It is with great pleasure that I prepare this, my first editorial for JCN. I am delighted to be appointed as Editor for the issues of the journal covering patient experiences, family participation and professional roles. These three areas, while seemingly disparate, are ones that captured my interest during my years of nursing practice, and have absorbed and engaged much of my intellectual and research endeavour. The decision to focus on patient experiences and family participation reflects the desire to illuminate the experiences, needs and perspectives of the end users of health services and nursing care, and position these accounts as central to our discourses about nursing, nursing knowledge and clinical practice. In doing so, there is acknowledgement of the value and significance we as nurses place on the consumers of nursing services – patients, clients and families.
Patient experience and family participation
The focus on participation of families acknowledges not only the importance of families in promoting health and wellness, but reflects awareness of an increasing reliance on family members in caring for people during illness and incapacity, rehabilitation and recovery. In focusing on family participation, we take a broad and inclusive stance, and recognize that families take many forms and may or may not be linked by blood or legal ties. Family members engage with nurses in diverse clinical and community settings, and participate in shared caring and other, sometimes quite lengthy, professional relationships with nurses (Kellett 2007). Experiences of illness and infirmity, injury and disability, health and healing are lived within the context of family relationships (Eggenberger & Nelms 2007, Taylor & McMullen 2008) and often, nurse interaction with family members occurs during times of trauma, stress and crisis (Brysiewicz 2008). Eggenberger and Nelms (2007) have recently highlighted the need people have for a caring and connected nursing presence when faced with the critical illness of a family member, and the ways nurses contribute to shaping their experiences.
Primary among the major obligations of researchers and scholars in nursing and midwifery is the imperative to generate knowledge that can contribute to improved outcomes for patients, their families and communities, and to support nurses and midwives in their clinical practice. That is, to provide information that is accessible, useful and relevant, and cognizant of the contexts in which nurses and midwives go about their practice. Nurses are facing several challenges in seeking to provide better care to more people. Many work in climates of constant change with very limited resources, and serve complex, troubled and disadvantaged communities in which people are living in environments of conflict, penury, tension and stress. In facing these challenges, and meeting the needs of these communities, there is an imperative to reflect on how we organise and deliver care, and to envision new roles for nurses and midwives.
In selecting professional roles as the third key area for this section of JCN, there is a commitment to contribute to the development of new nursing roles and to create a forum where nurses and midwives can engage in critical conversations about nursing, nursing practice, practice-related issues and possibilities for role development. Phrases such as extended role, role expansion and advanced practice are increasingly visible in our literature and influence our practice, research and education. In his paper on advanced nursing practice, Callaghan (2008) positions the ‘advanced nurse practitioner as expert, leader and collaborator’ and a catalyst for challenging and transforming entrenched values and practices. However, many of the extended roles that nurses take on are more in the manner of physician assistant. That is, they are self-limiting, task-based and initiated as a response to breakdowns in the health system due to shortages of allied health or medical staff and thus, as Callaghan (2008) points out, could be seen as arising from organizational necessity, rather than any imperative for developing enhanced professional autonomy for nurses.
When considering this nature of professional role expansion there is a need to consider workforce issues, and carefully reflect on the implications and possible repercussions. Many questions arise. If nurses are taking on ever more extended roles, how do the demands of these roles affect the work environment? The nursing workforce is facing several threats associated with putative shortages of experienced nurses, an ageing workforce, limited resources and challenging working environments. Do extended roles contribute to workplace stress by putting individual nurses in situations in which they just cannot meet all the demands placed on them? Are nurses supported adequately to meet the demands of their extended roles? Are nurses adequately remunerated and legally protected to enact these extended roles? While nurses are acting in de facto physician (assistant) roles, who is it that will provide the nursing care to patients and families?
Whilst considering these matters, it is also important to take account of the patients and families with whom we work. Extended roles for nurses do have the potential to enhance the health care and health seeking experiences of patients and families, particularly in under resourced areas and populations. However, in adopting new roles it is important that we do not accept them uncritically, and take the time to reflect on the impact these will have on our ability to meet our traditional roles, and how we ourselves position these new roles and skills in relation to our existing roles and skills. In drawing links between nursing knowledge and nursing shortages, Fawcett (2007) has noted the tendency to privilege the medical functions performed by nurses. This privileging of tasks normally associated with physicians may result in the attenuation and diminution of nursing specific activities and knowledge. It is important that we engage in debate and robust discussion about the consequences of role development, and thus retain some self-determination and autonomy about its nature, intent and extent. In claiming our autonomy, we reduce the possibility that role extension for nurses be seen as little more than a political measure designed to cover cracks in the health sector, and of little inherent benefit to nurses, nursing, patients or their families.
While recognizing the contested nature of nursing shortages, it is undeniably a fact that many facilities across the world experience difficulties in recruiting adequate numbers of skilled nurses. Many wealthy countries (in particular) have sought to ease their own nursing shortages through aggressive international recruitment. However, the hardship this can cause in source countries is causing growing concern (Pittman et al. 2007), therefore, this strategy is becoming increasingly viewed as morally dubious. Source countries are often economically disadvantaged, and are themselves in urgent need of a strong and effective nursing workforce. However, despite their investment in educating and preparing their nurses, these nations are unable to match the enticing offers made by more wealthy countries (Pittman et al. 2007), nor are they able, easily, to replace the nurses who are poached. Furthermore, this strategy is shortsighted and does not address the underlying causes of local nurse retention problems. Rather than relying on international recruitment as the major response to shortages in the workforce, it is preferable to increase local nursing workforces by addressing the issues causing shortages, identifying and initiating strategies to enhance the working lives of nurses, and improve recruitment through better positioning of nursing as a gratifying, worthwhile and fulfilling career.
The challenges facing nursing are pressing, complex and defy simple solution. Nursing has never been in greater need of a relevant and robust research base from which generate knowledge to inform positive change. However, here too are challenges: in this age of evidence-based practice, we are engaging with important epistemological issues including ways of knowing, and the notion of hierarchy of evidence. Nursing draws on many forms of knowledge, and debate continues about what counts as evidence in a discipline such as nursing (Mantzoukas 2008). These debates are important, and critical comment is necessary as we continue to generate a strong research base grounded in nursing and responsive to issues of concern to nurses and nursing.
In taking the stance of ensuring that published papers must be directly applicable to practice, JCN actively embeds our scholarship and research into the practice of nursing. JCN has a strong and increasing role to play as an international forum for nurses and midwives to disseminate finding of their research, raise issues, share ideas, interrogate problems and canvass solutions. I look forward to working with the editorial team of JCN to contribute to fostering strong discourses around the practice and scholarship of nursing and to the continued development of nursing as a responsive, effective and sustainable practice profession.