Nursing Inquiry 2007; 14(2): 99–113

Feature

The sustainability of ideals, values and

Blackwell Publishing Ltd

the nursing mandate: evidence from

a longitudinal qualitative study
Jill Maben,a Sue Latterb and Jill Macleod Clarkb
aKing’s College London, London, bUniversity of Southampton, Highfield, Southampton, UK

Accepted for publication 1 February 2007

MABEN J, LATTER S and MACLEOD CLARK J. Nursing Inquiry 2007; 14: 99–113
The sustainability of ideals, values and the nursing mandate: evidence from a longitudinal qualitative study
This article reports on research that examines newly qualified UK nurses’ experiences of implementing their ideals and values
in contemporary nursing practice. Findings are presented from questionnaire and interview data from a longitudinal inter-
pretive study of nurses’ trajectories over time. On qualification nurses emerged with a coherent and strong set of espoused ideals
around delivering high quality, patient-centred, holistic and evidence-based care. These were consistent with the current UK
nursing mandate and had been transmitted and reinforced throughout their ‘prequalification’ programmes. The existence
of professional and organisational constraints influenced their ability to implement these ideals and values once in practice.
Data analysis revealed that within 2 years in practice the newly qualified nurses could be categorised as sustained idealists, com-
promised idealists, or crushed idealists. The majority experienced frustration and some level of ‘burnout’ as a consequence of
their ideals and values being thwarted. This led to disillusionment, ‘job-hopping’ and, in some cases, a decision to leave the
profession. These data are explored and discussed to inform the question of whether the current nursing mandate is sustainable.
Key words: newly qualified nurses, nurse education, nursing ideals, stress and burnout, the nursing mandate.

The global shortage of health professionals (WHO 2006) In this paper we draw on empirical data which suggest that
makes the retention of qualified practitioners imperative, professional and organisational constraints in the workplace
particularly those who have just completed expensive educa- are a serious threat to the implementation of nursing ideals
tion programmes. Some influences on retention in nursing and values in practice.
have been identified, such as shift work, poor rates of pay The focus on ideals in this paper represents the core
and limited resources, limited career prospects, and issues values held by members of the nursing profession. They are not
of health safety and security, to name but a few (While and ‘ideals’ in the sense that they are unachievable — rather they
Blackman 1998; Hadley et al. 1999; Buchanan and Considine represent the values and aspirations of professional nurses.
2002; Finlayson 2002; Landon, Reschovsky and Blumenthal Indeed, the ideals and culture of nursing are to be found in
2003; Rafferty et al. 2005; Zurn, Dolea and Stilwell 2005; what the sociologist (Hughes 1984) called the profession’s
Priest 2006). However, little attention has been paid to the mandate and its assertions about its contribution to society
factors that impact on the ability of qualified nursing staff to (Dingwall and Allen 2001). All health professional educa-
maintain their ideals and provide high quality patient care. tion programmes are underpinned by strong ideals and
values (UKCC 1986; CSP 2002; GMC 2005). In nursing, a
philosophy of individualised, holistic care is explicit (Woods
Correspondence: Jill Maben, Senior Research Fellow, Nursing Research
1998). In the UK a nurse is expected to be a ‘knowledgeable
Unit, Florence Nightingale School of Nursing and Midwifery, King’s
College, London, James Clerk Maxwell Building, Waterloo Road, London doer’, with practice underpinned by research, and who
SE1 8WA, UK. is ethically responsible and accountable, and able to give
E-mail: <jill.2.maben@kcl.ac.uk> individualised holistic care through caring and therapeutic

© 2007 The authors. Journal compilation © 2007 Blackwell Publishing Ltd

J Maben, S Latter and J Macleod Clark

interventions with patients and clients (UKCC 1986, 1999). the extent to which, over time, they are translated into prac-
The mandate for qualified nurses elsewhere in the world is tice after qualification, together with the factors that impact
similar (College of Nurses of Ontario 2002; NCSBN 2004; on ideals in the work environment. This paper draws on
ANMC 2005). longitudinal data collected between 1997 and 2000, in the
Few studies have examined the fate of ideals in health wake of UK nursing education reforms (UKCC 1986). These
professional practice. Early work in medicine found that reforms culminated with a move into higher education
medical students develop cynicism in specific situations, but for nursing and a curriculum emphasising holism, and indi-
their idealism is not lost and is reasserted as the end of train- vidualised and evidence-based care. It also coincided with
ing approaches (Becker and Geer 1958). Similarly, a study of a climate of increased managerialism as part of the new
nursing students suggested that they hold long-term altruistic public management in health-care (Ackroyd and Bolton
and professional ideals, which they may temporarily abandon 1999; Traynor 1999; Cooke 2006), in which notions of
in order to meet the requirements of the moment (Melia efficiency, performance objectives, resource constraints and
1987). More recently, a study of midwives found evidence of cost effectiveness are paramount (Wells 1999; Wong 2004).
contradictory models of practice between senior and junior The data presented here illuminate the trajectory from student
midwives and suggested that ideological dissonance was to newly qualified nurse, and provide graphic examples of
exacerbating workforce attrition (Hunter 2005). the tension between the ideals that nurses hold and the ability
Seminal works in the UK and USA over 30 years ago of individuals to apply the nursing mandate in practice.
(Kramer 1974; Bendall 1976; Melia 1987) examined the
extent to which students and qualified nurses managed METHODS
this distinction between their nursing ideals and values
and the constraints of practice. In the USA Kramer (1974) An interpretive research design (Lincoln and Guba 1985)
identified a disparity between the idealised role conception based on the collection of longitudinal qualitative data was
(taught in school) and the role found in the work situation, used. Ethical clearance was obtained from the relevant NHS
which she described as ‘reality shock’. The ideals and values trusts and education institutions included in this study. In
promulgated by school were professional, and included phase 1 a 24-item self-administered questionnaire, adapted
notions of autonomy, and individualised and personalised from an instrument used by Macleod Clark, Maben and
care, and relied on a whole task analysis of the work. The Jones (1996), was administered to three cohorts of final-year
reality in practice was an impersonal orientation towards student nurses during the last week of their course (n = 72)
patients, and aspects of the work were broken down into in three well-established UK universities running ‘typical’
tasks and procedures. In the UK Bendall (1976) examined prequalification programmes. Questions asked for back-
the relationship between traditionally trained students’ ground demographic details and, for example, asked students
descriptions on paper of how they would care for patients the extent to which the course had equipped them to be
(theory) with actual observed behaviour (practice), and was a promoter of health, to effect change, to utilise research, to
one of the first to draw attention to the fact that ‘what is work as a qualified nurse, and the extent to which they
taught in school is not practised on the wards and vice versa’ expected to be able to relate theory to practice. In an open
(6). Indeed, in 84% of cases there was no correlation response question, students were also asked to describe their
between saying and doing, and nurses were rarely involved ideals and values for practice as a qualified nurse. That is, if
in anything approaching total care of patients. Rather, most they were able to choose how to practice, how would they
nursing was task centred. describe the approach to care they would like to adopt. This
Melia (1987) identified differences between how students provided baseline data on respondents’ ideals and values
wanted to practice and the reality of nursing. She found before becoming qualified nurses. Phase 2 in-depth inter-
pressure for students to be quick at the nursing tasks, to not views were undertaken with a subsample (n = 26) of those
ask questions, to have a tidy ward, to ‘pull their weight’, and completing the phase 1 questionnaires to gain an under-
to ‘look busy’ even when the ward was quiet. Students found standing of these nurses’ experiences and trajectories at
this difficult, suggesting it prevented them really talking 4–6 months post qualification, and again at 11–15 months.
to patients and giving good quality care. More recently, work Forty-nine of the 72 nurses completing the phase 1 question-
in Australia (Henderson 2002) has described the reality as naire indicated that they were willing to participate further
‘utilitarian’, suggesting that it prevents nurses giving holistic and 26 of these were purposively sampled (Mason 1996).
care to patients. Few studies have recently examined the This selection reflected information-rich cases as advocated
ideals and values held by students of nursing in the UK and by Erlandson et al. (1993) and a range of first destination

100 © 2007 The authors. Journal compilation © 2007 Blackwell Publishing Ltd
 Nursing mandate in professional practice

practice settings, age and gender. Theoretical sampling There was little evidence in the data to suggest that
(Silverman 2000) was utilised within the purposive sample practice-based staff influenced the development of these
to provide the broadest range of views possible. For example, ideals and values, although a few participants cited good role
differences and variations in questionnaire responses were models, who were able to reinforce their ideals and values.
crucial in this sampling strategy, and newly qualified nurses For example, whilst nurse 1 was a student, the ward sister had
who had a range of views to some of the key questions in the indicated her positive attitude towards nurses sitting and
questionnaire were sought. At interview participants were talking to patients:
asked detailed questions about their current practice environ-
ment, their work and to comment and reflect upon their I remember the sister saying to me when I was a student
‘it’s good that you sit and talk to patients’ I remember
original ideals and values identified in the phase 1 question- her saying that to me which is good, and made me feel if
naire. For the final and third phase of data collection, ques- anything I am doing something good rather than bad.
tionnaires were mailed to the interview subsample (n = 26) Some of the wards I was on I felt like I was constantly doing
something wrong (nurse 1: interview 1).
3 years after qualification. This phase 3 questionnaire asked
participants to respond to a series of open questions. These Primarily, however, it was the nursing faculty that appeared
included, for example, details of their current workplace, to be direct socialisation agents in relation to the nursing
reasons for leaving previous employment, whether they mandate. Newly qualified nurses were acutely aware of their
had considered leaving nursing and their future plans. influence, using words such as ‘indoctrination’, ‘moulded’
They were also asked for their initial thoughts on reading and ‘conditioning’ to reflect the effect their education had
their most recent interview transcript and on re-reading had upon them:
their ‘ideals for practice’ from the phase 1 questionnaire.
Participants were asked whether they still agreed with these You can still be a nurse with whatever training, but I still
think the standard that you can give — obviously it is all
ideals, could implement them and what does or would help
dependent on the individual, but I think certain training
them to achieve their ideals in practice. can mould you in certain ways.
Open responses in the questionnaires were content
analysed (Green and Thorogood 2004). All interviews Interviewer: Do you feel moulded?

were audiotaped, transcribed and analysed using constant I do (nurse 2: interview 1).
comparative analysis (Lincoln and Guba 1985). Deviant case
analysis was used to address alternative interpretations of the I mean, the only principles I’ve been given were stuck on
me at college (nurse 3: interview 1).
data (Silverman 2000).
It was good, it was an all-round training. It didn’t all gel until
the end, but at the end you could then look back and say
THE IDEALS AND VALUES OF FINAL YEAR ‘Oh yeah, I can really see who they’ve turned me into’;
NURSING STUDENTS because that really is what it’s like (nurse 4: interview 1).

Nursing students in the final week of their prequalification It’s good, having done Project 2000 that I’ve been taught
that ... you’ve actually got a research background into the
courses emerged from their education programme with a ethics and the sort of psychological research that’s been
coherent and largely consistent set of nursing ideals and done to show that the way that you treat people, in people’s
values, which reflected the aspirations of their nurse educa- health behaviour and illness behaviour, you know, I think
that those principles, the really major principles ... have
tion curriculum and the nursing mandate. These ideals fell
completely indoctrinated the way that I think (nurse 5:
into three dominant categories embracing the delivery of interview 1).
patient-centred holistic care, the delivery of high quality
care, and care influenced by a theoretical knowledge base The pursuit of patient-centred holistic care
and research evidence.
In the interview data there was much evidence to In the initial phase 1 questionnaire responses nearly all
support the fact that these ideals and values were ‘taught’ subsample participants (n = 26) cited patient-centred holistic
during the prequalification nursing course. Interviewees care as a key component of their concept of ideal care. They
often cited examples of how they had been taught to think in a emphasised psychological care, a therapeutic relationship
certain way. This confirms the key role of nurse educators in the with patients as active participants, and nursing care organised
‘socialisation’ or, as one nurse suggested, ‘conditioning’ around the needs of the patient, as opposed to care organised
process: ‘I do believe the college has conditioned you to around the needs of staff or the hospital, reflecting the nurs-
think a certain way’ (nurse 1: interview 1). ing mandate:

© 2007 The authors. Journal compilation © 2007 Blackwell Publishing Ltd 101
J Maben, S Latter and J Macleod Clark

I would like to aim at ... seeing the client as an individual the notion of respect for patients, and non-judgemental and
and having time to support them in a holistic way. Being unprejudiced care. At interview 2, reflecting on the impor-
able to pick up when they are worried or distressed while at
the same time ensuring their independence (nurse 6: phase tance of what she had learnt in college in this respect, nurse
1 questionnaire). 2 recorded her horror at the judgemental attitudes of other
staff she witnessed on her ward and felt that labelling
[We need] more staff so care can be more patient centred
— this enables us to have more nurse–patient ‘quality’ time patients was not acceptable:
where my patients’ [worries and fears] psychological needs
Umm, I still try and draw from what I have learnt at
are met (nurse 7: phase 1 questionnaire).
college ... when we hand over, some people are just so
Respondents distinguished between physical and psycho- judgemental it’s like, right this is so and so, hi, you’re a
moany one, and I just think, I just completely cringe, and
logical care and emphasised the importance of the latter and the other day someone said something and I said look this
a desire to spend ‘quality’, and ‘unhurried’ time with patients. really isn’t on, we haven’t got to have a judgement on every
‘Patient-centred care’, ‘holistic care’, ‘non-judgemental care’ patient, we can all make our own opinions and keep them
to ourselves, it’s just not on, you are just labelling (nurse 2:
and ‘empowerment’ were thus important principles for the interview 2).
participants. Not surprisingly these ideals were apparent in
their university learning. Nurse 8, reflecting on the course, Respondents also highlighted safety and the need to
highlighted this: undertake everything to the best of their ability:

I think because of the actual philosophy of the Project 2000 Provide high standards of care ... No cutting corners (nurse
course ... a lot was toward patient orientation, so at the back 11: phase 1 questionnaire).
of your mind whatever decision you make with a patient,
you can’t go ahead with it unless you’ve thought of what the The pursuit of high standards of care were again seen to
consequences are going to be when you actually do that spe- have come from their course:
cific thing. So for instance, if you are going to give any news
to somebody, what it’s going to actually do to the patient, Interviewer: The standards of care you talk about here
and before doing it, is there going to be enough back-up to [questionnaire] and have talked about; where did they
see that patient supported in any specific way? (Nurse 8: come from?
interview 1.)
From my training. Our lecturers were really good I think in
Others discussed how holistic and individualised care were making us aware of issues like that and you know what is
particularly noticeable elements of the course: acceptable and what isn’t acceptable ... Yeah, I mean, the
ideals don’t always work out but if you like learn the basic
I mean from the word go it was all holistic, individualised principle you know they become like set in you because we
care (nurse 9: interview 2). were able to discuss it freely at college. You are made to
think about things you know, what if it was you, what if it was
Coming out of Project 2000 I feel like, when somebody your Mum?’ (Nurse 12; interview 1.)
comes in, I automatically look at the whole person like I’m
not just looking at one or two problems, I’m looking at the
wider side of things (nurse 6: interview 1).
The pursuit of theoretical knowledge and
evidence-based care
The pursuit of high quality care
Just under half of respondents (n = 12) explicitly cited the
Half of respondents (n = 13) explicitly identified the impor- need to deliver care based on sound knowledge and research
tance of high quality care, with their descriptions of this evidence. For example:
embracing safety and competence, together with nursing
Desire to see psychological care seen as a priority for preop
strategies, such as advocacy and equality of care delivery. care, since research shows patient’s understanding pro-
Respondents also referred to ‘making a difference’ and cedures helps quicken recovery post op (nurse 8: phase 1
helping patients and families to cope: questionnaire response).

Good standards of care, based on research findings. Also Good standards of care based on research findings
safe care. Care that is consistent in members of staff that (nurse 2: phase 1 questionnaire response).
give it (nurse 2: phase 1 questionnaire).
There was evidence that the nursing faculty had taught the
For all patients to be safe and to feel that they’ve had the students the importance of nursing theory, research and
best care possible (nurse 10: phase 1 questionnaire).
interpersonal skills and the need to have a rationale for
Delivering high quality care also included ‘big principles everything they did. One nurse summed up the philosophy
and ideas’, such as unconditional positive regard for patients, she had gained from the course:

102 © 2007 The authors. Journal compilation © 2007 Blackwell Publishing Ltd
 Nursing mandate in professional practice

I suppose you’d say that primarily it comes from theory constraints included time pressures, staff shortages and poor
otherwise there’s no point in doing the course, I mean if skill mix, the intensification and routinisation of nursing
you’re not basing what you’re doing on your theory, then
what’s the point? ... I suppose theory, experience, and the work and role constraints. Analysis of the phase 2 interview
ethical side of it is always there, what’s best for the patient data revealed different practice environments experiencing
and also what’s best for the family.... So it’s a bit of every- these constraints to lesser or greater degrees. Thus, environ-
thing, but I’d say primarily the theory (nurse 13: interview 1).
ments that facilitated or inhibited the implementation of
Another felt the course had taught her to value theory and ideals in practice are described in three ways: ideal, challeng-
research and to have a rationale: ing or poor environments.

To know why you are doing things and believe the things
you are doing, rather than just doing things that you are The impact of professional constraints
told to do ... a rationale, the amount of times I heard that
during my training — rationale. It was definitely a Newly qualified nurses were exposed to a set of covert rules
buzzword ... — what others did we have? Theory based,
that they were expected to adhere to, but these rules were
research based (nurse 2: interview 1).
the antithesis of their values and ideals. Four ‘covert rules’
Students at the end of their course could clearly identify a could be identified in the data and were primarily identified
strong set of nursing ideals and values on which to base their in practice environments categorised as challenging and
practice. When asked to reflect on where this mandate had poor. These rules negatively impacted on the nurses ability
come from, participants almost exclusively suggested their to implement their ideals. The four covert rules were:
education course and college faculty. Only one or two nurses • Rule 1: ‘hurried physical care prevails’ (to the detriment
suggested these were reinforced or encouraged in practice of psychological care);
as students. As Allen (2004) observed, occupational man- • Rule 2: ‘no shirking’ (need to be seen to be doing a fair
dates serve a useful function in encouraging practitioners to share of the physical and ‘dirty work’ (Hughes 1984),
strive for their ideals and values. On the whole the students especially by unqualified staff);
in this study appreciated the way they had been ‘condi- • Rule 3: ‘don’t get involved with patients’ (keep an emo-
tioned’ to think, and felt that ideals were important, guiding tional distance); and
practice and giving something to aspire to. Some were aware • Rule 4: ‘fit in and don’t rock the boat’ (don’t try and
that the college vision was idealistic and felt that this was a change practice).
positive thing as it gave them a yardstick and something to These covert rules sent powerful messages to the new
aim for and a vision of themselves as professionals. There nurses. They were expected to emphasise physical care over
was also a plea for more realism: psychological care, maintain distance from patients, help
out and undertake a fair share of the physical and dirty work,
They did set us up for fall ... to have the ideals is great
because it gives you something to strive for. and it also helps and fit in and not rock the boat. These rules were almost
you know about what you should be doing as a nurse.... But always implicit, hence the label ‘covert’. Kramer (1974) sug-
if somebody had just said to us at the beginning, um, that gested that one of the main difficulties for neophyte nurses
you probably will encounter these difficulties and it will be
hard ... that it will be a challenge.... Just sort of sat down
was that they did not appreciate the existence of ‘front stage’
and said that this is going to be hard, it would have been a and ‘back stage’ realities, as described by the sociologist
help (nurse 4: interview 2). Goffman (1959):

I think that the theory was very good. But they needed to be The problem is that the new graduate actually believes, acts
more realistic in some ways, with the things that you were and lives by this rhetoric of the front stage reality that she
going to encounter (nurse 11: interview 2). has been taught. Furthermore she expects to be evaluated
on this basis (Kramer 1974, 147).

EXPERIENCES OF IMPLEMENTING VALUES In this study, the ‘front stage’ illusory reality and rhetoric,
AND IDEALS IN PRACTICE exemplified in statements of nursing philosophy displayed
on practice area walls for example, was that holistic and indi-
Analysis of the interview data revealed that the key deter- vidualised care were important, as was research, quality care,
minants of whether or not participants could implement the and involving patients in their care. The ‘back stage’ reality
ideals and values described above were the professional and was quite different, and was revealed through the key mes-
organisational constraints encountered in the practice en- sages of the four covert rules. These processes are described
vironment. Professional constraints included covert rules and in depth elsewhere (Maben, Latter and Macleod Clark 2006).
a lack of positive attitudes and role models. Organisational This paper explores the added impact of organisational

© 2007 The authors. Journal compilation © 2007 Blackwell Publishing Ltd 103
J Maben, S Latter and J Macleod Clark

constraints in the practice environment on participants’ erly lady and she’s 100 and we were doing pressure area care
ability to retain and implement their ideals. and we just all swept upon her stood her up put her on the
bed, swept out again and this old lady’s like ‘what’s going
on’, d’you know what I mean? I think it’s all the time factor.
The impact of organisational constraints In theory you should take time to talk to the patients, walk
through the procedures, in practice it doesn’t work that way
because you’ve got all these other patients to do pressure
We found that the ideals and values transmitted to and area care at this time and then get on and do the drugs
adopted by nurses during their education were not only (nurse 1: interview 2).
often sabotaged by professional constraints (Maben, Latter
The need to ‘hurry’ through patient care was seen as a direct
and Macleod Clark 2006) but were also thwarted through
result of the intensification of nursing work and inadequate
structural and organisational constraints beyond their
staffing levels and this compromised the delivery of quality care:
control. Two key constraints were identified from analysis of
the interview data: the intensification and routinisation of Sometimes, often, there are only two of us on you know, on
nursing work and the reality of nursing activities in practice. late and may be one healthcare assistant or one student. It’s
really hard to give the best care sometimes.... I would like
to spend more time with the patients ... talking and listen-
INTENSIFICATION AND ROUTINISATION
ing to them rather than having to rush off all the time
OF NURSING WORK because somebody is bleeping or buzzing in the next bed.
In this study the key constraining factors identified by all So in that way lack of staff does affect it definitely (nurse 14:
interview 1).
participants were staff shortages, resulting in work overload
and time pressures, and increased turnover and throughput of We’ve got a lot of patients who need a lot of time that we
patients, resulting in what has been called the intensification can’t give because we’re so busy, most of the time. And it’s
just, I’d like to spend time with patients, talk to them, but
of nursing work (Ackroyd and Bolton 1999; Adams et al. I can’t, I really can’t ... Well, I say, look, I’ll talk to you, but
2000; Cooke 2006). These thwarted participants’ abilities to I have to go, you know, I do talk to them for a while and then
implement ideal care, specifically the patient-orientated try and come back. But then often they just go ‘Oh, it
doesn’t matter’, which isn’t good ... I think it is like that on
and holistic aspects of care. A further constraint was identi- every ward, I don’t know, really. Everywhere I’ve been you
fied in the routinised and task-orientated organisation of never have time. Nurses don’t have time to care (nurse 7:
care, which was almost certainly a direct consequence of interview 1).
the former constraints (Allen 2004; Wong 2004). This also
A high patient turnover was detrimental to the neophytes’
had the effect of thwarting the implementation of the par-
ideals of providing holistic care, allowing less time with patients:
ticipants’ ideals and values. The inability to provide continuity
of care created conflict for many of the new nurses. They When patients came in they were staying 2 or 3 days,
whereas now they are coming in and they are staying
had been taught that a task-orientated approach was not
between 1 day and then going ... get them in, get them out
desirable, because it is not conducive to individualised and quickly, which ... from a holistic care point of view it is not
holistic care. However, even though this approach hindered very good at all (nurse 13: interview 1).
those aspects of care important to them, for example talking
This fast patient turnover was also a contributing factor to
to patients, it was also deemed necessary to get the work done:
neophytes feeling under pressure, which thwarted the
We are very task orientated, and routine work, there’s still implementation of their ideals:
a lot of that ... Because, like, you have to get things done.
I remember when I was a student I used to think you could
It’s really important not to be task orientated but you have
spend an hour, hour and a half doing an admission, then
to get things done as well, you know, because if things
you’d spent a bit of quality time with the patient and you’d
aren’t being done, there’d be questions. ‘Why aren’t these
try and work that out, but now if you spend more than
things done’, ‘Because I was talking to a patient for
20 minutes doing an admission, you’re wasting time, that’s
2 hours’ ... ‘That’s all very well, but you’ve got to get them
the approach on the ward now, basically because there’s
done. You’ve got to do it’ (nurse 7: interview 1).
such a high turnover. I mean, you try to get as much time as
you can in with the patient obviously, because the patients
A heavy workload resulted in feeling pressured and contrib-
need it, but it’s just not, time’s just not there ... that’s not
uted to the culture of needing to do things at speed, thereby proper care ... it is sad, but that’s just the way it is (nurse 13:
meeting one of the covert rules. One nurse articulated how interview 1).
this compromised and inhibited ideal care whilst working
Having adequate staff to give good patient care and have
with older patients:
‘time to think’ was both rewarding and ‘lovely’ but identified
The patients are saying all the time, oh things are happen- as a ‘luxury’. Insufficient numbers of qualified nurses
ing so quickly and I feel sorry for them. Like there’s this eld- created extra pressure and made high and arguably unrealistic

104 © 2007 The authors. Journal compilation © 2007 Blackwell Publishing Ltd
 Nursing mandate in professional practice

demands on those on duty. Thus, the undermining of ideal 11–15 months following qualification, for those who
care delivery was inevitable. remained in hospital settings (the majority, i.e. 24 particip-
ants) much of the work undertaken by the newly qualified
THE REALITY OF NURSING ROLE ACTIVITIES nurses revolved around general administration, drug
IN PRACTICE administration, and liaison and communication with mem-
The role and activities of the newly qualified nurses in this bers of the team and patients’ relatives and friends. Nurse 9
study were many and varied depending on the area of work. found that the reality of being qualified was that the drugs
However, all included a management role, a supervisory took precedence and were the most important thing, with all
role, a co-ordinating and liaison role and a patient-care role. other activities arranged around this task:
These different and increased role activities (compared to
You know what are the important things you have to do
those of student nurses) also militated against spending time throughout the day, the drugs and things, and then you just
with patients, often removing them from the bedside into organise yourself around that (nurse 9, interview 1).
more administrative and managerial activities. This supports
Whereas at the end of her course she considered her priority
the conclusions of Allen (2004) who suggests that nurses
was:
now predominantly act as healthcare intermediaries.
Participants were asked to describe in detail activities helping my patients to cope or adjust to their illness or
undertaken as a student and as a qualified nurse. Table 1 injury and facilitate their progress. It is nice to feel that you
have made a difference to someone’s day (nurse 9: phase 1
compares activities reportedly undertaken by the partici- questionnaire).
pants in this study as qualified practitioners with those they
undertook as students. Some activities were the same once In this study newly qualified nurses suggested that the
they were newly qualified nurses. However, they also system within acute wards removed the most qualified staff
reported taking on the unfamiliar duties shown in the ‘staff from those interpersonal aspects of care for which they had
nurse’ column (Table 1). The table therefore represents the been trained. Nurse 1 reflected that the role she found her-
total range of activities undertaken by the newly qualified self in as a staff nurse was much more managerial than she
nurses. Importantly, participants undertook the ‘student’ had anticipated:
activities much less frequently and for some this was a cause I came into nursing with this idealistic image obviously,
of concern. This was particularly so for the patient care role then I realised it’s actually quite managerial, actually, now.
and learner role. As a result many felt they had lost their That’s what I’m finding it quite managerial. Yeah, manage-
rial’s the word (nurse 1: interview 1).
patient-focused role in return for a more managerial and co-
ordinating role: Thus few described themselves as able to give direct and
patient-orientated care. Because of the skill mix2 on the wards
And giving a bed bath — I’m amazed at how few bed baths such work was delegated to healthcare assistants (HCAs),3
I’ve given since I’ve started ... first thing in the morning,
you’ve got the ward rounds going on I’m usually caught up and many suggested that they were simply undertaking a
in the ward rounds, so it’s the healthcare workers and the
students doing the washing, and I actually miss that, 2 Skill mix refers to the provision of nursing services through different combinations
because I think it’s really good for the patients having that
contact during bed bathing. Or you just do it really quickly of nursing skills (DHSS 1986). However, it is often grade mix as opposed to
straight away because you know the doctors are going to skill mix that is measured (Spilsbury and Meyer 2001), with different grades
come in any minute, and finish (nurse 15: interview 1). of staff assumed to reflect different levels of expertise. Skill is more than grade:
it is qualifications, experience, and competencies (Spilsbury and Meyer 2001).
Some days I haven’t got much actual patient contact, and The term is also often used colloquially to differentiate between numbers of
I’d like to, and I always thought I would have ... I thought as qualified and unqualified staff. In the UK there is both national legislation and
a junior staff nurse I probably would, but there are days local rules that govern what unqualified nurses (i.e. healthcare assistants
when by the time I’ve done the drugs, given all the IV drugs,
(HCAs) can and cannot undertake and this can vary between practice settings.
and the doctor’s round and written out referrals, spoken to
the social worker, written my Kardexes,1 there hasn’t been 3 Healthcare assistants (HCAs) — sometimes known as nursing auxiliaries or
all that much time for any hands on care, and having to ask auxiliary nurses — are a grade of unqualified support workers in the UK and
all my A grades if they wouldn’t mind doing all these things, work in various settings including hospitals, residential care homes and the
it’s all quite difficult (nurse 16, interview 1). community, supporting other healthcare professionals with the day-to-day
tasks of patient care under the guidance of a qualified nurse. They undergo
Unsurprisingly this focus thwarted the implementation of
basic on-the-job training supported by day release courses. New entrants are
many of their ideals and values. By the second interview trained in hygiene, health and safety, personal care, and communication with
patients, and may also be taught how to measure and record temperature,
1 Flip chart folders or files where patient nursing notes are recorded. pulse, respiration, and weight.

© 2007 The authors. Journal compilation © 2007 Blackwell Publishing Ltd 105
J Maben, S Latter and J Macleod Clark

Table 1 Comparison of nursing activities undertaken in the role of student and staff nurse

Additional (often unfamiliar)

Category of activity Activities undertaken as student* activities undertaken as a staff nurse

Patient care role† Wound care/dressings Breaking bad news

Care of IVs Supporting dying patients and their relatives
Lifting and handling patients Cardiac arrest
Observations Passing NG tube/catheter
Hygiene care Removal of drains
Care of dying patient Bladder washout
Care of, e.g. stroke/surgical patients Up and down to theatre collecting patients
Talking to patients IV drugs
Patient assessment Drug rounds
Washing patient’s hair Advocating for patients
Pressure area care Dealing with emergencies
Talking to relatives
Handing out meals
Making beds
Management role Giving handover Dealing with complaints
Writing and evaluating Arranging interpreters
care plans/paperwork Discharge planning
Admitting patients Ward rounds
Getting equipment for new patients Sorting out patient problems/social situations
Attending ward meetings Management of beds
Answering the phone —
dealing with enquiries
Co-ordination and Liaising with MDT
liaison role Bleeping and talking to Drs
Referrals to MDT
Meetings with MDT — presenting patients
Learner role† Attending teaching sessions Being preceptored
Being mentored
Doing research
Teaching and Undertaking/arranging teaching sessions
supporting role Being a mentor
Supporting other staff, e.g. students
and Health Care Assistants (HCA)

*Activities undertaken as a student were also undertaken by the newly qualified nurses, in addition to the duties in the staff
nurse column. †Indicates those activities much less frequently carried out once qualified.

series of tasks. However, because of the pressure and working with HCAs and students who are limited in what
intensification of qualified nurses’ work, few reported being they can legally and competently do, it is inevitable that task
able to adequately supervise the HCAs. This supports work allocation in some shape or form will prevail. The interviewees
by Foner (1994), Allen (2001) and Jervis (2002). None of were in some cases the only members of staff who could
the participants worked in areas where there was an all- give drugs, manage chemotherapy regimes, assess patients,
qualified workforce at interview 1 and only one (in intensive and complete discharge and other paperwork, and these
care) reported this at interview 2. We tend to agree with were the tasks they undertook. The holistic patient-based
Lundgren and Segesten (2001) who argued that, when care they would have preferred to deliver, and indeed had

106 © 2007 The authors. Journal compilation © 2007 Blackwell Publishing Ltd
 Nursing mandate in professional practice

been taught to give, was not possible and was largely under- about people, about how they feel about being ill, or how
taken by others. they feel about dealing with more psychological issues ... I
do find I can do that more ... Whereas in X we tended to
Taken together, the backstage realities of practice meant just not really bring those issues in ... It is good to actually
that most participants had to find a way to accommodate their know that there is more holistic care happening now (nurse
ideals and survive or find other ways to cope with their ideals 8: interview 2).
being challenged and frustrated. Our data reveal that expec-
Sustained idealists worked in conducive environments, with
tations were adjusted over time and we next describe how
few time pressures, high staffing levels and good skill mix.
different participants, who we have categorised as ‘sustained’,
Support was excellent and expectations of them were appro-
‘compromised’ and ‘crushed idealists’, made such adjustments.
priate, with minimal evidence of the covert rules. Continu-
ing professional development (CPD) was valued and there
Impact of organisational constraints on the was a ‘culture’ or philosophy of care that facilitated individ-
sustainability of ideals in practice ualised and holistic care and opportunities to work one-to-
one with patients. These new nurses were able to identify
Examination and analysis of the longitudinal evidence from many more ‘good’ or ‘excellent’ role models than the com-
the three data time-points allows us to examine some impor- promised or crushed idealists were. They were most likely to
tant questions. Did the new nurses maintain allegiance to find nursing rewarding and fulfilling and had no intention
their ideals? Were any able to implement them in practice? of leaving. None of these nurses ‘job-hopped’, a term used
If so, what were the most important influential factors? To by Kramer (1974) for nurses who constantly look for the
answer these questions the three different data sets were ideal situation or environment. Two remained in the same
analysed in terms of a number of issues pertaining to the areas for the duration of the study (3 years) and the other
work environment that emerged as important. Within the two remained in the ‘good’ environments they had found
different practice environments these included the presence 1 year after qualifying.
or absence of the covert rules; the number and presence of
I enjoy the day to day working and just being in this envi-
the organisational constraints identified above; the support ronment, being on the ward, being in such a great team and
that staff were offered in dealing with the conflicts they being a part of something which I think is really special,
encountered; the resources for staff training and support; giving good care to patients who can have their quality of
lives improved so much if they’re helped by the right people
and the presence or absence of role models. I think. And I just love being a part of that (nurse 17:
Close examination of these issues across interviews and interview 2).
questionnaires shed light on the sustainability of partici-
However, these environments could be fragile. In one
pants’ ideals and values, the extent to which they were able
example an increase in workload resulted in less support
to implement them, how different nurses dealt with discrep-
and psychological care for patients and more frustration for
ancies between how they ideally wanted to practice and how
nurses. Despite being on the same oncology ward, the qual-
they were able to practice, and the consequent effects on them
ity of care this nurse was able to offer at interview 2 was
as individuals. Participants could be categorised as ‘sustained
compromised by staffing shortages:
idealists’, ‘compromised idealists’ or ‘crushed idealists’.
Interviewer: ‘What’s staffing like?’
SUSTAINED IDEALISTS
Not as good as we were ... We all had a discussion the other
Only four out of the 26 participants were categorised as day saying that L ward was very very good care and that we
‘sustained idealists’. Two implemented their ideals in their didn’t want to lose that but we felt that we were struggling
first working environment and retained them and two were at the moment because of staffing. I get frustrated when
we are short staffed and I know that everyone goes home
able to implement their ideals a year after qualifying, once
and says that was bad care. I don’t think, even when we’re
they had moved to a new environment. For example, nurse short staffed I don’t think our care is as bad as a lot of
8 moved to a very well staffed ITU with 30 staff per shift for places ... But I think the oncology patients have a lot of
14 patients from a 28-bedded urology ward, where she had needs, psychological and physical (nurse 17: interview 2).

been responsible for 14 patients with the help of a HCA. In COMPROMISED IDEALISTS
her new environment she was able to deliver the care that
The 14 who were identified as ‘compromised idealists’ 4–
was consistent with her ideals:
6 months after qualifying were still compromising 11–15
It is good to know that all the basic nursing care can still be months post qualification. These compromised idealists felt
done but then you’ve got the opportunity of finding out frustrated that they could only partly implement their ideals:

© 2007 The authors. Journal compilation © 2007 Blackwell Publishing Ltd 107
J Maben, S Latter and J Macleod Clark

I think sometimes it’s just frustration, when it is so busy and If the things don’t improve then I don’t think I’m going to
there are so many things to do at once, there’s a phone stay in nursing ... I think that there are so many things that
going, our phone is constantly going ... In the mornings it we can do. Perhaps if I become charge nurse or something
can be such a nightmare, you know, if you’ve got a few ill then I will make sure (nurse 19: interview 2).
patients it’s just impossible, because you’re short staffed
half the time ... so yeah I think it is just frustration ... feeling The possibility of achieving a position in nursing where
as if you’re not getting anywhere, and yeah, feeling helpless one could have power and influence was also appealing, and
(nurse 14: interview 1).
so staying in nursing in order to try and change practice was
Their clinical environment included one or more of the tempting. This mirrors the findings of Kramer (1974), who
following barriers: poor staffing and skill mix, few role models, also suggests other methods of remaining in practice, such
lack of support and feedback, ideas not welcomed, covert as switching to different jobs (job-hopping) or retreating to
rules, organisation of care where tasks and physical care education, either to maintain motivation or as a way of con-
prevailed, high expectations and few resources for CPD. flict avoidance. ‘Job-hopping’, was common for this group.
A lack of staff and resources was demoralising for many and Eleven of the 14 in this group moved posts at least once
physical tasks were prioritised over holistic, spiritual and in the first 12–14 months. Of these, four subsequently left
psychological care: nursing to go travelling and two moved to primary care in
search of more patient-centred care.
Rarely have I seen a nurse sit down, just sit down, just sit at
Most of the compromised idealists had not yet given up
the bedside with an unconscious patient. It’s something
I haven’t seen, nurses sit down with patients and you know, on nursing and some still had strong visions of what could be
just be there.... I don’t know, I’d say, actually 99 per cent, achieved. They were struggling in their current environ-
95 per cent of the physical tasks I would achieve in a shift but ments, having their ideals regularly thwarted and thus lead-
psychological and spiritual and emotional care, I would say
twenty, 25 per cent or so.... We do the physical tasks but you ing to adjusted expectations and compromise. What is not
know, you know, there’s the side that we don’t do, so that’s known is whether they have been able to retain their ideals
a compromise (nurse 6: interview 2). for future implementation and action, or whether, as
Aware that they were often not able to implement their Kramer (1974) suggests, their ideals will have been gradually
ideals and values, these participants still retained a desire to eroded over time.
do so, unlike the crushed idealists. By the second interview
CRUSHED IDEALISTS
(11–15 months post qualifying) many found themselves
even further removed from the bedside, having taken up These eight nurses had their ideals comparatively ‘crushed’
senior staff nurse posts. As a senior staff nurse, nurse 18 — some after 11–15 months at the second interview and
found himself responsible for giving chemotherapy to most others by the end of the study after up to 3 years in practice.
of the patients on the ward, not just his own: They showed no sign of regaining any idealism over time,
citing their ideals as impossible to implement:
Often you feel quite frustrated because even in the morn-
ing, about 1 p.m., I’d not even seen any of my own patients (Laughs) Mmmn ... I think they are still my ideals, but they
because I’d been running around and trying to sort out really are ideals. I think most of it is impossible. Unhurried
some of the other people first. And that could be quite frus- care especially is impossible in this environment. I do feel
trating as the primary nursing can go right out the window like I rush things, I would much rather spend more time
(nurse 18: interview 2). over things, but with the pressure of work ... research base,
yes, I think that is really important.... I think I obviously
Ideals and values were not thwarted all the time but often wrote those thinking this is the way I’m going to nurse and
looking at them now makes me feel a bit sad really. ‘Cos it’s
enough to make the nurses become increasingly frustrated and impossible (nurse 20: interview 2).
think of leaving the profession. They had not (yet) given up
on nursing and many had strong visions of what could be They were exposed to clinical environments in which care
achieved: ‘I’m still really keen, I haven’t lost them, I’m just was reported as often hurried and where physical care pre-
waiting for the right environment’ (nurse 12: interview 1). dominated. They said they did not feel valued, and that their
They struggled in their clinical environments and their thwarted ideas and suggestions were not welcomed. Most were experi-
ideals led to adjusted personal expectations and compromise. encing more than one difficulty and some experienced
Most compromised idealists were keen to give nursing a many. This resulted in reports of frustration and these
chance, to try to find a different environment or wait until nurses expressed the way they were able to care for patients
their ward was better resourced. Thus, few spoke of leaving as ‘awful’, ‘terrible’ and ‘horrible’:
nursing altogether, although some were only prepared to Being so busy all the time, feeling like I can’t do enough for
tolerate such conditions for a certain period of time: the patients because there isn’t time, and I find it very

108 © 2007 The authors. Journal compilation © 2007 Blackwell Publishing Ltd
 Nursing mandate in professional practice

frustrating that so many things aren’t done, it’s so far from within the NHS and am quite shocked at my naivety regard-
idealistic. I feel sometimes that I’m struggling an uphill ing the profession, although my ideals were being dashed,
battle sort of thing (nurse 16: interview 1). I perhaps believed in my career more than I do now (nurse
4: phase 3 questionnaire).
I used to feel, oh, this is really awful, I’m having a terrible
shift. I’ve not seen my patients, God alone knows what’s These ‘crushed idealists’ felt unprepared for the differences
happened to the bloke in side room 2, you know, because
between the way they were taught and the realities of prac-
I can’t see him. But, it’s horrible actually thinking, God
I haven’t seen this patient for 2 hours (nurse 9: interview 2). tice. They considering leaving nursing completely and
indeed 3 years after qualifying, two had left for good and two
Asked how this made her feel, she suggested she had had left for a while at least. Surprisingly there was less job-
adjusted her expectations: hopping in this group than in the ‘compromised group’ and,
despite the frustrations and demoralisation, some nurses were
I basically adjusted to it. Yes, I didn’t have such high expec-
tations when I went to work each shift. It was enough to just initially willing to stay in nursing in the hope of perhaps trying
get through it and not for anyone to die ... not quite like to change practice. Nurse 13 speculated at interview 1 that
that, it was just enough to get everybody washed in the she would have to wait until she became a ward sister to really
morning, make sure that their observations were all fine,
and go home, because basically that was all I had time to do start the revolution and implement changes in practice:
(nurse 9: interview 2).
It has occurred to me in the past, where I’ve been places as
a student, especially in care of the elderly, where you see
Others like nurse 9 said they had lowered their expecta-
nurses who genuinely don’t care, don’t really care at all, and
tions and simply made sure the ‘basics’ were done. The way I thought I would like to come back here. But I’ve always
they had wanted to care for patients became buried or said I would never go back there as a junior member of staff,
forgotten, perhaps as a way of coping with the cognitive dis- I would go back there as a sister, and try to revolutionise the
ward. I would actually quite like to do that, I mean the pros-
sonance encountered. This group was likely to suggest that, pects of that, the challenge of it all, that would be absolutely
with hindsight, their ideals had been naive and unrealistic. phenomenal, and I’d love to do that, that would be fantastic,
Their morale was poor and they had lost enthusiasm: revolutionise the ward ... but as a D grade4 ... I’d just get
shouted at and squashed straight away. It’s very difficult
I’ve lost the enthusiasm to go and read up on things, which (nurse 13: interview 1).
I should be doing you know, that’s because morale is so low,
but yes I mean ideally you should be dedicated to your Unfortunately her ideals became ‘crushed’ before she got to
job ... it’s difficult (nurse 13: interview 2). a position of power, and she was burnt out and exhausted by
12 months after qualification (interview 2). Three years
Many crushed idealists experienced severe stress and
after qualifying as a nurse she had returned from 10 months
some signs of ‘burnout’ (Freudenberger 1974). Some of those
travelling, was pregnant and did not intend to stay in nursing.
categorised as ‘crushed’ based on their phase 2 data were
Her future plans were to:
themselves only able to recognise how stressed and burned
out they were with hindsight. Three years after qualifying Have my baby, and do agency shifts intermittently for 2–
4 years. Go back to college, do a short course in computing
participants were sent the interview transcripts from their last
and either full time or Open University in some area of
interview (interview 2: 11–15 months post qualifying). Thirteen forensic science (nurse 13: phase 3 questionnaire).
nurses (50%) responded. They were asked, ‘What were your
initial thoughts on reading through the interview transcript This appears to confirm Kramer’s (1974) work suggesting
in relation to your “ideals and values for practice”, which you that ‘school bred values seem to gradually erode’ (159) with
identified as a student in the first questionnaire?’. Three of some coping by withdrawal from the profession.
those in the crushed idealist category responded thus:
DISCUSSION
I sounded like I was definitely burned out! I’d forgotten
how miserable I was the last few months on that ward (nurse Explaining the fate of ideals and
9: phase 3 questionnaire).
values in practice
I’d forgotten how unhappy and unstable emotionally I’d
felt in nursing and how I constantly felt an inner battle to Newly qualified nurses emerge with a coherent set of nurs-
try to convince myself I enjoyed nursing (nurse 13: phase 3 ing ideals and values. Organisational constraints in the prac-
questionnaire).
tice environment play a key role in determining the fate of
I hadn’t realised how much strain I was under and how my these. It is clear that the ideals and values of nursing and the
professional life was affecting my character and my per-
sonal life. I am still disappointed at the pressures on nurses 4 Junior staff nurse: first post after qualification.

© 2007 The authors. Journal compilation © 2007 Blackwell Publishing Ltd 109
J Maben, S Latter and J Macleod Clark

nursing mandate instilled in students through their educa- in training and the roles implemented in practice (Kramer
tion cannot be implemented in practice without adequate 1974; Bendall 1976; Clarke 1978). Indeed, nursing and nurs-
levels of support, staffing and a good skill mix. As discussed ing education has been slow to articulate, and some would
elsewhere (Maben, Latter and Macleod Clark 2006), the say value, the education and skill required to undertake
implementation of ideals in practice is also influenced by these roles in nursing, and nurses themselves are keen to
the presence or absence of professional constraints such as avoid talking about the concrete, routine daily activities
covert rules and good role models. Absence of these involved in their work (Gordon 2006). We may understand
resources undermines the ability of newly qualified nurses to the emphasis on individualised, holistic care in nurse educa-
implement their ideals and values of holism and individual- tion curricula as a professional legitimating strategy — a way
ised, quality and evidenced-based care. This leads some to create a framework to convince practitioners (and others)
newly qualified nurses to become disillusioned, to burnout, that nursing had evolved to a higher stage (Nelson 2000).
to job-hop in search of the ideal environment and ultimately Lawler (1991) goes further, suggesting nursing academics
to leave the profession. have proselytised holistic practice in the belief that it ensures
With contemporary health service drivers, such as tar- a route for nursing to move away from the dominant medical
gets, performance management and increased patient turn- model, enhancing and professionalising nursing’s status.
over, there has been a significant increase in nursing This has become the dominant discourse in nursing
workload. This has resulted in an intensification of nursing academia and therefore preregistration nursing courses,
work over the past three decades, with greater demands on perhaps at the expense of a focus on the roles that qualified
nurses’ role in an increasingly pressured environment nurses are expected to undertake. Nelson, Gordon and
(Office for National Statistics 2002a, 2002b). Nurses have McGillion (2002) have recently argued that the professional
taken on more and more of the technical work of junior doc- nursing mandate and thus the educational direction of nurs-
tors and sloughed off the essence of nursing to less qualified ing is disconnected from the pressing realities nurses in
staff (Adams et al. 2000; Vere-Jones 2006). In this study, practice face, with a curriculum that often fails to identify
these factors clearly had a significant impact on participants’ the actual focus of the registered nurses’ work and the chal-
abilities to implement their ideals and values in practice. lenges of the practice environment. As this study has shown,
Nelson, Gordon and McGillion (2002) have gone so far as to this disconnection leads to disillusionment and for some a
suggest there is a crisis surrounding the delivery of bedside desire to leave the profession. In consequence a greater gap
care: ‘one of the most discouraging things for nurses giving than ever before now exists between the ideals and values
direct care is that they work in environments that do not adopted by students during their education and those evi-
allow the time to practice direct, hands on care’ (Nelson, dent in the practice settings where they work as qualified
Gordon and McGillion 2002, 63). They further ask how the nurses (Maben, Latter and Macleod Clark 2006).
practice of bedside nursing may be saved from extinction in
the twenty-first century. More recently, in the UK, in a The way forward
Nursing Times survey of 300 nurses (Vere-Jones 2006), 98%
agreed that care is being squeezed out of the nursing and EDUCATION AND SUPPORT
eroded from the professional registered nurse role. The reality of pressured health services means that newly
A second, related, explanation for nurses’ lack of ability qualified staff will always need support in translating their
to implement ideals and values in practice is the lack of prep- ideals into practice. Therefore programmes that help stu-
aration in prequalification nursing courses for the actual dents to become aware of and manage the ideal–real conflict
roles that qualified nurses undertake. Earlier work in the UK may prove useful. These have had some success in the past
on traditional students and qualified nurses by Clarke (Kramer and Schmalenberg 1977) but have not been widely
(1978) and Melia (1987) suggested that nurses were not implemented in the UK, nor are they currently very evident
systematically prepared for the role they are expected to in the USA or elsewhere in the world. Whilst using such strat-
perform as a qualified nurse. In their studies, students in egies may provide a solution, the scale of the mismatch
training delivered direct nursing care, but the end focus of between the reality and ideals is such that they are unlikely
activity for the trained nurses was care co-ordination and to be successful at addressing the issues evident in this study.
administration. The study reported in this paper suggests
this is still the case 20–30 years on and supports the findings HIGH QUALITY WORK ENVIRONMENTS
from previous UK and US studies, which highlighted a Certainly, the experiences of the four sustained idealists in
discrepancy between nursing ideals and standards taught this study lend weight to the importance of organisational

110 © 2007 The authors. Journal compilation © 2007 Blackwell Publishing Ltd
 Nursing mandate in professional practice

factors in providing an appropriate environment for ideal essential nursing care in an ageing population with multiple
care. In environments where there was adequate staffing, long-term conditions make this model more compelling. If
good skill mix, a culture of support, and CPD, ideal practice organisational and professional constraints are inevitable
flourished. Importantly, these were also environments in then we are inclined to agree with (Allen 2004), that a refor-
which the holistic ethos and the decision-making role of the mulation of the nursing mandate is needed to include better
nurse were more evident. Findings from this study add to the preparation for nurses’ intermediary role, their leadership,
mounting evidence that high quality work environments support and supervision of healthcare teams, and relation-
retain and motivate staff, reduce burnout and achieve better ship to systems and contexts of care rather than individual
outcomes for patients (Aiken et al. 2002; McClure and Hin- hands on care for patients. Indeed, a recent UK policy docu-
shaw 2002; McGillis Hall 2005). ment suggests nurses should lead, co-ordinate and commission
care as well as being direct care-givers to bring about change
A MODERNISED NURSING MANDATE? measured by health gain and health outcomes (DH 2006).
More fundamentally, these enduring findings should also A reformulated nursing mandate could be based on
alert the profession to the potentially unrealistic nature of placing greater emphasis on a proactive clinical decision-
the current nursing mandate (Allen 2004). The stories from making focus, and on providing supervision and leadership
the participants in this study add weight to the argument to support staff or lay carers in healthcare contexts where
made by Dingwall and Allen (2001) that an overambitious direct patient contact and care is delivered within multi-
mandate may be the source of chronic dissatisfaction and skilled teams. In this way the professional responsibility for
poor morale, as ‘the professions’ dreams are broken on the setting and influencing the standard of ideal care and for
wheel of its licence’ (64). Whether it is the mandate that is deciding on the need for care remains in the registered
‘over-ambitious’ (Dingwall and Allen 2001) or whether, nurses’ mandate, but the direct delivery of hands on care is
as (Allen 2004) suggests, ‘current educational processes delegated to others and supervised and managed by quali-
which emphasise holistic relationships produce exaggerated fied nurses. In other contexts, such as in ‘advanced practice’,
expectations of the possibilities for practice’ (280), this study consultant nurse roles and/or in other clinical contexts such
has demonstrated that the care that nurses are able to give as ICU and primary care, where nurses retain direct account-
falls short not only of recognised standards but of the high ability and responsibility for building one-to-one patient
quality care they want to provide for patients. Further, recent relationships, nurses will continue to have a role in deliver-
evidence from the UK Australia and the USA confirms that ing care directly to patients. In these contexts, nurses will
newly qualified and indeed other nurses are more likely to need to enact values, such as individualism and holism, in
experience burnout and/or leave as a result of the inability their relationships with patients as they provide care in these
to give ideal care (Schaufeli and Enzmann 1998; Aiken et al. settings. Reconceptualising qualified nurses as leaders,
2002; Reeves, West and Barron 2005). advisers, supporters and commissioners of good, high qual-
The time may therefore have come to ask the difficult ity care, as well as knowledgeable direct care-givers, would
question of whether organisational and professional con- also provide the solution to ensuring a continued emphasis
straints, which form the barrier to delivering the current on the core values of nursing such as dignity, and holistic,
nursing mandate, mean that the mandate itself is unsustain- person-centred, individualised care.
able. We are not denigrating the importance of the provision The need for well-educated, highly motivated career
of bedside care by registered nurses, but asking whether a nurses has never been greater. We are not suggesting that
continued focus on their role as care deliverer is still realistic? nurses abandon their ideals and values. Instead, we are pro-
Can holistic, person-centred, individualised care predicated posing that nursing needs to find a realistic way to maximise
on an unmediated relationship between practitioner and the potential for those values to influence practice in a
patient remain feasible? Or should a more fit-for-purpose resource-limited healthcare system, in which dilution of skill
mandate be promulgated, which retains these nursing mix and new public management techniques are likely to be
values and ethos but removes the overwhelming responsibility here to stay. The future challenge will be to educate regis-
on the qualified nurse to provide the care delivery? Has the tered nurses to lead, manage and supervise others and to act
time come to acknowledge that the future professional as role models in giving bedside care. Given the findings of
nurse will be responsible for ensuring that the quality and this study, it is not defensible or ethical to sustain the current
ethos of care is maintained through the support, advice, approach to preparing nurses for practice. In the short term
clinical decision-making and supervision of nursing assist- there is a need for adequate support for those newly quali-
ants and lay carers? The inevitable increases in demand for fied nurses who are thrust into difficult work environments

© 2007 The authors. Journal compilation © 2007 Blackwell Publishing Ltd 111
J Maben, S Latter and J Macleod Clark

and required on a daily basis to negotiate the disjuncture of Bendall E. 1976. Learning for reality. Journal of Advanced
the nursing mandate and its day to day practice. An urgent Nursing 1: 3–9.
analysis and reformulation of education programmes is also Buchanan J and G Considine. 2002. Stop telling us to cope!
required. In the longer term, nursing must continue to articu- NSW nurses explain why they are leaving the profession.
late the importance of the values that were held in this study Sydney: Australian Centre for Industrial Relations,
and track the impact that this has on nursing care in order Research and Training (ACIRRT).
to provide evidence to support the case for high quality work Clarke M. 1978. Getting through the work. In Readings in the
environments. Nelson and Gordon (2006) suggest ‘nurses sociology of nursing, eds R Dingwall and J McIntosh, 67–86.
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care reforms for the profession of nursing. Nursing Inquiry
The authors wish to thank the Smith and Nephew Founda- 8: 64–7.
tion who provided financial support and the participants Erlandson DA, EL Harris, BL Skipper and SD Allen. 1993.
who shared their thoughts and gave their time so freely. Doing naturalistic inquiry: A guide to methods. Newbury
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