Editorial

Te Puawai August 2008

Recent editions of Kaitiaki Nursing New Zealand have carried two articles in which recipients of nursing care in acute hospital care have felt very deprived of the kind of attention to their needs, which we would identify as caring.  In one especially poignant article (Kai Tiaki 14,5)  Dr. Robin Youngson is quoted describing the experience of his family in trying to meet the caring related needs of their badly injured 18-year-old daughter who was in spinal traction and forced to lie flat for a long period of time. In another article a registered nurse herself describes details of her own feelings of neglect during an admission (Kai Tiaki 14: 4).

Much of the reality of these stories is noted by nurses themselves who constantly articulate their personal dissatisfaction because each shift leaves them with a feeling of persistent discomfort because they know they have missed many of the small but critically important details which make a difference to patient’s comfort and indeed safety.  From time to time nurses have sent me letters about those feelings and experiences, which are the flip side of patient feelings of neglect and loss.  Here is a nurse (5 years post registration) speaking of her experience in a busy surgical ward;  “ I can remember only one shift in the past few months in which I felt satisfied walking out of the ward knowing I had given my patients the best nursing care I’m capable of…. I don’t mind being busy and I enjoy a challenge but the constant suffocating pressure of the current work situation is killing the spirit of nursing”.  

My reaction to the voices of patients and to the voices of such nurses is of course huge concern. How could any of us not be concerned about a situation which suggests patients are suffering and which clearly shows the related concern and personal dissatisfaction of nurses as they struggle to do what they envisaged nursing would involve. One recent correspondent described nursing as being in “a dark place” and I am inclined to agree with such a view.

But in what I would term a darker place some commentators argue that the failure to provide true ‘caring” is the product of “too much book learning” compounded by the need to engage in seemingly pointless exercises like the PDRP program and increased requirements for documentation. This response is what one might term the “anti intellectual” response which argues loosely that the situation of “failure to care” is variously a product of fundamental flaws in the undergraduate education curriculum, an over dependence on postgraduate qualifications, the loss of enrolled nurses and the excessive control of nursing academics who are held responsible for a number of seemingly punitive developments including the escalation of required qualifications.

The best (or worst) example of this is misunderstanding about the HPCA (2003).  Nurses themselves sometimes seem oblivious to the fact that the HPCA and the requirement to measure ongoing competence to practice applies to all health disciplines equally and was not invented by nursing.  Certainly the PDRP program itself was invented by nursing as a response to the HPCA and I am aware of arguments that the program makes some demands, which are seen as excessive by many nurses.  Similarly I am aware of nurses who having completed the process are surprised by the sense of personal satisfaction and the insights gained. What is important however is that to the best of my knowledge the dreaded ‘academics” have played little role in its development or implementation and there are constant opportunities for nurses themselves to shape the process which falls under frequent review in most institutions.

In a related example another recent retired RN correspondent shared a piece that she had had published in a New Zealand newspaper as an explanation of the nursing shortage.  The article included the following statement  “ the academics and quality control experts have laid on nurses the legal burden of having to be answerable to a Judge or the Nursing Council disciplinary body for all aspects of their work, including other health workers under their supervision” The author notes that   “ Doctors used to supervise the work of nurses and take ultimate legal responsibility as long as orders were carried out correctly” and goes on to imply that this situation (if indeed it ever existed)  was preferable.  The article takes a shot at nursing based racial apologists. Feminists, anti medical attitudes and evidence based practice, which have apparently combined to push common sense, getting your hands dirty and easing the pain of others by nurturing, into the back seat.

The views of Chris Cottingham are well known to readers of Kaitiaki as he utilises his monthly column to take pot shots at the seeming control of academics and managers in the nursing environment. We should take every opportunity to use humour to challenge nursing and nursing developments but undoubtedly Chris ascribes strongly to the anti-intellectualist stance and uses it to vigorously challenge the behaviours of nurse academics in particular. Recently (14; 6) he speaks of the Management- Academic complex and the “descent of an iron curtain across the continent of nursing thought and discourse”.  In language interestingly redolent of the very tryranny he despises, Chris notes that the work of the academic - management complex is designed to dismiss and discard the realities of nursing work.

Ironically the realities of nursing work are well captured in a large research project with which I am currently involved. An alternative explanation for nursing’s dark days is to consider the known changes in the nursing work environment in the last 10-15 years.  New Zealand’s National Health Information System’s (NHIS) data clearly reveals the sharp drop in available nursing hours in the second half of the 1990s as National’s health “reform” policies caused an intense focus on the “bottom line” of hospitals at the direct expense of nursing leadership and nursing seniority and sheer numbers of available registered nurses. This data has been captured in McCloskey and Dyers (2005).  Similarly (with economy in mind) the patient length of stay has shortened steadily over the last 15 years compounding a significant increase in patient acuity. As most of us know, nurses are now caring for higher concentrations of very sick people, with considerable “churn” (the rate at which beds fill and refill).  They are doing this in much the same spaces as they previously cared for a ward mix of a few very sick patients, more moderately unwell patients and a good number who were simply convalescing (remember those bored men who desperately wanted something to do to fill in the time!!). 

The demands on nurses in acute hospital wards have never been greater and nurse’s current sense of dissatisfaction is not surprising.  Nor is it surprising that nurses struggle to provide comfort, dignity, privacy, communication and those small but vital personal touches, which make a world of difference to patients.

The different responses of various commentators reflecting on this situation are of immense interest.  The anti-intellectual stance always saddens me somewhat as I consider the potential response to this particular world-view.   What do the anti-intellectualists want? Would this mean no further research, no further critical examination of how and why we do what we do, no voice for health as opposed to illness and a return to training nurses to be rigid procedurals carrying out the orders of an increasingly diminished medical workforce without using their own intellect or decision making. To be sure that is an extreme response but it is of course hard to have half measures, we are either in the tertiary environment along with every other health discipline and contributing appropriately or we are out of it and I am not sure that is what anyone really wants?   I cannot imagine today that intelligent young women and men of the calibre required for nursing would ever be attracted to such a world.

Again drawing on research, the international body of work around Magnet hospitals has shown us that for patients to be safe in hospital a number of things are important. The number and quality of RNs available on a ward, the direct leadership or reporting line of nurses from bedside practice through to the executive director of nursing and the quality and quantity of postgraduate education all make a measurable difference. At bedside level there is a close connection between the intelligent and close surveillance of patients 24/7 by registered nurses. Furthermore the research has also now demonstrated pretty clearly that the level of education of the RN improves the quality of that surveillance and thus directly impacts on patient safety.  Additionally education whilst demanding and often stressful, improves confidence and job satisfaction as well as the quality of patient care as captured in this comment from a postgraduate student in a pain management paper:  I am not sure why this paper has challenged me in the way it has.  Was I receptive to learning, was it the way the subject was being presented, was it that I enjoy the pain management aspect of my work?  I know that I want to be able to care for patients to the best of my ability. My eyes were opened, my awareness has been raised, my knowledge increased and I have the ability to put this learning into my clinical practice.  This leads to the patients I care for having more effective pain management leading to a quicker recovery and an increased quality of life.

What is it about nursing work that allows the persistent (albeit diminishing) discomfort about the connection between intellect and action?   Critical reflection is vital and complacency always dangerous but I do not understand why the anti intellectual stance has been so persistent in nursing. The worst feature of this is that it causes us to look inwards at ourselves far more than we engage in an active and vigorous critique of the nursing workforce environment.  Ensuring the nursing workforce environment is conducive to nurse’s comfort and job satisfaction and to patient’s safety and comfort is critical. Compromising or reducing the drive to have an intelligent and highly educated nursing workforce alongside all other similarly educated health professionals will not achieve improved patient care. Attention to Magnet principles in the workforce environment offers more potential for nurses to have the time and energy to attend to those small details, which so profoundly impact on the patient experience.