Reclaiming nursing care
Article Outline
It's a great time to be living and working in Australia and in particular South Australia. Having moved with my family from the United Kingdom in 2009, I have just celebrated my first year in this wonderful country. The climate and lifestyle of course are not the only attractions. I am particularly impressed by the current government's commitment to health system reform, tackling some of the most deep seated challenges in any modern health system including service integration, improving access, moving to a primary care led service and addressing workforce redesign.
All of these reforms will impact on the shape of nursing in the short, medium and long term. We are fortunate to have the Chief Nursing and Midwifery Officer at Federal level ensuring that the right voices are heard and professional and trade union organisations continue to exercise influence in the important local, state and national debates.
The challenges we face are not new; indeed the reform ideas put forward would hardly be a surprise to any of us. We are familiar with the trends and see the impact of demographic change, increased chronic illness, and more lifestyle related illness and multiple co-morbidities in our clinical work places every day. In addition to these clinical characteristics social trends are starting to show that we are tending to live more isolated lives with more distributed family members. The would be family carers are also more likely to be in paid employment themselves which means that when the need of informal care arises it is less clear who will undertake the role and whether the family will have the ability to cope.
As far as the healthcare workforce is concerned, we all recognise the trends – Australia, like the US and the UK, is struggling to meet the ever increasing demand for doctors, nurses and allied health professionals. Despite the increased investment in student numbers in all three countries, we cannot keep up with the demand. Healthcare Workforce Australia (HWA), a newly created federal organisation to have its headquarters in Adelaide, will be leading the reform agenda around workforce strategy and planning.
In particular, this new organisation will be responsible for co-ordinating the clinical placements for all healthcare students. This is a daunting task and one that will require a significant amount of collaboration and new ways of working if it has any chance of success. A recent attempt to electronically co-ordinate the placements of medical students in the UK ended in disaster for the health minister and total chaos for a whole cohort of newly qualified doctors. We ought to learn from these experiences rather than repeat them.
We would also have to acknowledge that for nursing the whole question of clinical placements (not to mention clinical competence) is a vexed question. Coming from a different system, I am used to the notion of a minimum number of clinical hours within a undergraduate student education program. Regardless of the university or the curriculum the regulatory body would stipulate a minimum number of hours and outline the minimum competencies. Indeed, in the UK a couple of years ago, there was a big outcry around the perceived failure of the education programs to be guaranteeing “basic” caring skills in its newly qualified nursing students. The debate, which went public as these debates tend to do, centred around the need for nurses to be able to master the caring skills – ensuring dignity, respect, comfort as well as knowing how to provide the fundamentals of care to patients (DOH, 2007).
The paradox of course is that these so called fundamentals of care are anything but basic and in no way are straightforward skills to acquire. Again, a cursory browse through any of the significant policy documents relating to quality and safety (Institute of Medicine, 2001, Department of Health, 2000, Runciman and Moller, 2001) repeatedly identify simple, routine elements of care as being the litmus test for the overall safety of the system. So if we know the fundamentals of care are so integral to patient care, why is it that the prestigious Robert Woods Johnson Foundation (2009) in the US has just invested millions of US dollars in a program to “align forces for quality” and the Institute for Healthcare Improvement (2009) has set up an initiative around “transforming care at the bedside”? In the UK a recent policy initiative, championed by Sir Michael Parkinson, has been around ensuring that nurses provided “dignified care” (DOH, 2006).
Notwithstanding the feeling that these essential elements of nursing care are being taken out of our control by such initiatives, we do have to ask ourselves whether we have been faithful and proper custodians of some of these fundamentals of patient care (New South Wales Health, 2009). How do we know we are skilling up the next generation of nursing students to have the confidence, skill, compassion and interest in bowel care, oral hygiene, nutrition, personal hygiene? In the rush of other clinical challenges, are we somehow overlooking the fundamentals of care?
These are not rhetorical questions. Two recent initiatives (Cochrane Nursing Care Network, 2009, Kitson et al., 2010) have started to look at how nursing accesses and uses existing evidence to inform its practice. Using a meta narrative review methodology (Greenhalgh et al., 2005), an international team has undertaken a thematic analysis, categorisation and synthesis of selected contents extracted from seminal nursing texts relating to nursing practice (Kitson et al., 2010). The questions we are exploring include: what are the Fundamentals of Care – what is the conceptual basis upon which nursing care is delivered and how have the fundamentals of care been defined in the literature and in practice?
So far, we have analysed more than a dozen key texts and a number of interesting patterns are emerging. For example, in reviewing the key texts on nursing across the last hundred years (starting with Nightingale's Notes on Nursing 1861), we found marked variation in elements defined as fundamentals of care (nutrition, elimination, breathing) and marked variation in the generic terms used to describe them (is eating and drinking the same as feeding or nutrition?). We also found variation in the focus or underlying conceptual framework used to describe the specific element i.e. whether it was physiologically oriented (explanation of the underlying physiological mechanisms of swallowing and eating for example) as opposed to a self-care focus(outlining the skills and ability required for the nurse to support the individual in eating or swallowing after a stroke for example) or an environmental focus (what resources are necessary to enable the nurse to support the individual perform the activity for example)?
Doubtless, these questions have been asked before and we are not claiming originality of concept or idea. However, what we are hoping to start is a more systematic and structured debate about the fundamentals of nursing care and to do this in such a way that we will begin to agree what terms we use and where and how we find the evidence to support our interactions with our patients. The Cochrane Nursing Care Network (CNCN 2009) has been established to explore where existing evidence from systematic reviews can inform nursing interventions. One of the nodes to have been established is the Fundamentals of Care Node, co-led by Dr. Suzi Robertson-Malt and myself. We are hoping to create multiple teams who will be able to work with us to explore the fundamentals of care. If you are interested in becoming involved them please email me or contact CNCN at http://www.joannabriggs.edu.au/cncn/about.php.
This work will not be easy and it is fraught with all sorts of linguistic, conceptual, theoretical and practical challenges. But perhaps, in the centenary of Florence Nightingale's death we owe it to her to revisit and reclaim those fundamental aspects of nursing care.
References
- Cochrane Nursing Care Network. (2009). accessed 31/01/10 http://www.joannabriggs.edu.au/cncn/about.php.
- Department of Health. (2000). An organisation with a memory – report of an expert group on learning form adverse events in the NHS. London: The Stationery Office.
- Department of Health. (2006). About the Dignity in care campaign. Available from http://www.dh.gov.uk. Accessed august 23,2009.
- Department of Health. (2007). Creating a patient-led NHS – delivering the NHS improvement plan. London: The Stationery Office.
- . Storylines of research in diffusion of innovations: A meta-narrative approach to systematic review. Social Science and Medicine. 2005;61:417–430
- Institute for Healthcare Improvement. (2009). IHI collaborative: Transforming care at the bedside. http://www.ihi.org/IHI/Progams/Collaboratives/TransformingCareatthebedside.htm. Accessed 20 January 2009.
- Institute of Medicine, Committee on Quality of Health Care in America. (2001). Crossing the quality chasm: A new system for the 21st century. Washington, DC: National Academies Press.
- Kitson, A., Conroy, T., Bell, M., Wengstrom, Y, Profetto-McGrath, J., & Robertson-Malt, S. (2010). Defining the fundamentals of care: Developing a stronger evidence base for nursing practice. In Position paper prepared for 3rd international learning collaborative meeting 22–24th February, Oxford.
- New South Wales Health. (2009). Essentials of Care. Accessed 16th June 2009. http://www.health.nsw.gov.au/nursing/projects/eoc.asp.
- Nightingale, F. (1861). Notes on nursing. What it is and what it is not (1980 edition). Edinburgh: Churchill Livingstone.
- Robert Wood Johnson Foundation. (2009). Aligning Forces for Quality (AF4Q) http://www.forces4quality.org, accessed 27 January 2010.
- Runciman, W. B., & Moller, J. (2001) Iatrogenic injury in Australia. Adelaide: Australian Patient Safety Foundation.
PII: S1322-7696(10)00003-X
doi:10.1016/j.colegn.2010.02.001
© 2010 Published by Elsevier Inc.
