The following extended blog is based on an address given to staff at Erskine Veterans on Friday 10^th May, in celebration of International Nurses Day which is held every year on the 12^th May, the birthday of that original nursing pioneer Florence Nightingale born some 204 years ago.

The theme for this year’s International Nurses Day 2024 is ‘The economic power of care’ which might seem at best a bit of a tangential topic but when you reflect on it, I think, makes complete sense.

I want to share some reflections this morning on this theme and to do so in three strands:

• What did money mean to Florence?
• The economics of nursing care, and why I believe,
• Social care nursing has a particular and unique contribution to make to economic and wider societal wellbeing.

I think it is fair to say that Florence came from a relatively well-off family. She was the second daughter of a prominent family, and her father William was a successful banker. The family owned properties in Hampshire and also an estate in Derbyshire. Like many wealthy individuals of the age, they had a large number of servants and staff. What was more unusual was that William insisted that his daughters had an education, and they were schooled in science, history and mathematics.

Florence was a religious child even by the standards of the age and from an early age she had decided she wanted to in her own words ‘alleviate suffering’ and to do so she decided to become a nurse. At the time nursing had a very low social status and the idea of someone from a wealthy background who simply did not need to work, becoming a nurse seemed unthinkable. It certainly was to her father William who resisted the protestations of his daughter. But like many fathers might recognise he eventually gave in and in 1851 he agreed that she should attend a school for women in Germany where she learnt core patient skills.

Two years later Florence was improving the treatment of patients at a women’s hospital in London. Then the war that changed nursing started. The Crimea War broke out in 1854 and British troops went off to fight in the Crimea – an area in the south of Russia, now part of Ukraine. When news reached the Minister for War, Sidney Herbert that hundreds of men were dying from their battle wounds and diseases he asked Nightingale to lead a team of nurses and go to the Crimea.

Her frontline heroism, her emphasis on hygiene and cleanliness, her transformation of hospital conditions became legendary and modern nursing really started.

After the Crimean War Nightingale was awarded a huge sum of money – over £250,000 from the British Government and in 1860 she used the money to establish the Nightingale Training School for Nurses at St. Thomas Hospital in London. Indeed, during the War in 1857 a fund was set up to support Florence’s work and it raised £44,000 equivalent to £2 million pounds today.

If you read her many letters and the histories and biographies produced over the years you can’t help but be struck by the fact that here is a woman who had economic and financial savviness, and knew the cost of things to the penny but she was always confident that she could raise the money needed in order to focus on what was paramount in nursing – the patient. Indeed, she is quoted as saying that ‘I attribute my success to this – I never gave or took any excuse.”

Money was a means to an end; its absence or lack could not or should not be used as an excuse for poor patient treatment or poor nursing skill and education. And ever since the Florence Nightingale Foundation has invested millions of pounds over the years to improve and advance the quality of care and nursing across the globe. And still does so today.

So, I think Florence teaches us our first lesson on economics and nursing – namely don’t let economic excuse or fiscal challenge become the reason for inaction.

In our modern era then what do we mean by the economics of care?

When the International Day of the Nurse theme was decided it was declared with the statement that ‘nursing creates healthy people and societies and drives healthy economies.’ In other words, there was an assertion that to have a healthy economy you need to recognise the contribution of nursing to societal and national wellbeing and health.

But when the ICN President, Dr Pamela Cipriano explained the reasoning behind the chosen theme, she also issued a warning:

“Despite being the backbone of health care, nursing often faces financial constraints and societal undervaluation … ICN has chosen to focus IND 2024 on the economic power of care with the aim to reshape perceptions and demonstrate how strategic investment in nursing can bring considerable economic and societal benefits.

We believe now is the time for a shift in perspective. We have seen time and again how financial crises often lead to budgetary restrictions in health care, typically at the expense of nursing services. This reductionist approach overlooks the substantial and often underemphasized economic value that nursing contributes to health care and society as a whole.”

Couldn’t be any clearer – if you want a healthy society then invest in nursing and what it brings to the health and wellbeing of that society. When times are tough and economies are struggling it is NOT the time to disinvest or draw back – quite the opposite – it is the time to prioritise in a profession which enables people to remain healthy (especially in austerity); it is a time to ensure that nursing continues to support people who want to and are able to remain part of their communities and who can then contribute themselves to the economic and social wellbeing of their place.

We very rarely view nursing as an economic contributor – we tend to be uncomfortable with that sort of language – but I think we need to get real and recognise that without the daily contribution of nurses up and down our country, then the functioning of our society and economy would simply over time grind to a halt.

It is especially the case in a country like Scotland that nurses enable communities to thrive and people to flourish, and where they contribute to our wider societal wellbeing and health. It is because of nurses that communities live better, and we are all able to become healthier. Without nursing the horrendous health inequalities of our country would become even worse and deeper.

My third strand for the economic contribution of nurses – is what I consider to be the distinctive, unique and particular role of nurses who work in social care settings and contexts.

There is a very active debate about what it is that is special or unique about social care nursing. I am not the only one in this room I suspect who has been reading a lot of threads on Twitter or X and Facebook discussing what a difference social care nursing makes.

There seems to be nothing new in this… more of that in a minute… But here are three descriptions: (so you know what it is that you should be doing.)

‘Nurses in social care have distinct expertise. They use their clinical skills to understand the variety of needs of patients, and also deliver relationship-centred support. They recognise the importance of giving each individual a sense of security, purpose, achievement and significance.’  NHS England

The distinct expertise of this group of registered nurses is in enabling individuals with care and support needs, many of whom have multiple co-morbidities and complex health issues, to live positively in their own homes. They embody the capabilities and cultures of both health and social care professions and employ their nursing knowledge and skills within a social model of care. Their focus is not only on an individual’s health condition and resulting impairment but also on the impact this has on their participation in social and community life.  Skills for Care

​A healthcare need is related to the treatment, control or prevention of a disease, illness, injury or disability. And the care or aftercare of a person with these needs. A social care need is focused on providing assistance with the activities of daily living.’  MIND

My former colleague Dr Jane Douglas researched and wrote a brilliant report which was published two years ago. It stated that:

“While participants to the study struggled to define the role of nursing, they were able to clearly articulate the knowledge and skills required to undertake the nursing role in care homes, along with the value of having Registered Nurses. They easily reflected on how they use their own knowledge and skills to ensure residents in their care remain as well as they can.’

It went on to say:

‘The Social Care Nurse focus is to ensure better outcomes for people experiencing care and their relatives, to ensure a quality of life and a quality of death. To support the person to be as well as they can with the understanding that wellness fluctuates daily. This is achieved through a holistic person-centred approach.’

That definition and the findings of her report in part grew out from and drew upon a Twitter debate about the distinctive role of social care nursing. And lo here we are again two years on and we are still debating what is distinctive and special, unique and particular.

But the very fact that there is need of a conversation in the first place tells its own story about the under-valuing, the stigma and the marginalisation of social care nurses. I find it astonishing that there is such a high level of ignorance amongst nurses who have never worked in the social care sector about what it is that their colleagues and fellows do. I find it shameful that there are so many instances of casual dismissiveness that suggest that social care nurses are folks who are wanting an easy life away from the hard work and grind of the acute hospital ward; I find it demeaning that there is so little understanding of the ultra-professionalism, astonishing levels of skill and autonomy that exists in the care home sector.

Can you imagine that surgeons in different disciplines would so easily dismiss a colleague or worse than that would not even consider that it was worthwhile that they should know the scope, expertise, clinical ability or patient insights of a colleague.

Maybe we have got it the wrong way around – rather than social care nursing having to defend its position, propose a theory of its uniqueness and posit its distinctiveness – maybe our colleagues in the NHS can tell us what is so special about the jobs that they do that all others in social care should be so casually excluded from value and appreciation, from recognition and notice?

In the theme of the day perhaps more than any other form of nursing it is social care nursing that helps turn the wheels of our economy. It enables people to be supported and nurtured so that they can continue to contribute. It nurtures relationship, fosters community, attends to not just the clinical needs but the holistic requirements of a person in community.

Social care nursing has to re-discover the spark of passionate identity which Florence Nightingale fostered – for if nothing else it strikes me when you read the works of Nightingale that it is social care nursing that seems closest to her original person-led, relationship based, autonomous understanding of nursing from life through to death. In social care nursing we get Florence’s sense that nursing was not an added extra or luxury, but an essential ingredient which bound our common humanity together especially to those who were wounded or ill, broken or fragile.

Florence once said:

“The world is put back by the death of everyone who has to sacrifice the development of his or her peculiar gifts to conventionality.”

It is time for social care nursing to stop being put back by dying to be defined … we should not be continually having to defend a definition but rather need to proclaim the irreplaceable benefits, the peculiar gifts, that the women and men in this room and outside across Scotland’s care homes and social care organisations are bringing every single minute of every single day.

Happy International Nurses Day when it comes.

Donald Macaskill

I sat last week and listened one year on from the day since Joan’s husband had died as she recalled the ups and downs, the tears and laughter that had been her year’s journey of grief. She had so many thoughts and memories which came tumbling out almost without ceasing, not least as she told me she needed to talk because when folks asked how she was she knew that it was just a passing off the cuff remark and that it did not really mean that they were wanting or prepared for an outpouring of truthfulness in all its raw and contradictory reality. So, she grabbed the chance of an anniversary hour and spoke and spoke and spoke.

It is unfair to try to summarise anyone’s mourning and grieving in a phrase or even anecdote, but one thing Joan said to me struck a resonance of recognition within me – that her grieving was all about ‘the silence of emptiness.’ I have often reflected over the years in this blog about the nature of emptiness and loneliness as it affects people as they grow older and age and as relationships change and come to a physical end, but there is in truth something unique about the emptiness of living in the absence of a loved one. There is something about silence stripped of sound, of energy and purpose which arrives when someone you love has died.

Joan talked in a way that spoke to me of all the moments I know and have myself experienced. The phone call you start to make before you come to the realisation that there is no number to call that will end up with you hearing that voice; the days when in excitement and happiness you rush home to talk and share but as you open the door you know that the crushing emptiness of silence will be all that will greet you; the fragile forgotten moments when you used to just gossip and opine, argue and agree; the rituals of a week whether the midweek night out at the cinema, the Friday night glass of wine, or the Saturday morning walk – all now accompanied by absence and silence and emptiness.

Now life seems full of the manic desire to fill every moment with activity and action in a failing attempt to forget just for a moment. And to top it all the sense that beyond a few people there is no one out there who really understands what you are going through and your sense of self-guilt that you aren’t further down the road, that you are still back at the first step on so many days, that sleeplessness is more often your night-time companion, and that there seems to be a never ending path ahead. That first year – and the next and the next – in the calendar of absence and loss seems to tick inexorably slow.

I sat there and listened not trying to do anything other than to be present so that the tears and sound might find some solace, but as I did I thought to myself why is it that personally, individually, and as a community we are failing still to give place to those who are lost in grief, real attention to those whose pain is locked silently within them, and have and are continually failing to offer true solace and compassion to the bereaved.

Nearly 6 years before the time I spent with Joan a handful of folks met together in May in Glasgow to talk about the sad state of bereavement support in Scotland at that time. Our concerns were that as individuals and as professionals we were continually coming across people who were broken by grief and a system of health and care, workplace and community, which seemed so inattentive to the needs of the bereaved and the grieving. We knew the personal and societal cost, the economic and community burden which resulted from grief unspoken and an inadequacy of effective bereavement support.

Out of those early discussions we set up the Charter Working Group which resulted in the creation of Scotland’s National Bereavement Charter for Children and Adults. Since then, we have continued as a group to raise the profile of bereavement and the importance of changing the way in which we support those who are grieving. We have developed guidance, and animations and videos, held webinars and seminars. All of this rooted in the conviction that good and adequate bereavement support should be a fundamental characteristic of our society. Indeed, our premise was and was and still is that bereavement support should be a fundamental human right.

Six years on it saddens me that I can sit with Joan and still have to conclude that Scotland is a country where we simply do not do death and dying, grief and bereavement well. I still have that hope and aspiration that Scotland could be that nation, our communities could be those places, where the bereaved are able to talk without a sense of burden, where businesses and organisations do more than tick the box in their offering of support and practical care; where we talk openly and honestly, emotionally and rationally about what it means for us to grieve and to mourn. But we have a huge distance to go and in part one of the things that holds us back from the achievement of the Charter’s aspirations, is that we are still too silent in our talk around death and dying, grief and loss. We are still as likely today to cross over to the other side of the road when we see the bereaved approach rather than to stay and be present.

That is not to deny the amazing work that is happening in communities and cafes, in pubs and parks, in theatres and church halls across Scotland. There is more chatter about grief and in no small part that is due to the work of Good Life, Good Death, Good Grief. This brilliant programme holds an annual week in which it seeks through small local projects and events, using the ordinariness of the commonplace and the creativity of the arts, to get us talking about death and dying. Demystifying Death Week is starting on the 6th and across Scotland this week in many places and spaces near to where you are you will have the opportunity to experience an honest conversation. As Good Life, Good Death, Good Grief says:

‘People usually want to do the right thing when someone they know is affected by serious illness, death or grief.  But often they can feel awkward offering help or worry about making things worse. People can have questions about serious illness or dying. But often they don’t know who to ask. Making plans when you’re healthy means there is less to think about when you’re ill. But people can put off making plans until it is too late.

Demystifying Death Week is about giving people knowledge, skills and opportunities to plan and support each other through death, dying, loss and care.’

My hope and aspiration live on. We can and must become more comfortable not just with talking about grief and loss but putting our words and platitudes into practical authentic living. I hope in the days and months ahead we might all continue to shatter the silence of emptiness around grief.

I end with some of the words of the British author and educationalist Abi May who also writes a grief and loss blog and who in a post entitled ‘Griefbursts and silent screams’ wrote this:

I screamed today.

A silent scream.

Nobody saw.

Nobody heard.

I clenched my fists

And breathed in deep

A silent scream

Nobody saw.

Nobody heard.

There were no words.

None to speak

None to say.

I closed my eyes

Shut them tight

My face was creased

And stretched

Muscles tense

But soundless

My silent scream

Came from the heart

From a place so deep

There are no words

I didn’t cry

I just bore down

I screamed alone

Without a sound

There is no why

Nor where and how

For what, it can’t be said

But for whom.

I screamed today.

A silent scream.

For her, that special one

The one who long is dead.

Donald Macaskill

Photo by Ann on Unsplash

On Monday and Tuesday of this past week I had the pleasure of spending time with colleagues from across the United Kingdom and Ireland at a meeting of the Five Nations Care Forum. This is a bringing together of senior staff from social care representative bodies and happens a couple of times a year. This spring meeting was hosted by Boots and took place in their headquarters in Nottingham.  As well as discussions on the key issues facing social care, I particularly enjoyed the opportunity to discover more about the history of Boots and the critical role of pharmacy in the support and care of all citizens but most especially for our older population.

In many ways the world of pharmacy is facing similar challenges to social care with issues  around public and governmental funding especially for community pharmacy, issues relating to recruitment and retention of staff, changes in the role of the pharmacist and the need to prioritise resource around research and development. But one thing I was continually struck by in my discussions was just how important it is that we have a constructive and positive relationship between those of us who work in social care and those who work in pharmacy. From the need to better support community care staff to assist folks in their use of medicines, and this will only grow as more and more people are supported at home rather than in hospitals, to the need to address issues of ecology and sustainability around medicine waste there is a need for a very close and developed relationship between social care and pharmacy. And as in all things this relationship needs to be nurtured at both local and national level to be of real benefit to all.

I was reflecting on all this when I discovered that in a couple of days on Monday 29th April, we will be recognising World Immunology Day. Indeed this year’s theme is “Immunity Through the Ages: Navigating the Science of Aging and Immunology.”

Some might ask why is someone who works in the world of social care reflecting on immunology? But in the light of a global pandemic which devastated so many lives and communities I would hope the role of immunology would be self-evident but also that its significance for all in both social care and in community would be better understood and elevated. Sadly, I suspect with the passage of time except for those who continue to be concerned about the impact of Covid on their own lives and those of others, for the majority thoughts of viruses and pandemics are fading into the rear or even worse are being deliberately ignored or deprioritised.

The British Society for Immunology states that:

‘Immunology has its origins in the study of how the body protects itself against infectious diseases caused by microorganisms, such as bacteria, viruses, protozoa, and fungi, and also parasitic organisms, such as helminth worms.’

This year there is a particular focus on the impacts of infectious disease amongst the old.

For those of us working in social care issues of immunology, infection prevention and control and vaccination have become centre stage to our concern and focus since Covid and for the majority of practitioners they remain so. Sadly, there are still people dying of Covid every week and there are still individuals who every week die as a result of developing other infectious diseases such as influenza. Yet the impact of infectious disease seems to be continually marginalised and ignored. So, the role of immunology remains or at least should remain of primary concern to the practitioners of social care.

When I was in Nottingham the latest report from Public Health Scotland was published and it showed a fall in Covid-19 and flu vaccine uptake for all eligible groups in the winter that has just passed when the figures of uptake were compared to winter 2022/23.

Like many I am increasingly concerned that vaccination rates seem to be going in the wrong direction. That concern has critically to do with the extent to which – despite the naysayers and anti-vaccination lobby – there is clear evidence that vaccinations have saved the lives of and protected tens of millions of individuals against so many conditions, not least Covid and influenzas.

In addressing the figures, Dr Sam Ghebrehewet, Head of Vaccination and Immunisation, at Public Health Scotland said:

“Vaccination remains the best protection against severe outcomes of both flu and COVID-19 and reduces the likelihood of severe illness, hospital admission, and in some cases death. Work is underway to understand the reasons behind the decrease in vaccine uptake. This is crucial to ensure that those most vulnerable are aware of their eligibility for vaccination.”

I suspect that some of the answer to those explorations will be (though I know this will not be articulated) a lessening in focus and priority on the role of vaccines in general not least by the prioritisation given to it through planning and resource allocation. At the height of the pandemic or most especially in the latter days of late 2020 when the first vaccines began to be rolled out, there was significant co-operation between the worlds of health and social care around vaccination both for residents in care homes, older people supported in the community and the health and social care workforce. That co-operation and joint working is sadly much diminished and so I fear that there is a lack of co-ordination, targeted support and priority.

We know for vaccination programmes to work well that vaccines need to be delivered to people in a manner which is as easy as possible. For many this will be at their local community pharmacy and for health and social care staff at their place of work. Whilst vaccines at work remain a priority for colleagues in the NHS sadly this is not the case for social care staff. Expecting workers in their own time to go and get vaccinated is inevitably going to reduce uptake not least when we are talking about those who are in roles which do not earn a lot of money and many of whom have to work extra shifts or extra jobs. As I have said on numerous occasions for a vaccination programme to work in the care sector, we need to take the vaccines to people, and we need to make sure that we address myth and scepticism which exists around vaccination.

We can and must do a lot more to protect everyone from the very known risks of infectious diseases and as my own organisation, Scottish Care, commented in response to the report, I believe that this should, include a targeted campaign to increase the confidence of all, especially social care staff, which both addresses vaccine scepticism and also popular myths and attitudes which suggest that catching Covid-19 or the flu are not serious.

Walking around the Boots headquarters and exploring the rich history of an organisation that for the last 175 years has been bringing medicines and pharmacy to the British public showed me just how critical pharmacy has been in addressing the ravages brought about by diseases. The fact that in general terms life expectancy has been extended and most live in health has been because over history we have eradicated so many infectious diseases which were once deadly. But addressing the challenges of infectious disease did not happen by accident – but rather it was achieved through targeted, joint working, relationships and partnerships at local level. So increasingly I feel we need to break down the barriers which sometimes exist between the worlds of pharmacy and social care, increase mutual understanding and professional regard, and together prioritise ways in which we can ensure all who need to be are protected from disease and infection. If the pandemic has taught us anything it has surely taught us about how important it is to work across boundaries, to know the worlds of others and to avoid silo thinking and planning.

As we think about immunology and vaccination, like many in the world of social care I think about the challenges that a new season of infectious disease, whether Covid or influenza might bring, and I increasingly wonder as to whether we really have learned the lessons of a pandemic for which we were so badly prepared. Are we working together to address known and unknown immunological threats? Certainly, given the complete absence of social care provider contribution in the current Scottish Government pandemic planning, the signs are not good.

Donald Macaskill