The hardness of COVID ethical choice

Nelson Mandela in a speech in 1998 stated:

“A society that does not value its older people denies its roots and endangers its future. Let us strive to enhance their capacity to support themselves for as long as possible and when they cannot do so anymore, to care for them.”

Like many others I have been waiting with interest for sight of the ethical guidance which would be made available to our frontline clinicians who are engaged in the struggles against the Coronavirus epidemic. I read the ‘COVID-19 Guidance: Ethical Advice and Support Framework’ with considerable expectation and hope for a clear grounding for hard decision making. When I finished I was left with more questions than answers and no small sense of disappointment.

The reason for such a document is self-evident. Despite all the best efforts of planners and politicians we may get to situation where there is insufficiency of resource to be able to provide the optimum clinical care and treatment to every citizen.  As the document itself states;

‘if immediate need exceeds what is required and there is no additional capacity, changes to healthcare delivery and scope may be necessary.’

It is in this context when we are clearly not in ‘normal times’ that we need to be able to give our frontline clinicians the ethical, moral and rights-based tools to allow them to do their harrowing job with dignity and authority. I am afraid this document fails to give that sense of grounding and raises fear and concern for many of us. It fails to live up to its declared self confidence that ‘This guidance is considered both clinically sound and on firm moral ground.’

Some of my concerns include:

The Guidance describes the role of Ethical and Advice Support Groups at both a national and local level. Whilst the membership is delineated as including clinical professionals, academics, lawyers, religious groups, social workers and lay persons, it does not describe for us HOW these individuals will make their decisions. What will be the moral and ethical boundaries, principles and framework which will guide them? What will be the clinical criteria to enable them to make impossibly hard recommendations? Will these be based on utilitarian views? How will we be assured that their decisions and advice will be non-discriminatory and based on a robust human rights critique? To what extent will characteristics of age, co-morbidity and frailty influence decision criteria? What indeed will be considered the interests and obligations that this decision-making has to the ‘wider population.’

Secondly, the Guidance uses a lot of ‘feel good’ language but does not illustrate how that assurance is going to be played out in reality. It states that:

‘Everyone matters…

Everyone matters equally…

the interests of each .. are a concern for all of us

Harm suffered by every person matters…’

All undeniably laudable aspirations and statements but how are these fulfilled in practice in an emergency, resource constrained environment?

The Guidance describes the principles of Respect, Fairness, Minimising Harm, Working Together, Flexibility and Reciprocity, but again one is left asking what it means to state that

‘Patients should be treated as individuals, and not discriminated against.’

Perhaps more challenging is the statement:

‘No active steps should be taken to shorten or end the life of an individual, however the appropriate clinical decision may be to withdraw life prolonging or life sustaining treatment or change management to deliver end of life care.’

Thirdly the use of certain phrases beg more questions than they deliver answers:

‘Where there are resource constraints, patients should receive the best care possible, while recognising that there may be a competing obligation to the wider population.’

‘Under normal circumstances, these decisions would be made of the basis of patient choice and anticipated clinical benefit to the patient. In the context of increased demand, it may also be important to consider fairness of healthcare distribution within the wider population.’

What in this context is meant by the ‘competing obligation of the wider population’? If we are to supplant patient choice and anticipated benefit for an individual what does ‘fairness of healthcare distribution’ actually mean not just at a theoretical level but in raw reality for individual citizens? Care is to be rationed- I can understand – but ethically what does the needs of the majority mean for the care of the vulnerable minority?

Fourthly, I am really concerned that issues of equality and human rights are mentioned explicitly only in two footnotes. I have stated before that Scotland should be rightly proud of its articulate defence of the human rights which have framed both our legal and parliamentary process, not least since Devolution. To present a document which articulates some of the most challenging ethical choices of our generation, perhaps of any time since the Second World War, and to have that devoid of a robust human rights articulation is wholly inadequate. How are we going to make an ethical decision which upholds the right to life and the right not to be subject to inhumane and degrading treatment? How is the State going to fulfil its duties to the Human Rights Act or the European Convention of Human Rights? I see no robust articulation of this within this document. If human rights are to be more than rhetoric in easy times they have to be real in hard times.

All this matters a great deal and it matters now.

Already we have stepped into questionable territory.

I can fully understand that for many frail and older people who develop Covid19 in a care home that the best place for them to be supported is within the care home, that transfer to an acute setting is likely to be over traumatic and result in little effective clinical outcome.

I can accept and know at first hand the astonishing professionalism around palliative and end of life care delivered in Scotland’s care homes which makes them in ordinary time hospices in the heart of our communities.

What I am deeply uncomfortable with is a blanket presumption that there will be no transfer of any individual (except in the instance of large-scale fractures) from a care home into the acute context. This leaves me disquieted because it presumes that all individuals within a care home are old and frail and it assumes a sufficiency of resource in care homes which would potentially enable some individuals who have a severe infection to respond well.

What I am equally appalled by in the last few days is the numerous instances of DNACPR being demanded as routine and automatic from care home residents by some general practitioners up and down Scotland. Quite rightly the Chief Medical Officer has robustly challenged this.

I am equally dismayed at the number of GPs who have in recent days intimated that they will not visit care homes. I fully understand that the risk of infection has to be taken into account but a presumption of non-attendance to meet the needs of individuals, even with the best use of video diagnostics, is wholly unacceptable.

If equality of access and treatment mean anything then we must not abandon our care homes, their residents and staff to an unequal level of clinical support.

The next few days and weeks must surely be those where both the clinical community and wider Scottish society needs to have a proper debate about ethical treatment and care in the face of reduced resources. It is simply too important a set of decisions to be left to a document which though it tries hard is too subjective, too generalist and lacking in a foundation of human rights and equality.

The way we respond to harrowing issues of choice will determine the society we will be as a nation after Covid-19. In Mandela’s terms decisions which are potentially based upon an over-reliance upon age and do so in a discriminatory manner endanger the rootedness and the future of the whole of our society. I trust that over the coming weeks by our actions and decisions we will all create a future we will be proud of.

Dr Donald Macaskill

‘Who inspired you to be a nurse?” – Nursing Blog by Transforming Workforce Lead

In this the International year of the Nurse/Midwife we can look back in history and see examples of nurses who have been inspirational in encouraging people to make nursing their career.

There are some women and men who have been instrumental in making nursing and midwifery what it is today.

Some historians would argue that as far back as 250AD, men were in fact predominantly the ones who provided nursing care to the sick and the poor, with the first nursing school thought to be all male in India.

St Agatha of Sicily is the most well known patron saint of nurses, with three other patron saints, St Catherine, St Elizabeth with St Camillus de Lellis being a male. In fact, he is one of the first male nurses of the profession. He decided to become a priest only to resign in 1607 to continue to care for people affected with alcoholism. All these saints were known to inspire nurses.

Despite this, many view Florence Nightingale as the founder of modern nursing. However she was thought to hold the view that nursing was more natural to a woman and this was detrimental to the acceptance of males into the profession. More recently there was Clara Barton who was the founder of the American Red Cross and was an inspiration for going into the battlefields to help those needing first aid. Males were also present on the frontlines but were thought to have had less training.

Elizabeth Grace Neill was responsible amongst other things for creating the nurse register that ensured nursing was seen as a profession. In 1919 males also were recognised by a register.

The Nursing Theory was developed by Avenel Henderson, who was considered as the most famous nurse of the 20th Century , with all her contributions and influence to American and international nursing education, practice, research as well as its implications.

There was also Mary Eliza Mahoney who was the first registered black nurse, who continued to work throughout her career to fight discrimination and co-founded the National Asssociation of Colored Graduate Nurses in 1908 .The NACGN became Mahoney’s instrument in improving the status of black nurses in the profession nationwide.

In relation to recognising mental health issues, Dorothea Dix was the first advocate nurse who fought to improve care for people with mental health issues, with Margaret Sangar who was instrumental in ensuring the rights of women and worked for over 40 years to ensure birth control was available to women from the 1950s.

Edward Lyon in 1955 became the very first male nurse to be commissioned in the Army Nurse Corps in the US as a reserve officer.

These are only a selection of international nurses who worked tirelessly to ensure the rights of all people, alongside challenging legislation to establish nursing and midwifery as it is today, which is now devoid of discrimination . Nurses can now work and lead in all fields which offer positive career pathways, regardless of background, race, ethnicity or gender.

Nowadays we often see the young student nurse who has spent their whole childhood dreaming of being a nurse, but for many their decision comes out of a personal or family situation that changed them in such a way that they  were inspired to want to be an nurse themselves.

The more I explore this subject, the one thing that can’t be disputed is that those who choose nursing as a profession want to make a difference, to give back, they are determined and genuinely care for people, often going above and beyond.

For me personally, my childhood dream was to be a police officer, not a nurse, because I felt that by joining the police it was the one job I could help people, keep them safe and which would challenge me and make me a stronger person.

I believed this was the job that I would get the most satisfaction from and that would make me a better person in the process.

The year before I applied, my gran suffered a stroke in her late 70s. Post-stroke despite still being mobile, she was no longer able to look after herself and she subsequently came to live with us.

Psychologically she had changed due to the stroke, as did our relationship. My gran was my inspiration and to see her dependent changed my whole mindset and view on what really mattered in life.

I was always close to my gran, but our roles had reversed,  having to care for her and hold her hand and comfort her, to help her understand things and still to enjoy life despite its frustrations,  as well as being beside her, 3 years later, when she passed away peacefully at home .

Alongside this, I watched my mother with two teenagers take on the role of carer, give up her job and manage all the dynamics of the family.

It made me realise that nursing someone can give so much joy and gave me everything that being a police officer would’ve and more importantly gave me the empathy that ultimately directed me into nursing. Nursing someone you love is different, as its personal, but it gives you the insight to understand what the families of those you nurse are going through. Never underestimate this.

I believe her illness gave me the best gift. I started my training in 1987 and haven’t looked back.

Our patients and residents without question remind us every day why we are nurses, they let us into their lives, tell us their secrets and trust us to provide the care they need, literally for some, putting their lives in our hands.

The nurse-patient/resident relationship differs depending on which area of nursing you choose to work in, but can teach you how to be compassionate, and develop a patient centred approach, which ensures people’s needs and rights are met.

We know these are challenging times and there will be points in your career that you question if you still want to be in nursing, but I ask you to stop and remember why you became a nurse, and maybe  consider that you may just need a change of environment, not a change of job.

As the workforce lead for Nursing at Scottish Care I would promote  working with older people in care home nursing, as it offers a homely environment to build relationships with residents and families and provides the potential for an exceptional career pathway for you as a nurse. We do need an increase of younger people, men and people over the age of 40 years, as well as more people from Black, Asian and ethnic minority backgrounds to continue to join the profession, to ensure future workforce stability.

As nurses we hope we inspire others to do their best, nothing more or less and others to continue to inspire us in the same way.


Jacqui Neil

Transforming Workforce Lead for Nursing, Scottish Care


A thought piece on Coronavirus from our CEO Donald Macaskill

“ I don’t know what people are worrying about. It’s just going to kill the old folks.”

That’s one of the many remarks I have overheard on public transport this week since conversations started to focus in on COVID-19. When you couple these comments with public officials stating in the media that the majority of deaths from the virus have been “just amongst the elderly” you are left with the distinct impression that this is not a pandemic the majority of us need to get too worried about.

But the place where such attitudes have almost become endemic is social media. There are literally hundreds of tweets suggesting that those of a youthful age and who are not  immuno-suppressed need not worry – all will be well –  just clean your hands! Some of the content on Twitter really doesn’t hold back:

‘Corona virus is killing pretty much just old people. It sounds like Earth is getting revenge for them destroying literally the entire planet and not caring about it.’

‘What I find so funny about this is the corona virus is deadly to old people which are the establishment and conservatives biggest base. If god uses diseases to punish I wonder what message hes saying with this one.’

Not since the AIDS epidemic was painted as the judgment of a righteous God has there been such a negative discriminatory association between a virus and a specific group.

Of course, the reality is that any virus never discriminates by the age of its victim but rather anybody regardless of their date of birth and most especially those with a supressed or limited immune system are disproportionately affected.

I find it immensely despairing that there is both within the wider public and in the media a creeping ageism in the reporting of and discussions around COVID-19. It is almost as if because someone is older in years that their dying is of less impact or importance; that their loss to the community, to family and friends is somehow less painful and distressing to those left behind.

At one level you could say that what we are seeing here is simply classic age discrimination playing out on Covid-19 as it does in so many walks of life from employment to the allocation of public funding. But I suspect at another level what is happening is something much more significant and profound.

What does this say about us as communities and as a nation in Scotland? Is the virus beginning to strip away the polite veneer that hides attitudes and beliefs that are simply ageist and hostile against the old? Are we finally unmasking a popular consensus that considers that to be old means that your worth is over, your contribution complete and your value limited?

The way in which we respond to any challenge marks us out both as individuals and as a community. Are we going to be one which in cold-centred self-interest and protection considers the value of an old person to be less than someone much younger? Are we going to become blasé to the fact that perhaps thousands of our older citizens will be affected by and many will die as a result of this disease?

Over the next few days and weeks thousands of women and men who work in health and social care services will be putting other people, their care and support, before their own needs. We will undoubtedly as we often have in the past witness a selfless dedication and professionalism that doesn’t just go the extra mile but an extra marathon in terms of commitment, compassion and love.

The days ahead will help to shape us as a society. Will we be a Scotland which cares for others, gives value and grants respect regardless of chronology or age? Or will we care less, commit less, consider less because someone is in their eighties or nineties?

Coronavirus will be a test not just of the infrastructures of health and care, of business and commerce, it will be a test which will determine the nature of our nation. Will we be a Scotland that cares for the old or will our compassion be limited by discrimination?

Dr Donald Macaskill

This piece first appeared in The National newspaper on Sunday 8th March 2020. 


International Women’s Day: a blog from our National Director, Karen Hedge

Yesterday I dropped my children off at school on ‘World Book Day’. Amidst a sea of Harry Potter characters and superheroes I spotted someone else. There over by the door was Frida Kahlo, this girl of about 9 years old had brought the book ‘Good Night Stories for Rebel Girls’, 100 tales of extraordinary women. I purchased our own copy that morning.

Yet in doing so, I felt discontent. Of course I want my son and daughter to hear about the impact that women throughout history have made, but I could not overlook that twinge of disappointment and perhaps also a bit of rage that in 2020 we are still having to create our own platform to do so. Given the recent decisions and discussion around immigration, with a UK Government irresponsibly  and incorrectly describing social care as low skilled, this is a theme sorely and dangerously evident in social care. Intersectionality makes this worse.

The reality is that social care staff are highly skilled, professionally registered and regulated. They spend their working hours (and often more given that a significant proportion have personal caring responsibilities) supporting our loved ones, some of whom may require palliative or end of life care, have multiple co-morbidities, advanced neurological conditions or dementia and so on.

SSSC data shows that 86% of our care home workforce and 81% of our homecare workforce is female. Anecdotally from previous Scottish Care focus groups, we believe that many of those who do work in social care often take on ‘male-dominated roles’ such as handyman or chef. That there is such a gender divide should not really be surprising, it mirrors other sectors – 83% of primary school teachers are female.

We have a his-and-her-story of working with peers of our own gender; one of the contributing factors to the gender pay gap. A recent report by the Kings Fund[1] states ‘Jobs done by women are undervalued’ both in terms of the value society places on the jobs and the wage people are paid. Jobs with a higher percentage of women tend to be lower paid, and if, over time, the proportion of women increases average pay goes down further.’. Sadly I can evidence this from my own experience. I first worked as a paid carer in 2000 earning around £8.75 per hour. In 2020, social care is purchased by local authorities (usually) on the premise that social care workers are paid the Scottish Living Wage of £9.30. That makes a rise of 55p over 20 years.

One of the suggestions to counter this imbalance is to encourage more men to work in the sector as if balancing the gender of the workforce, would increase the value of the job. Of course having a more diverse workforce is welcome and a positive proposition, and from an academic perspective, this move makes perfect hypothetical sense, but a cultural shift takes time, and in many ways dilutes the issue to hand. The other solution is simply to recognise and value the workforce for the registered and highly skilled people they are.

Another example, to use the term coined by Carolina Criado-Perez in the same-titled book, of ‘Invisible Women’ is that social care contributes £3.4 billion to the Scottish Economy, which is more than agriculture, forestry and fishing. It seems no coincidence that the latter is a sector traditionally dominated by men.

Yet there are positive changes and opportunities. Whilst women are less likely to be company owners or shareholders, this trend is bucked in social care. Where other Boards are implementing 50:50 rules for the make-up of their Board, the Scottish Care Executive required no design to meet that criteria, it happened naturally as a result of the significant number of women in those roles.

At middle manager level, it is still the majority of staff who are women. Bringing their frontline leadership skills with them – social care staff are very often lone workers adept at making decisions in what can sometimes be challenging situations, they are well-prepared and qualified for the responsibility. As evidenced in the Scottish Care report ‘The Experience of the Experienced’ others have entered the sector bringing skills from elsewhere. We must also recognise that many have taken a reduction in pay or conditions to pursue this career where they can make a difference every day. But why should they have to?

We have also recently seen Project Lift, a leadership programme which started in the NHS open its doors to social care staff, growing our leaders of the future and potentially opening doors across health and social care. In addition, the current campaign to encourage more people to work in the sector and the Adult social care reform programme both have potential to promote the value of social care.

And so in raising the profile, we raise the value. Today is International Women’s Day. The theme for 2020 is #EachforEqual a statement of ‘Collective Individualism’ pointing out that it is as individuals we challenge, but only together that we can achieve change. This is not simply a call to women, or even to create the conditions for a counter-movement calling for an International Men’s Day. In collective individualism we work together and for mutual benefit. In this industry we might use the words collaboration and co-production.

Equality brings health and wealth to whole communities. So I ask you to channel your inner Frida Kahlo or whom-ever your inspiration might be. Perhaps they are a care worker.

Share this message wide and if you feel as I do, turn your disappointment (and rage) into action. #EachforEqual is for all of us, but to achieve it we must recognise and raise the true value of social care incorporating the value of our care workers, managers and owners of all genders who devote their time with skill and compassion, and who inspire us every single day. #careaboutcare #independentcare 

Karen Hedge, National Director, Scottish Care 


Latest blog from our National Director: Immigration Workforce

A career in care is one where every day you can make a difference. Yet everyone who has any contact or connection with social care knows that we have a workforce shortage. In short, we’re talking about 29% nursing vacancies and a steady turnover for frontline care staff with a 24% attrition rate. If you fancy a deeper dive into the intelligence, both the SSSC and Scottish Care have written plenty on the subject and it’s available on their websites.

It is a critical time to raise the profile of the sector, recognising it for the vital role it plays in supporting the human rights of our some of our most vulnerable citizens and recognising its workforce for the skilled role they play in that as registered and regulated staff. Social Care enables people to stay healthier for longer, able to contribute to their communities and easing pressure on the NHS. I heard only yesterday about an 87 year old lady from a care home in Dumfries and Galloway going to local primary schools to teach German and French.

There is currently a national recruitment campaign for the sector, devised by Scottish Government and with contribution from many across the sector. It includes a campaign website and clear examples of career progression expressed by the SSSC, PR in the form of advertising and the promotion of case studies. A real opportunity to promote the many positives so often overlooked.

But this positive promotion has just had a coach and horses driven right through it by the Migration Advisory Committee and UK Government. Their complete and utter ignorance and underestimation of the critical role of the sector despite repeated warnings has led to the creation of a migration system which will see the care sector lose significant numbers of staff from the EU and beyond.

This is an action which has ripped apart families and caring relationships undermining the concept of continuity of care and the critical role which the sector plays. Whilst between 6 and 9% of our care staff come from the EU, this rises to as much as 40% in some parts of Scotland. Places where families have settled into local communities, where several members of that family might work in one care home taking on a variety of roles from nurse to carer, to handyperson and gardener.

Last month, the Scottish Government launched a report seeking for the option to introduce local solutions to address local challenges, this proposal was drawn from local evidence and systems which already exist in Australia and Canada, and could be implemented in any country or region of the UK.

Yet, by lunchtime the paper had been rejected by Westminster.

What is clear is that decisions around immigration need to be based upon facts and evidence, removed from any political rhetoric, whilst focussing on prosperity and wellbeing. There needs to be a move towards a more flexible policy which recognises social care as the skilled and vital service it is. It needs to accommodate the reality of regional difference such as the demographics of rural and remote areas, adjusting income thresholds to recognise a lower rate of pay outside of London, and also to allow for families to immigrate which means recognition of the contribution made by part time staff too. The system must not rely on funding from employers – the care sector is mostly funded by the public purse and this effectively produces bureaucratic duplicity.

There is also a need to consider the context for staff who may bring their qualifications with them come from abroad for instance, in supporting projects such as the one at Glasgow Caledonian University on migrant skills recognition to enable people to work in the care sector more easily, whilst also offering protection both to the workforce and those they care for.

The situation for social care is critical. Simple and effective solutions exist but cannot be implemented because of political jurisdiction made by those who are far from the frontline. To add another 9% to the social care vacancy rate risks blocking the whole system, an issue fundamentally of human rights given the catastrophic risk to people and their families.

Whilst our NHS colleagues have raised significant concern about what a reduction in social care would mean for acute services including NHS 24, the ambulance services and hospitals, I urge you also to share this message. For social care, for the people who access care and support, and the workforce affected by the proposals, we need to act now – time is running out.

Karen Hedge

National Director, Scottish Care


Read Scottish Care’s response to the UK Government’s immigration plans here.

Nurse Empowerment Blog by our National Workforce Lead for Nursing

How do we empower nurses today?

Nursing has long been seen as a challenging profession but viewed by many as a vocation for the dedicated and the selfless, which relies on nurses being professional, self-aware and motivated educators to lead change. Being caring and compassionate were integral to the role, as was the ability to follow instruction, which for some led to ritualistic practice for a number of years.

The development of nurse education led to evidence-based practice through nursing data and research, which has been key to empowering nurses to influence change, resulting in service improvements and better quality of care, and recognition of the need for nursing to be part of a life-long learning process.

Nursing empowerment is a structural process which supports shared team goals and ability. This is  supported by open communication and positive leadership which has the desired outcome of motivating staff to work to the best of their ability which will improve achieving outcomes and  creates the capacity to utilise resources and to provide support, opportunity, and information.

Research shows that empowering nurses allows for better decision making, job satisfaction, reduces stress and improved outcomes for patients. Subsequently when nurses are in a position to influence, they are less likely to suffer from ‘burnout’ as they feel listened to and are empowered to work to the top of their job descriptor.

Within the care sector nurses should not only be empowered but expected to work with a high degree of autonomy, and to act as an advocate for the residents, as they can’t always do this for themselves.

According to the RCN ‘One of the most important principles of safeguarding is that it is everyone’s responsibility ’.This requires strength of character to challenge other professionals, who may often hold more senior roles, to ensure the views of the residents are upheld, and more importantly no harm ensues. The quality of care is reliant on nurses measuring risk and harm and being educated and skilled to act appropriately to ensure safe practice.

This is particularly important within the independent care sector to ensure that despite some residents being frail and having cognitive deterioration, that they are still given the opportunities for improvement and achieve a level of stability through preventative programmes

Research would indicate that a move to an inclusive approach empowers residents through self- determination and autonomy although this does require the nursing staff to think differently and be more innovative.

The World Health Organisation (WHO) defines patient empowerment as “a process through which people gain greater control over decisions and actions affecting their health” and should be seen as both an individual and a community process.

This is evident within interventions such as the Care About Physical Activity (CAPA) programme and meaningful activities used with care home nursing, which show that empowerment initiatives provide both a process and an outcome. Research is limited in this field however if empowerment is present for staff then residents may benefit in a way that promotes an awareness of self-ability that can influence goal setting, with the potential to improve quality of life.

So how do we empower our nurse today?

Education, alongside a determination to provide quality care within a positive culture of change has brought nursing to where it is today, but it is through positive leadership that we will harness our nurses to be empowered today and into the future.

We know that disempowerment can be related to deficient leadership interventions. Some nurses may feel that managers are insensitive to their staffing needs, don’t support employee well-being, and don’t invest enough in training or career or professional advancement. This is fundamental to ensure successful recruitment and to retain staff in this field. Many nurses leave their positions because of negative experiences with heavy or unrealistic workloads, as well as a feeling of being unheard and undervalued.

On the other hand, several studies have indicated that when staff rate their managers then they feel that they’re listened to, and more likely to get, and be involved in the decision-making process. This is an indicator of positive leadership. Therefore if our managers’ behaviours support a team -based approach, then this will ultimately impact on empowering our nurses.

Creating supportive environments where staff have the psychological safety to speak out, to have an opinion and ultimately grow, is also a reflection of positive leadership. This should not be underestimated as highlighted within this recent article:

Creating a positive culture that provides access to appropriate training and development will provide staff with the necessary knowledge and skills to carry out their role efficiently and effectively .This will boost self -awareness, give staff a voice, and the ability to be confident to act as a representative across a variety of arenas. It will continue to challenge staff to find solutions and promote nurse led initiatives.

This needs however to be done as a systemic organisational approach, as even when positive changes are adopted where staff are not consulted about these changes in advance then the changes can still be perceived negatively by staff.

Through this visionary intelligent leadership approach a supportive culture will exist that expects staff to question, to take risks and to have the permission to ensure transformational change.

Ultimately the message to our nurses is one that continues to push the boundaries for excellence, promotes our new nursing standards, ensures advocacy for our most vulnerable adults and doesn’t lose sight of our ability to care.


Jacqui Neil

National Workforce Lead for Nursing, Scottish Care

Workforce well-being blog by Jacqui Neil – Workforce Lead for Nursing

2020 is the ‘International Year of the Nurse and Midwife’ so it seems the right time for my first ever nursing blog. These will continue each month to celebrate the contribution and dedication of our nursing and care staff across Scotland.

This year offers the prime opportunity to hear about the spectacular work that is happening across our care homes in Scotland ,and to showcase this through our Nursing Blogs and to get our talented staff involved by being guest speakers, and take on the Nightingale Challenge.

Our aim at Scottish Care is to provide a topical platform for updates to keep staff informed and to support employers, and through our staff guest speakers to inform the wider care sector that this sector offers fantastic career opportunities for staff at all levels, and delivers quality care to our residents across Scotland.

January’s blog is looking at Workforce Wellbeing, as it’s the start of the year, and it’s important that all our staff take time to think about their own health and wellbeing, to ensure safe and quality care to their clients/residents.

The social care workforce in Scotland is predominantly female and organisations like Scottish Care have long argued that the way in which the workforce is treated in terms of fair work practices, equal pay and other related matters is often one rooted in a discriminatory approach and is evidence of gender segregation. Research indicates that gendered ageism seems to be the cause of many problems women experience whilst working. This will require a change in prevailing values, beliefs and norms within organisations. Viewing the treatment of female staff through a human rights lens would have a significant impact on the retention of staff.

In light of this I have decided to look at Menopause in the Workplace due to the fact that 86% of the workforce are women and to promote awareness of how managing this can improve retention of staff and reduce the days lost to sickness absence.

The average age of the workforce employed and applying for posts in the care sector is 46 years and above. Many are likely to be mothers, grandmothers or informal carers, alongside choosing to work in an extremely physically and emotionally demanding workplace.

Being aware of this and also that staff may also be experiencing issues as a result of bereavement (personally and or/at work), financial pressures, or other health conditions, is important and knowing that all of this could escalate their menopausal symptoms. Beyond the menopause, the lack of certain hormones in women can lead to increased risk of brittle bones and heart disease.

According to the National Statistics Department (NSD) the average age of women experiencing the menopause is 51 years, although this can happen much earlier for some women, with 1 in every 100 being under 40 years. Nationally there are 3.5 million women over 50 in the workplace and this is set to increase due to the increased retirement age.

The Care Inspectorate’s recent report found women workers over 50 years account for 45% of care workers. This therefore means that a significant amount of women working in care are experiencing symptoms in relation to the menopause, and for some these are very significant and impact on their work and personal lives. It is therefore paramount that this issue is recognised and understood so we can ensure that the working environment is supportive, and that staff feel secure and valued.

The true impact of this is under-reported as many women do not seek help, despite experiencing severe physical and psychological symptoms such as anxiety, depression, loss of confidence as well as severe fatigue and difficulty sleeping. At a time when the care sector is in crisis in relation to recruitment and retention of staff, it is key that the staff who are employed take responsibility, and feel empowered to raise this if they are experiencing menopause symptoms that are impacting on their job.

Findings from a new national report revealed that over 370,000 working women in the UK aged between 50 and 64 admitted they have left, or considered leaving their career, because dealing with the symptoms of the menopause in the workplace was too difficult. As in the NHS, staff absence in the independent care sector for short and long-term absences is increasing in this age group, with data suggesting 1 in 4 experiencing menopausal symptoms consider leaving their jobs. Moreover, in a recent study involving a 1000 women, nearly a third of women surveyed (30%) said they had taken sick leave because of their symptoms, but only a quarter of them felt able to tell their manager the real reason for their absence.

Presenteeism is highlighted as a bigger issue than absenteeism in some areas, as staff are fearful of being reprimanded for being off sick. Especially when many are being managed through inappropriate HR policies, with a lack of occupational health support, which not only prevent staff caring for their own health, but also can negatively impact on the quality of care provided to residents/clients.

This can be achieved by developing more support and by introducing mandatory equality and diversity training around age and gender. This may include the implementation of policies around menopause related absence and flexible working arrangements, as well as encouraging informal women’s support networks across the workforce.

The Equality Act (2010) protects women against workplace discrimination on the basis of sex or age, whilst other pieces of legislation place a general duty on employers around Health and Safety and the welfare of workers.

Recent figures have shown that women aged 50 to 64 are the fastest growing economically active group, and therefore have the potential to support the social care recruitment crisis if they are encouraged to join the workforce and managed and supported to be at work.

The employee should adopt a self -management approach and consider ways to ensure that they are looking after their own health and well-being:

  • Keeping hydrated in line with the RCN’s ‘Rest Rehydrate Refuel’, which campaigned to ensure staff get nutritional breaks. Ensure breaks are taken, it’s in no one’s benefit to work on.
  • Uptake of the flu vaccine remains considerably low, even in the NHS where staff can access free. This needs to be available to all care staff working with vulnerable adults as this prevents unnecessary short-term absences. It’s not too late ……
  • You don’t need to join the gym, go for a walk.
  • Eat healthier / Drink responsibly
  • Seek help with smoking cessation.
  • Mental health and wellbeing information guidance.

The following is a list of organisations/websites that offer valuable help and support to women suffering the symptoms of the menopause:

  • British Menopause Society:
  • Menopause Matters:
  • NHS:

Employers should consider positive changes within the working culture and environment to alleviate the difficulties for women to enable attendance at work, and when absent are able to be supported back to work at the earliest opportunity:

  • Encourage all managers to undertake a course to deal with this, and to take account of the menopause transition. This would be a positive step to improving retention and days lost through sickness absence. The 2013 TUC report, Supporting working women through the menopause, found that 45% of managers did not recognise the problems associated with the menopause.
  • More recently according to the Wellbeing of Women Survey (2016) despite employers requiring an inclusive workforce, around two thirds offered no specific support to women experiencing difficulties related to the menopause.
  • Ensure supervision meetings. The Strathclyde’s Scottish Centre for Employment (SCER) research findings and interviews found that care workers valued supervision as a source of support and an opportunity to reflect on practice.
  • Managers and colleagues should be more understanding, including education for ALL members of the workforce.
  • Option of flexible working hours and time off for appointments.
  • Provision of a quiet, cool room with fan to allow staff time out.

Finally in 2019 the Laura Hyde Foundation  launched a well-being badge for nurses to wear  that states ‘Ask me how I am’,  in a bid to allow the public  to consider the staff wellness.


Jacqui Neil

National Workforce Lead for Nursing, Scottish Care

An introductory blog from our National Workforce Lead for Nursing – Jacqui Neil

It’s now 3 months since I took up my new post with Scottish Care as National Workforce Lead for Nursing , I feel revitalised and reconnected to Nursing,  and so proud to be a nurse in the ‘International Year of the Nurse’. As you will be aware 2020 marks 100 years of nurse registration, and 200 years since Florence Nightingale and a team of nurses improved the unsanitary conditions at a British base hospital, reducing the death count by two-thirds, which led to worldwide health care reform.

Subsequently Care Home nursing has evolved to meet the increasing demands and changing demographics of older people and will require to continue to evolve in light of the numbers of older people predicted to continue to rise up until 2035. Demographic change is complex, with links between the different drivers of demographic change, and a range of social and economic factors which can impact on trends, leaving projections open to uncertainty . Transformational change and leadership is therefore paramount for sustainability of the workforce.

Networking with front line staff who are delivering first class care and compassion within extremely challenging times, alongside working with strategic stakeholders has confirmed the importance of having a shared goal of improving the profile of care home nursing.

Prior to taking up this post I had a 32 year NHS career managing staff groups across acute and predominately community nursing, taking up my first staff nurse post in 1990 , then working as District Sister, Clinical Team Leader and finally as Service (Locality) Manager within  a HSPC.

Despite not having worked within the independent sector I have had strong partnership alliance with the third and independent sector throughout my career.

Working on improving the recruitment and retention of staff within the care sector at a strategic level allows the opportunity to make a difference at service level. Be reassured that I am fully committed to raising and transforming the profile of nursing, and the quality of care provided within the sector through strong leadership.

In September the pre reg nurse training will ensure all students will have a placement within a care home and it’s up to the staff to make it a memorable rewarding experience, that hopefully will see a trend in more newly qualified nurses seeking to work in care home nursing, and see it a positive long-term career opportunity.

Do not hesitate to contact me if there are any workforce or nursing issues concerning you. It’s important that I am focused on areas of concern that are an issue to service delivery, quality and client safety.

My nursing blogs will start this month starting with Workforce Wellbeing and will continue throughout the ‘Year of the Nurse’  to encourage staff to get involved and undertake the Nightingale Challenge. If you have any topics that you would like highlighted please get in touch by email [email protected] or Twitter @TransformNurse.


Jacqui Neil

National Workforce Lead for Nursing, Scottish Care

On a separate but related note, Tom McEwan from UWS will be hosting a webinar on Friday 17 January at 11:30 am to discuss the new pre reg nursing programme, as well as their proposed pilot of care home placements around their 4 campus areas – Ayr, Lanarkshire, Paisley and Dumfries. They are currently looking for care home providers to nominate themselves to take part in this pilot. Please click here to find out more.

Imagine a Decade of Care: a new year blog from our CEO

As doors of all sizes, shapes, and colours open up across Scotland to welcome in the first foots of the year; as peat, log and paper kindle an open hearth, as hand and hug, food and drink foster hospitality and welcome, so we find ourselves standing at the brink of a new decade. What to say at such a point in a blog for the New Year?

It would be the folly of futility to try to prophesise what this decade will bring. Indeed, at its edge we are witnessing almost unapparelled times of political uncertainty and societal challenge and no little fear and discomfort. But in the spirit of the optimism and hope with which we traditionally greet the new year as Scots, I for one would want to be positive and optimistic for to be any other is to bring into life the darkness that risks our tomorrows. So, what of social care? I would like to imagine and hope that this will be a Decade of Care.

I imagine a decade where women and men who do the astonishing job of caring for others, whether as a family member or as a paid professional, will be recognised as the vibrant heart of our country not as is so often the case as a drain and drudge. Where they will be properly remunerated and resourced either by appropriate respite and support or by being paid a wage, which is not just about ‘living’ but about being valued and affirmed, being able to dream their own dreams and live out their own future.

I imagine a country which turns the tables on what is considered to be of fiscal value and sees that those who care for others, those in our people sectors as the true entrepreneurs and navigators of our nation’s future; where the economic value of social care is not just talked about but that we consciously choose as a society to invest in, to finance and support the innovation and growth of our care sector.

I imagine a decade where we will be able to shape the way in which technology can enable us to be better at caring, to be more present when we need to be, which frees people up to care and which reduces the drudge of the practical. The 2010s have seen enormous progress. It was that decade which brought us technology as diverse as the iPad, driverless cars, smart devices by the score and 3D printing. Who knows what the 2020s will offer. But I want to hope that all innovation will be rooted in an ethical and human rights framed understanding that commits to the human and the personal, to citizen autonomy and control over data; and for each of us, but especially those who require care and support, to be the directors and leaders of their lives and not actors to someone else’s script.

I imagine a society which finally takes seriously the environmental and natural challenges we are all going to have to address. A Scotland where we do not just leave it to our children to be the campaigners for our planet. Admittedly the care sector has much to do in this regard, but this decade will have to be one which reduces waste, replaces unnecessary use of plastics, transforms our use of energy  and which makes being green a core part of what it means to care.

I imagine a society which does not just talk about human rights in pious platitudes and political catchphrases, but which acts to enshrine the rights of others at the heart of all we do and who we are. Where dignity, fairness, respect and choice are ethical values which are also underpinned by the robustness of legal recourse. Where we do not just talk the talk by passing great legislation in our Scottish Parliament but robustly enable change to happen through progressive work on issues like self-directed support, mental health legislative reform, palliative and end of life care and bereavement support, and every other piece of work that enables citizens to lead, removes power from vested social and political interest and truly democratises the way we do things.

So, I have no shortage of imagination as I stand on the edge of the decade – but that is not enough. Imagination has to be rooted in a determination to do different and be better. Imagining tomorrow starts with struggling with the issues of today.

For me in the work I do those struggles are against the discrimination of the old who are too often treated as if they are ‘has beens’ with nothing to say, contribute or change. It means challenging the cult of youth by recognising the mutuality of community, the inter-generational nature of belonging and the inter-dependency of all. It means challenging the easy complacency which inadequately resources and funds the costly task of care. It means the end to a naivety which thinks that quality care and compassion can be bought on the cheap and delivered on a shoestring. It means giving real power to citizens and real choice, not the creating of one-size fits all solutions or the drawing back of choice on the questionable presumption that Mother State knows what is best for you. It means shouting down the casual excuses of ‘It’s Aye been done like that’It’ll no work here’ or ‘We’ve tried it afore.’ – these three sisters of Scottish passivity – which are holding back so much across Scotland that is innovative, progressive, challenging and new.

To imagine a decade of care is to imagine a time where all those with something to say are heard and listened to; where those who struggle to be heard because of disability or self are able to find voice and recognition; where the scars of mental health are recognised and reshaped regardless of age; where the emptiness of a lonely life is populated with the presence of others; where personal purpose and meaning unleash the shackles of addiction and dependency; where the stranger is seen not as an outsider but as the one whose presence shapes our communities; where the contribution of those who are migrant and new citizens is celebrated and valued; where we no longer debate difference as the means of creating identity but where inclusion and openness foster belonging and citizenship.

I hope with others to reach a 2030 having contributed my own small share to creating a Decade of Care.

Bliadhna mhath ùr agus deichead ùr sona

Happy New Year and Happy New Decade.

Dr Donald Macaskill

CEO, Scottish Care