The 6 Cs — are they relevant to practice nursing?
The Department of Health is encouraging nurses to focus on the 6 Cs as a way of improving patient care but many of us working in practice face a daily struggle balancing the desire to provide patient focused consultations while juggling the demands of evidence based medicine and QOF. In this article we will consider the unique challenges of trying to practise both the art and science of nursing in the general practice setting.
September 2013 marks an important milestone in nurse education as from this date onwards nursing becomes a degree-level only profession. This focus on the academic, scientific component of nursing is important if we are to demonstrate academic parity with our medical colleagues and other professionals allied to medicine.
Practice nurses as a demographic group tend to be older and many are nearing retirement. We tend, therefore, to be more familiar with the 'old school' type of vocational training where a few weeks spent learning the theory of anatomy and physiology, diseases and drugs delivered by nurse lecturers in the school of nursing within the hospital were followed by months on the wards putting theory into practice. We were often counted as part of the staffing complement on the wards and felt anything but supernumerary, working under the guidance and authority of the ward sister or charge nurse and learning from our more senior and experienced qualified and unqualified colleagues. In contrast, modern nurse training has moved from this vocational ward-based approach to the universities and encompasses a more scientifically grounded, academic education, supplemented with practical experience in a variety of clinical settings.
VISION FOR NURSING
At the same time as this move towards degree level education for all nurses was happening, the Department of Health launched its vision for nursing which focused on the importance of the 6 Cs: care, compassion, courage, communication, competence and commitment.1 Of these 6 Cs, only one could really be described as 'scientific' in its concept: competence. The others: care, compassion, courage, communication and commitment are attributes, attitudes and approaches which, it could be argued, are considerably less easy to teach or learn in an academic sense. So how do we ensure that the art of nursing is not lost in the drive to focus on academic achievement and the development of strong research skills?
For many of us who trained years ago, it may seem odd to think there is any need to express the 6 Cs as a standard to be strived for — instead we would consider them to be integral to nursing since time immemorial and might go so far as to argue that anyone who does not already understand the importance of the 6 Cs is perhaps not suited to the profession.
EMOTIONAL INTELLIGENCE
The essence of the 6 Cs lies firmly in emotional intelligence,2 and perhaps resonates with what some might consider the old-fashioned view of nursing as a vocation — literally a 'calling'. The Oxford English Dictionary defines 'vocation' as meaning 'a strong feeling of suitability for a particular career or occupation: "not all of us have a vocation to be nurses or doctors".' The word 'suitability' is important as this is not the same as being able or qualified. In the past, people who were not suitable for a career in nursing were quite quickly weeded out during their training as reality hit home. There was ample opportunity to practise the art of nursing right from the start while washing, dressing and feeding patients, caring for their physical and emotional needs, listening to and addressing their concerns, and providing succour and support to them and their relatives in a wide range of environments. The science came along the way as we learned in school and in practice, from books, studies and colleagues.
Currently, a new student nurse will split his or her time equally between theory and practice, according to the NHS Nursing Careers website. However, a browse through the figures provided by one university regarding their 3 year nursing degree course demonstrated that approximately one third of the time is spent on placements, approximately half on independent study and one fifth on formal lectures and seminars. Assessments are split between written exams and coursework (two thirds) and practical assessments (one third).3 Does this mean that the science and art of nursing get equal weighting? Are student nurses allowed and enabled to develop both? How do we measure which matters more? Is there a danger that an academically adept nurse could be successful while the more emotionally intelligent and less academically gifted nurse on the same course 'fails'?
Recently nursing has come in for some significant criticism and intense scrutiny as a result of investigations such as the Mid Staffordshire enquiry and the subsequent Francis report and Berwick reports. 4,5 It has been suggested that people in the nursing and caring professions have forgotten how to provide compassionate care. So how can we ensure that we do not educate our nurses in the science of nursing at the expense of the art? Jeremy Hunt's response to the publication of the Francis Report was to say that 'the vast majority of NHS staff"¦do everything in their power to give their patients the high quality, compassionate care they deserve.' However he also went on to say: 'The health and care system must change. We cannot merely tinker around the edges — we need a radical overhaul with high quality care and compassion at its heart.'6 So are we already doing it or do we need a radical overhaul to put the 6 Cs back into healthcare? Even Mr Hunt seems confused.
'REAL LIFE' EXPERIENCE
A key recommendation of the Francis Report was that people who would like to train as nurses should in future spend up to a year working as a health care assistant (HCA) to get real life experience of nursing. It is interesting (and to me personally, quite depressing) to consider how that recommendation reflects on nursing and nurse training — the implication being that the best way to get experience of nursing in its traditional sense is to work as an HCA. Hopefully, nurse educators are now referring to the 'Too Posh to Wash' report when developing education programmes.7 Many of us are only too aware that providing personal care improves the closeness and intimacy that encourages better communication and greater compassion in every element of care provision. Working in general practice offers us a window into the reality of how our patients live — we get to know about their lives, their relationships, their families; we help to keep them well and treat them when they are ill, we support them through pregnancies, childhood, failing health, recovery and even death. We offer health education across the board and learn to work with them in a true partnership. All of this makes us better equipped to understand their perspective and offer care which is tailored to them as individuals. The principles and practice of the 6 Cs are already embedded in practice nursing.
Florence Nightingale is often thought of as the founder of modern nursing. She built her reputation and that of nurses of her time on the need for high standards of cleanliness in hospitals where the injured from the Crimean war were being treated. She did this through the use of statistics and research, not simply from a feeling that cleanliness might be important. Indeed, in 1859 she was elected the first female member of the Royal Statistical Society. She felt that the key to developing nurse education was through both statistical and empirical research. Nightingale was an advocate of the idea of nursing as both science and art and described the goal of nursing as one which fosters health in patients in the broadest, most holistic sense.
So what is the definition of a 'good' nurse? What proportion of art versus science is the key? If we work to the 6 Cs can we still be evidence based and scientific in our care? If the patient who prefers complementary medicine skews our QOF figures by declining medication do we focus on the 6 Cs and show our caring, compassionate side by recognising their right to self-efficacy and decision making or do we 'encourage' them to reconsider, using the science and research to back up the evidence-based way which also allows us to hit our QOF target?
COMPASSION FATIGUE
Furthermore, are nurses and other caring professions suffering from compassion fatigue? The NHS commissioning board perhaps recognises the challenges of implementing the 6 Cs in the modern NHS by describing the feelings of many nurses and which it refers to as the 6 B's: bullied, burnt out, bruised, blocked, bemused and bewildered.8 It is probably fair to say that nurses experiencing these feelings may view the 6 Cs as so much rhetoric with little or no bearing on their real life experience of nursing in the current NHS. Target driven healthcare and pressures on budgets mean that those of us who chose 'caring' as our profession are often prevented from doing just that; the NHS and in particular general practice, is a business which may at times seem to know the cost of everything and the value of nothing as it pushes us on to hit targets, cut costs, save resources and measure and record everything we do quantitatively with little or no consideration for the quality. This may well leave nurses feeling disenchanted and disempowered, passively ticking boxes instead of actively improving care in the fullest and most holistic sense. One thing harder than having to keep up to date with evidence-based care, new therapy areas and innovative practice is being aware of all of this and then not being able to implement what has been learned because fulfilling the requirements for QOF disincentivises personalised care.
Overall, however, the essence of the 6 Cs is surely central to practice nursing. The importance of recognising how we deliver care as well as why is the key to patient focused consultations. Our frustrations with having to deliver template based, tick box care even though it has been developed from scientific evidence is proof of our desire to meet the 6 Cs and avoid the 'one size fits all' approach that science sometimes advocates. Rather than railing against it, perhaps we should celebrate the fact that we see so clearly why science cannot and should not trump art and vice versa. Both ingredients are vital and as patient advocates, we should be able to deliver both in the ratio which is relevant to each individual that we see. Sometimes it will feel like a struggle but we need to be able to stand our ground and argue the case for taking the best approach for each individual patient that we see.
It may be that we have not got the balance of nurse education quite right yet, but in terms of the care we deliver it should not be necessary to reduce the amount of science we use to get back some of the art, if indeed it ever went missing. A careful balance of both should ensure that nursing is able to move through the 21st century with a successful blend of sound scientific knowledge and a strong commitment to recognising the importance of the 6 Cs. This can be achieved through our own individual approach to patient care but it also relies on strong leadership at all levels to allow the creation of supportive caring cultures that foster all of these attributes.
Maybe we should take a leaf from the story of the Wizard of Oz and remember that to get on in life (and arguably to be a 'good' nurse) we need courage, a heart and a brain — and that all three are mutually compatible.
REFERENCES
1. Chief Nursing Officer (2012) Compassion in Practice Available from http://www.england.nhs.uk/wp-content/uploads/2012/12/compassion-in-practice.pdf
2. Salovey P, Mayer J. Emotional intelligence. Imagination Cognition and Personality 1990; 9(3):185-211. Available at: http://heblab.research.yale.edu/pub_pdf/pub106_Salovey,Mayer1990EmotionalIntelligence.pdf
3. Coventry University Adult Nursing statistics page available at http://university.which.co.uk/coventry-university-c85/adult-nursing-3-years-b740-370073
4. Francis R (2013) Final Report Of The Independent Inquiry Into Care Provided By Mid Staffordshire NHS Foundation Trust Published. Available at: http://www.midstaffsinquiry.com/pressrelease.html
5. Berwick Report (2013) Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/226703/Berwick_Report.pdf
6. Hunt J (2013) Putting Patients First: government publishes response to Francis Report Available at: https://www.gov.uk/government/news/putting-patients-first-government-publishes-response-to-francis-report
7. Beer G (2013) Too posh to wash? Available at: http://www.2020health.org/2020health/Publications/Publications-2013/Too-posh-to-wash.html
8. NHS Commissioning Board (2012) Developing a vision and strategy for nursing, midwifery and care givers. Available at: http://www.local.gov.uk/c/document_library/get_file?uuid=c92482c8-1659-4fcd-98b9-05bc9b6da4b9&groupId=10171
