January 16, 2019, by Richard Bates
“Families coming into hospital are guests in our house, and we should make them welcome”: An interview with Dame Elizabeth Fradd
Dame Elizabeth Fradd is one of the UK’s foremost nursing administrators, and was vice-chair of the University of Nottingham Council from 2012-18. She has variously served as Assistant Chief Nursing Officer (Nursing Practice) for the Department of Health, Director of Nursing and Education in the West Midlands Regional Office, and Nurse Director and lead Director for the Review and Inspection programme in the Commission for Health Improvement. She has also been an advisor to Health Education England for their national programme of work on the “Shape of Care”, and a member of the National Information Governance Board for Health and Social Care.
Coincidentally, Elizabeth shares a birthday (May 12) with Florence Nightingale.
In this interview, Richard Bates talks with Liz about her career, the values that she developed over decades in the nursing profession, the ongoing relevance of Nightingale, and her advice to today’s trainee nurses.
RB: How did you get into nursing? What made you decide to become a nurse?
EF: I can’t be anything other than truthful – it was a lack of knowing what else I was going to do! I was an absolutely hopeless scholar at school. All the things I was good at were the practical skills. I had two friends in my class who were becoming nurses, and I thought, why not? I didn’t think that I was capable of doing the SRN [the three-year course, requiring a number of ‘O’ levels, needed to qualify as a state registered nurse], and in any case I particularly wanted to work with children, so I planned to do the enrolled nurse course. But a family friend, who was an orthopaedic surgeon at the Middlesex Hospital, advised me very strongly to do the three-year course, and I’m glad I listened.
RB: You were undervaluing yourself at the time?
EF: Yes – mainly because I’d never been encouraged at school. I scraped through enough ‘O’ levels to get into nursing. But from the minute i started nursing, I never looked back, never failed another exam, won the medal for my year, and went on to do the combined childrens’ and adult course. It was the first time I’d ever had it recognised that I was capable of doing something.
RB: You didn’t really have a sense of a vocation to become a nurse?
EF: No, not at all. Although there maybe was something there – I did use to line up all my dolls in shoeboxes in a walk-in cupboard at home, or bandage up my siblings when they cut their finger, caring things like that.
RB: There’s a story about Nightingale doing something similar with her dolls as a child, which some biographies point to as an indicator of her future trajectory. I’m a little dubious of those kinds of things actually, because I think lots of children do those sorts of caring things, and it doesn’t necessarily mean a lot for their future! When you were doing your training, was Nightingale a significant presence?
EF: Interestingly, not really. I think in that period, in the 1960s, she was seen to be quite ‘dead’, quite outdated, there was a feeling that some of her legacy and the structures that had come down from earlier in the century needed to be swept away. Our training at that time was heavily influenced by medical lecturers, as opposed to nursing experts, and it was very much about signs and symptoms and treatments – very medicalised. Very little of it was about the philosophical notion of care.
RB: When did your interest in Nightingale come about?
EF: Really only when I realised that my interests were slightly out of kilter with everybody else’s. For example, when I decided that I didn’t think it was right to be looking after children in hospital, that I didn’t think there should be a single planned child death in hospital.Professor Sir David Hull, who was the professor of child health here at Nottingham, a wonderful man – he said to me at one point that I was effectively de-skilling his medical colleagues, because I’d made them realise that they no longer knew how to look after a child that was dying.
In doing these things I wasn’t necessarily seeing myself as treading in Nightingale’s footsteps. But on reflection, I realised that her influence was there, that there was some similarity of thinking.
RB: How did you develop your sense of ethics, of nursing ethics?
EF: A lot of it comes from my parents. My dad was a Methodist minister. We had a happy balanced home, and I knew from early on what was right and what was wrong and how I should behave with people. He was a role model for me in terms of his dedication and commitment. I was also fortunate in that I had an extraordinary hospital chaplain, and one or two extraordinary paediatric doctors, who sat down and said ‘we need to look at what we’re doing here’.
But it didn’t come from the system – it was completely missing in my training. I’d started nursing in 1967, and at that time, we were doing things that today would not be applauded. In my early years, I felt no one explained to me the moral and ethical implications of what we were doing. You just got on and did what you were told to do. I remember my last ever shift as a student nurse: I was looking after a child who had 40 fits in one night, but there didn’t seem to be a culture of questioning why that sort of thing might be happening, and whether our treatment patterns were good or not. Everybody avoided the subject, I think because they were afraid of the implications of asking difficult questions.
In fact, after I did my training, I came out of nursing for a year, which I spent looking after the actress Glenda Jackson’s son. That was very important for me, looking after a child in an ordinary family (she absolutely made sure it was ordinary) and seeing his development. I needed that space because I wasn’t sure I could live with people in hospitals not speaking with me openly and honestly about things.
RB: What kinds of ethical issues were coming up? And how did they influence your move into public health?
EF: For example, I can remember having really difficult discussions about babies who had both male and female sexual organs, and how we would help the families to decide which sex they would choose. But the ones that created the most heartache were the spina bifida children, that had deformities of their spine that created a blockage so that their head swells enormously (Hydrocephalus). I kept asking myself, how did this happen? Why are these children like this? Eventually, I went and did a midwifery course, because I needed to understand how children got cerebral palsy, how children were missed in utero that were badly deformed, what could be done about it.
Having done the midwifery programme, I realised that actually the place to start is right at the very beginning, even before birth – which is what took me into health visiting and prenatal support. I began to think about how a child is not just an individual but part of a family, part of a community, which I think does fit with some of Nightingale’s thinking, the holistic approach. I learned a lot about community public health work, and when I went back into hospital work, I brought that with me.
RB: How did you use your public health / health visiting experience in a hospital setting?
EF: Things like putting up public health information boards on every ward. I also created the first children’s community outreach service in Nottingham. That put my unit on the map, and we were publishing a lot. Subsequently I was asked to go to manage the children’s service in Grantham, after the Beverley Allitt scandal [Allitt, a nurse at Grantham and Kesteven hospital in 1991, attacked 13 young children with dangerous injections, killing four]. This episode brought back the ethical questions from earlier in my career – how could something so unthinkable have been allowed to happen?
My experience in Grantham led to my work as regional nursing chief for the West Midlands, where they’d been through their own scandals over cervical screening and bone tumours. I was asked to work on the notion of risk and the prevention of failure, to think more systematically about major problems. Later on, I helped set up the Commission for Health Improvement, where I led 700 clinical governance reviews. That gave me a huge understanding across England and Wales of what makes an organisation work and what makes it good, what the influences are.
RB: That’s quite a Nightingale-style project in itself – she liked nothing better than sending out questionnaires and analysing the results to drive public health policy…
EF: Exactly. A good example was the first ever child safeguarding review across England. We coordinated that with the police, probation, social services, education – nine regulators came together. It was a huge job, but so worthwhile. It increased knowledge by 200% in some areas – partly because we’d framed the questions to help different bodies think about their own knowledge and where they needed to improve that, rather than just feeding information to the centre.
RB: You’ve been an advisor on the future of children’s nursing – what were the principles that you suggested should guide the future of children’s nursing care?
EF: Still ones that are very much based on the model that we developed in Nottingham. So: family-centred care, in the sense of choice for the family. While we push the idea of care at home, we have to accept that for some families that’s not always appropriate. They need to have a choice between home, hospital or hospice – I’m involved in the children’s hospice movement too.
In Nottingham we created something called negotiated care, where families are asked what they would like to do. That way they get a sense of involvement, rather than getting the feeling that they are bystanders. That creates its own challenges – for example I had to push to bring in double beds onto the childrens’ wards, so that parents could stay over together, which wasn’t easy! The idea is to co-create a care plan for the child. In some cases, for example children with cystic fibrosis, we taught families to set up their own intravenous feedings, and ran training for them. We wanted to give the families some ownership over what was going on. That takes away from the staff the sense of ‘my ward, my patients’ – because in fact, all those patients belong to a family, to a community.
That’s where my health visiting helped me. Health visiting is kind of scary if you’ve been used to working in a hospital – scary because suddenly you don’t control the environment, you’re a guest in their house. It made me realise, very powerfully, that families coming into hospital are guests in our house, and we should make them welcome. The hospital belongs to the patients, to the city, not to us as nurses and doctors.
RB: My gran is in a care home, which has a sign on the wall saying: ‘Our patients don’t live in our workplace, we work in their home’, or words to that effect …
EF: That is exactly what I’m saying. So for example I asked if the children could go down to the staff dining room, as a treat. It was a nightmare to win the staff who didn’t work in children’s services over to that idea, because they saw the dining area as somewhere they could go to get respite from patients. I said to the staff, ‘it is not your space, it belongs to them, not to you’.
But there were ripple effects: I hadn’t prepared the staff in the dining room for the fact that some of the children might die, and when that happened, they were upset. That was another lesson, one that I also associate to Nightingale: that you’re not just part of your small immediate team, you’re part of a much wider group including non-clinical people and you have to think about all aspects of the care environment.
RB: A big theme of our project is the theme of home – we’re looking at Nightingale in the context of going into people’s homes and providing healthcare at home, but also in the sense of what Jane Hamlett has called being ‘at home in the institution’ – the idea of making care institutions into home-like spaces, which was something Nightingale was very big on.
EF: When I first came to Nottingham, the hospital had only been open for a couple of years. I remember being shown the parent accommodation. It had linoleum floors, NHS beds, NHS lockers, magnolia paint on the walls! And I said, ‘this is meant to be home-from-home accommodation for people whose children are seriously ill, who are really stressed: why are we putting all this ghastly furniture in here? Why haven’t we got carpets and wallpaper?’ And the Estates manager who was taking me around looked at me, and said ‘well – no one’s ever asked me!’ Those basic things can make a difference.
RB: Nightingale often suggested very simple changes that could have big effects – for example, at one point she noticed that standard army barracks often were too dark to read in. Just improving the lighting meant that the soldiers were more likely to spend their time reading rather than simply getting drunk of an evening, leading to other knock-on effects.
EF: And the very simple things she emphasised about sanitation and washing still hold true. I’m an advisor on an African prisons project, started by a law student at Nottingham – in one prison in Uganda alone they’ve managed to reduce the death rate in one wing from approximately 47 a year to nine, through washing hands, clean linen, clean water – the core standard basic things from Nightingale’s time are still true today. The person who started the charity sent out 7,000 books to the prisons in his first year at law school, and supplying books has continued. As a consequence, we’re now seeing the first prisoners come through who are self-educated, better able to advocate for their own position. They’ve also formed a link between universities and the prison staff, so that the staff can come here and receive two weeks’ training on human rights, for example.
RB: There was a story recently about a prison in Nottingham that’s installed photo machines, so that when family members come to visit they can take selfies – those little things that help mental wellbeing. Nightingale again was sensitive to those things, e.g. by encouraging the soldiers in Crimea to write letters home, send back part of their salary, maintain family ties.
EF: When I was training, we used to have allocated women that came in as ‘ward aunties’ – it surprises me that we don’t have ‘ward grannies’ or ‘ward aunties’ now to help children with complex emotional needs, who don’t have the support from their families.
RB: What would you say are the main challenges facing the nursing profession at the moment?
EF: The three main ones I’d mention are: 1. Keeping pace with the increasing technology, versus the need to never forget to use your eyes, your ears, and your hands. 2. Living with the increasing pressures from public expectation – so many patients now have been on the internet, have already decided what treatments they should be given. 3. Trying to please so many different masters – political, management, families, patients, your team, yourself – these are big things for people to juggle in their heads when they’re working.
RB: I thought you were going to say recruitment…
EF: Well, I am, but I still think there are different ways of working. If I look back at what we did in terms of community outreach, with no extra money, we kept 250 children with diabetes out of hospital for 18 months by doing home visits. There is a recruitment issue, but it’s even more important to look at retention and returners, as well as recently retired people – there are lots of trained people not being used, who could offer all sorts of skills and advice.
RB: We’ve talked a lot about home visiting – is that given enough weight at the moment in terms of public understanding and policy?
EF: The new NHS policy, Simon Stevens’ plan, does promote the notion of community-centred care, as did the previous one. But it takes a brave politician to take money out of hospitals and give it to community care, because if it leads to a queue of ambulances outside the hospital, it’s an immediate political problem. One reason we could do it was because we were a relatively small unit. So I think there should be a look into relatively small specialties to see what can be done from existing budgets.
RB: What advice would you give to nurses starting out in their training today?
EF: I mentor some students who are on Masters programmes, and what I always say to them is: Take every opportunity you can that comes your way. Don’t turn things down out of hand – you don’t know if you can do it until you’ve tried.
And take the time to reflect. I love that quote which I think comes from Alice in Wonderland – ‘don’t just do something, stand there’. In hospitals today everybody’s always rushing around lurching from one thing to another. They never, or rarely, spend any time on reflection. At the end of a shift, just take five minutes to think: what went well, what can we do differently tomorrow to make our lives a bit easier? All our meetings at the Commission finished with an item asking attendees to consider what went well during the meeting and what could we do better. I have tried to adopt the same approach in my work since. It only take a couple of minutes to ask everyone, ‘what have we learned from this meeting?’ That has made me into a more reflective person about my everyday work.
RB: Is Nightingale relevant to trainee nurses now, do you think?
EF: I do, but I think it does need a project like yours to re-ignite the light again, simply because people still tend to think that we’ve moved on from her – and yet the relevance of what she was saying is still there. People don’t know that she placed so much emphasis on health in the home, and health visiting – things that teams I’ve worked with have achieved so much doing. Inevitably there are elements of her legacy that are outdated, but it’s a jigsaw, and she still has a place in that jigsaw that is firmly embedded.