Nursing role redesign: rising to challenges or sticking in mud?
The nursing workforce is under strain internationally. Ageing populations are served by ageing nursing labour forces, with nursing shortages beset by increasing competition from alternative careers and perceptions of nursing as a less rewarding option, even before current financial cutbacks. Nursing is responding by reviewing ways of working and seeking new or alternative approaches to service delivery, including new specialist roles such as the Nurse Practitioner (Gardner et al. 2010), and service reconfiguration. Such changes do not occur effortlessly or painlessly: publications detail ‘push’ and ‘pull’ factors, ‘supports’ and ‘barriers’ to role and service redesign. Theories and models delineate factors with potential to influence how such initiatives are received and what they achieve, in relation to characteristics and preferences of individual staff and patients, organizational and cultural features, inter and intra-professional relations, health policy and resource environments.
Community nursing has perhaps been a particularly contested area. In the UK, this has entailed demarcation of specialist District Nurses and creation of Community Staff Nurses, and policy has favoured by turns increasing role specialism and promoting generalist practice. Successive policy changes and initiatives have received mixed receptions and response.
The study by Gray et al. (2011) in this issue of JAN sets out the responses of community nursing staff and managers from one urban Scottish setting to a new model for community nursing that absorbed previously specialist roles (District Nurses, School Nurses and Health Visitors) into one generalist community health nurse role. Four group discussions were held with 27 community nursing practitioners, 20 of whom were specialist staff. Individual interviews were conducted with three community nurse managers.
Their construction of the new generic community health nurse model was of ‘a jack of all trades, master of none’. This denigration married loss of specialist knowledge and skills to the generic tasks required of the new role. They equated this with incompetence and with the generic nurse seen as ‘incapable and deficient in the face of knowledge about the complexities of patient care’. Local issues were cited to question the feasibility of the new role, which was roundly discredited. Specialist roles, on the other hand, were linked with individual job satisfaction, autonomy and overall job performance. Accountability for future changes in the profession was raised, with both clinical staff and managers locating this beyond the management and responsibility of individuals.
As the authors acknowledge, this study presents the views of one group at one point in time in relation to a particular role redesign. How such views relate to those of the wider workforce is beyond the study scope, although the authors refer to a previous national study reporting support for the new role from one-third of staff.
How might readers interpret these findings? As an example of how ill-prepared change can backfire? As the authors refer to a subsequent policy move away from the role, is this indicative of the positive power of articulate specialist staff to advocate for services that address their perceptions of patients’ needs? Given the predominance of specialist community nurses in the sample, is this an indication of how wedded to the status quo and how influential senior nurses can be? Is this study an illustration of empowered nurses responding to financially driven autocratic policy enactment ridding rough-shod over all they hold dear? Or a knee-jerk refusal to change from disempowered nurses?
The authors do not pursue this question. They comment on similarities with other studies that have revealed tensions between specialist and generic community roles, but do not speculate on sources of tension in this situation. This being so, the message I take from this study is both a warning and clarion call to those who redesign roles and services to ensure staff are consulted, and their expertise recognised and engaged at all stages.