Jane's Blog

The European Union and nursing - better in or out?

Should the UK stay in the EU, or pull out?
The EU is such a complex phenomenon that a simple Yes or No is a hard call. It’s easy to deplore big bureaucracies and the self-interest of this international capitalists’ club. The rubbish spoken about the EU by many of those who want out, and their media pals, doesn’t help. Our individual decisions should be based on evidence and common sense, not political posturing and power games.
On the plus side, this Europe-wide organization and its networks is of huge positive importance - never more than today, with our world ravaged by human-induced climate change, armed conflict and the migration it triggers, gender-based violence, and health problems that know no borders.
The EU does vital work on all these issues. The UK must therefore remain part of finding solutions and maintaining international peace and stability. This will be much harder if we retreat to our island fortress.
Nursing has something to say and to do about all those issues. With Brexit, we would be absent from yet another major international forum. Our voice, that has previously offered much to global and European nursing development, would not be heard or heeded.
It’s also a matter of self-interest. For example, the Royal College of Nursing has worked through EU networks to create legislation to make a real difference on issues that matter to every British nurse - from needlestick and back injury to better working conditions.
I’ve worked on many EU-funded projects to empower nurses throughout Europe and beyond, and improve their practice and education for health improvement. They have enabled UK nurse practitioners, teachers, researchers and policy-makers to work in partnership, learn and share with colleagues from many countries, and bringing home benefits and funds. If we leave, we will let them and ourselves down.

Nursing's Got Talent

In May every year, nurses round the world celebrate International Nurses Day. May 12 is the birthday of Florence Nightingale, the founder of modern nursing, whose legacy continues to inspire nurses everywhere. In 2015, as part of my Writer in Residence role at Kingston University, we decided to have fun with Flo, challenge the stereotypes, and celebrate nursing in all its gore and glory. Just remember, Nursing’s Got Talent!
My brilliant colleague, artist in residence Alban Low, ran an art exhibition called the Art of Caring featuring 252 artworks produced by 133 artists from far and wide (http://caringandcare.blogspot.co.uk). This was shown at the Rose Theatre, Kingston, along with a cabaret-style event organized by the Nursing Society, the School of Nursing and my programme, The Word is Nursing.
We celebrated nursing around the world with poetry, fiction, live music and art, theatre, and expert speakers on the challenges of modern nursing. We linked by video with colleagues from different countries, who sent us greetings in many languages. I gave a talk on Florence’s Demons and chaired a discussion on Nurses in Fiction, with readings from prize-winning novelists Patricia Ferguson (a qualified nurses and midwife) and Louisa Young. Much of the talent on show was home-grown by Kingston. 
It went so well that we’re already thinking about an event next year. Watch this space! For a flavour of this year's event, here are some highlights:

Sketch of me by Alban Low, artist in residence at Kingston Sketch of me by Alban Low, artist in residence at Kingston
Quizzing the politicians

On BBC Radion London,  April 20 2015, in a debate with party health spokespeople, I challenged them thus:  'The disappointing pre-election debate about health has talked mostly about money and ideology. I haven’t heard enough about investing in what works, and investing to save. The evidence shows beyond all doubt that the more graduate registered nurses who work in our hospitals, the fewer deaths there are, and the higher the quality of care. Poor care costs lives and money. Expert nurses save lives. Substituting them with less qualified staff to save money is a false economy. It leads to more deaths and illness, and damages quality. Yet government cuts have led to fewer nursing posts, and fewer nurse training places. What do the parties propose to do about investing to save - in nursing and in safe staffing levels? And what is the evidence base of your proposals?'
Now here's a surprise - none of them answered the question adequately. And I'm still waiting for the answer. So are the UK's nurses. 

Letter to an unknown soldier

I wrote this letter as a contribution to a thoughtful, creative way of engaging with the Great War centenary.  Have a look at the other letters at http://www.1418now.org.uk/letter/
Dear Great Uncle Fred,
You are unknown to me, and no-one knows where you are buried. Yet your Walker blood runs in my veins, and your impact echoes down the years.
As a little girl I stayed with your Mam and your sister Trot, climbing their apple trees and ‘helping’ to make chutney. I slept beneath a large sepia portrait of you in uniform, surrounded with faded silk poppies. Later I learned who you were, but not much else till I read a memoir by my Grandad, John Walker.
He was 11 when you joined up in the first week of the war. The eldest of five, you were sorely missed. Your Dad was sent away to cook for the Suffolk Regiment, and the others slaved in the Streatham shop. Your postings to Dublin, Salonika, the Middle East and, finally, France must have seemed exotic.
The Walkers were a bright, adventurous, larky lot, but there wasn’t much laughter in 1918 when your brother Harry was drafted to France, aged 17. He brought back physical and mental scars, terrifying John, whose bed he shared. ‘He was sheer murder, jumping about and screaming with nightmares,’ Grandad wrote. Harry attempted suicide, and had depression, terrible headaches and fits. As a child I found him kindly, but odd.
On your second home leave in four years, you ‘looked big and strong and marvellous to the girls and me,’ Grandad said. They never saw you again. You were killed in late 1918; what must you have endured in those four years?
John was too young to fight, but soon enlisted in the Royal Marines. Not the military type, he called his memoir Not officer material. Decades later he still measured himself by you, his adored and lost big brother, who won two medals and was promoted to sergeant in the Queen’s Westminster Rifles.
Our family rarely spoke of their heartbreak: the grief, the suffering of the dead and the living, the roads taken and not taken, the limited life choices, the hardship. I knew little of it, though I’m sure I bear its imprint. Now it’s too late to ask, but I think of you with longing. As Grandad wrote, ‘My brother came on earth to kill and be killed, for he did precious little else, and yet he was a big gentle man in my memory, for ever.’
Your great-niece, Jane Salvage

Having it all

If you think all-eventing is just for horses, think again! The select but growing band of all-eventers at the annual festival at Charleston seek neither rosettes nor trophies, but pleasure, companionship and philosophy. Our rewards are many - although attending every single event at the festival may sometimes require the chutzpah of show-jumping, the discipline of dressage and the stamina of cross-country.
Charleston, near Lewes in East Sussex, was from 1916 the country home of the Bloomsbury group of artists, writers and thinkers. Regular visitors included Virginia Woolf, John Maynard Keynes and E M Forster. My friends and I have been attending its amazing annual festival for a long time as Friends of Charleston, and for the past few years as all-eventers. The many joys of occasional events are not only multiplied but also synergized by coming to all of them. Every year artistic director Diana Reich tunes into the zeitgeist to put together an astonishing programme of which the whole is always much more than the sum of its many excellent parts. Its stellar speakers are bang on or ahead of the curve on the arts and current affairs across the globe. Creativity swirls around a few key themes which, while never too rigid, create a structure of feeling and thinking that enables much cross-fertilisation over the nine days. Last year’s highlights for me included Tom Keneally on nurses in World War I, Stephanie Flanders’ tour de force on economics, and Alex Jennings’ flawless readings from Auden to commemorate Benjamin Britten, whose music reverberated through the Sussex dusk – I’m sure the sheep enjoyed it.
Sometimes, though, it's  the festival sessions you fancy least that turn out the most exciting and take you down a new path. Surprising connections and echoes enrich most sessions, especially when speakers make explicit connections with Bloomsbury history and values. These run like a golden thread through the colourful Festival tapestry, not only in the presentations but also in the aesthetic appeal of the house, gardens, marquees and South Downs – not forgetting tea, cake and Harvey’s beer. Even the weather joins in. One year the garden will be in bud, the next in full bloom. You can begin the festival in a heat wave, lolling in the long grass under an apple tree with a glass of fizz, and end it wearing your wellies in a creaking tent that seems determined to shake free and fly over Firle Beacon, all-eventers clinging tightly to the guy ropes.
The camaraderie is another big draw. Many all-eventers come every year and become friends, greeting each other happily from our reserved seats. There’s always a talking point with your neighbour. Speakers and staff seem like friends too. Feeling part of the scenery, as well as the intimate scale of the festival, makes it easier to sidle up to an author and start a conversation. In fact we all-eventers provide a kind of social glue that probably helps with the huge challenges of feeding, watering, directing and pleasing the crowds.
There are practical advantages. Booking for the whole programme is better value, with those front-row seats, discounted tickets, reserved parking and a drinks reception. Above all, though, it’s an experience to be treasured on many different levels. It gives us soul and brain food for the whole year – not just in the pile of alluring books we buy, whose authors we heard and whose signatures adorn the flyleaf, but in memories, connections, knowledge and inspiration. Surely this is the Bloomsbury spirit at its best.
This is a revised version of my article in Canvas, Issue 39, Spring 2014, pp14-15, http://www.charleston.org.uk

Policy, politics, profession

One of the most exciting thinkers in nursing today is Michael Traynor, professor of nursing policy at Middlesex University. Check out his his new book, Nursing in Context: Policy, politics, profession (Palgrave Macmillan 2013). The Royal College of Nursing Research Society hosted the launch last November and asked me to talk about it. Here’s what I said.
I was delighted when Michael told me he was writing this book – he is a stimulating and provocative thinker with an unusual take on many nursing issues, and I knew he would come up with something worthwhile. Nursing in Context is indeed stimulating and provocative, and brings fresh insight to nursing issues.
I also have a selfish reason for welcoming this book. Since my book The Politics of Nursing was published in 1985, I’ve been asked many times to write an update. Each time I went back to the book I felt daunted by the prospect. By covering some of the same ground in a fresh way, Michael has relieved me of my burden.
I feel I’ve been saying more or less the same things in different ways ever since I published my first letter in Nursing Mirror in 1977, describing nurses as ‘a herd of vocational donkeys’. So much has changed, but I am troubled that my diagnosis of nursing’s ills remains broadly the same. Are the changes are so slow and incremental that they are hard to spot, even over a lifetime working in nursing? Have things moved on and somehow passed me by? Or have things not really moved on at all?
A key difference between Michael’s book and mine is that I wrote it as a fairly young activist, not as an academic. I had left hospital nursing to work as a nursing journalist, because I felt it was a major way of getting nurses to think and act differently. My Cambridge degree had given me excellent grounding in critical thinking, and in student politics.
I hadn’t done any structured academic work on nursing at that time, though I read plenty. And as a staff nurse I joined groups on the thoughtful Left – including the intellectual activist Politics of Health Group, and rainbow community alliances defending public services in the East End of London. My book started out as a collective project with the Radical Nurses Group. As Michael summarises it when he interviewed me for his book, we wanted to ‘have an effect on the consciousness of nurses and… of others such as the public and politicians about nursing issues’ (p152).
Being a nurse triggered mixed emotions that led me into passionate discussions, professional and party politics, writing and public speaking; and have fuelled my career ever since. I ransacked feminism, history and sociology for studies of what made nursing and nurses tick, but didn’t find many. This puzzled me, and still does. Nurses are so numerous, so important, so interesting - and so invisible. We are in a black hole: no-one can see in and no-one can see out.
Nurse and scholar Jane Robinson and sociologist Phil Strong suggested this in their study of the management of nursing following the introduction of general management. They suddenly realized, they said, that ‘despite the impressive statistics… nursing is relatively unimportant to government and to managers in comparison with medicine.' They went on, 'The tensions to which this situation gave rise - the nursing group locked into the gravitational force of its internal preoccupations, and the others, on the outside, unable or unwilling to look in and comprehend the nature of nursing's dilemmas - seemed to us to be the social equivalent of an astronomical Black Hole' (Robinson 1992).
Almost all those who try to peer out of the black hole and to illuminate it are nurses. There is little significant scholarship on nursing by those who have not themselves worked as nurses, with a few shining exceptions – above all the sociologist and historian Celia Davies, whose book Gender and the Professional Predicament of Nursing (1995) remains, to my mind, the best analysis of all.
Why, though, is nursing apparently so uninteresting to most others, and why do most nurses collude with the submissive roles assigned to them? In trying to answer those questions, and to encourage fellow nurses to get out from under, I continue to walk a tightrope between analysis and activism. Strong feelings may of course stand in the way of objective scholarship, but they also provide the driving force of this often thankless work. You must go out on a limb - to challenge stereotypes, to make the decision-makers sit up and take notice, and to ask tricky questions of yourself and your peers.
On those tricky questions, Snow and Willard’s 1989 American study attempts a research-based ‘psychoanalysis of nursing’. Less than 3% of the nurses they surveyed believed they were filled with value or were valuable simply for who they were. Lack of self-esteem was the core issue. It resulted in submissive behaviours or, in over-compensation by some, apparent arrogance. Nurses were needy, in a working environment that told them not to be, and often had their needs met indirectly by taking care of the wants and needs of others. The resulting co-dependence, the authors concluded, took nurses off balance ‘into caring for others at the expense of ourselves, creating professional disillusionment and personal pain.’
This, I think, is nursing’s biggest guilty secret. It was partly mine. Only when I started psychotherapy aged 30 did I begin to grasp that going into nursing was partly driven by my unconscious desire to bring my dead brother back to life, as well as my huge need for love and approval.
Snow and Willard is dynamite but I rarely see it referenced. I took a very deep breath and wrote about it in 2003 in my column for Nursing Times. I said, ‘You may feel as uncomfortable as I once did with the idea that nursing cannot come of age until it starts to explore its collective psychopathology, and until each nurse commits to a similar personal exploration. But nothing will really change until we do.’ I waited to be drummed out of the profession, but no one said a word. Did no one want to go there? (Or had they stopped reading my columns?)
Deep-rooted neediness and low self-esteem among nurses does not mean they cannot change. But it does mean that major changes in the responsibility, accountability and leadership of nursing must be facilitated through massive development programmes that help people find a sense of purpose and dynamism, as well as equipping them with the necessary skills. A supportive workplace culture is also essential.
Nowhere is this more salient than in the current debates about what Michael calls ‘the mystery of poor care’. His four-part argument (p116) adds important psychoanalytic and psychosocial dimensions to the historical and sociological insights of Davies, Robinson, Rafferty, Nelson and others.
Changing things is hard because most of the levers of change are beyond nurses’ grasp, and the actions needed to prompt change go against the prevailing societal grain, as they require nothing less than a social revolution. What might such a revolution look like?
If I could wave my magic wand I would make three things happen. The first would be a social transformation in which society truly valued caring, and the millions of people, mostly women, who are skilled and kind care-givers at home and at work; and in which the men would finally play a full part.
The second, linked magical act would be a demedicalization and decommercialization of the health system, so that it was no longer driven by corporate and individual greed, and doctors were no longer the masters but members of the team. Thirdly, the whole system would move upstream, away from death denial and pointless or ineffective interventions, towards helping people and communities lead healthier lives.
Waiting for the revolution, I wobble almost daily on my tightrope with every fresh report of yet another care scandal, yet more abuse of nurses and yet another futile political or managerial response. I am swayed by rage, angst, exasperation and defensiveness, none of it conducive to clear thinking. As an ageing activist I wonder whether it’s time to leave the ring, and let the younger ones who I hope, armed with this book, will take up the challenges.
Nursing in Context: Policy, politics, profession by Michael Traynor, Palgrave Macmillan, 2013

The Daughters of Mars

Nurses get so much bad press these days that it’s a rare pleasure to be reminded of their many virtues. Heroism is the right description for what so many nurses do, day in day out – and never more so than in wartime, as shown in Thomas Keneally’s celebrated new novel, The Daughters of Mars.
Its setting is World War I and its two central characters are young nurses, sisters who leave their family farm in New South Wales for Egypt, Gallipoli and France. This gripping epic combines grand themes with detailed psychological portraits of Naomi and Sally Durance and their colleagues in the military and civilian medical services. In Keneally’s words, he tries to render the human and intimate moments among the thunder and fury, and he succeeds admirably.
The flow of books, films and TV dramas acknowledging next year’s centenary of the war’s outbreak is well under way. We may think we know what it was like, but this tale has a new twist. This Australian author, by telling the story through a nursing lens and from a colonial perspective, sheds new light on both past and present.
As you might expect from a writer whose Booker Prize-winning novel Schindler’s Ark became an astonishing film, this is a wonderful book - on so many levels. The hardback is a massive 520 pages but I raced through and didn’t want it to end. It is an extraordinary feat of imagination, conveying vividly what it was like to care for the endless wave of horribly wounded, diseased, gassed and dying soldiers.
When I met Mr Keneally at the Charleston literary festival in May (http://www.charleston.org.uk/whats-on/festivals/the-charleston-festival/), he told me how the idea was sparked by reading Australian and British nurses’ war journals and letters. He came across them while researching a social history of Australia, was surprised and moved by what he read, and decided, ‘It was too interesting not to write about.’  He was particularly struck by how poorly the nurses were treated. ‘They really were angels of mercy, junior madonnas, bossed around by the hierarchy – it was the wounded men who loved them,’ he says.
In one telling episode, the nurses are billeted on the Aegean island of Lemnos to care for the Gallipoli survivors. With the collusion of senior men in the medical and military chains of command, they are treated like skivvies, forced to do domestic work, forbidden to use their nursing skills, and verbally and physically abused. A nurse raped by an orderly is sent to a mental hospital to hush it up. Standing up to authority, feisty Naomi becomes their leader.
The impeccably researched detail of what the clearing stations and tented wards were like is one of the book’s highlights. You can really imagine yourself there, using instruments and medicines that we now consider archaic, nursing young men and boys with appalling injuries or ravaged by sexually transmitted diseases and fevers, with few analgesics or anaesthetics and no antibiotics. The nurses worked 24-hour shifts in converted houses or primitive tents, sometimes under fire.
They paid a heavy emotional and physical cost. These nurses, many of them also very young, are ‘crushed under the wheels of Mars’, their lives changed forever. Their brave letters and memoirs show how tough they were, but also how traumatized. Like most returning combatants, when they got home they could not speak of their experiences.
Mr Keneally was intrigued by what the nurses’ memoirs said about their battle for recognition and status. ‘It is fascinating when women become stroppy and determined in a male-dominated world’, he says.  ‘Their struggle was at the core of feminism at the time’ - and continues to this day. A staunch, plain-speaking feminist at the age of 77, ‘I am amazed that men have got away for so long with being the master gender,’ he says.
Some insights come from his family. For advice and fact-checking he called on two nurses - his wife Judy and sister-in-law Jane, to whom he dedicated the book - and his late brother Dr John Keneally, a distinguished anaesthetist and medical historian.
He has also been nursed recently in hospital, and is angered by the bad press. ‘The nurse’s status is still uncertain, and the angels/bitches dichotomy will probably get worse as medicine becomes more complicated and governments are not convinced of the need for a national health service,’ he told the Charleston festival audience.
The novel is a refreshing change from the usual nursing stereotypes. It portrays heroism with no whiff of sentimentality, but plenty of strong feeling. It exemplifies Keneally’s long-standing preoccupation with putting ordinary people in extraordinary dilemmas. That’s nurses, in a nutshell – ordinary people called on to do extraordinary things – and it sometimes makes them heroes, whatever the papers say.
Reviewed in Nursing Standard, 25 September 2013, 28:4, 28-9

Think nursing, think global

Jane Salvage, Maura Buchanan, Christine Hancock, Pat Hughes, Tom Keighley, Shelagh Murphy, Anne Marie Rafferty, Jane Robinson
May 2013
The RCN is on the cusp of a decision that could have profound effects on nursing worldwide. On April 23, 539 members at an Extraordinary General Meeting voted for a resolution ‘to authorise RCN Council to withdraw the RCN from membership of the International Council of Nurses’.
Council now faces a momentous choice about whether and when to exercise its new power. Either way, the shock waves will electrify the forthcoming ICN 25th Quadrennial Congress, to be held in Australia on May 18-23. ICN delegates will be voting on a new fee structure, and choosing a new president – though the RCN will have no say, since it is suspended for withholding part of its ICN subscription.
While only 49 members voted against, the heated EGM debate revealed deeply held views, and much ignorance of what ICN actually does. At this critical juncture, our aim here is to explore the issues more thoroughly, and to suggest a constructive way forward. The authors are all longstanding RCN members with many years of nursing experience in the UK and overseas, including RCN fellows and former elected officials and staff members.
ICN, a federation of over 130 national nurses’ associations (NNAs), was founded by nurses from the UK, the US and Germany in 1899 - 17 years before the RCN. It has grown steadily, now represents many millions of nurses, and is the only organization that speaks for nurses from a truly global perspective.
ICN works to ensure quality nursing care for all and sound health policies globally. Its many activities include leadership development; shaping nursing policy; fighting for nurses’ socioeconomic welfare; improving nursing practice, regulation and education; and many projects in the field, from providing mobile libraries for nurses in 17 African countries to campaigning for positive practice environments.
It represents nursing at the annual World Health Assembly, and works with the World Health Organization, the International Labour Organization and other partners. This skilled work in the corridors of power is not always visible. Its leadership is all the more important at a time when nursing is losing ground globally. WHO leaders are presiding over a shameful decline in its nursing posts and influence, while global health is increasingly dominated by private philanthropists and multinational corporations.
ICN uses its unique role and pulling power to forge new alliances, attracting partnerships and sponsors to tackle major challenges like TB, HIV/AIDS, mental illness, and primary health care. It leads International Nurses Day to promote nursing in countries where the profession has little influence or visibility. Its role in leadership development has been formidable and it is sometimes a lone force in capacity-building for low income countries.
It has also done seminal work as a global resource for workforce management policy and mobilization. All these initiatives and impacts demand working across a united front with United Nations agencies; no other body represents the interests of nurses so forcibly. Many major health problems, like the economic crisis and climate change, do not respect frontiers, and can only be solved collectively and globally.
Nurses around the world value their ICN membership in a way that may be surprising to UK nurses, who have so many different forms of support. Being part of an international organisation increases their influence at home, and provides a coordinated opportunity for richer countries to help others. They understand that the financial contributions made by big associations like the RCN enable ICN to do its work. And they appreciate that many ICN programmes would not happen without them.
We find it hard to envisage an ICN without the RCN. After Florence Nightingale British nursing continued to lead the way worldwide. It still influences nursing in many countries, and is hugely respected worldwide. Many countries base their nursing systems on the British model.
You could say that ICN is in the RCN’s DNA. Headquartered in London for many years, ICN boasts previous RCN presidents and general secretaries among its presidents and directors, most recently Christine Hancock. Its current chief executive officer, Scotsman David Benton, is an RCN Fellow. The RCN’s charter and charity objects require it to promote the art and science of nursing through international agencies. Much if not most of this has been achieved though ICN membership.
The push for reform
Why, then, would RCN want to leave? It’s not as though ICN is a bloated organisation of fat cats – it’s actually a tiny organisation with a huge reach, trying to meet massive needs on a budget of less than £5m. It is by no means perfect, but the amount of work undertaken by its staff - less than 20 people -is awe-inspiring.
Like many other international organisations, though, it was founded in a different era and has found it hard to modernise. Its member associations  need to agree how to improve its decision-making processes and membership model, and reform its fee structure, which places a heavy burden on around half a dozen of the wealthiest countries. 
The RCN leadership has worked tirelessly to promote ICN reform, and we share the frustration at the slow pace. There have been years of patient effort behind the scenes. Like reforming the UN, WHO or the EU, it’s like reversing a juggernaut. ICN, like RCN, is a member organisation, and major changes must be agreed by its large, diverse member states.
The governance of multi-country international organizations is always problematic. Member states have to trade off the advantages of influence by having a seat at the table against the frustration of inertia, conflicts of interest, and cost. RCN leaving ICN would be like the UK saying that membership of the UN was too expensive and too cumbersome, and that it intended to give up its seat at the table.
What of the financial arguments, of which much has been made? It is the fluctuations in exchange rates of the pound and the Swiss franc - beyond the control of either RCN or ICN – that have increased the costs to the RCN in the past few years, rather than major changes in RCN membership numbers.
It’s a question of priorities. Yes, £624,000 in annual dues is a lot of money, though this will reduce in future. The RCN is a victim of its own success here, because with a per capita fee system, it looks a great deal when added up. To put it in perspective, international expenditure is an estimated 1-2 % of the RCN’s £84m budget, and ICN fees are 0.7%.
And yes, there are many competing demands on RCN resources. There is always more that could be done to support UK nurses as they fight for their jobs, for justice and for the survival of the NHS. But do RCN members really resent allocating ICN just £1.80 per year from their RCN subscription? And let’s not forget that the economic crisis affects all ICN members, especially those who are much poorer in the first place.
Reform is in the air at ICN. Its forthcoming vote on a new fee structure could give RCN a 17% reduction in its dues. The election of a new president offers potential for fresh leadership. We can all see the difficulties of democracy in action in the international arena - but the responsible solution is to stay in the tent, continue to negotiate and shape the future together. 
Why ICN still matters
We have offered some answers to the question, what does ICN do for us? But the other question is what the RCN, the world’s second biggest NNA, gives back to the global nursing community. As well as the cost, the value of ICN membership and the UK having a voice at global level should be considered. To paraphrase President John Kennedy, ask not what the ICN can do for you, ask what you can do to promote the art and science of nursing on the only truly global platform.
Nursing is a global profession, and the RCN reflects its wonderful diversity. Many people attending the EGM were born outside the UK, and many more have roots outside the UK. Many have worked overseas. The International Slavery Museum in Liverpool, near the Congress venue, is a powerful reminder of how Britain’s past and current prosperity - despite all, we are still a rich country - was built on conquest and exploitation of other peoples. And for decades we have reaped the benefits of recruiting skilled nurses from other countries to fill our own gaps.
This gives us a moral duty to extend the hand of friendship to nurses worldwide. And as everyone who has done international development work knows, our generosity is repaid many times over, and we learn and grow though the experience.
ICN is not ‘them’ or ‘it’, it is us – just as the RCN is us, its members, and is what we make it. It’s integral to our legacy, our shared history, our institutional memory, and our humanitarian commitment. Indeed, at a time when the planet desperately needs our collective wisdom and energy, scaling up our international engagement – not retreating into isolation – is the only way forward.
A message to RCN Council
RCN Council should urgently lead a wide, informed debate to clarify whether the ICN is still the best vehicle for RCN international engagement. If it is not, we need to know what would replace it. There should be a full, open risk analysis of the impact of RCN withdrawal. Issues we should think about with enormous care include the damage to the reputation of the UK and the RCN, and our loss of influence in the global arena. There could be devastating political consequences that would be difficult to repair. Fellow nurses in many countries will feel shocked and let down. The RCN might be perceived as selfish and arrogant.
Withdrawal from ICN is the last resort - the nuclear option - and we urge Council to use its power wisely and cautiously. There is no immediate reason to leave ICN now, and everything still to play for. At least await the outcomes in Melbourne and the possibilities of fresh ICN leadership. Take a leaf from Trevor Clay’s book – when he was RCN general secretary, he proposed and funded an independent review of ICN. See Box 1 for further suggestions.
We take comfort from the words of Kath McCourt, chair of RCN Council, that ‘the RCN is fully committed to working with international partners on issues of common interest to nursing at home and abroad’. Whatever decisions are made about ICN, we need a lively, engaging, balanced debate on how to strengthen RCN engagement as a fully contributing member of the global nursing family, and how to increase UK nurses’ understanding of the value and importance of international engagement.

Suggestions for further action

·      Continue to work for change from inside ICN through constructive dialogue with ICN leaders.
·      Seek impartial mediation between RCN and ICN to seek an amicable solution.
·      Fund an independent review of ICN.
·      Launch debate on how to strengthen RCN international engagement and promote the value and importance of international engagement to all UK nurses.


Jane Salvage, FRCN, independent nursing consultant
Maura Buchanan, director, Uganda-UK Health Alliance, and RCN Past President
Christine Hancock, director, C3, and former ICN president and RCN general secretary
Pat Hughes, consultant, C3, former Chair of RCN Council and former ICN staff member
Tom Keighley, FRCN, management consultant
Shelagh Murphy, former RCN International Secretary and past board member, ICN
Anne Marie Rafferty, FRCN, professor of nursing policy, King’s College London
Jane Robinson, FRCN, Editor, International Nursing Review

This article was first published by Nursing Times, May 7 2013: http://www.nursingtimes.net/jane-salvage-the-rcns-withdrawal-from-the-icn-could-have-devastating-consequences/5058168.article

In memoriam Peter Farmer

‘What’s all the fuss about?’ is how my friend and colleague Peter Farmer, who died suddenly in November 2012 of a stroke, aged 68, would have responded to this tribute. Modest to a fault, he never quite realised how talented he was, and how much he was loved. Countless people had their lives touched and improved by him, and his loss is felt literally worldwide.
Born in Birmingham, Peter was educated at Handsworth Grammar School and was a graduate of London University (mathematics, 1966) and Birmingham University (operational research, 1968). He then worked as a management consultant and a statistician before joining Ernst & Young Management Consultants in 1980, where he became executive director for Europe, the Middle East and Africa. From 1997-2000 he was managing partner for central and eastern Europe at PricewaterhouseCoopers.
In 1985 the Department of Health and Social Security commissioned Julia Cumberlege, then chair of Brighton Health Authority, to lead a review of community nursing in England. She invited Peter to be vice chair, and later as a government health minister sought his help to review maternity services in 1993.
Peter put his expertise to good use in many other pro bono and public service projects. A quietly passionate believer in social justice and strong supporter of the NHS, he was actively involved with numerous charities and health organisations. He was vice-chair of the Whittington Hospital NHS trust, London, from 1998 to 2007.
Managing a major World Health Organization project to reform the health system in Bosnia and Herzegovina from 2004 to 2009, Peter’s talents were brilliantly suited to building trust in a post-conflict country. There like everywhere else people adored him, and his beloved West Bromwich Albion football team acquired a devoted Bosnian following.
His empathy, intelligence and compassionate pragmatism made him a fantastic friend and superb consultant. Lest all this sounds too saintly, it was seasoned by a wicked sense of humour and love of the good life. He would invite lucky chums on annual cricket pilgrimages to Lord’s and the Oval, his backpack laden with prosecco and pork pies. As his friend Terry Wiggs said at his memorial event, ‘Whenever I think of Peter, it’s always July and the sun is always shining.’
Peter is survived by his first wife Ingrid; their daughters Kirstie and Leila; his second wife Rosalynde and her children Amanda and Ben; and their six grandchildren Ryan, Jago, Anna, Ethan, Rosie and Isaac.  

The quiet scandal - September 2012

Public protection, patient safety and the quality of care are all inextricably linked with the performance of nursing staff – to state the obvious. So it follows as night follows day that the state of nurses’ mental and physical health has a defining influence on patient safety. Every practitioner knows all too well that if you are feeling tired, stressed, overworked and fed up, you cannot give of your best. You are more likely to make mistakes, your concentration drops, motivation is low, and accidents and injuries are more frequent.
Some striking research by the Royal College of Nursing illuminates the backstory. Around 92% of nurses regularly work extra hours, a third usually work four or more hours a week overtime, and around half regularly do unpaid overtime. These are staggering findings, yet they don’t find their way into the mainstream media alongside endless nurse-bashing stories of poor care. Think about it: health services would grind to a halt if nurses and midwives stopped moonlighting and working extra hours. Put another way, services are kept going by employees who give their time gratis when they should be having a break or going home, and by people who are working extra shifts after a busy working day. In both scenarios they are likely to be tired and stressed – thus putting patients at greater risk.
Being a practitioner is usually busy, demanding, emotionally loaded and physically tiring. An ordinary shift can be exhausting, even more so when you have skipped breaks because numbers are down, or stayed on to supervise untrained staff, or gone yet another extra mile to help a patient after your shift ends. And people who do agency work on top of a full working week don’t do it for fun or to pay for frills, but to make ends meet – keep the kids well clothed and fed, support an unemployed partner or pay the mortgage.
Extremely hard work and long hours have always been part of nursing. Even in the supposedly golden days when life was slower and more gentle, whether through compassion or necessity people routinely missed breaks, worked long shifts, and moonlighted. No one has ever grasped this nettle: employers are in denial, while practitioners just keep going and never draw the line. Rarely discussed outside professional circles, perhaps this is the real scandal of our health services.
It is really alarming is that things are getting worse, not better. ‘Staff reported mixed emotions of feeling pilloried, hard worked, stressed and abused on the one hand but proud and satisfied on the other.’ No change there, then – this was reported in 2003 by the now defunct Commission for Health Improvement. Cuts, pay freezes and unemployment are hitting pockets and pushing people to work overtime or double shifts for less money. Front line staff in health and social care are being laid off and skill mix diluted while demand, throughput and the complexity of patients’ needs continue to rise. There will be even less staff support. Amid the chaos and instability of an expensive, unnecessary and deeply resented NHS reorganisation in England, more horror stories will be easy to find.
Everyone is holding their breath to see how the long-awaited report on Stafford Hospital will play out. The government and the media might use it as another excuse for nurse-bashing and victim-blaming, and a rationale for pushing through ‘tough’ measures that don’t really get to the heart of the matter. If inquiry chair Robert Francis QC has really grasped what makes the health system dysfunctional, he should recommend that the pay freeze is lifted, skill mix is enriched, staffing levels are improved, and front line staff are properly supported. All that will help to promote a safety culture in these troubled times. Dream on?

My book The Politics of Health explored these themes back in 1985. Plus ca change?My book The Politics of Health explored these themes back in 1985. Plus ca change?
A case of mistaken identity - June 2012

I couldn’t believe my eyes, but there it was in the Charleston Festival programme. SKIOS – a new novel by Michael Frayn, author of the West End hits Noises Off and Copenhagen. Skios, I thought? Never heard of it. I know my Greek islands pretty well, and couldn’t locate anywhere by that name.
Last year I published a book called SKYROS about a well known holistic holiday centre. Frayn’s story was ‘set on a sunlit Greek island’ where guests at the Fred Toppler Foundation’s Great European House Party study Minoan cooking and early Christian meditation techniques. ‘They had interspersed their labours with swims and siestas…now they were moving towards further intellectual refreshment over dinner and various pre- and post-dinner drinks.’
It sounded familiar – like my Skyros Centre. Yet my mental roll-call of the famous writers who’ve taught at Skyros didn’t summon up Michael Frayn. So I bought a ticket for his talk at the festival, and up I popped at the end. ‘I often visit a real and magical Greek island called SKYROS – yes, that’s SKIOS with an R!’ I said. ‘Of course I’m dying to know whether you knew about SKYROS when you wrote SKIOS!’
Some of the writers who taught at Skyros, including D M Thomas, Hanif Kureshi, Nigel Gearing and Sue Townsend, have written marvellous comic turns on it. Not, though, Michael Frayn! He clapped his hand to his head in shock, claiming not to know about the real Skios. And he quipped that my book might help his sales, though it’s more likely to be the other way round.
Afterwards I joined the queue of fans. He signed my copy of SKIOS with a witty dedication, and in exchange I gave him a signed copy of SKYROS. At last I’m a literary lion - swapping books with Michael Frayn!
If you haven’t read SKYROS yet, it’s available as a free download at www.skyros.com/about_us.htm. SKIOS by Michael Frayn, published by Faber and Faber, is a good laugh. Almost as good as mine.

A street in Skyros - or Skios?A street in Skyros - or Skios?