Health ?nd Medicine, Research Paper Example

Introduction

Over the last few decades throughout much ?f the industrialized world governments have attempted t? reform their healthcare systems. The primary driver for reform has been escalating costs from factors such ?s new medical technologies? increasing drug costs? greater public expectations ?nd ageing populations (McKee et al.? 1997). The need for efficiency ?nd cost effectiveness has been ?n important influence t? changes ?n nursing’s skill mix ?n Organisation for Economic Cooperation ?nd Development countries (Buchan ?nd Calman? 2005).

Skill mix was a generic term that included the combination ?f jobs ?n the division ?f labour? the blend ?f employees ?n a post? the activities they performed ?nd the skills available ?t a particular time (Buchan et al.? 2001). There were a number ?f different ways ?n which skill mix could be altered. These included substituting one type ?f worker for another; delegation ?f a task from one occupational group t? another; job enhancement by enlarging the skills ?r scope ?f practice ?f a particular group ?f workers; ?nd by creating new types ?f job roles (Sibbald et al.? 2004). In countries such ?s America? Australia? Canada? New Zealand? South Korea ?nd ?n the UK new nursing roles have been implemented ?nd existing roles extended t? improve efficiency? ?s a response t? medical staff shortages ?nd t? improve services ?n rural ?nd remote areas (Buchan ?nd Calman? 2005).

Arguably such skill mix changes have added t? nursing’s historically broad ?nd uncertain jurisdiction (Davies? 1995). An occupation’s jurisdiction ?s its area ?f responsibility within the division ?f labour (Abbott? 1988). There has been longstanding debate within the occupation about whether nurses can ?r should attempt t? claim ‘caring’ ?s the occupation’s unique jurisdiction ([Paley? 2002]? [Salvage? 1992] ?nd [Traynor? 1999]). There has also been discussion about whether healthcare reform ?nd skill mix changes have valorized technical competence over less measurable ‘caring’ skills (Corbin? 2008).

The English NHS ?s a good context for examining these issues. The UK Government has been keen t? empower nurses seeing them ?s key t? cultural change ?n the NHS. Policy initiatives have offered nurses the opportunity t? increase their occupation’s status by skill mix changes which challenge the dominance ?f the medical profession ([DH? 2000] ?nd [DH? 2005]). However? there ?re concerns about falling standards ?f nursing (Revill? 2007) ?nd the government now plans t? measure the quality ?f nursing (DH? 2008). This article seeks t? provide a better understanding ?f the consequences ?f skill mix change for nurses ?t the workplace level. Thus adding t? understanding about the relationship between government policy ?nd the occupation’s development.

Post-devolution changes have resulted ?n a divergence ?f health policy within the UK? thus this paper concentrates ?n England ?n particular. T? improve efficiency ?nd service quality? the Labour Government elected ?n 1997? sought t? generate more competition within the NHS by introducing new providers thereby creating a supplier market. Private sector providers such ?s independent treatment centres added capacity t? the system ?nd were intended t? break down the public sector monopoly ?n the delivery ?f clinical services (Timmins? 2005). The English NHS ?s now a managed market with the government remaining ?s the single purchaser with the power t? control the operation ?f the market ?n its own political self-interest. Arguably reform ?f the public sector has produced contradictory developments (Klein? 2006). Simultaneous centralization ?nd decentralization has occurred ?s management ?f NHS trusts has been devolved locally with government remaining ?n control ?f strategy? resource allocation ?nd performance targets.

Reform ?f the English NHS

The NHS Plan (DH? 2000) described the government’s plans for the Service for the subsequent ten years. The government said that the NHS needed t? change from ?n over centralized system which disempowered patients t? a service designed around their needs. This required ?n organization where ‘staff ?re not rushed off their feet ?nd constantly exhausted’ (p. 17). The document also stated that rigid professional role delineation could result ?n poor responsiveness t? patients’ needs? while unnecessary bureaucracy placed institutional requirements ahead ?f those ?f patients (DH? 2000).

Reform was t? be achieved partly by increasing workforce capacity ?nd productivity through skill mix changes (Gershon? 2004). Delegation ?f tasks from doctors t? nurses had been occurring since the early 1990s. This was required by gradual reductions ?n junior doctors’ hours ?n line with the European Working Time Directive. Before the NHS Plan (DH? 2000) work delegated t? nurses involved routine technical tasks such ?s the administration ?f intravenous drugs ?nd phlebotomy (Castledine? 2007). Nursing numbers declined during the 1990s thus reduction ?n overall workforce capacity probably increased nurses’ workloads (McKenna? 1998). Indeed? recent UK studies have found evidence ?f work intensification ?n nursing ([Adams et al.? 2000] ?nd [Cooke? 2006]).

In the NHS Plan? England’s Chief Nursing Officer (CNO) listed ten key roles for nurses. These were intended t? break down hierarchical role boundaries between doctors ?nd nurses (DH? 2000). The tasks? such ?s prescribing medicines? running clinics ?nd performing minor surgery had previously been monopolized by the medical profession. The government was intending t? empower nurses by providing them with greater authority ?nd responsibility ?n the provision ?f clinical care (DH? 2005). Recently the Health Secretary said ‘It ?s nurses who the public look t? ?n order t? maintain high standards ?f care…?nd ?t ?s nurses that we must look ?t t? empower them t? carry out the role that the public expects them t? have’ (Johnson? 2008).

Nursing’s Uncertain Jurisdiction

Both Florence Nightingale ?n 1859 ?nd the first CNO ?f the 21st century were concerned about nursing losing its unique jurisdiction by nurses taking ?n medical tasks which they argued served t? reinforce nursing’s subordination t? medicine ([Nightingale? 1859] ?nd [Mullally? 2003]). Nightingale (1859) believed that subordination would have limited the occupation’s potential ?nd resulted ?n nurses doing little more than carrying out tasks like administration ?f medication. Nonetheless? nursing leaders have failed t? articulate clearly what comprised nursing’s unique jurisdictional claim ([Davies? 1976] ?nd [Paley? 2002]).

Originally Nightingale aimed t? construct nursing’s jurisdiction ?s being indistinguishable from health. Its purpose was t? improve ?nd restore health through the proper use ?f fresh air? cleanliness? diet? education ?nd housing (Nightingale? 1859). Nightingale did not talk about nursing ?nd ‘care’ ?n the manner ?f contemporary texts. Instead the concept ?f care during the 19th century has been described ?s ‘the means by which the conditions likely t? produce danger were constantly monitored ?nd kept under control’ (Dunlop? 1986? p. 663). Thus nursing’s jurisdictional claim was arguably the individualization ?f public health. In the schools ?f nursing? lectures for probationers were given by doctors ?nd Nightingale became concerned that teaching by doctors would result ?n subordination ?f the occupation t? medicine (Baly? 1997). The growth ?f hospitals resulted ?n the dominance ?f hospital-based medicine? subordination ?f nursing ?nd the public health aspects ?f the job being submerged by ill-health (Webster? 2000). Recently? internationally nursing bodies have attempted t? improve nursing’s occupational status by raising the level ?f its educational preparation (Traynor ?nd Rafferty? 1999) ?nd by claiming that ‘caring’ was nursing’s unique jurisdiction ([Dunlop? 1986] ?nd [Kitson? 1995]).

Education ?nd Nursing’s Professionalization

In the UK? reform ?f nurse education known ?s Project 2000 began ?n the 1980s (UKCC? 1986). The Project 2000 recommendations? accepted by the government ?n 1988? included pre-registration education ?t diploma level ?nd closer collaboration between colleges ?f nursing ?nd institutes ?f higher education. This involved the relocation ?f pre-registration education t? higher education institutes. The course was t? be over three years with the first eighteen months comprising a common foundation followed by another eighteen months ‘branch’ programme ?n a selected area either adult? child? mental illness ?r learning disabilities. Students were t? be supernumerary for 80% ?f the three years ?nd have a 20% rostered contribution t? service? receiving student grants rather than salaries. The focus ?f the education was t? be towards health ?nd community care rather than illness ?nd acute care ?s had been the situation previously (UKCC? 1987).

Project 2000 was based ?n nursing’s unique caring function. It aimed t? assert the occupation’s autonomy ?nd distinctiveness from medicine through the development ?f nursing models (Robinson? 1991). These models provided a framework t? enable ‘holistic’ treatment? not treatment solely focussed ?n discrete symptoms ?f disease ([Robinson? 1991] ?nd [Kitson? 1995]). Nurses were encouraged t? establish a close psycho-social therapeutic ?r ‘caring’ relationship with their patients ?nd t? use a systematic problem solving approach t? care basing their practice ?n models devised for nursing ([Pearson? 1989] ?nd [Davies? 1995]).

However? some nurses were sceptical about the advantages for nursing’s professionalization from claiming caring ?s its unique jurisdiction. It was argued that this approach was fundamentally flawed ?s caring had not been defined? therefore could not be measured ?nd was not unique t? nursing (Baker et al.? 1995). The nursing-?s-caring construct was also a source ?f vulnerability for nurses ?s caring was ?n undervalued activity (Traynor? 1999). Arguably? a more appropriate strategy was t? compete with medicine for jurisdiction over the distinctive fields ?f chronic illness? rehabilitation ?nd recovery (Paley? 2002).

Furthermore? the health care assistant (HCA) role was created ?n place ?f nursing auxiliaries t? assist nurses ?n carrying out their clinical role (UKCC? 1987). National vocational qualifications formed the basis ?f HCA education? which increased employer influence relative t? that ?f nursing. In addition? HCA role boundaries were not clearly defined. These factors opened the possibility ?f nursing losing some ?f its jurisdiction over caring work (Francis ?nd Humphreys? 1999).

The Labour Government added t? uncertainty over nursing’s jurisdiction. A Health Minister said he wanted a health service that ‘liberates nurses not limits them’ by enlarging nurses’ skills ?nd scope ?f practice (Beecham? 2000? p. 1025). Arguably enlarging nurses’ scope ?f practice would add t? nursing’s already broad jurisdiction (Davies? 1995). Furthermore? the government expressed concern that the fundamentals ?f nursing such ?s safety? dignity? hygiene? nutrition ?nd hydration were being overlooked (DH? 2001). Additionally? the government’s aspiration was that the NHS became patient-led. This required ‘a change ?n culture where everything ?s measured by its impact ?n patients ?nd the benefits t? people’s health. Becoming patient-led means thinking about the whole person ?nd being ?s much concerned with health promotion ?nd prevention ?s dealing with sickness ?nd injury’ (DH? 2005? p. 6). This suggests British Government support for a holistic approach t? care delivery.

Research Setting and Design

T? explore these questions ?t was necessary t? gather information about the details ?f the day-t?-day reality ?f NHS reform for nurses’ working lives ?nd t? collect data that reflected their beliefs? opinions ?nd experiences. These data were best collected by semi-structured interviews (Pole ?nd Lampard? 2002). This article ?s based ?n the data from interviews with nurses ?n three hospitals comprising ?n NHS trust ?n England. The trust provides acute services t? a population ?f over half a million people. It has over 5500 staff ?nd a revenue budget ?f over £200 million per annum. The reason for choosing this trust was that ?t ?s a typical medium sized acute trust. Although NHS reform was designed for the whole ?f the Service? the hospital service still dominates the political landscape. It also maintains its historic hegemony within nursing (Abel-Smith? 1979). Over half ?f all nurses ?n the UK ?re employed ?n NHS hospitals. By comparison the next largest sector ?s primary care where only 18% ?f nurses ?re employed (Ball ?nd Pike? 2004). A purposive sample ?f ward sisters? specialist nurses ?nd staff nurses was sent a letter inviting them t? interview. The sample was selected t? ensure that the variety ?f clinical specialties within ?n acute trust was captured ?nd that the sample included nurses from all three hospitals ?n the trust. Eleven ward sisters ?nd fifteen specialist nurses responded ?nd the first ten people from each group were interviewed. Only three staff nurses responded ?nd they were all interviewed. ?f the other seven staff nurses? three were nominated by their peers. The remaining four volunteered from a group ?f 25 staff nurses who were ?n a study day.

The use ?f semi-structured interviews allowed the interview agenda t? be shaped ?n line with the research questions? while ?t the same time providing the opportunity t? be open-ended ?nd flexible. The aim was t? allow interviewees t? describe the situation ?n the basis ?f their own experience thereby focusing ?n what they considered relevant. Interview questions explored occupational tenure? the type ?f activities involved ?n their current job? how the NHS ?nd nursing had changed ?n the past five years ?nd the advantages ?nd disadvantages ?f change for nursing. Approval for the study was gained from the Local Research ?nd Ethics Committee.

Each interview? lasting between 30 ?nd 60 min? was recorded ?nd transcribed. All participants signed a consent form? confidentiality was assured ?nd anonymity preserved. Interviews typically lasted 30 min t? 1 h ?nd were carried out between July ?nd September 2006. The demographic ?nd employment characteristics ?f participants ?re given ?n Table 1.

Table 1.

Demographic ?nd employment characteristics ?f interviewees (N = 30).

Data Analysis

Content analysis was used t? analyse the data. Content analysis focuses ?n what people say about events ?nd how they make sense ?f them ?n a particular context. In addition? ?t assumes that groups ?f words reveal underlying themes ?nd frequent repetition ?f keywords can be interpreted ?s reflecting associations between the underlying concepts (Pole ?nd Lampard? 2002). Analysis involved firstly transcription ?f each ?f the interviews all ?f which were recorded. Each transcript was read ?nd re-read t? gain a sense ?f the whole for every interview. The interview transcripts were read further ?n their sub groups? again t? gain a sense ?f the whole for each sub group. The transcripts were subdivided into their respective clinical specialties ?nd re-read ?n order t? achieve a sense ?f shared ?nd divergent experiences ?n this respect. At each reading marginal notes were made about significant words? sentences ?r statements t? identify emerging codes ?nd categories. Connections were then established between codes by clustering together the data that represented ?nd reflected the underlying themes. In this way the codes began t? relate t? dimensions ?f the phenomenon under investigation (Bryman? 2004). Having described the research design? the following section addresses the research purpose which ?s t? examine the effect ?f NHS reform ?n nurses’ working lives. The following discussion presents the findings ?nd ?s organized around four themes which emerged from the data: greater empowerment? losing nursing? government targets ?nd waiting times.

Findings

Greater Empowerment

Skill mix changes have provided specialist nurses ?n this study with greater job autonomy ?nd the opportunity t? develop new knowledge ?nd skills. One nurse said:

‘I have my own operating lists I get the GP letter? list the patients s? no-one else ?s seeing those patients unless ?t’s my decision s? ?f I feel I need t? see a patient ?n clinic they will come into a clinic appointment ?nd ?t’ll be my decision whether I do that procedure.’ (Specialist nurse? peri-operative care) Three ?f the specialist nurses were independent nurse prescribers. They believed this had empowered them by increasing their confidence t? challenge doctors ?nd by being ‘a lot more involved with clinical decision-making’ working ‘with medical colleagues ?s peers ?s opposed t? being a bit lower down ?n the hierarchy.’ There was some opposition from the medical profession t? the new specialist nurse roles. Furthermore? skill mix changes had resulted ?n greater empowerment for nurses ?n respect t? taking immediate action ?n ?n emergency. A staff nurse said that the doctors ‘took a step back… by the time you’ve called the doctor you’ve done everything that you would ?n someone who ?s poorly.’ Another staff nurse explained:

‘I know a lot ?f nurses refuse blatantly t? do the cannulation because ?t’s not their role… If I didn’t have t? do it? ?f I knew that someone else could do ?t ?nd be there t? do ?t all the time? then that wouldn’t be ?n issue. In the past when I’ve bleeped the doctor ?n a medical emergency ?nd its taken about 45–50 min for the doctor t? come down t? insert a cannula t? get IV drugs going through that’s quite harsh for me. S? my own personal experience made me do venepuncture ?nd cannulation.’ (Staff nurse? medicine) This indicates that the nurse did not see such tasks ?s genuine nursing. Nonetheless? she experienced job empowerment by having the skill t? enable her t? control the situation.

Losing Nursing

Indeed? interviewees said that performing tasks such ?s intravenous drug administration ‘pulls you away from essential nursing’ adding t? their workload t? the extent that fundamental nursing care was being neglected such that ‘patients were lying ?n wet beds’ ?nd ‘mouth care [was] not being done’. Instead nurses ‘?re running round like headless chickens doing task orientated things.’ A staff nurse said:

‘Staff ?re being given more ?nd more ?nd the patients ?re being neglected. Things like blood pressures ?nd just talking t? the patient become minor t? the nurse…… The bloods have got t? be done ?nd ?f another patient needs a cannua t? put IV fluids through. Obviously they [patients] could be going off [becoming critically ill] because they’re quiet; because they’re still you think right I can carry ?n with these other patients….. I think ?t [nursing] has got t? go back t? basic nursing care before ?t can move ?n any further.’ (Staff nurse? surgery) A specialist nurse with sixteen years experience ?n nursing expressed similar concerns. She said:

‘When you ?re sick ?nd ?n hospital you need t? have your teeth cleaned ?nd your hair washed ?nd all those other things. And I think that basic care stuff? t? me ?s absolutely essential? ?nd ?s what nursing ?s about? ?s being lost ?nd I think that’s quite sad. And ?s a nurse even though I am ?n a specialist service I see patients ?n the ward ?nd I get quite distressed about that. I find ?t quite difficult ?nd I find ?t quite embarrassing. Sometimes even from personal experience when I’ve had relatives ?n hospital I just think what ?s going ?n?’ (Urogynaecology Specialist nurse)

The ward sisters ?nd staff nurses interviewed perceived their work t? have become more pressurized ?n the last five years despite increasing funding ?f the Service. In addition t? skill mix changes other factors influencing the nurses’ views ?f work intensification included increased patient throughput? shorter ?n-patient stays? greater patient ?nd relative expectations ?nd staff shortages. As one staff nurse said:

‘You have got too much t? do ?nd too little time. Too many patients t? look after ….its quite demoralizing really. You walk away ?t the end ?f the day ?nd you sort ?f feel that you haven’t really done ?s best you can for the patients.’ (Staff nurse? urology)

Government Targets

In addition t? changes ?n skill mix being perceived ?s having a detrimental effect ?n the quality ?f nursing? management’s imperative t? meet government targets was also seen ?s having a negative impact. One staff nurse said:

‘….the four hour bed wait ?t’s a pain? they [the bed managers] ?re absolutely frightened t? death ?f being fined for going over the four hours s? ?t jeopardizes the care that you give your patients.’ (Staff nurse? Medical Admissions)

The nurses recognized that ‘lots ?f work [was] going ?n’ t? try t? ‘improve the patients’ experience.’ However this was being attempted through intensification ?f work with ‘less ?f us doing more work.’ It was also thought that although the NHS Plan had been promoted by the government ?s being ‘geared around the patient’ the reality was that ?t had been ‘geared around targets…geared around waiting list initiatives ?nd geared around four hourly A&E waits.’ The drive t? meet targets was considered t? have increased the number ?f managers whose behaviours by ‘saying do this do that’ ?nd ‘coming ?n ?nd having a say when they don’t actually know the area ?nd how the area works’ had reduced the autonomy ?f nurses. Respondents believed that they had been disempowered by managers sending patients t? inappropriate areas where nursing staff did not have the knowledge ?nd skills t? nurse them? patients being transferred ?r discharged too early? ?nd ?n over emphasis ?n the quantity instead ?f the quality ?f care. For example? ‘bed managers asking you t? move the patient ?n’ before the patient had received the required treatment? ?nd ‘opening overspill areas when we ?re not adequately staffed’ ?n order t? meet targets. A surgical ward sister said:

Waiting Times

Despite the additional work pressures? ?n general skill mix changes were thought t? have reduced the time patients had t? wait for medical treatment. Specialist nurses described how they had reduced waiting times for specific targets for example for treatment ?n A&E ?r for surgery. One nurse described the influence she ?nd her colleague had had ?n waiting lists for some minor surgical procedures. She said:

‘We’re reducing the waiting list. I know one ?f our surgeons has not got a waiting list for minor ops. We ?re taking them from throughout the trust now. With the dermatology ?f we start cracking through that we’ll get that down ?nd also ?n theatre we can see where the vacant slots ?re ?nd just slot ourselves ?n.’ (Specialist nurse? peri-operative care)

For the staff nurses ?nd ward sisters the reduction ?n waiting was for ongoing? day-t?-day treatment requirements. A staff nurse explained:

Discussion ?nd Conclusion

In England the Government’s strategy for NHS reform (DH? 2000) aimed t? redesign the Service around patients’ convenience instead ?f ?n the interests ?f the system ?nd t? improve its efficiency ?nd cost effectiveness. Methods for achieving these aims included skill mix changes between doctors ?nd nurses ?nd measuring performance using specific targets. However? the reform strategy may have had its foundation ?n contradictory processes such ?s the government aspiring t? decentralize operational control ?nd empower staff while retaining strategic control over resources ?nd performance targets. The purpose ?f this article was t? explore the manner ?n which NHS reform has affected nurses’ working lives ?n ?n acute trust. In particular the article sought t? examine whether there have been contradictory consequences for the occupation with respect t? factors such ?s greater empowerment? intensification ?f work? technical tasks ?nd nursing-?s-caring. By examining the intra-occupational consequences ?f healthcare reform ?n England this article has added t? our understanding ?f the effect ?f skill mix changes ?nd government policy for nursing. The article revealed that for staff nurses ?nd ward sisters the reform agenda has resulted ?n a perception ?f being rushed off their feet suggesting work intensification rather than empowerment. The data demonstrated that the delegation ?f aspects ?f junior doctors’ work was ?n important factor ?n nurses’ perceptions ?f work intensification ?nd that this was creating disheartenment among both ward sisters ?nd staff nurses. In this study nurses perceived that more ?nd more had been added t? their jobs ?nd nothing had been removed. Similar results were found ?n the Royal College ?f Nursing’s workforce survey ?nd ?re a cause for concern ?s that survey found that 49% ?f all nurses who left the occupation did s? because ?f stress ?r workload pressures (Ball ?nd Pike? 2005).

Nurses ?n this study articulated the practice-based aspirations ?f Project 2000. These were that nursing’s jurisdiction was unique ?nd based ?n a theory ?f nursing-?s-caring. What the nurses described ?s ‘essential’ nursing included hygiene? continence care? pressure area care ?nd nutrition which reflected aspects ?f nursing’s jurisdiction ?s described by the CNO (DH? 2001). Recent studies ?n Britain ?nd America have shown a positive correlation between low patient-t?-nurse ratios ?nd better patient outcomes ([Aiken et al.? 2002]? [Needleman et al.? 2002] ?nd [Rafferty et al.? 2007]). In addition? ?t has been demonstrated ?n America that ?n hospitals where the majority ?f registered nurses ?re educated t? baccalaureate level there ?re significantly lower mortality ?nd failure-t?-rescue rates for elective surgical patients (Aiken et al.? 2003). However? there ?s a paucity ?f empirical evidence which explains whether ?nd how the delivery ?f fundamental nursing care by registered nurses has a positive influence ?n patient outcomes. Results ?f this article suggest that the question? ‘What ?s the proper task ?f a nurse?’ remains ?s germane today ?s ?t was ?n 1946.

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