tax loss of £32m. in 2011 and  raised  £46m. through the issue of 68m. new shares to institutional investors. The firm said that funds raised would be used to bid to take over the management of further NHS trusts, and paying off a £14m. loan from James Caird Asset Management, for which Circle was paying an interest rate of 25% a year. The company made pre-tax losses of £38m. in 2010. What sort of company would borrow money at 25% interest? - a desperate one, and what sort of company would give it them? - one that thinks the business is a high risk. Napoleon is always right, remember, but when his propagandists say that  efficiency is the preserve of the private sector, they do so in the face of fact, with no mention of the debt-driven failures of companies speculating in health care.

xxxiv. Circle told investors in 2011 that it had identified eight health trusts which it considered to be an “NHS growth opportunity” of more than £8b. (, The majority holding of circle is held by private equity companies,* which include Lansdowne Partners, co-founded by Paul Ruddock and David Craigen, who  have donated more than £300,000 to the Conservative Party, the majority since David Cameron became leader; and Odey Asset Management, run by Crispin Odey, another donor to the Conservative Party. Circle's potential losses are capped at approximately 0.7% of the NHS funds it will manage. The UK government thus facilitates a 'bet to nothing'. The National Audit Office reported that Circle made an operating deficit on its contract of £4m. by September 2012, forcing Circle to make savings by cutting several hundred jobs and closing two wards. (It can be supposed that the RCN opposed any job cuts imposed on any of its members). Hinchbrooke has plummeted in a patient satisfaction survey undertaken in August 2012 ( Circle operates a equity incentive program under which consultants and GPs are offered equity in the company in return for a share of the consultants’ private work (  Pigs at the trough.

xxxv. *Private equity firms that control the vast majority of care homes in the UK already recruit heavily from Bulgaria, as stated, with the RCN (and UNISON) vying for the right to represent these workers (collect their subscriptions). How does this stand in relation to the RCN's role in protecting the rights of their UK members? When it is said that worker migration is a central tenet of European Union policy, and has to be complied with, a lie is being told; France only allows migrant professionals to take a job if a suitably qualified local applicant is not available. It must be said that being affiliated to an organisation does not necessarily mean agreeing with its every policy, and the RCN may be actively lobbying within the EFNA to safeguard the rights and interests of its UK members. Pigs may fly.

xxxvi. The Commonwealth Nurses Federation ( The Commonwealth Nurses Federation (CNF) is a federation of national nurses' associations in Commonwealth countries. It aims to influence health policy throughout the Commonwealth; enhance nurse education; develop networks; strengthen nursing leadership; and improve nursing standards and competence. ... Membership of the Commonwealth Nurses Federation (CNF) is open to all national nursing and midwifery associations in Commonwealth countries. Members associations of the CNF are divided into six regions: Atlantic Region; East, Central and Southern Africa Region; Europe Region; Pacific Region; Asia Region; and West Africa Region. ...The CNF’s current work programme includes the following: collaboration with other international nursing and health bodies, participating in and contributing to Commonwealth Health Ministers’ and Heads of Government meetings, participating in and contributing to Commonwealth Health Ministers and other Commonwealth meetings.

xxxvii. The European Health Management Association ( Active since 1982, the European Health Management Association (EHMA) is a membership organisation open to all organisations and individuals committed to improving health and healthcare by raising standards of health management. With over 170 members in 38 countries our members represent all levels of the health system ...  OUR CORE AREAS: Policy: translating EU policy to the organisational level and influencing the EU policy agenda bottom-up. Research: engaging in cutting edge research with some of the top research associations in Europe, including on health professional mobility and quality of care. Management improvement: supporting healthcare delivery to be as good as the best in Europe, through networks, events and projects. Management education: joint European accreditation of postgraduate health management courses with FIBAA (Foundation for International Business Administration Accreditation). OUR KEY CONSTITUENCIES: Senior managers who need to network and share information and intelligence in a rapidly changing health sector. Policy-makers who want to exchange ideas and debate policy, both across Europe and at the EU level. Academic institutions and educators who want to participate in research and share learning amongst their peers across Europe. Its members include:

xxxviii. 1.The Centre for Innovation in Health Management, University of Leeds. 2. David Peat Solutions Ltd. David Peat: 'Current: Non Executive Director at North West Ambulance Service NHS Trust, Partner at David Peat Solutions Ltd, Honorary Fellow at Manchester Business School. Past: Chair North of England at Community Health Partnerships Ltd, Director Commissioning Development at NHSNW. Education:  University of Leeds. ... David was involved in the NHS LIFT (Local Investment Finance Trust Initiative) from the start in 2002, recognizing that this provided 20/25 years investment in a 5 or 6 year timescale, but more importantly could rid the East Lancashire area of poor old health care buildings and provide new flexible 21st century buildings' ( 3. Department of Health Social Services and Public Safety, Northern Ireland. 4. Goodwin Hannah: 'We have led the creation of new inter-organisational partnerships such as academic health science centres in London and Merseyside; and facilitated the acquisition of hospitals by NHS Foundation Trusts.   ... We currently hold chair and non-executive roles in regional and national organisations in the NHS and third sector. We have an extensive board development practice and we have also undertaken confidential and sensitive inquiries into adverse governance issues within boards, clinical services and across health systems. Our work with Manchester Business School has included developing and delivering programmes for current and prospective non-executive directors of NHS Foundation Trusts. These programmes were accredited by Monitor, the NHS FT economic regulator. Our work with other business schools, such as Ashridge Business School in Hertfordshire and Cass Business School in London, has included developing and delivering leadership programmes for directors and senior managers. ... Our clients have included almost all types of NHS organisations across England and Wales: hospitals, mental health and community services providers; commissioning organisations; and NHS regional headquarters. We have also worked with the English Department of Health, the Welsh Assembly Government and the Cabinet Office. ... We work with boards, executive teams and the emerging NHS clinical commissioning groups to help them identify the ...  leadership and people challenges they are facing, and to translate them into meaningful, practical action plans for team, personal and organisational development' ( 5. Health and Europe Centre. 6. King's College, London. 7. King's Fund. 8. NHS Confederation. 9. Royal College of Nursing. 10. Stockport Metropolitan Borough Council. 11. The Nuffield Trust. 12. University of Birmingham - Health Services Management Centre. 13. University of Durham. 14. University of Manchester, Manchester Business School. 15. University of Surrey - European Institute of Health & Medical Sciences. Individual Members: Prof. Jim Buchan,  associate fellow at the Kings Fund. Policy Adviser at Royal College of Nursing. Ms. Pippa Gough. University of Leeds profile: Pippa has 14 years experience of providing consultancy in organisational and leadership development and policy research, initially whilst working as Senior Faculty at the Kings Fund. She has held a number of senior health positions, including that of Director of Policy at the Royal College of Nursing. ( It may seem to some that the RCN support the notion of an increase in the number of jobs for nurses whilst being bedfellows of those who make sure this will not happen.

xxxix. European Public Health Alliance ( 'The European Public Health Alliance (EPHA) represents over 100 non-governmental (NGO) and other not-for-profit organisations working in support of health in Europe. It aims to promote and protect the health interests of all people living in Europe and to strengthen the dialogue between the EU institutions, citizens and NGOs in support of healthy public policies. The European Public Health Alliance runs projects which receive financial support from the European Commission. The views expressed in this website do not necessarily reflect the official views of the EU institutions. EPHA is a change agent – Europe’s leading NGO advocating for better health. We are a dynamic member-led organisation, made up of public health NGOs, patient groups, health professionals, and disease groups working together to improve health and strengthen the voice of public health in Europe. EPHA is a member of, among others, the Social Platform,* the European Public Health and Agriculture Consortium (EPHAC), the Health and Environment Alliance (HEAL),** and the EU Civil Society Contact Group.***

xxxx. *The Social Platform: 'We fully support the initiatives aimed at promoting and developing social economy and social enterprises across Europe. However, we warn about the danger that member states could disengage themselves from their public tasks, as well as from the provision and funding of public services, in particular in the social and health sector. Therefore, we work to ensure that an adequate legal and financial framework is in place to support the development of social economy and social enterprises. **HEAL: ( Beginning in 2003 as the environmental ‘wing’ of the European Public Health Alliance (EPHA), HEAL was created to bring the health voice to the centre of a wide spectrum of EU environmental policies, and to integrate environmental concerns in public health decisions.***The EU Civil Society Contact Group brings together eight large rights and value based NGO sectors - culture, environment, education, development, human rights, public health, social and women. The members of these sectoral platforms are European NGO networks. They bring together the voices of hundreds of thousands of associations across the Union, linking the national with the European level, representing a large range of organised interests, including Green 10: The Green 10 are ten of the largest European environmental organisations/networks. They coordinate joint responses and recommendations to EU decision makers. Membership of the Green 10 alone is more than 20 million people. The informal platform of environmental NGOs is composed of the following organisations: European Environmental Bureau (, BirdLife International European Division (, Climate Action Network Europe (, European Federation for Transport and Environment (, Friends of the Earth Europe(, Friends of Nature International (, Greenpeace European Unit (, WWF European Policy Office (, Health and Environment Alliance (, CEE Bankwatch Network, c/o Friends of the Earth Europe ( The accusation that the RCN solely allies itself to business interests is refuted! RCN members will be heartened to learn of their leadership's connection to such as Greenpeace and Friends of the Earth, and to an organisation that warns governments not to disengage from funding public services!

xxxxi. The European Federation of Public Services Unions ( The European Federation of Public Service Unions is a federation of independent trade union organisations for employees in public services in Europe. It covers various industries and vocational categories within the public service sector including health. It liases with the ETUC and the European Institutions to establish suitable industrial relations structures with public sector employers at EU level to reach collective agreements on employment issues.  A core activity of trade unions is negotiating, on behalf of members, with employers. EPSU’s affiliates concentrate on good pay levels for public service workers at the workplace, the sector and national level. Good working conditions are just as important. The health and social services sector is a large and diverse sector, including many different services such as hospitals, child care, community health services, social work and homes for older and disabled people. We represent 3.5 million health and social services workers across Europe, and are engaged in a wide range of issues on their behalf. The categories of workers range from social worker to doctor to hospital cleaner to medical secretary to nurse. EPSU is the recognised European social partner organisation for workers in the hospital sector throughout the European Union.

xxxxii. The following excerpt of Dennis de Jong's article, 'the trade union movement at European level' (Dennis de Jong, 2010), shows the difficulty facing any trade union that seeks to influence policies on a national level. National policies are dictated by multinational corporations who demand that their puppet governments create a 'flexible' and cheap workforce. There are only slight variations in this choice, whatever the name of the UK political party or parties fronting the multinationals.

xxxxiii. 'Since the mid-1980s, Brussels has been associated first and foremost with Europe's neoliberal policies. The trade union movement in Europe appears to have been taken in by Brussels' institutions and thus rendered harmless ... (There is a) blue print for a neoliberal Europe: a clear run for unbridled competition, even if this should be at the cost of social rights, market rules for the public sector, and 'flexibilisation' of the labour market (for which read: getting rid of protection from dismissal), to name just a few examples. The multinationals got their wish. ... The trade union movement plays no role in this scenario. ... I would put the blame for the movement's scant influence on the EU primarily on three factors: (1) lack of sufficient personnel; (2) infection of representatives in Brussels with the EU virus; (3) a complete absence of militancy on the part of the trade unions themselves. ... If you compare this to the major corporations' enormous lobby industry, it's no wonder that the trade union movement doesn't get much of a hearing. ... To stay critical of European policies, you must be sure to maintain close contact with your supporters, because everything in Brussels is designed to take you in and win you over. ... The European Federation of Public Service Unions ... does raise important criticisms regarding the continuing introduction of market methods into the public sector.

xxxxiv. Developed in the framework of the Lisbon Agenda, which was to make Europe's economy the most competitive in the world by this year, this idea included accepting that workers could no longer be offered effective protection against dismissal, and that instead you should direct yourself towards guaranteeing employment in a general sense. Pity if you find it agreeable to work for the same employer for any length of time, because after a few years you'll have to go looking for another job. And a shame if by coincidence there happens to be a crisis on and there are absolutely no other jobs to be had. But the trade union movement believes that ‘flexicurity’ is good for everyone. Yet this isn't about 'modernisation' but rather an attempt to allow employers to dictate matters. So it's unbelievable that the unions have adopted such an idea.

xxxxv. In the last few years there have been moments when the trade unions did indeed make a fist of things. This occurred in the response to the Port Services Directive and to the Services ('Bolkestein') Directive. Here were two instruments which would have led in each case to extremely adverse effects on the position of workers. The rank-and-file wasn't prepared to put up with this and offered massive resistance: tens of thousands of dockworkers demonstrated on Rotterdam's Coolsingel against the Port Services Directive, while it also proved possible to organise large-scale protests in Brussels and Strasbourg. The visibility of so many angry workers meant that the European institution could no longer ignore their interests. The Port Services Directive was withdrawn and the Services Directive amended.

xxxxvi. So, it can be done! And that's why it's important to strengthen contacts with the trade union movement in Brussels. At the same time it's necessary to ensure that pressure on union representatives in Brussels is exerted from within and without: don't let yourself be seduced by the Brussels institutions, but listen to the rank-and-file, and listen well! Also – invest time and effort in European and international contacts. It will never be financially possible to defeat the multinationals' lobby, but if you can resist or force changes to legislation in Brussels, it will save you an enormous amount of work on the national level.   

xxxxvii. Some may disagree with Dennis de Jong's optimism. UK unions are not going to call for an end to the hegemony of multinational corporations, and of puppet governments in their pay, for, to do so would be to advocate revolution, and to attempt to overcome military oppression. Unions will continue to engage in peaceful protests, and in pleading for concessions from their masters, and their masters may humour them for a time, throwing them a few scraps fron their whiskey-laden tables, but this will cease when subjugation is complete, and workers are told that they should be grateful for their two slices of daily bread, for they could only be given one, and this will be conveyed to them by their 'unions', as subscription-gathering representatives of slaves. It does not matter whether the union is called the RCN, UNISON, or UNITE; same beast.  Russell Brand is correct, what is needed is a revolution, a sweeping away of the dictatorship dressed as democracy model of oppression, and of all its representatives, 'unions' included. This is very unlikely to happen. You will be fed just enough.

c. Lenin Nightingale 2013



Adams S, Smith R (2012) Nurses are 'losing their sense of compassion', The Telegraph, 9 November

Dennis de Jong (2010), March 16

Donnelly L (2013) NH employees make plea for  a pay freeze to secure jobs, The Telegraph, 23 September

Gregory A (2013) Seven care workers arrested after 'dungeon' found at care home, The Mirror, 23 October

Howell D (2013) Residents at St Andrew's Lodge, Basford. were given sleeping pills when they did not need them,  Nottingham Post, 22 October pay_work_conditions/pay_comparisons

Parsons E (2013) Ticking Timebomb of Cumbria's Care Homes,, 21 October

Rush J (2013) A manager who oversaw "institutionalised abuse" at care home where pensioners died of neglect was handed new job by firm that took over, Daily Mail, 22 October



Where is the manager?

 All care homes must have  a registered manager according to CQC guidelines England. Of  a residential home, this may be a senior care assistant as not required to be  a nurse. Of a nursing home, this must be  a nurse.

 Acceptance of registration means that the manager is legally responsible for care provided within that home. This extends from clinical care such as wound dressings, to PAT testing of electrical equipment. Indeed, in the UK registered managers have been jailed for such as low staffing ( Bunyan in Dimon 2013) , Within the USA , managers are jailed for opposing the human rights Act concerning residents . Therefore why do some homes not have registered managers? The only report I can find, informs us the CQC allowed 3500 care homes to run in England without a registered manager (Brindle 2013). They may argue they cannot afford them or they cannot get an appropriate person ;it would be interesting to identify the owners or companies, who have been allowed to continue without  a registered manager. The argument in the case of nursing homes, may be that each nurse is registered and accountable but not for general issues to do with running the home which do affect care. Yet it is difficult for many registered managers who are torn between demands of residents and relatives, staff, and the owner or registered manager of  a company. Indeed, there are also requirements of the CQC or NMC offering further conflict. Yet managers also function differently. Some do not leave the office to such a degree that staff and residents do not know if they are there or not. Many argue there is too much paperwork. Others fear accepting responsibility further; if they are unaware  a dressing has not been done for 10 days – how can they be responsible? There are some who  would argue this. Yet with huge homes of 200 beds plus, is it possible for the manager to be aware of the needs of all individual patients? Some homes do for this reason, employ a care manager who is not registered and  a budget manager who is registered. Yet there may be conflicts between the two for example, when resources or more staff are not allowed.

Why has the CQC allowed such situations? The CQC does have concerns about closing homes as there are few alternative places for residents; there is also evidence that they hush up findings of  inspections ( Matharu 2013  ) . The government do claim that the CQC is independent . However, the degree of this independence is questionable when they announce they are now to extend this (Dimon 2013   ). Nor is it known who selects CQC board members; most likely the privy council. In effect, the situation seems to be, is  a registered manager required within a care home at all? If not- who will be responsible?


Brindle D (2013) Orchard View inquest: Care home regulation has  a long way to go The Guardian 22.10

 Dimon C (2013) Nursingandeducationplatform.webs Further articles, also wideshut "staffing Dilemma"


 Matharu H (2013) ‘CQC launched witch-hunt against me’ Claims ‘Failing’ Care Homes whistleblower from Epsom Your Local Guardian (3.10)




Nursing POLITICS IN bed 1

Nursing "does not exist in a vacuum" (DIMON 2013). The approach of  the government to society is dictated by politics at the time.
This influences social attitudes and priorities. For example;
individuals must earn a living, individuals must earn status. They who do not earn and depend on those who do, are unworthy or "scivers".Darwin- the fittest species survive by cooperation.
This is especially reflected within the workhouse era according to the poor law, and the approach towards the unemployed within today's society.
International forces do dictate government policy regardless of which body is in  power.
So, consider patient care.
The nurse or carer at the side of the patient is not solely responsible for poor care. Yet there are exceptions such as sheer abuse.
Think wider; who manages the environment? Who owns the establishment? Who dictates? Why are people reluctant to complain? Many staff fear loss of job, repercussions, living on the street and becoming "unworthy".
Resources too depend on politics. Yet so too, do decisions for the allocation of resources.
Consider the management structure. Trotsky called for (as did Marx), the return of power to the people; nurses, doctors and domestics- away from managers with profit motives.
Think broader; why do individuals adopt a certain political orientation? They may have ulterior motives. Many politicians may not even believe what they themselves say. Others are indoctrinated and support without question. Thinking too, is discouraged.Certain publications are blocked.
Thus consider;
Who is in charge? Who benefits? Who is blamed? How is care organised? Why is privatisation occuring? Who benefits from privatisation? Who appoints board members of the "independent" NMC and CQC?
Are people afraid of caring? Is caring now, a sign of weakness within a  market environment?
Put politics on the nursing and nurse education agenda.
Read G Orwell Animal Farm (1954).
Politics do not only exist at number 10 Downing Street.
Dimon C (2013) The Commodity of Care Cloister Press

Nursing Students: Are you Prepared for the private Sector?  C Dimon copyright 2013

In the UK there are 20,000 nursing students a year largely funded by the government (Campbell 2013 ). Many of those leave ( Kendall -Raynor 2012 ) or fail to work as nurses afterwards, or cannot get jobs in the UK , or work abroad (figs unknown). Furthermore, many nursing students may work within the private sector. Are they prepared for doing so? This article will highlight some of the key differences between the statutory and the private sector, with a recommendation to address the private sector to a greater extent within nurse education.

Care within the private sector which includes hospitals, clinics, care homes and prisons for example, is increasing. This is likely to continue with the commencement of Foundation Trusts (Dimon 2013 wideshut). Then why do care homes need to recruit nurses from overseas, because UK nurses will not apply for the posts? Overseas nurses do not necessarily receive the equivalent training to UK nurses. Consider , how can they be aware of different regulations such as the Human Rights Act 1988 and the Deprivation of Liberty safeguards? There are also cultural differences to address (Dimon 2013 ). Yet the NMC declare that any adaptation training given, is based on the assessment of the individuals needs. Although a test is proposed ( NMC 2013 ).

The private sector does differ largely from the NHS sector. Let’s also remember the voluntary sector here . Awareness of these differences can only be gained from vast experience and research within these areas. Even different private establishments differ so it is not enough to have worked in only one of them.

Here are some of the differences;

Mrs Smith walks with a frame and is not confused. She wants to go out alone. What do you do?

Mr Downs wants to die alone outside. What do you do?

It is midnight, you need to consider the Deprivation of Liberty safeguards and place bedsides on Mrs Smith’s bed. What do you do?

Three residents have diarrhoea and 2 members of staff. What do you do? Are you aware of regulations requiring you to contact environmental health immediately and how to do this out of hours?

The care assistants often have a huge turnover and a very different approach to health care assistants within a hospital. Motivating staff and dealing with stress are essential skills within this sector.

You may find huge restrictions on resources and staff levels. There may well be within hospitals. Yet within a care home, you are alone on your shift. What do you do in these situations?

The complaints procedure for residents and staff is totally different to within hospitals (Dimon 2013 in print), it very much depends what the issue is and how the care of the resident is funded. Are you aware of Contracts Compliance for example ?

Policies are totally different. Yes CQC standards apply and the same regulations but there are additional guidelines to the Health and Safety Regulations for example .

When do hospital nurses have to think about PAT testing or lift inspections? Recall the manager of a care home is actually registered- unlike a ward manager. This means the manger is responsible, even if he or she has a regional manager above him or her.

Medicine management differs- you cannot routinely keep oxygen in care homes (unless prescribed for a specific resident) unless you pay for it and you need specific homely remedy policies signed by each GP for each patient and agreed by the care home inspector. .

Even salaries differ. Agenda For Change pay scales which apply to the majority of staff within the NHS, do not apply to the private sector- nor are they required to apply to Foundation Trusts. Indeed, many staff within the private sector are paid less than within the NHS and may also have less terms and conditions (Dimon 2013 in print). Yes there are Unions but not all staff are members of Unions- which in some cases are ineffective (Francis Report 2013). Not many staff are however, aware that they can obtain free employment advice from ACAS,

The list may go on. There are further differences within private hospitals.

When I hear lecturers and nurses announce the private sector is the same as the NHS, I begin to realise why problems occur. We are not preparing the student nurses adequately. The NMC do state that the private sector must be addressed within the standards for education. Yet this needs to be more specific. When lecturing students , all topics need to be applied to the private sector as well as NHS. For example, medication or nutrition. It is so easy to inform students to refer to the dietician but they need to know how to do this in the private sector when there is a shortage of such services (BBCnews 2012). There are also prisons to consider, which are totally different again.


Many students work in care homes as a last resort. They need to regard it as the challenge and specialist area that it is. This will only occur if Universities realise the potential of employing lecturers who are specialist in this field. Students fear that working in care homes will bar them from ever returning to hospitals. Hospital staff need to recognise the high level of skills involved within care homes. No longer is it appropriate to continue to employ solely clinical hospital nurses as lecturers. Students need a case study approach discussing actual situations within care homes and how to deal with them. Providing students with theory is nowhere near enough. Students can read theory for themselves. The skill is how to apply it. You only know how to apply theory if you are experienced within that field. Such case studies need to address good as well as bad practice. We ought not to keep rose coloured spectacles on ourselves and our students. They need preparing so they need the truth. 50% of nurse education is required by the NMC to be placements. Usually this involves care homes for students, depending where Universities can obtain placements- and on the students’ interests in some cases. We need to prepare students for this.

Universities- you can accept the challenge and prepare students for the private sector or you can await the demise of the role of the nurse certainly within the care home sector. Already we have debates considering the feasibility of employing nurses in nursing homes . Or is the issue- a full three year degree is inappropriate when nurses know exactly which area to work in? Already many overseas courses include for example, 6 months in theatre to be a theatre nurse. Could we consider, six months to be a nursing home nurse or a nurse within another specific field ? Let’s look at reality.

Key points,

There are differences between working within the private sector and the statutory sector.

Nursing students need preparing to a greater degree to work within the private sector.

Lecturers need to be more aware of these differences.

Lecturers who are experienced within the private sector need to be employed.

Working in care homes, ought not to be regarded as a last resort


BBC news (2012)

Care Home Residents Lack NHS Services- CQC Survey 7.3

Campbell D (2013)

Nurses Must Spend a Year on Basic Care

The Guardian 26.3

Dimon C (2003) 

The Commodity of Care

Choir Press

Francis R (2013)

Public Inquiry Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry

Exec Summary

Volume 1

The Stationary Office


Kendall-Raynor P (2011)

Nationwide Initiative To Reduce Student Dropout Rates Revealed

Nursing Standard p14 Sept 21 v20n3

NMC (2013)

Adaptation and Aptitude Test (6.2)


This is a response to the NMC's nurse revalidation proposal, as submitted in Item 10. NMC/13/146. 12 September 2013. Annexe 2 - Options Appraisal, from which I quote:

"The primary purpose of revalidation is to provide greater assurance that nurses and midwives on our register remain fit to practise and capable of safe and effective practice. It needs to include a means of checking that those nurses and midwives continue to meet our standards, both in terms of conduct and competence, and that they have continued to keep their skills and knowledge up to date. The system of revalidation that we adopt must contribute to our core regulatory purpose which is public protection. We aim to deliver a proportionate, risk-based and affordable system that will provide greater public confidence in the professionals regulated by the NMC. It is also important that revalidation raises standards of care and promotes a culture of continuous improvement amongst nurses and midwives."

"11.1. Description: This option is similar to option 2 with the additional element of the third party input on the practice of the registered nurses and midwives. This third party input would be in the form of employer confirmation (where applicable) and feedback from patients, users, peers etc. In the case of employer confirmation, the appraisals would be the main source for confirming that a nurse or midwife is compliant with the Code and standards in their practice. The confirmation model will be

flexible to take into account the diversity in scope of practice and employment situations. The details regarding the sources of confirmation/feedback will be informed by the public consultation."

"11.2. Any documentation collected as a part of the third party input would be retained by the registrant. They will only need to submit this to the NMC when they are selected for the audit (detailed in paragraph 10.3) where the documentation will be called for as a part of the audit. The registered nurse or midwife will be solely responsible for the submission of their revalidation information sought by the audit to the NMC. Third parties will not be expected to submit any information directly to the NMC for revalidation of nurses and midwives."

"11.3. Advantages: There are considerable advantages to this option. Added to the advantages of option 2, the element of third party input means there

will be significant improvement on current assurance levels of fitness to practise of the registered nurses and midwives".

"11.4. There is a strong support from the patients and public about including patient feedback as a part of revalidation to enhance public protection. This is evident from the view of patients’ organisations on GMC revalidation. These organisations value the patient feedback as an aspect of the revalidation and consider it a key resource in helping to improve the practice. This view is further supported in the Francis report  ... where it is recommended to the NMC that the information that feeds into revalidation be evidenced by feedback from patients and their families".

"11.5. This will also provide NMC extended and enriched data to inform risk andenable effective triangulation with other regulators".

"11.6. Disadvantages: There are a few disadvantages to this option. The input from third parties regarding the registrants’ fitness to practise means there is a cost element in the amount of time spent by the registrant in collecting them as well cost to the third party confirmer. In the organisations where there is a robust appraisal system it would be most cost effective to integrate revalidation into that appraisal system".


The scope of the NMC's proposals remains extremely limited, confining itself to a small sample of nurses chosen for audit.

The central tenet of the proposal gives undue power to employers to determine whether a nurse is fit and safe to practice.

The dangers of this proposal are:

Employers may misuse their power. The private sector of health care provision is increasingly being taken over by venture capital companies (Nightingale 2013), whose aim is to make a return to investors, a modus operandi invariably accompanied by cost-cutting measures, such as a reduced number of staff. The positive correlation between low staffing levels and poor care outcomes is well documented (UNISON 2012). The competent practice of a Registered Nurse can be negatively impacted by the nature of their work environment, with increased pressure arising from such factors staff shortages, which are an ongoing feature of organisational cultures centred on the 'business objectives'. Nurses working within such cultures are not supported by unions, the RCN stating a desire to support the business objectives of companies* (ibid). The result is a power imbalance between employer and employed, with the latter being afraid to report poor nursing care, in that reprisals in the form of 'cold-shouldering', lack of promotion, or the threat of being dismissed as a ' troublemaker', are an everyday reality for many nurses (Dimon 2013). The pressure to conform to the cultural norms of the work situation particularly impacts negatively on student nurses, as highlighted in research (Levett-Jones et al 2009), in which students "described how and why they adopted or adapted to the teams and institution’s values ... rather than challenging them, believing that this would improve their likelihood of acceptance and inclusion by the nursing staff." Overseas nurses may also be at risk of employer intimidation, in that many are charged large and often illegal fees by recruiters who brought them to the UK, leaving them feeling "manipulated and cheated", stated the Royal College of Nursing. Its report - We Need Respect, Experiences of internationally recruited nurses in the UK (2003) - found that many of those questioned describe their employment, both in the NHS and the private sector, as "slavery".

(*In this regard, the independence of the NMC is called to question. The NMC and the RCN both place organisations involved in patient care as central to policy; the NMC would give employers a key role in revalidating nurses, and the RCN gives consideration to the profit-making goals of organisations, making employers more likely to allow the RCN to have bargaining rights within workplaces. (Other unions, such as UNISON, take a similar stance). The NMC website  ( informs that its central committee is composed of twelve members, six of those being registrant members, with previous nursing experience. Of these six, three are shown to have declared in the NMC's register of interests membership of either the RCN or RCM; the remaining three registrant members not having declared their interests. Would it not be reasonable to require all NMC committee members, whether of its central committee or its various sub-committees, to declare any affiliation to the RCN or RCM, and whether they serve on any RCN or RCM committees? Any suggestion of the RCN having undue influence within the NMC needs to be considered.

The NMC's central committee are appointed by the Privy Council - a formal body of advisers to the Sovereign in the United Kingdom. Its membership is mostly made up of senior politicians who are (or have been) members of either the House of Commons or the House of Lords. The Council has a delegated authority to issue Orders of Council, which are mostly used to regulate certain public institutions - which is to say that they are appointed at the behest of the Political Establishment, which has generally been supportive of the principle of the privatisation of state assets and institutions. The NMC's register of interests asks members to state any affiliation to a political party, and those members who have made entry in the register declare no such affiliation; yet, being a member of a political party is not the sole criteria of being 'political', or politically biased. Will the NMC ask its committee members to state their views on two current issues? - private sector acquisition of NHS services; the RCN's sympathetic approach to the business objectives of companies involved in nursing care - so as to reassure the public and nurses that the NMC's committees are composed of people with a diversity of views, and not ones carefully selected to sing from the Establishment's hymn sheet. Further, would the NMC and the Privy Council comment on why NMC committee members are not democratically elected by a postal ballot of all current nurse practitioners? The principle of elected governance has often been used to justify the overthrow of unelected and unpopular (to some) governments; why do nurses deserve any less than, say, the 'liberated' citizens of Iraq and Libya? Although it can be safely assumed that NMC central committee members, and members of their family, do not have any personal or business association with members of the Privy Council, can the same claim be made regarding any such association with the hierarchy of the RCN? The apparent independence of the NMC is stated in an email (16 July 2013) to Carol Dimon, researcher and author, from an official of the Department of Health, where it is stated to be "an independent body". To what extent is this the case?

Further, the very high academic eminence of NMC committee members suggests that it may be some years since they worked 'on the shop floor'. Will NMC committee members comment on how they make themselves acquainted with the everyday experiences of nurses working in understaffed hospital wards or privately run nursing homes? - other than by attending RCN conferences, that is. Do committee members consult the many blog posts of nurses complaining of understaffing and employer intimidation? Do they maintain their registrations by, say, working an occassional shift in a nursing home owned by a private equity company? On the same theme, it is noticeable that the NMC's revalidating proposal is fronted by a non-nurse academic. Can nurses be assured that the result of the revalidating exercise is research-based - were questionnaires sent to a large sample of registered nurses of various specialities, and their responses analysed? Has recent literature that comments on the everyday experiences of nurses been consulted? ( Or is the revalidating proposal of the logico-deductive school? - wherein a conclusion has been drawn from 'sound arguments'; a definition of which might be - not ones necessarily favoured by the NMC).

There have also been fabricated NMC cases that falsely accused nurses who did not fit in with their colleagues (Middleton 2012). One way of encouraging a member of staff to leave is to collect minor issues against them. The NMC's proposals are a blueprint for the abuse of power by an employer, and will severely lessen the likelihood of nurses 'whistleblowing' about poor care standards. Employers may use their input to attempt to 'get rid' of unliked employees through the NMC's validation process, rather than risking being taken to an industrial tribunal. Colleagues may be coerced into giving false witness.

The above mentioned considerations apply equally to the public sector, which is also run on a business model of management, geared to reducing costs, and employing a 'flexible' workforce; i.e., one which has little say in the types of contract offered. The increasing use of zero-hours contracts in both the private and public care sector makes it less likely that nurses will complain on behalf of patients, fearing not being offered work. The fear of being called to audit will make for a compliant workforce, which will not be in the best interests of patients.

In short, the NMC's proposal to give employers a major role in determining whether a nurse is fit and safe to practice is one which is naeve, if it is based on a belief in employer impartiality, and is an abrogation of a duty to protect nurses if not. The proposal is an abstract based on a false premise, rather than the result of research into the realities facing nurses. It seeks to enforce a dictatorial paradigm in which the the abilities and personal qualities of nurses are interpreted by the whims of potential dictators, as opposed to the right of an individual nurse to make claims about themselves and their situation.

Other means of revalidating a nurse's abilities and attitude have been successfully used in the USA, where mandatory continuing education for all nurses is required by a number of states. This is not claimed to ensure competency, or compassionate attitudes toward patients, but it can form the cornerstone of an approach which promotes competency and compassionate attitude on an ongoing basis.

It is suggested that:

(1) Nurses within the same locality, working within the same speciality, be placed into 'educational cohorts'.

(2) There will be a number of same speciality cohorts within each locality, restricted to a membership of approxomately twenty.

(3) Each cohort to be affiliated with a local university.

(4) Individual cohort members to be given a 'continuing competency' and 'personal observation' computer file by their university.

(5) Members of cohorts to have access to university  library facilities.

(6) Members of cohorts to have the (non-compulsory) opportunity to be 'guests' at lectures of their choice, or of simulated practical sessions.

(7) Universities to assign cohort co-ordinators with experience of their cohorts speciality.

(8) Cohort co-ordinators to collate (and disseminate via email on a monthly basis to cohort members) research articles pertinent to each speciality, and articles concerning compassionate care, pertinent to all specialities.

(9) Cohort members to read this information, and reflect on how it may enable them to deliver competent and compassionate nursing care, entering such reflection into their 'continuing competency' file. Entries can be short and simply expressed, without any formal academic format, thus being of a non-threatening nature. Nurses without the simple computer skills necessary to maintain their file, to be given tuition in doing so. Attendance as a guest at any lecture or practical session to be similarly recorded. Cohort co-ordinators to inform members of available lectures and practical sessions.

(10) Each cohort to attend, every twelve months, a two day 'school' at their designated university, with each 'school' delivering lectures concerning updated practice information, practical demonstrations where applicable, discussion concerning members individual experiences of attempting to deliver competent and compassionate care, and any factors which mitigate against this in their practice setting; discussion about how to better promote professional competency and compassionate care in their practice setting. Discussion to be led by the cohort co-ordinator. Some members may not wish to disclose factors, such as continuing low staffing levels in their working environment, which may negatively impact on their ability to deliver competent and compassionate care. Such disclosure can be entered on an ongoing basis in their 'personal observation' file. This file should be personal to them, to be accessed only by code. The file may be used as mitigating evidence against claims of poor practice by employers. Distinctly, the 'continuing competency' files should be in the public domain, accessible to employers and patients' relatives.  Each cohort member will record in them a yearly review of their continuing effort to remain a competent and compassionate nurse after the two day 'school'.

Members will receive travel expenses to attend the 'school', and, in the case of transport problems, financial assistance to obtain overnight accomodation in the university campus.

(11) Cohort members will be able to scan any written evidence from patients' relatives or colleagues which details their competency and compassionate attitude, and download it  to their competency file, or take such evidence to their 'school', where it can be scanned and downloaded on their behalf. 

(12) Employers will submit a brief statement before the 'school', giving their opinion of their employee's competency and attitude toward patients and colleagues, which will be seen by the employee, who will be able to attach their response to it. This evidence to be downloaded to the 'continuing competency' file.

(13) This file will be available for download by a validating agency, which will check a random sample of files to be assessed against set criteria, and will be tasked with reporting any concerns arising from their assessment to a standards agency, which will inform the nurse, who will be asked to submit a corrective action plan.

(14) This proposal will be funded by a levy paid by employers of 20p a hour for each nurse they employ, which will be partly tax refundable, with greater discount to smaller organisations.

(15) Attendance at the 'school' is mandatory, except in the case of certified sickness, and employers will be legally obliged to release employees to attend. Limiting a cohort to twenty members from a range of organisations will ensure that employers should not face staffing shortages relating to 'school' attendance.

Continuing competency requires lifelong learning. Nurses are responsible to continually reassess competencies and identify needs for additional knowledge, skills, and personal development. This must be a collaborative process including individual nurses, educators, patients' relatives, colleagues, and employers, not a process which gives undue emphasis to employers' evaluations of nurses, which are open to abuse. Employers must be made aware that the competent practice of a nurse can be impacted by the nature of the work environment, and that employers have a duty to provide a suitable environment for good practice.

Current procedures allow nurses not to keep updated records of professional development, with anecdotal evidence of nurses running the risk of being audited, and concocting records only when notification of auditing is given. Mandatory continuing education ensures a framework of professional and personal development, uniting nurses of different generations in a common goal of improving the care given to patients.


Dimon, C. (2013). The Commodity of Care, pp. 69-72. Coister House Press.

Nightingale, L. (2013). Who Owns Care Homes?, cit. The Commodity of Care, Dimon, C., appendix.

UNISON (2012). Care In the Balance. A UNISON Survey Into Staff/Patient Ratios On Our Wards. Web: 1 February 2013.

c.   lenin nightingale 2013   [email protected]


Private healthcare versus Statutory copyright Carol Dimon 2013

There are 20000 nursing students in the UK ( Campbell 2013) , fees paid for by the government unless student is from overseas. Education content to be addressed is identified by the NMC (2010 ) but modules are determined by the University. Of those 20000 students, many may not practice as nurses at all, many may leave nurse training(Kendall-Raynor 2012 ), some may go abroad and many may work in the private healthcare sector. There are no available national figures for this. Whilst care homes must be referred to according to the NMC, how prepared are student nurses to practice in the private sector? Is there indeed a difference? It is further indicated with the establishment of Foundation Hospitals that there may well be a greater increase in the private sector. Indeed, private beds are presently used by the NHS for patients who cannot be accommodated elsewhere. Foundation Trust hospitals do appear to mirror school academies which the Government do propose to privatise (Merrick 2013). One wonders why the increase in privatisation? It may well be that the Government therefore abdicates responsibility for standards within them as reflected by the existence different policies and procedures .

This article will explore some of the major differences between the two sectors, focussing largely on care homes and NHS hospitals.

You may all say CQC standards are the same. But different issues arise within care homes to hospitals. It must be noted also that the CQC Registration Regulations (2009) also apply which refers to such aspects as notification of death and statement of purpose of the registered premises . Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 also apply (CQC).

The manager of a care home is the registered manager according to CQC and the 2009 regulations. Ina residential home this may be senior care assistant. In a nursing home it is a registered nurse. This means he or she is responsible for everything from light bulbs to staff levels ( Dimon 2005 ). Indeed there are cases of home managers jailed for low staff levels that resulted in poor resident care (Bunyan 2012). Speaking of the home manager, in large company, the judge declared “ As the home manager, you were responsible for the care and well being of residents” (Bunyan 2012). Consider this. The running of the home also depends upon who or which body owns it. What can the manager do when he or she is forbidden to ring agency? (Dimon 2005). Here the manager is torn between budget and quality of care. Indeed, it may well be that nobody is available via the agency. Reporting staffing levels in the private sector differs to an NHS hospital.

The registered manager of an NHS hospital is the chief executive or equivalent; who is not necessarily a qualified nurse or doctor.

In an NHS hospital- the nurse in charge informs the ward manager. The ward manager contacts other wards. Informs higher manager if the problem keeps re-occurring. Does the book stop there? There is higher- the CQC if need be.

In a care home the manager may ring the owner if individual owned. Then the CQC if no satisfaction. If company owned- ring the regional manager and go higher and ultimately inform the CQC inspector each time they are short of staff. Easy isn’t it? I will not discuss whistleblowing here and possible repercussions.

What of other differences? Al l hospital care assistants receive planned training , the content did vary between them but now in ll care establishments, must be based on Skills for Care Core elements. Yet variations may continue to occur since no duration is specified for the training, no exact content and assessment is done in –house. There are a vast number of influencing factors here. Who will provide the training? What will it consist of? How long will it be? Will staff be given time to attend?

Regarding regulations ;The Health and safety Act 1974 applies to all establishments regarding education and records for example. Home managers need to be aware how to inform appropriate agencies concerning RIDDOR; unlike hospital, they may have nobody else to refer to. Yet separate issues may arise within care homes. The HSE website offers a free downloadable booklet regarding specific issues and guidance for care homes. Whilst it is a 2001 publication, it is still of relevance. When in hospital does a nurse have to be aware of electrical and gas regulations? When do nurses in hospital have the responsibility of ensuring that all items are PAT tested? When does a ward manager have to ensure that equipment such as lifts are checked every year and maintained? When is there a stairlift in a hospital? Hence the differences.

Food and hygiene. The European Community Food Hygiene Regulations (2006) replaced the Food Safety (General Food Hygiene ) regulations 1995 (westberks). Care homes must be registered as food business with the local authority Environments Health Department. There is separate guidance for care homes since so many different issues apply such as residents who wish to have relatives bringing food in for them (HPA 2013). Anecdotal evidence and a study (2010) indicates that many care home staff and managers are unaware of legislation governing infection control; how many care home managers are aware to inform environmental health if they have 2 or more outbreaks of vomiting and diarrhoea? All staff in a care home need to be aware of this requirement. It is against regulations to wait from Saturday until Monday to do anything. Not all are aware that the environmental health is on call for this purpose and can be contacted via the accident and emergency dept of the local hospital if you do not have the emergency number. Also education or resources may be lacking; some respondents in one study (HPA 2010) washed bedpans in communal baths or residents’ sinks. HPA (2013) also detail advice regarding waste control, uniforms which are not required to be removed when leaving work but recommended and such infections as scabies which do arise in care homes. Regarding responsibility, the HPA does state clearly, that the person in charge within a care home, is responsible for such as waste removal for which they recommend an audit. Hence the difference regarding hospitals .

Staff who serve and prepare food need appropriate training. In a care home, this may mean all care staff as there is not always anybody in the kitchen. Staff in hospital- do not even usually enter the kitchen.

Hence whilst the same regulation applies, individual situations and establishments, must be considered.

Pharmacy regulations also apply, in addition the NMC medicine guidelines (2008) if you are a registered nurse. Yet there are different issues in care homes.

Often doctors may ring and change the dose of a medication over the phone. What does the nurse do then? It is recommended that you insist upon a fax or other means of written information (NMC 2008). In care homes, staff may not always have access to a fax or computer however, out of hours.

In care homes oxygen may only be kept when it is prescribed for a specified patient. You can however, buy the oxygen or rent it which means you have to contact an oxygen supplier (NICE 2010, Mr McGill). Even then, not all staff are aware how to use it. In hospital, there is a wider team of staff to draw on.

Homely remedies. There are no specific regulations here apart from what actually may be given at all without a prescription of course (Mr McGill) but there will be local policies. How many staff are aware that to give homely remedies in care homes a home remedy protocol (NMC 2008) must be agreed according to the GP of those residents, the pharmacist and the care home inspector. Different GPs will allow different medications to be given unprescribed. This also applies to creams and simple dressings. In hospital, there is already an agreed protocol and policy within that hospital. Further dressings may only be given to the resident for which it is prescribed. Same applies to medication.

Disposing of unwanted medication is also an issue. This depends on agreements with local funding bodies . Residential homes unwanted medications are removed by their pharmacist. In nursing homes the nursing home owner must pay a company to remove them (Mr McGill). So despite regulations such as the Medicines Act 2012 being the same, their implementation differs.

Obtaining medication in emergencies may well be a problem in care homes. Is there enough staff to enable one to go and does he or she have a car?? If nurses are not taught this and especially overseas nurses, how can they be held responsible? Yet every care home differs according to who owns it. They all have different policies.

Maintaining finances of residents. In hospital do not usually maintain bank books yourself. This would be done by hospital admin. Does however again, depend who owns the care home. Some home managers have had to establish bank accounts themselves on behalf of residents.

All residents within care homes have a right to receive all aspects of healthcare. Yet there are indications and is anecdotal evidence, of difficulties obtaining GPs or physiotherapists for example (BBCnews 2012). Some homes do actually employ specific professionals themselves. GPs may be reluctant to visit for example, yet there are dilemmas regarding how to transport the resident to the GP practice.

This may well be the future of hospitals. Foundation hospitals instil a business-like approach, Managers are thus able to opt to use private services such as Boots the pharmacist. It may also mean that hospitals establish their own policies hence they too, become different to one another. If we are marching towards privatisation, we need to be prepared.

How many are aware of Deprivation of Liberty Safeguards? Indeed, CQC recently found there was a neglect to apply these safeguards and failure of some care home companies to educate staff regarding this (Samuel 2012 ), hence restraint was being used such as bed rails without obtaining permission , and locking patients in their rooms on occasion. There are issues for night staff when this safeguard must be applied but there is no emergency contact for the procedure apart from the manager who cannot grant permission normally . Again large companies do generally update and inform their staff . Yet problems still occur within them .

What of the complaints procedure? Within the private sector this is actually weaker. NHS hospitals have PALS and if they are foundation trusts which they all soon will be , they also have Monitor. Private establishments do not have this, yet they do have complaints procedures. If it is a private hospital the Independent Healthcare Advisory service will advise patients about complaints, if the hospital is a member. If it is a care home and it is owned by one person, you complain to the home manager or owner. All have a right to ask a patient to leave the care home with one months notice, if they cannot meet their needs in whatever way. There is evidence of this having occurred (alzheimers) and in some cases, alternative reasons for informing the resident to leave may well be provided such as, “we cannot meet your needs”. This may well be the case in some situations but not others. It is a business after all. Where can you go in a restaurant if you do not like the service?? Personally- I just opt to go elsewhere but not always an option in healthcare. Companies have regional managers and board of directors. Homes may also be owned by charity bodies which many are reluctant to complain to or about or indeed, the NHS owns some care homes. Regarding Charity bodies, the Charity commission will only consider extreme issues.

The complaints procedure for residents and relatives in care homes, does depend on how the resident’s care is funded ; by themselves or Local authority or NHS. (Article in print Dimon 2013)

So what of support for staff? There are actually many staff who wish to raise issues. Anecdotal evidence informs us that within some areas of the private sector, individuals especially overseas staff or care assistants, are discouraged from joining a Union. ACAS does exist however, to offer free independent advice and mediation regarding employment issues.

Regulations regarding staff differ in application between private and statutory establishments. Indeed, some private establishments have clearer policies and procedures than others concerning disciplinaries for example.

So what about care? How can different issues arise there?

Examples remain of getting all residents out of bed at 4am against their wishes( Ford Rojas 2011 ) due to short staff and pressure from the opposite shift. Hence Human Rights consideration is essential within this vulnerable area of care. Or is it just common sense?

Consider a patient with extreme diarrhoea; Clostridium Difficile who needs barrier nursing. He is so confused he removes his incontinence pad and wanders about. Can happen in hospital possibly longterm care, more likely in a care home due to the nature of the resident. In either place, there may not be enough staff to enable one person to sit with him all day. It is illegal and inhumane, to lock him in his room . Resources such as available bins and appropriate sinks may differ, even carpets are an issue. In some care homes, cleaning resources may be inaccessible when the domestic has returned home.

Whilst Government action concerning the Francis report (2013) has yet to be determined, these recommendations will not necessarily apply to care homes or indeed, the private sector, unless the Government decide otherwise.

Whilst this article may appear to be critical of the system, it is merely meant to inform people of the differences in practice concerning actual regulatory requirements and the implementation of regulations . For this, we need to prepare nurses which is essential within nurse education. Yet how can students be prepared when the majority of lecturers, have never worked within a variety of private establishments, owned by different bodies? Many students leave education because they are unhappy with situations they are finding. They need open and honest discussions concerning actual dilemmas of practice.



Human Rights Issues Arising From The Treatment of Old Persons in Hospital and Residential Care


BBC news (2012)

Care Home Residents Lack NHS Services- CQC Survey 7.3

Bunyan N (2012)

BUPA Put Profit First and Filthy at Understaffed Care Home, says Judge

The Telegraph 17.3

Campbell D (2013)

Nurses Must Spend a Year on Basic Care

The Guardian 26.3

Dimon C (2005)

The Challenging Role of The Care Home Manager Nursing and Residential Care

December. V 7 n12 p571

Ford Rojas JP (2011)

Residents At Short-Staffed Care Homes “Woken At 4am”

The Telegraph 11.1

HPA (2010)

A Report On The Management of Diarrhoea in Care Homes

HPA (2013)

Prevention and Control Of Infection In Care Homes- An Information Resource

Dept of Health

HSE (2001)

Health and Safety in Care Homes

Health and Safety Executive

Kendall-Raynor P (2011)

Nationwide Initiative To Reduce Student Dropout Rates Revealed

Nursing Standard p14 Sept 21 v20n3

Merrick j (2013)

Secret Memo Shows Michael Gove’s Plan for Privatisation Of Academies

The Independent 10.2

Mr J Mcgill

McGill’s pharmacy

Ross T (2013)

Care Home Staff to Have Compulsory Training Under Government Plans To Protect The elderly

The Telegraph 8.3

Samuel M (2012)

CQC:Care Homes Failing To Train Staff in Deprivation of liberty 27.3


Foundation Trusts Ahoy! Copyright Carol Dimon 2013

Foundation trusts were introduced in 2004 in England, by the Government as a response to financially failing NHS hospitals. All NHS hospitals in England must be Foundation trusts by 2014 according to the Health and Social Care Act 2012 but the government does recognise it may take longer for some. They require the hospitals directors with input from the governing body, to independently manage the budget without Government involvement. As such they must be declared to be “ financially and clinically” viable by the independent regulator Monitor. So what implications does this have for patients and staff?

If hospitals are failing (publications.parliament 2011) surely there are questions regarding their ability to manage their own budgets? Indeed there is evidence of poor leadership. Yet Foundation Trusts require extremely strong leadership skills. There will be input from members of the local community but how representative will they be?

Despite having had a limit on the private services they may use, NHS hospitals have used private beds , care homes or hospitals for many years. The cap on this for Foundation hospitals, has been increased to 49% (Kmietowicz 2012). This means there may be a much greater use of private services. We may even see Boots the chemist within hospitals or McDonalds cafe. Staff themselves, may be provided by private contractors. Indeed there is nothing to stop a private company itself from running a Foundation Trusts as UNISON suggests (2003). This has huge implications for the type of patient within hospitals. 70% of hospital patients are old people (Campbell 2013) many so called “bedblockers” who simply cost the hospital money. Such vulnerable patients may well be returned to the community where services are lacking. Indeed, there is a proposal to use unused NHS buildings managed by hotel chains to accommodate old people who need care such as people with dementia. Within some districts for example, we already have certain services being returned to the community. There is already a proposal to do this by some members of the Clinical Commissioning Groups who control the NHS budget within England (Campbell 2013). Surely if hospitals are paying for private beds elsewhere, it still costs money? Or is it reshuffling of the budget? Indeed there have been issues with NHS funded patients using private beds within private hospitals . For example care of NHS patients may be delayed unnecessarily by the private hospital to encourage them to actually pay (Laurance 2012).

Legally Foundation trusts, can oppose Agenda For Change for staff . This specifies staff’s salaries and terms and conditions such as sick pay. Indeed many Foundation Trusts are considering this despite union objections (Calkin 2012). Yet are unions strong enough? There is evidence that unions are far weaker than they once were (Milne 2012). Hospitals do have enormous agency bills for qualified staff, after reducing the number of their own permanent staff. Use of agency staff may actually offer further problems as we discuss elsewhere. For example lack of familiarity.

Indeed a greater number of overseas staff may well be used to save money. Many overseas staff are paid less and are keen to work for less pay and conditions. This may bring additional problems such as their training and language difficulties. Even the validity of their qualifications may be under question (McFarlane 2013). Yet some newly qualified nurses indicate they have been rejected for posts as the hospitals have to employ a certain number of overseas nurses.

If it is possible to oppose such regulations regarding staff, what other regulations may be opposed? Foundation Trusts are actually as UNISON declare, a “means to privatisation by the backdoor” (2003). The private sector does have different procedures and guidelines and staff generally receive less pay and fewer conditions apply. Regarding the complaints systems, in Foundation Trusts Monitor will apply but not necessarily PALS. Presently the health ombudsman will still apply also. Healthwatch also established according to the Health and Social Care Act 2012, is an independent body to influence health and social care within the local area and link back to national Healthwatch. Healthwatch can advise patients where to go to complain. The GP care consortium will investigate complaints for NHS funded patients; NHS England will do so regarding primary care. Some areas in England also have independent advisory bodies established by charities. The existence of foundation Trusts will generate competition between hospitals; some may well merge to make more central services. Will this actually reduce patient choice? Yet as such, hospitals may well be reluctant to highlight problems and complaints as can happen within the private sector.

Professionals such as physiotherapists may be regarded as a luxury as they often are within care homes. The Chartered Society of Physiotherapists and others, are campaigning against this erosion of their important role.

Foundation Trusts reflect school academies. Within them we have less pay staff, in some cases the need for qualifications is not demanded, less of a complaints procedure with no involvement of the LEA and there is some debate regarding lower standards within academies. Nor is there any requirement to adhere to the national curriculum within school academies. Indeed we now read, academies are actually to be privatised despite the government having denied this for several years.

Are Foundation hospitals in essence a means to reduce costs such as staffing that the Government could not otherwise do if it remains part of the NHS? Are they a means to privatisation? Or are they a means to abdication of government responsibility hence blaming the individual hospital and governing body, not the Government itself? Only time will tell.

Meanwhile many nurses, student nurses and lecturers remain frighteningly unaware of the possible implications. We all need to be politically aware of how such decisions affect the care that we provide at the patient’s bedside.

Article used by 4Bit news 2014

For further analysis of this and other issues, watch for our forthcoming book;

“The Commodity of Care”.


Calkin S (2012)

South West Trusts Set Up Regional ‘Pay Cartel’ (25.5)

Campbell D (2013)

Hospitals Must Shrink or Shut, doctors Warn

The Guardian 7.4

Kimietowucz Z (2012)

Hospitals will be able to earn 49% of their income from

private patients from October

Laurance J (2012)

Private hospital told doctors to delay NHS work to boost profits

The Independent 21.

Lintern S (2013)

Foundation Trusts To Start New Bids To Cut Pay Cuts 15.4

McFarlane J (2013)

Freeze on foreign nurses as NHS chiefs admit they have no idea how many lied about qualifications and experience using fake IDs
Mailonline 10.3

Milne S (2012)

The Problem With Unions is They’re Not Strong Enough

The Guardian 11.9 (2011)

House of Commons Committee Of Public Accounts Achievement of Foundation Trust Status by NHS Hospital Sixtieth Report of Session 2010-2012

The Stationary Office London 15.12

UNISON (2013)

Seven Reasons Why UNISON IS Opposed to Foundation Trusts March

Care and Criminology Copyright Carol Dimon 2013

Criminology which involves the exploration of reasons for committing crime, would appear to be the antithesis to care. Yet the subject and research findings have immense relevance. This article will explore this relevance, highlighting the need for broad literature searches and consideration of work done within other fields.

Poor care has always occurred with the field of care (Robb 1967) within the UK and overseas . Whilst the nature of poor care may differ and reasons for it, it occurs within all areas to some degree; whether it is medication errors, failure to write in records, neglect or direct abuse. It may also be unintentional or intentional.

The delivery of poor care could be considered as a crime- that is, moral and legally unacceptable behaviour. In care, this could address many cases from failure to give a patient a drink to direct a abuse; as in criminology. It is acknowledged that what is considered to be poor care does vary between individuals considering such factors as culture (Dimon 2013 in print). Could the consideration of criminology also extend beyond care staff themselves? Consider managers for example who may face conflicting demands between care and budget or wish to protect their role thus avoiding any aspect of controversy. Way beyond we have registration bodies, politicians and professional bodies who also may have vested interests and do influence the provision and quality of care (Dimon 2013 in print).

Criminology could certainly apply to staff behaviour; criminological research has addressed gender differences which has implications for care, in which the majority of care staff and nurses are female. Females for example, are considered to undertake less crime but rely more on group (gang) membership (Steffensmeier, Allan 1996 in Dimon 2013 in print). This means that males are more likely to lead in cases of crime and women more likely to follow the rest. Men also commit more serious crimes than women. However there have been cases in care of women care assistants and nurses, committing serious abuse (Marsden 2013). In some cases it is accepted that the individual was suffering from some form of psychiatric illness . There are also additional factors to consider such as social background and expectations.

One theory of relevance in particular is Sykes and Matza (1957) techniques of neutralisation. This link to behaviour has been recognised by Woods ( 1990 ) in education and Martin (1984) regarding care.They propose that “delinquent behaviour is learned—in the process of social interaction. “Techniques of neutralization” refer to justifications for behaviour. Of relevance is consideration of a sense of guilt. The authors also describe admiration and respect for “law-abiding persons”. The individual to whom misbehaviour is directed is also a factor; the author discuss an example of not stealing from friends. One would think this applied to care; not mistreating patients , relatives and other staff members. Yet the overriding work ethic and neoliberalstic political influence, demands that all individuals be contributors towards society. Hence the more vulnerable and dependent, may be regarded to a less degree. The authors suggest that demands of conformity made by such as family or society, does actually influence behaviour. However, they do note, that some individuals may be careful not to be identified. Hence in care, the actions of some staff members are undertaken in isolation from other people or behind closed doors. Or they will not admit when something has been wrong. Although there are factors to consider such as fear and guilty conscience.

Some individuals for example , conform more than others . Is this then to be regarded as a form of deviance which begets a label ? Becker (1973) does raise this point; an individual could be labelled as deviant if he or she is not performing an illegal act and so fails to fit in. Whilst the intentional delivery of poor care may be classed from a social perspective as deviant, within the work area it may not be deviant if it is common practice. Within care, this is applicable when lower standards may be accepted as the norm ( Prielippet al (2010) in Dimon 2013). Whilst Sykes and Matza do refer to children, the theory is of immense relevance. Within education more recently, there has been a huge amount of research concerning behaviour of students (Beaman et al 2007). Applying this to care, we may begin to identify why certain behaviour occurs. It may not always be due to a low staff levels but also upbringing and lack of knowledge.

 Merton (1968) too discusses the adaptation of individuals within society. He identifies conformity, Innovation, Ritualism, Retreatism And Rebellion . Hence the influences of society do affect an individual; do they conform or do they retreat ? This too may be applied to a team of staff. Whilst the majority of people prefer to work as a group, hence conform, there are some individuals who prefer to remain independent and challenge the beliefs of the group. Such individuals may become isolated ( Hess 1972). An effective manager needs to be aware of such factors and the individual needs of staff.

Additional factors include self control; if individuals lack self control they may be more likely to react to situations of stress which is known to be high in care, anger or lack of tolerance to particularly vulnerable people. In order to care constantly, despite challenges, it may well be that staff require a great degree of self-control, in addition to support. Vazsonyi, Huang (2010) did study this with regards to deviance and children. It is stated that individuals who are low in self- control are “impulsive, insensitive, physical, risk-taking, short-sighted and nonverbal (Gottfredson Hirschi 1990 in Vazsonyi, Huang 2010). It is important however, not to generalise or make assumptions based on this.

Many may suggest that such behaviour is determined by one’s possession of a conscience or moral awareness; hence the guilt factor. To what degree is this innate or influenced by external factors? Dahlqvist et al (2007) applied a perception of conscience questionnaire to 444 nurses, nurses assistants and physicians in Sweden in order to explore the relevance of conscience to ethical dilemmas and the multiple factors involved such as culture and regulations. Fear of punishment is also a factor. Countries such as Iran are orientated around this with their use of executions for example. Applying this point to care, whilst cases of abuse may result in imprisonment (Chorley and Greenhill 2012) , some cases are unreported for several reasons . Also care assistants are not registered. When individuals are registered they are at

risk of being removed from the professional register for cases of poor care.There are examples where positive deviance approaches, have been applied to promote

high quality care . This approach involves recognising high performing hospitals for example,as measured by such as survival rates (Bradley et al 2009).

When interviewing staff or creating teams or the off duty, considerations of staff behaviour needs taking into account in addition to actual numbers and skills of staff. For example, having s strong leader who is caring and separating same gender staff as far as possible.

It may not always be possible to do this however, due to low levels of applicants or staff shortages when any staff member on shift is welcome. Yet it could be enabled by such as psychological testing at interview and a manager who knows the individual staff members. Such factors especially need consideration at night when there are lower staff numbers.

Accepting a criminological perspective towards poor care may promote acceptance and recognition of the existence of poor care. Many individuals and organisations, are afraid or ashamed, to acknowledge that it does exist and try to protect the image of the nurse or carer as a saint.


Bradley EH, Ramanadhan S, Rowe L, Nembhard IM, Krumolz HM (2009)

Research In Action: Using Positive Deviance To Improve Quality of Healthcare

Implementation Science v4n25

Chorley M, Greenhill S (2012)

Winterbourne View Care Home Abuse Reveals The ‘Criminal Acts’ Nurses and Care

Assistants are Capable of, Health Minister Warns Mail Online 3.8

Dahlqvist V, ErikssonS , Glasberg AL, Lindahl E, Lu¨tze´n K, Strandberg G, So¨derberg A, Sørlie V and Norberg A (2007) 

Development Of The Perceptions Of Conscience Questionnaire  Nursing Ethics . ; 14(2):181-93.

Dimon C (2013) in print

The Commodity of Care

Gloucester. Choir press.

Hesse H (1972) 1st pub 1927



Marsden S (2013) NHS Staff ‘Threw Cushions at Disabled People as Target Practice’

The Telegraph 18.4

Martin (1984)

Hospitals In Trouble

Oxford. Basil Blackwell

Robb B (1967)

Sans Everything


Vazsonyi AT, Huang L (2010)

Where Self- Control Comes From :  On The Development Of Self- Control And Its Relationship  To Deviance Over Time

Developmental Psychology v46n1 p2450247

Woods P (1990) The Happiest Days: How Pupils Cope With Schools


The state of care

This article is based on the forthcoming book “The Commodity of Care”. Published by Choir Press, the book analyses care within nursing homes and hospitals in UK, USA and Australia considering little researched perspectives. It is hoped that the book will promote further discussion and research within this field.

Aspects of poor nursing care have been well documented concerning care home and hospitals  in the UK , Australia and USA (Vladeck 1989, Robb 1967, Newton). Involving neglect of pressure care and failure to feed patients. Whilst good care does exist in all countries, poor care continues .

Why is this so? Nursing is a caring profession surely? Or has it been overtaken by the Darwin principle of survival of the fittest? It depends what “fit “ means; does it mean the most caring or the one who gains the most accolades for the best attendance at work or adherence to the manager’s requests? Is anybody who dares to question or raise issues, blocked? Consider Heywood who raised issues in UK but went to press as no satisfaction with internal management. She was removed from register but reinstated following an appeal (  ). There are cases overseas involving staff who complained “whistleblowers” and their dismissal.

There is also the business orientation of universities in many countries (Popenici 2012) which has implications for the award of registration to students. Is there an emphasis on passing assignments ? It is possible. There are also implications of society at large. Of how much a priority is care? The Government here in the UK has chosen to focus upon the issue of poor care following numerous newspaper reports, supported by other major organisations and some academics. Yet sadly, the occurrence of poor care was highlighted many years before in many countries.

Does poor care continue because all nurses have different priorities? Does it depend upon how nurses are educated? In the UK all nurses are now educated at degree level. Yet what the degree consists of, is open to interpretation by different universities .Universities decide what modules to have and how to assess them, despite NMC standards and validation procedures. In all countries, we have care assistants largely delivering what once was the nurses role. There has been  no uniform training for care assistants in the UK. Now care assistants in all sectors, are required by the CQC to undertake training based on Skills for Care Core Standards. Yet this remains open to interpretation with no specific content set , no set duration and assessment undertaken by the registered manager (in care homes). Such standard requirements for training care assistants do not exist within USA or Australia. In all 3 countries, care assistants do not have to be registered. This means they are free to work elsewhere if they do anything wrong. Unless a good manager tells the truth to the following employer. Students too are implicated. Some research does indicate that students are afraid to raise issues  due to conformity but it is  a small study(Levett-Jones, Lathlean 2009   ). Is it the same in the USA or Australia? The difference in healthcare fields is also a factor. Nursing homes/ hospitals do differ in USA to the UK. Yet  within nurse training in the UK, students are not always informed of the differences. Few lecturers have considerable experience within various private care establishments. Without this experience and considerable research, general nurses remain unaware. For example, the complaints procedure is totally different (Dimon 2013 in print). Further the content of the qualification of overseas nurses is under question (Dimon 2013 in print). Overseas nurses will be unaware of UK regulations and will need additional education whoever they are.

Education alone is not a simple remedy for poor care. Without resources and staffing levels, there will be effects on care. For example, how can residents in  a care home be bathed on  a unit of 30 EMI residents when there are only 3 staff? Low staff levels may be  for several reasons, sudden staff sickness or unavailability of bank or agency staff. Yes in hospitals or care homes, there are times when managers are informed not to book agency- or even bank staff. The approach-“let’s roll our sleeves up and cope team” has to stop. Otherwise complacency arises with the acceptance of lower qualities of care. Indeed not all incidents of poor care are due to low staffing levels, as supported by CQC reports. There are indeed several reasons why staff who do in essence care about patients, fail to report such situations or examples of poor care. The work ethic prevails with individuals afraid of losing their job, they do need money to live on. There may be lack of support or staff bullying as  a consequence. There are also cultural differences whether concerning people from overseas or people from different regions of the UK. Some may consider a situation to be poor care and others not for example. Indeed many relatives are so pleased to receive care for the patient, they do not wish to complain about what they believe are one off incidents. This also applies to older residents in care homes with memories of workhouses prevailing. Combine with the work ethic, there are additional factors such as consideration of certain vulnerable people as being non- contributors to society. This particularly involves older people and disabled people. Often fuelled by political influences for example if you earn nothing it is your own fault. The aim towards empowerment will soon result in-  you chose the services, there is nothing we can do. Especially it seems. If it is a private service. This political slant is termed “neoliberalism”.

Within the field there are additional factors such as stress and there are differences in the type of poor care between specialities such as Children’s services or continuing care. This may be due to the nature of the patients, staffing levels and recognition of the skills involved. There are as raised by the Francis report 2013, Implications for management for example. Bring back the ward round they exclaim, yet this is not without problems. Paper forms are often falsified by frightened staff who fear being reprimanded for not doing something. Time staff documented, unable to turn Mrs Smith as there were only 2 of us on the ward, a drugs round was in process and a patient collapsed. Nurses, students  and care staff  live in fear. They fear management, loss of their job and the NMC. Time they felt able to be open and discuss actual problems. Even within nurses education, many lecturers fear discussing examples of poor care with students. Students need to know how to deal with these situations. Otherwise they just cope like the rest.

The question remains, why has it taken years (beyond 30) beginning with Robb 1976 in the UK, to accept that poor care exists?  This has occurred within other fields including social work. The work of authors has actually been rejected by journals who feared nurses would not want to read about poor care. Indeed many major agencies today, declare we can only publish good care.Politicians just referred people to policies. Other agencies were afraid of upsetting nurses. Some academics stated the topic was not trendy. So many people are loyal to nursing as a profession, that they overlook the actual patient. Yet the staff themselves often have the answers. It does not take major research projects. It is time people listened to individuals- not solely major bodies or reputable individuals.



PHD Dilemma. Written by T.I.M; (2013)


By late 1923, the Weimar Republic of Germany was issuing two-trillion Mark banknotes: Nowadays, the value of university degrees are undergoing a similar process of inflation, wherein the higher denomination of degree becomes almost worthless as a consequence of their over-production. Academic departments have an economic incentive to enroll graduate students. It also rewards those departments that persuade M.A. students to go into the Ph.D. program. The impetus of this market force is one that can be compared to encouraging the third class passengers on the Titanic to upgrade to second class, then encouraging a further upgrade to first class, the once spacious abode of aristocrats, or, in terms of a Ph.D. analogy, of the academic elite, which is of little worth as it becomes crowded.


In the same way that a first class cabin on one ship may only be equal to a second class one another, not all Ph.D.s are equal: What happens to graduates with Ph.D.s issued by Notasgood University? They go straight into colleges (if they are lucky), competing with hundreds of others to do something that was once the province of the BA/Bsc. holder.


What psychological imperative is served by entering a saturated degree market? That is, what psychological imperative is exploited by academic departments driven by economic considerations? Gary North's comments (within an American context) are perhaps more widely apt:


'Ph.D. students are a lot like gamblers. They expect to beat the odds. The gambler personifies odds-beating as Lady Luck. The Ph.D. student instead looks within. "I am really smart. These other people in the program aren't as smart as I am. I will get that tenure-track job. I will make the cut. I will be a beneficiary of the system."


Why does any Ph.D. student at any but the top graduate schools believe that he will get tenure at any university? The odds are so far against him, and have been for a generation, than he ought to realize that he is about to waste his most precious resource — time — on a long-shot. Investing five or more years beyond the B.A. degree, except in a field where industry hires people with advanced degrees, is economic stupidity that boggles the imagination.


Earning a Ph.D. may pay off if your goal is status, although I don't understand why anyone regards a Ph.D. as a status symbol that is worth giving up five to ten years of your earning power in your youth, when every dime saved can multiply because of compounding. If the public understood the economics of earning a Ph.D., people would think "naïve economic loser" whenever they hear "Ph.D."


Jim Sheng's overview:


Academic Inflation is inflation in academic qualifications and inflation of the minimum job requirement where too many college education individuals compete for too few jobs requiring these qualifications. This condition leads to an intensified race for higher qualification where a bachelors degree of today is no longer good enough to gain employment, and an inflation in the minimum degree requirements to the level of masters degrees, Phd's, and post-doctoral levels, particularly in areas where advanced degree knowledge is completely unnecessary to perform the required job. You can find Master degrees in hairdressing and it is not uncommon that the minimum job requirement for a secretary is a BA degree today.


The institutionalizing of professional education has resulted in fewer and fewer opportunities for young people to work their way up from artisan to professional status (eg. as an engineer) by 'learning on the job. Academic Inflation leads employers to put more and more faith into certificates and diplomas awarded. And we have become so used to inflation that we think it is a good thing and use the percentage of people with a university degree to measure the quality of workforce.


Looking back to the appointment policies of university lectureship earlier this century, and to compare them with those of today. We have forgotten, perhaps, that the PhD was brought to Britain only after the First World War and to China after the Great Culture Revolution in 1970s. Until then, scientists were trained up to Bachelar level. University lecturers were usually appointed after their first degree, in their early twenties. It is worth recalling that a PhD is not essential; even today there are a number of highly distinguished scientists who do not have one, and the great scientists of the past seemed to have coped happily without any equivalent.


This pattern was common until quite recently. Promising graduates were often appointed to lectureships before they had submitted their PhD theses, which they then completed as members of staff. One problem with this system was that performance as an undergraduate does not always correlate well with performance in research. The next step was to require PhD submission before appointment, allowing some assess ment to be made of a candidate's research potential - and incidentally bringing the age of a new lecturer up into the middle or late twenties.


But this was not enough. As competition for permanent positions increased, academic inflation began to set in. Departments were able to insist not only on a completed PhD, but also upon a substantial period of post-doctoral research. This brings our story up to the present day: most lecturers are being appointed in their early to middle thirties! Newly graduated PhDs find that it is very difficult for them to find an academic job in universities without post-doctoral experience and some of them begin to enter colleges and even middle schools to secure a perminant job. If this has not yet happened in U.K., at least it is happenning in biggest cities in China where competition for permanent positions in higher education is very severe.


Probably now it's the time to think again about why we require so many years of study before offering a proper job, some of which are completely unnecessary for the required work. Do we really need our hairdresser to have a MSc degree?


Jim Sheng n.d. hubpages


c. T.I.M




Plagiarism or bust?

Carol Dimon

Acknowledgements- my highly academic colleague T.I.M who remains independent, Professor Roger Watson  (Hull University) who mentioned the interventions utilised by journals and CORE, colleagues who made me aware this issue is greater than I thought. I had taken  it personally!!

The individuals who responded to the questionnaire. Surveymonkey which is extremely useful.

“No conflict of interest has been declared by the author”

“This research received no specific grant from any funding agency in the public, commercial, or not-for-profit-services.”


This study explores the acceptance of academic plagiarism within several countries and all fields. Academics are considered as being lecturers, professors or PHD students. Whilst most studies explore plagiarism amongst students (Ashworth et al 2008) plagiarism amongst academics is well known (Changgeng 2007) and appears to be an accepted part of the role. Yet what are the implications of this? The study uses questionnaire via survey monkey and analysis of some published articles to explore this topic. Whilst there are several limitations such as  low response, it does indicate areas for further research and thought for the whole field of academia.


This study will explore academic plagiarism. It was triggered by the researcher’s personal experiences and also, talking to other academics. Plagiarism applied to more than merely copying. It has much higher implications than failing to award the original author credibility. Indeed, many original authors today, are no longer alive. So what are the implications? Is it merely accepted amongst academics? Has it been accepted as part of their role? Are they actually expected to plagiarise? This is   a start to explore this phenomenon.


Confusion surrounds the definition of plagiarism ( Poyner  2007 ), many types being defined including deliberate or negligent (Poyner 2007).  Then why is it such  a big deal??

Most authors refer to plagiarism as occurring amongst students (Ashworth et al 2008). Yet there are authors who do address plagiarism amongst academics (Lewis et al 2011). Indeed this occurs in all countries  such as China (Chenggang2007) and all faculties such as science (Lewis et al 2011).Three may well be cultural influence s to plagiarism (Osipian 2008) depending upon political corruption for example. Further there may be an educational influence with Chinese students being taught to adhere to one text and not to critique( Hayes and Dintrona nd  ) Whilst some do explore via research (Lewis et al 2011), there are few research projects which explore the whole phenomena. Is it broader than we think? There is historical existence of plagiarism such as Shakespeare(milner nd  ).  However, is it avoidable? Does it mean merely building upon an idea of somebody else? Is there no original thought anymore? (Fish 2010) Even in art we have accusations of copied paintings (Alberge 2010); yet where does it end? In music there are only so many bars, so it is not totally avoidable (Irvin nd ) to repeat  music. Some may unintentionally plagiarise yet others, may do so intentionally. Yet plagiarism may well be beneficial .Consider Orwell (1984); Animal Farm is said to have been based on  a Russian book(Owen 2009  ). Orwell gained far more publications than the Russian book would have done. Is plagiarism fuelled by  a business orientation of Universities (Popenici 2012) and  aim to sell more copies? Indeed, reputable authors are published more easily (Chenggang 2007).This may be because more copies of their work are sold than an unknown person. After all, publishers are businesses. Unfortunately, individuals who have an original idea, may never personally achieve. Further, some  journals may actually adopt the idea of an unknown author but give it to  a more well known author to write (Das, Punjabi 2011  ).Although there are methods of identifying plagiarism used by individuals, Universities and journals such as Turnitin, the software may wrongly identify people(Zimmerman 2008 ). Nor does it identify an unpublished idea or piece of work. Yet that too, may well be plagiarism.

There are also legal and moral issues involved which may be emphasised by the focus upon Human Rights. There have indeed been some cases won in  a court of law for example (Lewis et al 2011  ) but not everybody can afford such court cases and plagiarism may be difficult to prove. Yet there are copyright agencies that for  a fee will protect ideas and pieces of work for  a set period of time.


This exploratory study aims to explore the acceptance of plagiarism amongst academics. There is evidence that it occurs but are they willing to discuss it and consider whether it is acceptable or not?


The study  utilised  survey design. A questionnaire was  displayed on survey monkey, following a pre test amongst academics. Published papers were  analysed for indications of good practice. Results  were  analysed quantitavely and thematically .


Respondents were openly given the option to respond via Linkedin, the researcher’s website   and twitter. Also individuals were asked to mention it to colleagues thus forming a snowball sample. No names, places of work or personal details were taken. It is beyond the scope of this study to consider such variables as this.

A request was displayed on linkedin, for published articles in any field or country. This was to prevent bias selection of the researcher. 5 were obtained. In addition, one author was recommended by a colleague as an example of good practice and this too was analysed.


 Various authors concerning ethics were considered ( Johnson, Christenson 2011 ).

Surveymonkey ethical proforma was adhered to with consent being requested. The researcher was not informed of names or emails by surveymonkey. They may also withdraw consent at anytime. The aim of analysis the articles, was not to indicate whether the author’s had plagiarised or not but to consider possible indications of good practice.

Data analysis

Data was analysed via survey monkey and displayed in bar charts. There was also themetic analysis of the open responses.

The articles were analysed for use of references, footnotes and acknowledgements.

Validity and reliability

The questionnaire was pre tested by 6 academics who were largely unknown by the researcher and volunteered via Linkedin. They suggested some helpful alterations. The results were validated by an academic colleague. The researcher also bracketed preformed opinions which may bias the study such as any personal experiences of plagiarism.

Analysis of the articles was also supported by the academic colleague.


Whilst the number of respondents was small; 29, the results are of significance and indicate the need for further research. Academic plagiarism does occur amongst academics. There is confusion surrounding the definition of plagiarism but most respondents considered it  to refer to direct copying of published work, rather than unpublished. It is largely considered to be unacceptable but occurs for various reasons such as lack of knowledge of the one who plagiarises.

Articles did indicate the use of methods such as references, footnotes and acknowledgements.


Whilst there are several limitations to this study such as the sample size, several conclusions may be drawn. The majority indicate that plagiarism refers to direct copying of sentences, papers or published ideas. If plagiarism is to refer to largely published information, it is to be remembered that others do have access to this and it may be identified by the use of software. Perhaps an additional question would have asked if the articles were published or unpublished. Yet there is a limit on survey monkey, to the number of unless questions one is able to pay an additional fee. Indeed 42% indicate that plagiarism does not refer to an unpublished idea but as one respondent commented, it is good practice to acknowledge the individual. One does suggest that it is impossible to copyright an idea. Yet copyright registration bodies do exist that will do so for  a fee. One suggests that plagiarism also refers to fabrication of results which is supported in the literature (Lewis et al 2011  ). This indicates that plagiarism extends beyond mere copying  and has huge implications involving dishonesty and misleading the readers.

There was little response to question 6 regarding the acceptance of plagiarism. This may possibly be due to the lack of definition of plagiarism or the broadness of the question. Most however, felt that plagiarism occurs amongst students rather than academics. Responses indicate that plagiarism is “fraud” and “stifles ingenuity”. It may however, enable ideas to be “built upon”. 12 respondents are aware that plagiarism occurs amongst academics and 4 had knowingly copied work themselves. This indicates the confusion that surrounds the issue or that individuals may be reluctant to question acceptability. It may also depend upon the individual situation of plagiarism. Further exploration is required to ascertain whether or not this was thought to be acceptable but this is not supported by some other responses such as reasons for plagiarism. There were however, 16 additional comments made by respondents, in response to question 6. The majority declared that plagiarism is not acceptable. One said it is acceptable to take somebody else’s idea.

Various reasons were suggested for plagiarism including lack of knowledge of the one who plagiarises, laziness, pressure, culture and accidental; fuelled by the use of websites. All reasons are supported by the literature discussed in the literature review. The reason “lack of knowledge of the one who plagiarises”, warrants further investigation. Is this a defence mechanism with the author pleading ignorance? Some of the reasons given in question 10, are related to one another. For example, completion, fame and money. There may be  an overriding factor of “survival of the fittest” (Darwin 1859). A new breed of lecturer is possibly emerging aiming to progress in their career at all costs. In fact, the most knowledgeable lecturers, may be asked to leave as  a consequence for fear of  being  a threat to the others. The same could well be said of other professions. Indeed, a question could be asked concerning how individuals adapt to their work role thus “Would you plagiarise, in order to maintain your position if you were not in danger of repercussions?” Indeed many lecturers today, feel insecure and are under pressure and stress as discussed earlier. Much depends upon the number of student intake. In 2012, the student applications to UK Universities reduced by 8.7%    (Vasager 2012  ) which is reflective of many factors including finances, prospects and job availability.

Most respondents thought that education needs to be improved concerning plagiarism and the use of software packages may assist to prevent it. Although, as discussed in the literature review, software results may be misleading. Whilst this suggests there is  a need to prevent plagiarism, again most respondents considered plagiarism to occur amongst students. Interestingly 4 respondents used software to check their own work which is good practice and indicates how it may occur unintentionally. This may however, be  means of proving their statements and verifying originality.


Whilst this was  a small study with some limitations, a number of interesting points are highlighted. Plagiarism does not merely prevent the original writer gaining recognition but it also “stifles ingenuity”, as commented  by one respondent. Indeed a number of cases may indicate this. Here is one example;

Sternberg (1998) identifies 7 types of love. Yet many years previously, the same types were identified by other authors including the Bible and classical Greek texts. It is important to recognise the socio-cultural factors that existed at the time the work was originally done.

I remember as a young man reading commentaries regarding Greek words for different kinds of love mentioned in the Bible, as examples, phileo, which can be translated as to be a friend ....... to be fond of an individual; a matter of sentiment or feeling, storge ........ natural affection between kinfolk; eros ......... (egotistical) sexual love; agape .......... esteem, principle, or duty, rather than attraction or charm ....... So, when Mr. Sternberg 'identifies' Liking - friendship where one enjoys the company of another; Companionate Love - most people feel companionate love toward their family members; Infatuation - passion without intimacy; Empty Love - a couple stay together for family reasons (duty), it is not as if these concepts have not been discussed since time immemorial. What modern 'acadaemia' allows is for anyone to be a 'cocktail-mixer'; call old things by new names, mix (synthesise) them together slightly differently from anyone else, and, hey presto!, you too can be the 'Harvey Wallbanger' of acadaemia!; quoted by endless streams of google academics. Classical Greek texts contain much of what is today re-hashed as 'new ideas'; they themselves a continuum of concept-tweeking. Nothing changes. (T.I.M. An independent academic)

There are other examples such as Maslow’s hierarchy of needs which may have been based upon the work of Carl Jung amongst others.

Evidence both literature and responses, indicates widespread occurrence of plagiarism amongst academics within all countries and faculties. There is however, lack of awareness or acknowledgement of what plagiarism is. Individuals seem to be unaware of the full implications or effects of plagiarism.

By quoting facts as though they are one’s own or recent findings, may result in the wrong facts being accepted and readers being misled. It also prevents the reader or researcher, from sourcing the original citation and thus further validating it or drawing additional conclusions. In this way, research and knowledge, may well be restricted by the repetition of commonly cited facts or authors. This is further unaided by the reliance upon web based searches which only search so far back.

The question may well be why does one become an academic or what is expected of an academic?  Does it refer to somebody who produces original work or does it refer to somebody who cites  a vast number of references or  plagiarises ?There is indeed, huge pressure on academics to produce publications, research and conference presentations. It may be very tempting for them to use the work of another. Also there may well be a lack of praise for individuals who do create their own work. Therefore some individuals, may fear proposing an original idea for fear of being ridiculed. Such pressure on academics may be enhanced by the business goal of Universities ( 2012 ). Plagiarism extends beyond acknowledging an individual; this is  a materialistic mode of thought. It is building upon and sourcing ideas’ to verify the facts thus ideas are not merely repeated and thinking is promoted.

Despite the need to acknowledge possibly unknown individuals, many journals will only publish the work of commissioned authors or those who are well known and linked to universities. One article actually describes a case (Changgeng 2007  ) of the rejection  submitted to a journal  . It was later accepted when more professional affiliation to an establishment was falsified . Journals do use methods to detect plagiarism such as software , which is to be recommended. Yet it remains difficult for unknown authors to publish their work or ideas thus increasing their vulnerability of plagiarism.

The fact that few individuals were prepared to respond to the questionnaire, despite wide advertising across the world, may indicate that people are reluctant to discuss the issue. It may also be unaided by the independent status of the researcher. Research undertaken by Professors in Universities gains more credibility and response ( Changgeng 2007). There also seems to be  a race regarding the citation of references and use of the greatest number. Changgeng (2007) discusses the demand by journals for  a vast number of references. Yet on the other hand, earlier references are ignored and work rejected if it is cited.

Plagiarism may well be a misnomer , placing emphasis upon the use of references with the aim of giving credibility to the original author. There are clearly additional factors and it has far wider implications than this. There may be different degrees of plagiarism for example, minor such as an idea, intermediate such as references or major referring to full copied sentences or paragraphs.

There may also be additional perspectives to consider. Authors may indeed over-reference bringing into question; what is referencing? Changgeng (2007) discusses the real need to refer constantly to history . It is what we do with the references that matters. Also readers may well misinterpret what they have read either unintentionally or fuelled by bias. For example the term “self-actualisation” described by earlier authors such as Jung, was redefined by Maslow. Whilst this is not plagiarism, if the original author is referenced, it surely is the opposite?

Based upon this study, a number of tentative recommendations may be made. These include; there is  a need for a greater degree of honesty and openness within the profession with less stress and pressure placed upon academic staff. The whole aim of the academic role needs to be reviewed which has implications for the whole of society. There needs to be greater awareness of earlier work such as Vladeck 1980 who referred to quality of care in USA. Plagiarism also implies the neglect of history and possible re-invention of the wheel. Research and writing must also be encouraged amongst independent individuals who are not fortunate enough to be attached to a University. This will dissolve elitism and encourage broader thinking. There is a need to reconsider education and policies surrounding plagiarism and allocate praise to academics who involve and acknowledge unknown individuals.

Avoiding Plagiarism is about caring- about priorities-about truth. If one cares,  one establishes correct priorities and aims for truth, not glory. “Subdued ingenuity” says it all (one respondent).

We are chasing materialism not humanism. That is life’s dichotomy. We are teaching the young to gain qualifications in order to get a job and money. This is not the answer. Take pride in acknowledging somebody else. Plagiarism is theft and illustrative of  the wrong priorities. Yet is it totally avoidable? It may well have become the norm.


Alberge D (2010) Sept

Damien Hurst Faces Eight New Claims of Plagiarism

The Guardian

Ashworth P, Freewood M, Macdonald R (2003)

The Student Lifeworld and the Meanings of Plagiarism

Journal of Phenomenological Psychology 34:2 p357-278

Changgeng L (2007)

Another Discussion About Academic Corruption

Chinese Education and Society v40n6 Nov/Dec p77-83

Darwin (1st published 1859) The Origin of the Species

Das N, Panjabi M (2011)

Plagiarism: Why is it Such a Big Issue For Medical Writers?

Perspectives in Clinical Research April-June v2 issue 2 p670-71

Fish  S (9.8.2010)

Plagiarism is Not a Moral Deal

Accessed 10.1.12, 2pm

Hayes N, Dintrona LD (No date) Cultural Values, Plagiarism and Fairness: When Plagiarism Gets in The Way of Learning

Accessed 20.10.12,2pm

Irvin  (nd)

Accessed, 1pm

Johnson B, Christenson l (2011) 4th ed

Educational Research Quantitative, Qualitative and Mixed Approaches

Thousand Oaks. Sage

Lewis BR, Duchac JE,Beets SD (2011)

An Academic’s Response to Plagiarism

Journal of Business Ethics  Issue 3,102;489-506

Milner C



Accessed 2.11.12,3pm

Osipian AL (2008)

Political Graft and Education Corruption in Ukraine

V16 issue 4 p323-344

Owen P (2009) June 8

1984 Thoughtcrime? Does it matter that George Orwell Pinched the Plot?   Accessed 4.11.12,4pm

Popenici (2012) The Perfect Storm For Universities

Poyner  RA(2007) The Little Book of plagiarism

Pantheon Books. New York

Sternberg RJ (1998) Cupid’s Arrow The Course of Love Through Time

Cambridge University Press

Vasager J(2012)

Number of UK University Applicants drops by 8.7%,UCAS Figures Show

The Guardian 30.1.12

Vladeck BC (1980) Unloving Care

Zimmerman TA (2008)

Mclean Students File Lawsuit Against Useful Tool or Instrument of Tyranny?




Anybody For Latin?? As spoken by T.I.M

There is  adebate about re-introducing Latin in education in UK . (2013). There are two types of Latin; medieval and modern.T.I.M is self- taught in medieval Latin. This enables him as historian to translate very early texts. There are indeed, several Professors who are able to do this, especially at Oxford and Cambridge Universities. Many years ago, it was a requirement at major Universities to be able to understand Latin. So what are the benefits?

Latin enbles us to transcribe and understand early texts. Indeed, there are several examples when such texts have been misunderstood. it is essential in any field, to read the original texts. This is sadly neglected today with people relying on what other readers have written. History in particular, requires an understanding of Latin. yet many history students, cannot understand it. So how do they therefore, use early texts? Latin is essential for translating early wills or deeds for example.

Medicine still uses Latin terms such as "PRN". Yet who really knows what this means in Latin?

The teaching of Latin has implications for other fields. It requires one to do a process of "mental gymnastics". Unlike other languages, it does not merely require words to be translated. Words and phrases in latin, can mean many different things in different contexts. Therefore the learning of Latin may promote a whole new way of analysing.





Dilemmas of care


This will be  a regular column aiming to discuss common dilemmas of care. Often dilemmas are neglected in nurse education, giving way to the mere input of theory. Yet, students need a case study approach with active discussion. Indeed, the approach to care differs between many environments such as care homes and hospitals, due to the nature of patients, or available resources, as examples.


Consider Mr Bloggs, age 82, in  a nursing home. He has clostridium difficile, but, suffering from extreme confusion, is constantly wandering. He will not stay in his room, and has running diarrhoes. He throws his incontinence pad across the lounge. In a care home, the domestic is not usually available 24 hours, nor may there be  a key to the cupboard in which is stored essential cleaning fluid. Safety - it must all be locked up, of course.


Easy - somebody could sit with Mr Bloggs in his room? Not so easy when there are 2 staff absent, and no additional staff available from agencies or the bank. Yes- the home has tried. Yet, the remaining 30 residents need to be helped out of bed. Even if somebody does sit with him, they cannot legally restrain him by tying him to the chair .Nor may he allow the carer or nurse to hold his hand.


The manager, of course, must be informed. Incident forms and risk assessments must be recorded. A problem must be identified in Mr Blogg's care plan concerning his care, with regular input regarding action and evluation. If Mr Bloggs has relatives, or close friends, they may assist to calm him down.


The care home inspector and environmental health officer may offer additional advice.


Whilst such situations may be less frequent in hospital, due to the nature of patients there, they may stil occur. Indeed, cases are known of nurses being unable to cope with certain patients, and speeding up their discharge to care  homes. Often relatives are unaware that a patient does not have to be discharged to a care home and may legally, remain in the hospital.


Educating students nurses is, therefore, not so simple. Often nurses and care assistants may find themselves faced by such dilemmas and, in fear, my undertake the inappropriate action.


Dimon C (2006)

Decisions and Dilemmas in Care Homes



The state of care


Aspects of poor nursing care have been well documented concerning care home and hospitals in the UK , Australia, and USA (Vladeck 1989, Robb 1967, Newton), Involving neglect of pressure care and failure to feed patients.More recently (Mandelstam 2011) but yes, there were earlier attempts by health care professionals to publish and change practice.  Whilst good care does exist (RCN 2012. ) poor care continues .


Why is this so? Nursing is a caring profession surely? Or has it been overtaken by the Darwin principle of survival of the fittest? It depends what “fit “ means; does it mean the most caring or the one who gains the most accolades for the best attendance at work, or adherence to the manager’s requests? Is anybody who dares to question or raise issues blocked? Consider Heywood who raised issues in the UK, but went to the press, as given no satisfaction by management. She was removed from register, but reinstated following an appeal ( ).


There is also the business orientation of universities in many countries (Popenici 2012), which has implications for the award of registration to students. Is there an emphasis on passing assignments? It is possible. There are also implications of society. Of how much a priority is care? The Government here in the UK has chosen to focus upon the issue of poor care following numerous newspaper reports. Yet sadly, the occurrence of poor care was highlighted many years before in many countries.

Does poor care continue because all nurses have different priorities? Does it depend upon how nurses are educated? In the UK all nurses are now educated at degree level. Yet what the degree consists of is open to interpretation by different universities. In all countries, we have care assistants  delivering what once was the nurses role. There is no uniform training for care assistants in the UK.Care assistants do not have to be registered. This means they are free to work elsewhere if they do anything wrong, unless a good manager tells the truth. Students too are implicated in poor care. Some research does indicate that students are afraid to raise issues due to the pressure to conform to the routines of their placement setting, but it is  a small study (Levett-Jones, Lathlean 2009).  The difference in healthcare fields is also a factor in the standard of care. Nursing homes/ hospitals do differ in USA to the UK. I need to know what those differences are. I am at present reviewing the situation in all 3 countries, and require a link in the USA to answer these questions and clarify my points. I have researched care for 20 years, trying to raise issues in the UK, which has largely gone unheeded.. If you care about care --- you will assist me.


A nurse’s dilemma


This column will be present regular discussions concerning dilemmas in care. Such dilemmas confront nurses or care staff, with decisions which may, if inappropriately selected, promte poor care, albeit unintentional.


A Registered nurse on duty in a care home is responsible to the manager, employer, NMC, inspector, and resident. At times conflicts arise and the nurse is in a serious dilemma. Unlike hospitals, the RN in a care home is often alone.


Consider the following. It is 8pm, nurse Harvey has worked for 12 hours. The night nurse fails to arrive. What should nurse Harvey do? Nurse Harvey rings the registered home manager, who refuses to do the shift and tells nurse Harvey to do it. This opposes the working time regulations. However, if nurse Harvey leaves the shift without handing over to a nurse, she opposes the NMC code of conduct, and could face disciplinary action from them. At 8pm, the inspector for the home is unavailable. Nurse Harvey is unlikely to ring them anyway, not wanting to jeopardise her position at work. This is a common scenario in a care home.


Nurses need support and encouragement. They need advice on what to do in such situations. Indeed, many nurses are inexperienced or from overseas and less aware of what to do.Yet, the NMC will not now advise nurses. If a nurse is not in a Union, where can the nurse go for advice?


The registered manager is ultimately responsible for the home. As such he or she should personally cover the shift, unless having a valid reason. This must be a requirement of the job of a home manager. Part of managing is to care for staff. This involves ensuring that they do not exceed working time regulations and become ill or under stress. Only then can we be assured of high quality of care in care homes.