Editorial

Dr Jenny Carryer

A recent edition of the Dominion Post newspaper reported that Capital and Coast District Health Board planned to disestablish a number of clinical leadership and educator positions in nursing. At this stage I am unsure as to the exact plans now intended but I am sure that even the suggestion of such a move warrants serious discussion and analysis.

The rhetoric of the article and the surrounding discussion, especially one radio interview, suggested that those nurses whose positions were being disestablished were to be "returned to the bedside". To the undiscerning public, and to non clinical managers, this might sound to be a good move. Everyone knows we are short of senior nurses, providing high quality clinical care right where it is needed. Ignorance of the importance of a professional practice model of nursing service delivery can lead to the simplistic decision that all nurses in hospital environments are best deployed in the direct delivery of patient care. Unfortunately antiquated notions of nursing as women's work and a process devoid of intellectual endeavour persist to this day in unexpected places.

I think it is extremely important that we review what actually happened in the so-called health reforms of the 1990s, and remember the consequences of those processes. Those who don't remember their past are said to be condemned to repeat it. As part of a drive to make hospitals more cost efficient, people in generic management positions came to see nursing as a "big budget" item, and looked for ways to prune that budget. Although individual nursing salaries are very small the sheer volume of the nursing workforce makes nursing salaries a significant part of the expenditure of any health organisation.

A number of myths were perpetrated at this time, including the notion that nurses added value only when engaged in the provision of direct bedside care, that specialisation in nursing was irrelevant and that "generic managers" were best placed to oversee the management and deployment of nursing services using management skills. Such myths served the interests of those balancing the books because the myths supported the destruction of clinical leadership and management positions in nursing and also of positions related to clinical education.

The consequences of this cost cutting, based on ignorance of nursing practice, have been far reaching. They have been extensively discussed in numerous peer reviewed journals in all developed countries, and it is agreed that these money saving practices have done considerable damage to the nursing workforce and have had far reaching consequences for patient safety. Simultaneously, the enormous body of work related to "Magnet" hospitals has steadily refined a body of evidence that demonstrates beyond doubt that a professional practice model of nursing service delivery with clear leadership lines, specialist nursing positions, education positions and good clinical education is critical to a cost effective, safe service.

It is thus deeply disturbing to see any apparent evidence of the resurgence of the sort of thinking that led to these disastrous decisions with the goal of budget cuts. Given the fiscal fragility of most District Health Board provider arms it must be considered that such events could begin to happen again. Whilst there is a very slow recovery from the destruction done to nursing in the nineties, there is now no resilience and no capacity in the sector to withstand any further damage. What alarms me most is that I think nurses are probably still not in an adequate position to challenge such decision making, despite the fact that we have a strong armoury of evidence on our side. I am in no doubt that there would be no real recovery should these kind of processes be rekindled. Any further damage to the nursing workforce would be quite simply fatal.

One major consequence of the last decade of nursing cut-backs is that we have lost a whole generation of leadership succession planning. Nursing leaders are few and far between and even where they are in place now, the lines of authority for nursing are fractured and unreliable. There is still considerable blurring of the boundaries between nursing leadership and generic management and many nurse leaders are caught in positions where they have limited power over their own domain. Such a situation makes us very vulnerable to a repeat of poor decisions about nursing workforce configuration.

Tragically such decisions are often invoked in a manner which leaves the nurse leader feeling isolated and unsupported. Even more tragically, the scenario is often played out in such a way that the nursing workforce instead of standing behind the nurse leader may come to believe that he or she is actually the author of their misfortune. The anger and misery this causes often confuses the issue, and allows the destructive changes to take place, with irrevocable consequences.

From a health sector perspective the final irony is that years of such decision making absolutely failed to gain any traction on hospital budgets; indeed the evidence now suggests that such decisions significantly increased the costs of running hospitals as numerous managers attempt to cope with the complaint industry and fund sick leave and high turnover costs from a distressed and decimated nursing workforce.

How can we stop all of this happening again? Some basic principles might help. Each and every nurse should clearly read and understand the evidence, which strongly supports the need for investment in professional development, clinical education and good orientation. They should have at their fingertips the evidence that so clearly shows the intimate connection between registered nurse staffing levels, strong leadership structures in the nursing service, autonomy over nursing practice and the resources which support it, and the availability of clinical educators to support novice practitioners. Knowledge is power.

We could adopt as a code of practice the practice of insisting that we no longer need to provide evidence to justify the status quo but generic managers must provide strong evidence to justify changing it. By evidence I mean a well-developed business case, which factors in all that we now know about the important connection between the nature of registered nurse staffing and patient safety. We should insist on overt authorship of the wordy "consultation" documents, which accompany slash and burn decisions. In such circumstances anonymity is never acceptable.

And finally and critically we must pull together and communicate strongly across all levels of the profession. Leaders must be supported and nurtured. It is always tough and lonely at the top and the pressures not easily understood until someone has been there.

It would be a tragedy if we were to see a return to the destructive processes seen during the1990s. The recovery from that desecration of nursing leadership and clinical education is still very fragile and will not survive further damage. Given the evidence we have a duty of care to powerfully, collaboratively and articulately challenge any further damage to the nursing workforce.

Back to Top
All rights reserved © College of Nurses Aotearoa (NZ) Inc.