Editorial. Life at work – modernizing nursing careers
This first issue of 2007 presents an eclectic collection of papers that draw our attention to the way nursing management and leadership impacts on the lives of nurses providing a service to their clients. It demonstrates the diversity of aspects that make up nurses’ lives at work, and which go beyond the overt aspects of the provision of care. These aspects impact on the quality of nurses’ lives, both at work and in their personal time, and contribute to the stability and maintenance of the workforce.
In many ways, this multiplicity of issues is indicative of the messages promoted in the Chief Nursing Officer's Directorate paper Modernising Nursing Careers – setting the direction published in September 2006. The authors of the report, which include the four chief nursing officers of the UK, nurse managers and leaders, and nurse educationists, recognize that:
‘nursing careers must respond to the profound changes taking place in the structure of health care delivery and the need for nurses to exercise leadership to bring about change (DoH 2006, p. 3)’.
This is not a new message – it has been apparent in the pages of this journal for the past 5 years, as the effects of reorganization of health care provision began to respond to market forces and changes in demography – not only in the UK but worldwide. This journal has experienced huge growth in this time, with online downloads of papers reaching 325 000 last year; the numbers of papers submitted for review have quadrupled, issues have gone from six to eight per year; and the number of pages in each issue increased by 50%. The first three issues of this year will be double that of a single issue back in 2002 to ensure that we get authors’ work into print within a reasonable time from their paper being accepted. This increase in the journal's activity suggests that nurses are engaging in the debates around management and leadership to a much larger extent than ever before, and at an academic level which impacts on the nature and scale of change taking place.
What I have seen over this time, is the expansion in the type and content of registered nurses’ roles, as they move from being primarily the care givers to what the report suggests will be ‘nurses leading, co-ordinating and commissioning care, as well as giving care, to bring about change measured by health gain and health outcomes’ (DoH 2006, p. 15). There is no doubt that nurses are now considered to be key to not only delivering care, but in the development and leadership of that care across the spectrum. The report identifies four activities that need to occur for nursing careers to be ‘fit for purpose’:
- •develop a competent and flexible nursing workforce;
- •update career pathways and career choices;
- •prepare nurses to lead in a changed health care system;
- •modernize the image of nursing and nursing careers (DoH 2006, p. 18).
The challenges of working in a changing care environment
All four of these aspects are picked up by papers in this issue – perhaps not overtly, but certainly in the ways that authors consider nursing within the wider socio-political and economic context and how this impacts on working lives.
The initial group of papers address the first two of these activities in considering how modernized roles contribute to service delivery. Venturato et al. consider the impact of changes to health care service delivery for older people in Australia – a pattern seen increasingly in the Western world as service provision moves increasingly from secondary care to care in the community. They suggest there is a ‘need to renegotiate nursing roles, responsibilities and values within an evolving care system’ and that this demands ‘a role for sensitive and proactive nursing management during periods of industry reform as a retention strategy for a qualified nursing personnel’.
This, perhaps is one of the keys to modernizing careers – what is apparent in these pages is the recurring issue of the challenges of retaining a skilled workforce, with its attendant aspects of recruitment, job satisfaction and stress. These perhaps can be seen as the less positive sides of managing a workforce, but these are equally as important as opportunities for staff development, creating new roles and increasing diversity and access to nursing careers. Retention is not only about keeping the staff once employed, it is also about the quality of the working life of those nurses; how involved they feel in the decisions at work that affect them; how valued they feel where they are employed; and how their contribution to outcomes for patients and the achievement of managerial targets is recognized. Without these, nurses become dissatisfied with their working lives, and an element of retrenchment and negativity meets changes proposed – an uphill battle for the managers involved, and detrimental to the spirit of ‘refitting’ service delivery to meet contemporary challenges.
One response is to create new roles for nurses. The other three papers in this group consider three of these newly developed roles – the clinical nurse consultant, the modern matron and the bed manager. Many new roles have been conceived and implemented almost overnight. We are now beginning to see evaluations of the effect and impact of these roles on both the service and the individuals concerned. O'Baugh et al. arrive at similar conclusions to previous studies published in this journal last year, in suggesting that the nurse consultant role is insufficiently focussed, leading to uncertainty for those taking it on. Whilst this results in freedom for the nurse to create their own parameters, the lack of focus results in divergent expectations from those viewing the role from the outside, and those undertaking it. In contrast, Dealey et al. consider that the implementation of the modern matron role in their NHS Trust in the UK has been successful. In part, this may be because of the fact that the Department of Health set 10 key responsibilities for modern matrons when devising the role, providing measurable outcomes of success. Proudlove et al. present the concept of bed manager as an essential nursing role and again, present evidence to suggest that the clearer the focus of the role, the more likelihood of success.
These four papers alone suggest that nursing has already started to respond to the challenge of modernizing careers that are appropriate for the complexity of care delivery and address the need for a ‘better balance of generalists and specialists to provide integrated networks of urgent, specialist and continuing care’ and ‘nursing roles defined according to patient need – to provide intervention that is timely, accurate and swift’ (DoH 2006, p. 15).
Issues impacting on nurses’ working lives
The 10 papers in this section highlight varying aspects – from quality issues to the development of evidence-based practice – that indicate the complexity of life as a nurse in today's healthcare systems. These represent the everyday reality of nursing at the frontline of care, and are the elements of working lives that impact on nurses as they go about their business. Although they seem remote from the features of the CNO's report in terms of careers, they are fundamental to whether an individual will derive job satisfaction from nursing and want to stay in the profession.
This does, perhaps, draw attention to the meaning of strategy for the majority of nurses, many of whom will not have even heard of this report, let alone read it. And, dare I say, how many managers of these nurses have also accessed the report and considered what it means for their nursing workforce? One envisaged target is that ‘nursing teams (will be) more self-directed and professionally accountable’ (DoH 2006, p. 15). This is within the scope of activity of all nursing managers, and need not be seen as a remote and lofty target to be enacted by nurses at directorate level with little relevance for the patient-based nurse. It is actually what we have been working towards in the UK for 25 years, as the dramatic changes made to nurse education in the late 1980s heralded higher academic preparation for nurses at all levels and the move towards autonomy of practice based on evidence, critical thinking and the development of reflective, accountable practitioners. At this time also, in the UK, we saw the introduction of the code of professional conduct to legitimize the notion of individual professional responsibility for action taken.
For many years, we have witnessed the global forward movement of nursing as a career. Modernising Nursing Careers – setting the direction (DoH 2006) can be seen as more of a position statement, and one of ratification of what has been achieved, than as a paper presenting something essentially new. The message it does give, for me, is that these initiatives need to become mainstream practice, rather than existing on the periphery of practice; that they need to become the rule rather than the exception. One step towards this is for managers to be taking notice of the work that is presented in the pages of this journal, and to be considering the evidence of innovative and good practice identified by authors who are responding to the needs of nurses and patients under their care. Constant and repetitive issues have been raised in these pages since the journal's inception 15 years ago, and it is disturbing for me, as an Editor, to see how many of these issues go unheeded or fail to be developed based on the experience of others. The last paper presented in this issue draws managers’ attention to the dangers of an entrenched and enduring culture in nursing management. The authors, Viitanen et al. suggest that ‘(it) may add to the permanence of operations and the stability of operative culture… It may also diminish the opportunities for nursing development in university hospital wards and weaken the potential for a new kind of competence among both managers and their subordinates’. The same messages about the quality of nurses’ working lives leap out of the pages of this journal – all of these issues contribute to the maintenance of the nursing workforce and require action by nurse managers. If the vision proposed by the Chief Nursing Officer's report is to be realised, it needs to be enacted by nursing managers working at grassroots level – without this the report is likely to be yet another of those residing in the graveyard of good ideas.