Las perspectivas de la Educación Básica de Adultos en el Proyecto Educativo Institucional (PEI) y los Proyectos Curriculares (PC) en las escuelas de adultos con

The causes of stigma most commonly cited by the participants were: lack of understanding on behalf of the public and other healthcare professionals regarding the NuH nurse’s role, the juxtaposition of care and business, and the view that NuH nurses are uninspiring and enervative. A few participants suggested that damaging media reports, ageism in healthcare, and the social status of migrant nurses were also influencing factors. A discussion of these causes follows.

Lack of understanding regarding nursing homes and the nursing home nurse’s role: Participants suggested that the public and other healthcare professionals lack

understanding of what the NuH nurse role entails. They said, this leads to assumptions about NuH nursing activities. Ellen suggested that because most NuH nurses are greatly involved in assisting residents with their personal care – activities which are associated with the HCA role, then the distinction between the nurse’s role and the HCA’s role lies on ‘woolly ground’ (Ellen, 1). The participants indicated that consequently, the public and

other healthcare professionals view NuH nursing as the provision of personal care rather than clinical care, or even assume that NuH nurses are in fact, not RNs, but a type of HCA:

Beth (2): I can’t stand it [emphasises by raising voice] when you tell people that you work in a nursing home and their first thing is something about you know like, personal care, ‘Is that all you do?’ And I hear that a lot, more than anything else. ‘Is that what you spend your day doing? Wiping people’s bottoms?’

Emma (1): One of the ladies, one of her [mother’s] friends said to me, ‘What do you do then?’ I said, ‘I’m a nurse’. She went, ‘Are you a nurse, or are you a carer? Because there’s a difference, and carers call themselves nurses.’ ‘No’, I said, ‘I’m a proper registered nurse’.

Many participants proposed that these assumptions lead the public and other healthcare professionals to doubt NuH nurses’ clinical ability, and consequently regard NuH nursing disparagingly:

Alice (1): I think we’re definitely looked down upon. I think they think we don’t have any skills, erm, and it’s very misunderstood…And I think, I think the hospital nurses just think that we’re not as skilled as they are.

Beth (1): I think there’s just a big stigma around working in nursing homes, you know. I think she [mother] wanted me to get the experience of working in a hospital on a busy ward, because with me being newly qualified, I think she thought I would get more, I would you know, develop skills and things that I wouldn’t here specifically.

Faye commented that the assumptions of the public and other healthcare professionals are sometimes inadvertently strengthened by NuH nurses themselves. This is because certain clinical procedures which are routinely performed in hospitals are not permissible in community settings. NuH nurses therefore have to admit to their limitations in terms of their ability to provide acute care. Faye stated that this admission gives the impression that NuH nurses are less proficient than acute care nurses:

Faye (4): I think they think that we’re not as skilled. Because obviously we’ve got to turn around and always highlight what we can’t do, you know. Where you’d probably never see a hospital nurse doing that. As I say, if they want surgery, they go onto a surgical ward and hopefully skilled nurses. But we’ve got to be able to say, ‘You do realise that if you need IV, you’ve got to go into hospital.’ So you’re kind of like just saying, ‘They’re better’. You can be perceived as saying that. I do think that they think that hospital nurses are more competent.

The juxtaposition of care and business: All participants suggested that the public in

England view healthcare as a gratis entitlement in which commercial gain should play no part. Consequently, they said that because NuHs are generally private businesses rather than public-funded services, the public assume NuH providers’ objective is purely profit attainment and not the provision of quality care. Anne explained her view that as a result, the public view NuHs as preying on the vulnerable:

Anne (1): I think we should be perceived perhaps as more like the NHS, and not so much as erm, some kind of private sector who’s just after the money and not interested in the care.

With regard to business and funding issues, however, some participants indicated that the pressure of overcoming the censorious attitudes of others is not the only challenge that NuH nurses face. As already discussed in 5.3.3, a significant difficulty for participants is reconciling their own negative views regarding long-term care funding, with their nursing role. Some suggested becoming a nurse in England involved supporting a health service financed by public funds, and free-at-the-point-of-care. However, in the long-term care setting, residents are often required to contribute to their care costs. Many participants referred to this funding scheme as ‘unfair’, and reported feeling ‘uncomfortable’ about being part of what they perceive as an inequitable system. In this instance, the stigma arising from other’s perceptions and attitudes is not the main issue. For these participants, doubt and uncertainty about being involved in a system which they view as morally questionable, taints their view of their own practice and role:

Alice (2): I do feel a little bit uncomfortable about how some patients don’t have to pay a penny and the other patients do. I feel a bit, we haven’t come to a good, it’s just not fair basically.

Image of the nursing home nurse: Most participants reported their view that other

people, in particular other healthcare professionals, have a preconceived image of the NuH nurse role that portrays NuH nurses as uninspiring, undistinguished, enervated and inept:

Barbara (1): This is a much kind of lower option and some people view the fact that if you work in a nursing home, you don’t have the skills to be employed elsewhere, or you’re at the end of your career and you kind of want to step down from, you know, the acute, busy side of things. And I think that’s very sad and it’s not true, er, so I think it puts a lot of people off.

As can be seen from the above comment, ths participant denied this image. However, an examination of the reasons behind the participants’ career choices reveals that only Barbara, Cath and Elaine had pro-actively sought positions in NuHs because they wish to work specifically in this sector. Most participants work in NuHs for personal reasons that

have little to do with progress towards, or achievement of, career goals (see 5.2). These participants stated that they work in NuHs because they are unable to obtain positions, or suitable positions within the NHS, that accommodate their personal circumstances. What is more, many participants do (or have at some stage in their careers) aspire to work in other settings once they are able to secure a position there, or when their personal circumstances allow. It could be argued therefore, that the career moves and behaviours of the majority of participants supports the perception that NuH nursing is not as dynamic a career as other types of nursing. While participants did not view the reasoning behind their career choices as problematic in itself, they proposed that it becomes so within the NuH context. They expressed the opinion that this is because NuH nursing is already imbued with a negative image. Anne and Georgia explained that their behaviours regarding their career choices reinforces the image of the NuH nurse as uninspiring, while the image magnifies their behaviours so they are perceived as enervated:

Anne (1): [Working in a NuH] it was a bit of an accident really. It wasn’t by choice. I think that’s probably the case for a lot of people in a lot of jobs…But in nursing homes, I think they perceive it as a second rate job, so by going there, you’re somehow, you’re a failed nurse, and you’re just working there just to, just for something to do.

Georgia (1): Due to the ill health of my parents, [I] came back to this region and needed a job. So that’s really what got me into the nursing home sector. It wasn’t something I wanted to do, something my heart was set on…I think there was a stigma attached, so everybody just thought it was a little bit of a cop out, an easy option.

Barbara suggested that the image of the NuH nurse as uninspiring and enervated is so pervasive that although she pro-actively chose to work in a NuH, other healthcare professionals question her abilities because they are unable to equate successful, dynamic nursing with the NuH environment:

Barbara (1): But I think many people look at you and think, ‘Well she’s a manager because she couldn’t go any further in the other areas that she may have worked in’. Not that they would know about it, but you know that’s very much the thought.

Media reporting: Although media reporting was not discussed at length by any of the

participants, some said they felt it contributed to the stigmatisation of NuH nursing. These participants acknowledged that poor practice has, and does, occur in a minority of NuHs. For example, in her second interview, Anne stated that in some NuHs, ‘there are issues, there are evidences of negligence’. While participants did not deny that incidences of

abuse do happen, they suggested that the media’s portrayal of NuHs focuses so strongly on reporting poor practice, that the reputations of all NuHs suffer:

Barbara (1): Well, I think the public’s view of nursing homes generally is negative. I mean because there’s a lot of bad press about situations. So I think we’re all being kind of tarred, lumped in the same group.

Of course, in the light of recent scandals regarding substandard and inadequate care in the NHS (House of Commons, 2013; Keogh, 2013), other healthcare settings are not immune from pejorative media attention. Many participants recognised this:

Georgia (1): There’s been a lot of black marks over the years. You know various documentaries and press. But then again, the NHS hasn’t faired much better.

However, Elaine suggested that damning media reports are more destructive to the reputation of NuHs than to other healthcare environments. She proposed that this is because other settings benefit from positive reports as well as being subject to negative attention, leading to a more balanced representation of their services. Elaine explained that NuHs do not benefit from affirming testimonials by the media, so that the incidence of damaging reports is not moderated, thus resulting in a biased view:

Elaine (5): I think that in the media you see a lot. Well you see a lot of bad things about hospitals, but you see a lot of good things like, ‘Oh they’ve saved my child’. But you never see a good thing about a nursing home. It’s always bad. It’s always bad.

Ageism in healthcare: A few participants expressed the view that the current healthcare

system is ageist, and the devaluation of the older population in healthcare leads to a lack of investment and resources in service provision. They proposed that, as a result, older people do not benefit from the same healthcare opportunities as other patient groups. Faye said that in her view, such ageist practices have an impact on NuH nurses’ ability to carry out their nursing activities adequately and effectively.

Faye (2): There’s many people in the team that come in with a self- righteous approach, a judgemental approach on the nursing aspect, but we don’t get the tools to do it properly. You know I think it’s very much them saying, ‘Well what’s the point of investigating because whatever the outcome’s going to be, what are we going to do? We’re not going to act upon it, so don’t investigate’. So sometimes you’re nursing them blind in this area, you know. There’s a mass on their lung. What is it? ‘Well, we’ll not bother putting in the expense, because you know’. So you can find yourself nursing them blind. What is the diagnosis? What is the prognosis? What do we do to prepare the client and the family? You’ve just got to go with it [angry tone throughout].

Faye’s response indicated a view that healthcare professionals’ discrimination against older patients has two outcomes. Firstly, older people receive substandard services, and secondly, NuH nurses are subjected to the criticism and ‘judgemental’ attitudes of other professionals for delivering these substandard services – criticism that Faye deemed unfair, as she proposed that NuH nurses’ inability to provide adequate care arises from the healthcare system’s failure to provide the necessary resources in the first place. Barbara suggested that healthcare professionals’ lack of insight into older people’s health issues, discounts older people from benefitting from acute interventions, which in turn inhibits NuH nurses from further developing their clinical skills. Barbara purported that ageism in healthcare fuels the assumption that NuH nurses are less dynamic and less skilled than acute care nurses.

Barbara (2): I don’t think they [older people] get the service they should have in a clinical, medical or surgical environment…I don’t think hospital staff erm have enough empathy for older people. I think they see them as an intrusion on their clinical field, you know medical or surgical wards. And they do sometimes take a bit more time to recover, and I think they [staff] find that frustrating…I think there’s still very much an ageist attitude, er, which is institutional. Researcher: Institutional ageism?

Barbara (2): I think so. I think, I think my impression from being a nurse and social worker in the hospital environment, that makes people perceive people working in NuHs as not being as skilled as the nurses in the hospitals.

Social status of migrant nurses: Two participants were non-UK born of Asian ethnicity –

Andrea and Bella. All other participants were UK-born of white ethnicity. During discussions regarding their views of occupational status, Andrea and Bella, like their UK- born colleagues, focused primarily on the nature of NuH nurses’ work activities, and their perception of the public’s and other healthcare professionals’ views of private NuH care. Andrea, however, also described experiences of being subjected to racism by some residents:

Andrea (3): Erm, I have encountered patients who are racist. Several times. A woman, a man as well. And when I go inside the room, the patient would say, ‘Go back where you came from. We don’t need you’. Well, erm, I’m hurt. I’m hurt. Especially as I didn’t come here for government to pay benefits. There’s a company that recruited nurses in the Philippines - I’m paying taxes. I don’t get any benefits, so, because that’s their thinking - we’re here for help from the government. It’s quite hurtful before. But I think if you get to know the patient, they see you work and pay, and say, ‘You’re nice’.

Researcher: Do you think your race affects your employment chances.

Andrea (3): No no. Not from the hiring system. Only times I have encountered with residents.

Offering this information during discussions implies that ethnicity and migrancy are implicated in her experiences of status. However, her narratives of racism do not appear to be directly related to her work role, but rather describe experiences that emanate from assumptions that she has migrated to exploit the UK benefits system. In these circumstances, her response indicates that her work role can mitigate against her migrancy status because it demonstrates she is contributing to health and social care services and the economic health of the country.

Bella briefly discussed migrancy too, but her narrative was not in response to questions about status or role, but occurred early in her first interview when she was providing biographical details. During this discussion, she described her experiences of being welcomed by people living in her locality:

Everyone is just nice. The people just greet you. They don’t know you but they lead you - like I was lost one time and an elderly couple even walked to go to that place, so I said, ‘Oh, its really nice to be here. A home away from home’, because my place in the Philippines is just like this as well.

The findings presented in this section suggest that while participants feel stigmatised for a variety of reasons, they are particularly concerned about three of these reasons i.e. the perception that their role primarily involves the practice of basic care which leads others to doubt both their clinical abilities and their identity as nurses, the censorious attitudes of both themselves and others regarding long-term care funding which leads to a tainting of their caring role, and the image of the NuH nurse as uninspiring and enervated. Andrea also referred to her experiences of racism during discussions about status, which implies she associates ethnicity and migrancy with meanings of status, although her responses suggested her work role mitigates against her migrancy status. Participants referred to other contributing factors (media reporting of abuse cases, and the perception that nurses working with older people are less skilled) to a lesser extent, which suggests that they are less concerned about these factors. It could be argued that this is because the primary causes seem to be directed against the participants’ personal abilities, values and professional and social identities. Conversely, the other factors are generally directed at organisations (media reporting), or are incidental to stigma directed at other groups (ageism in healthcare services). In other words, the primary causes have personal meanings for the participants, which prompts them to focus on these issues.