The last few months have been marked by an unprecedented focus on nursing and nurses’ despair about the conditions under which they provide care to patients.
It has caused me to reflect on a conversation I once had with the CEO of a DHB who asked, with genuine mystification, why it was that nurses constantly told him that they felt undervalued? In a nod to Elizabeth Barrett Browning – the poet who famously asked “How do I love thee? Let me count the ways” – I ask, “Why do nurses feel undervalued? Let me count the ways”.
Decades of struggling to be heard
It has been a salutatory experience to be a nurse leader now for more than 25 years. My overriding sense is of a long struggle to be present at the table, to be heard at the table and to be taken seriously.
As a nurse academic especially, I have been involved in numerous efforts to raise awareness of the enormous wealth of New Zealand and international evidence about the relationship between registered nurse staffing and patient safety. For years, nursing talked about needing to amass the evidence and it has now done so extensively all over the world. It is difficult to understand the complete lack of interest with which this evidence has been greeted in numerous settings here.
I remember the long struggle – and eventual failure – to have taken seriously the Magnet evidence on the nurse job satisfaction and patient safety factors that give a hospital ‘magnet’ status for attracting and retaining nurses. Numerous studies of the nursing workforce environment have also shown that nursing should have direct line accountability for nursing from the executive table to the bedside. But just this morning I read yet another DHB restructuring document that gives huge leadership to medicine and positions nursing as an adjunct.
DHBs have simply ignored the evidence about nursing leadership, with very few directors of nursing (DoNs) holding the budget for nursing. Many are sidelined to advisory positions where they experience full accountability for nursing outcomes but have little control over the mechanisms influencing those outcomes.
Lack of respect and recognition
As someone who teaches primary health care at master’s level, and through the College of Nurses, I have listened over and over to nurses from general practice and from older care settings who are treated appallingly in terms of recognition, respect, remuneration and collegiality. Yet at the same time, I have watched the contribution made by nurses in these settings escalating exponentially.
Despite the relative narrowness of biomedicine and the comparative breadth of nursing, it is almost always still necessary to ask tiredly, “What about us?” when new decision-making, leadership or review groups are being established. It is irritating and demeaning to consistently be reminding people that we are the largest health professional group with an enormous sphere of engagement and we are alongside consumers 24/7 in every possible setting and every possible experience. We know a great deal about what works and what doesn’t.
Nursing has also had to constantly defend its need for leadership positions, for advanced practice positions and for investment in postgraduate education (which to this day remains absolutely minimal, despite considerable evidence linking nurses’ education level with increased patient safety). We also now know that nurses and nurse practitioners can provide the full service in primary health care and general practice for a fraction of the investment made in the current workforce.
Taking notice of nursing – at last – but yet…
The recent industrial activity brought unusual media interest in nursing, with one journalist actually wondering aloud why she had been a health reporter for so long and never really taken any notice of nursing. Why indeed? I well remember fielding calls from journalists when nurse prescribing was approved and thinking journalists would be keen to know what this might mean for consumers and their access to services. Sadly, the only real question any journalist ever asked was, “What will medicine think about this?”.
This year there is finally a tacit acknowledgement that nursing has been the ‘go-to’ area for cost savings, leaving a wide gulf between what is needed and what we actually have, in terms of staffing. There is a belated race on now to close that gap.
The signing of the Safe Staffing Accord will hopefully bring major gains for nurses (and patients) in hospitals. Similar action is needed for other settings.
But I am aware of an intriguing and concerning development amongst health bureaucrats and generic managers. Just when there is some much-overdue attention being paid to the value of nursing, it has become improper or unwise to talk about nursing alone. Rather, we are exhorted to think and speak of the multidisciplinary team.
I have no argument at all with the vital importance and value of multidisciplinary teams; nurses have always understood the value of the team. But I would hate to think that this is an unconscious mechanism to distract us from some vitally needed, long overdue investment into nursing.
Nursing remains the largest, most generic, flexible and fit-for-purpose health workforce in the system – a workforce whose potential has never been fully released because of a persistent reluctance to acknowledge the value of doing so.
Professor Jenny Carryer is executive director of the College of Nurses Aotearoa and chair of the National Nursing Organisations (NNO) group.