Looking back, looking forward: enduring issues in nursing management


The pace of change in health care means that it is very easy to lose sight of our history and heritage. However, the past informs the present, and it is the cumulative effect of events and decisions that occurred many years ago which have determined the form and structure of existing organizations (Kieser 1994, Bedeian 1998), and this in turn has influenced nursing management. A consideration of history can aid analysis of the present by providing a vantage point from which to view current events (Kieser 1994, Usdiken & Kieser 2004). The purpose of this issue is to bring together a collection of papers some of which look back to this history and others which direct our attention to future challenges.

Until the 1960s, accounts of nursing history were mainly used to justify the process of professionalization, indeed many of the early histories were written by nurse reformers and their supporters, particularly those who promoted the idea of nurse registration (Rafferty 2000). Often characterized by a ‘congratulatory’ style, they incorporated notions of progress and were generally simplified versions of history which ignored the complexity of events, economic reality, social conditions and the role of religious and social movements in the 19th century (Nelson 2002). The three papers here take a more analytical approach and examine particular aspects of the history of nursing management. Carol Helmstadter considers the influence of key figures in the development of nursing in the UK. In recounting the contribution of these impressive women, she identifies a number of common themes which are as relevant today as they were in the 19th century. These include the importance of leadership, the need to motivate the workforce, clinical experience as a foundation for nursing management, the need to develop political skills, and the central requirement for success of garnering the support of the management board. Although the circumstances change and the terms used to describe the challenges facing nurse managers are different, the essential nature of what they have to do is surprisingly constant. For example, even though they were investigating community nursing in Australia in the 1960s, Wendy Madsen and Julie Bradshaw found that the support of the local community was crucial to the effective delivery of the nursing service, the practice of developing a ‘business’ case’ to justify the need for the purchase of equipment was well established, and through their findings illustrate that an awareness of the mixed economy of care has been a feature of nursing management for many years. Clearly the ideas of community participation, resource management and public–private partnerships are not new. In the third paper which looks back to our history, Judy Redman traces the involvement of nurses in key decision-making committees and structures between 1948 and 1974. Based on this analysis, she recommends that nurses must not only have access to these bodies, but that they need to exert political, economic and clinical influence in health care. She suggests that ‘Excluded from formal positions of influence and decision-making processes, senior nurses’ ability to secure the resources required to deliver services to their patients was circumscribed unless they were able to exploit either the opportunities derived from their own personal political skills or their already hard pressed staff’. Although it arises from a study of history, this observation could have been made at any point during the past few years.

It has been suggested that illuminating those factors which led up to the present can help to indicate possible ways of shaping the future (Kratz 1980). Although a relatively small number of papers which ‘look back’ are included here, our intention is to signal that some critical reflection on the past can be valuable in helping us to shape the future. The remainder of the papers in this issue direct our attention towards a range of managerial challenges and potential solutions that will be at the heart of nursing management as we look forward.

A particularly pressing problem has been characterized by Buchan (2002) as the ‘demographic double whammy’. This refers to the situation in the USA, UK and most other Western countries where there is an ageing nursing workforce caring for increasing numbers of elderly people. This situation also has implications for countries in the developing world as nurses are attracted away to supplement the depleted workforce in the regions noted above. Judith Blakely and Violeta Ribeiro consider one of the contributory factors impacting on this demographic challenge: early retirement among registered nurses in Canada. They suggest some strategies that managers can introduce to retain experienced nurses, thus reducing the adverse effects of nursing shortages. While Penny Sargent and colleagues evaluate the case management approach adopted in the UK to coordinate the care of people with long-term conditions. Elderly people are the heaviest users of health services and are more likely to have more than one chronic condition (Ham 2005) and so effective care of this group of patients is a significant organizational concern for nurse managers. This paper presents some useful insights on how management expertise is needed to balance an understanding of case management models with the complex contextual factors presented by local communities. Nurse managers ‘on the ground’ are ideally placed to make such adjustments and help ensure this service is delivered equitably.

If nurse managers are going to be able to adapt to the seemingly constant flow of changes that emerge from the demands of providing care in an increasingly complex world, appropriate education and training will be essential. Lucy Megginson focuses on undergraduate nursing education and concludes that measures need to be introduced in the USA to facilitate the progression of more nurses from the level of Associate Degree or Diploma to full Degree. She argues that not only would this be personally rewarding for the individuals concerned, it would also help address the shortage of nurses resulting from retirement – addressed by Judith Blakely and Violeta Ribeiro – because if the nurses are able to achieve their degree they are more likely to work for longer. This is followed by a report of a study by Rein De Cooman and colleagues, which demonstrates that many of the ‘traditional’ motivating factors associated with altruism are still important when nurses are making their career choices. Here again the links to the history of nursing are evident in that although nursing now incorporates many new specialisms and roles, the core values of caring and helping others remain a primary motivation.

The final three papers contain further information that may be of assistance to nurse managers as they play their part in creating the future. Helen Dryden and Ann Marie Rice give us a new take on an approach to learning and development that has been used in health care organizations for many years. Given the cost constraints facing managers, it can be difficult to release resources for traditional forms of training and education. In their account of how they used a secondment experience, it becomes clear that if agreed guidelines are used to manage the process secondment can be a valuable and constructive development opportunity. This also links with the paper by Mary Casey which draws out the essential ingredients of successful partnerships between organizations. The multifaceted nature of contemporary health care in the UK is purportedly founded on notions of ‘joined up government’ with effective partnership working between health and social care organizations, the voluntary sector and commercial enterprises (Spicker 2006). If nurse managers are to secure the best care for patients in this environment, then an appreciation of the issues raised by Mary Casey is important. Not only that, keeping the changing face of nursing roles under review is also required. Jitna Por analyses the concept of advanced nursing practice and concludes it is still unclear exactly how and where the roles that are encompassed by this somewhat imprecise term will fit into health care in the future.

In a sense, this brings the discussion full circle in that how and where advanced nursing practice, and indeed the other areas addressed in the papers, are of value to nurse managers looking forward involves keeping in touch with our history and using our core values as a guiding principle. It is evident that the enduring themes of leadership, motivation, the importance of retaining a professional focus and a grounding in clinical experience run through much of the nursing management literature. As a way of emphasizing the contemporary relevance of these themes, and in effort to provide managers, researchers and others with an opportunity to keep pace with events a new section is being launched that will appear in the Journal of Nursing Management from 2008. David Newbold will be editing a commentaries section. He is interested to receive short pieces on a range of issues that address key questions, continue the debate initiated in some papers, and synthesise evidence and practice reflections to inform nursing management. In this issue, a commentary by Amanda Henderson and Sarah Winch is included to introduce this new and interesting development. They present an overview of several management approaches and suggest that ethical, democratic and participatory leadership are needed if these approaches are to be successful, irrespective of their precise content and focus. It is our hope that these commentaries will add another dimension to the journal and increase its capacity to address key issues as they arise. In this way it can serve to underpin nursing management as we look ahead to an uncertain future.