The implications of healthcare reform for the future

The implications of healthcare
reform for the future of nursing and
care at the bedside

hannah.cooke@manchester.ac.uk

• “The nurses who looked after me were
mostly grubby — we are talking about dirty
fingernails and hair — and were slipshod
and lazy. Worst of all, they were drunken
and promiscuous,” Lord Mancroft
• The Royal College of Nursing said Lord
Mancroft’s comments were “grossly unfair”
and a “sexist insult about the behaviour of
British women”.

Daily Mail 2007-Melanie Phillips
• What has happened to the nursing profession,
where there has simply been a collapse of that
ethic of caring first promulgated by the inventor
of modern nursing, Florence Nightingale.

• Nursing is not a job but a vocation. That means
it is governed by a sense of moral duty to the
patient rather than by the self-interest of the
nurse.

Daily Mail 2007-Melanie Philips
• Our society seems to have turned into a
Darwinian nightmare in which the fittest prosper
mightily while the old and weak are tossed aside
as of no value.
• That's why we starve and dehydrate some
elderly people to death. That's why we turn a
blind eye to the dreadful conditions in so many
old people's homes.
• And that's why nurses become managers, and
preen themselves as expert professionals in
meetings and seminars and conferences and
away-days while patients in their hospitals are
left to die in their own filth.

The media account of
contemporary nursing
• A collapse of moral standards-nurses have
become 'selfish'-moral decline is ascribed
to feminism and/or social liberalism so the
solution is more discipline-'bring back
matron'
• Nurses have too much education-they have
become 'too posh to wash'. Nursing was
'turned into an academic subject' and
'nurses became too grand to care'-the
solution -cut educational content of training-
'back to bedpans'

In this presentation I will
suggest that the commentary
above offers a distorted
picture-the wrong
explanations for some real
problems

Ordered to care?
• In 1987 Susan Reverby said that nurses had
been 'ordered to care' by a society which did not
value caring
• Contemporary reforms appear to place even
less value on care and on the ‘cared for’
• Pejorative labels for the most sick and
vulnerable used to be vernacular-'rubbish',
'crumble' -now they have been legitimised-’bed
blocker’, ‘frequent flyer’

Two nursing traditions
• The case approach-whole person
nursing-'named nurse', 'primary
nursing','individualised care'
• The industrial model-fragmented,
'production line' care-dominated by 'getting
through the work'(Goffman 1961 Clarke
1978)
• The industrial model predominated where
clients were less socially valued-large scale
institutions for the elderly,mentally ill.

The corruption of care
• Hospital scandals of 1960s and 1970s
pointed to institutional roots of poor care
• “Policy is built up of fine words but the reality of
what is provided for these groups denies their
truth. The work is wrapped round with high
sounding terms such as care, reform,
rehabilitation but the resources and facilities
made available convey to staff the low value
which society puts upon their work and upon their
clients. Official aspirations and standards are
therefore deprived of legitimacy.”
Wardhaugh and Wilding 1993

McDonaldisation

• McDonaldism -extends industrialised, assembly line techniques
to the service sector.
• 4 basic dimensions:
• Efficiency (cost cutting), Calculability (quantification),
Predictability, Substituting people with non-human labour
(robots, IT systems).
• Shifts labour and service costs onto the consumer. Reduces its
own costs by 'putting customers to work'- clearing their own
tables etc. Similarly Ikea puts its customers to work building
flat pack furniture.
• As with all rationalised systems McDonaldisation produces
negative by-products - the dehumanisation of customers and
employees and unintended inefficiency and waste. Ritzer 1996

Changes in healthcare delivery
• Steady decline in hospital bed numbers-halved since
1980
• Biggest declines in provision of long stay care in
hospitals - 43% care of the elderly, 45% mental
health
• Fall of acute bed numbers of 16% between 1987 and
1997
• Increased hospital throughput (hospital stays for heart
attacks have dropped from 7 weeks to 7 days)
• Increased day case and outpatient work and private
nursing home care
• Consequent emphasis on self care - flat pack care?
• Fragmentation of care- neglect and poor care less
visible, care falls through cracks

Implications for ward
nurses-'sicker and quicker'
• Increased dependency
• Increased throughput=increased activity
• Increased bed occupancy
• Extended roles
• Increased paperwork
• “The only people you see are the really
poorly ones, you don’t have time for the
rest. The relatives want you, you keep
getting called to the phone and the bed
manager is always breathing down your
neck.” Staff Nurse

‘Pushing patients through beds’
Joanne Latimer 2000 The Conduct of Care

• Ethnographic study of medical nursing
• Nurses struggle to find a space for care
between demands of medicine and
managerial pressure for cost efficiency
• The pressure to push patients through beds
takes precedence over patients best
interests
• Demand on nurses is to 'get patients going'
• Some patients died in the process

Nursing home care
• Lee Treweek 1994
• Assembly line processing of elderly clients
• The production of the 'lounge ready'
patient-clean, tidy ready to be parked in the
lounge
• Led to 'bedroom abuse' in backstage areas
of home in order to get through the work

Nurses argued for the primacy of caring
• Nurses argued that effective caring, particularly of
the very ill, required more than a kind heart and a
willing pair of hands.
• Jean Mcfarlane (1971) identified caring as the
'proper study' of the nurse and stressed the value
of giving attention to the minutiae of basic nursing
care.
• Patricia Benner (1984) - nurses combined moral
commitment, skill, academic knowledge and
experience to produce 'expert' nursing care
• Reform of care of neglected clients groups such
as the elderly high on nursing agenda

Why nursing matters
• International studies show that higher nurse
staffing levels are consistently associated
with improved mortality rates (Clarke and
Aiken 2001, Needleman 2002)
• Studies also indicate that higher levels of
education in nurses are associated with
improved mortality rates-of particular
importance is care at the bedside by
registered nurses (Aiken et al 2003)
• Studies also show that good teamwork and
nurse autonomy are positively associated
with improved outcomes (Rafferty et al
2001)

Market reforms-restructuring of
nursing
– Nurses envisaged more qualified nurses at the
bedside-BUT Project 2000 eroded nursing
workforce
– Government acceptance of P2K conditional on
nurses a new grade of 'support worker' -NVQ
trained and outside the profession's control.
– This led to skill mix dilution – RNs were replaced
with NVQ trained or unqualified assistants.
– Thornley (1996)- the reforms led to fragmentation
and inequalities in the nursing workforce.
– The introduction of support workers lowered the
pay floor in nursing (Grimshaw 1999)
– Coincided with internal market reforms-market in
nurse training places-unplanned, unstable

Modernising nursing careers
5 Pathways
• Children,Family and Public Health
• First Contact, Access and Urgent Care
• Long Term Care
• Acute and Critical Care
• Mental Health and Psychosocial Care

Modernising Nursing Careers
3 Levels of care
• Senior registered nurse-
Advanced practice - delivering total care
packages or complete episodes
• Registered nurse-
leading care delivery, care coordination and
case management
• Associate
supporting health, self care and care delivery

The skills escalator

Staff are encouraged and assisted to constantly
renew and extend their knowledge enabling them to
move up the escalator. Meanwhile roles and
workloads are delegated down the escalator
generating efficiencies and skill mix benefits.’
(Department of Health 2002)

Difficult to avoid the image of nurses running uphill
in order to stand still

Recent changes in the nursing
workforce
• NMC register shows increased numbers
leaving or retiring
• Internationally recruited nurses hid problem
that more UK trained nurses were leaving
profession than joining it
• Sharp decline in internationally recruited
nurses in last 2 years (now a quarter of
2004 rate)
• One third increase in nurses seeking work
abroad since 2006
• 63% of nursing workforce over 40, 29%
over 50

RCN Workforce survey 2007
• 71% say they could be paid more for less
effort if they left nursing
• Agenda for change has made no difference
to dissatisfaction with pay and grading
• 58% of nurses worked more than their
contracted hours in the previous week-on
average nurses work a 44 hour week
• There has been a steady downturn in
career progression-fewer nurses obtaining
higher grades
• There has been a significant fall (44%) in
nurses access to professional development

RCN review of ward staffing
2007
• Average bed occupancy 97%
• 54% report bed occupancy of 100% (5%
over 100%)
• Average length of stay in medical wards
has reduced by 5 days in last 4 years (3
days across all wards)
• More than half of patients in highest
dependency category
• 90% of wards affected by reduced staffing
in last 12 months-recruitment freezes,
bank/agency bans, skill mix dilution

Nursing morale
• 28% of nurses would leave nursing if they
could
• There has been a worsening of
organisational climate
• There has been a reduction of nurses who
say that the quality of care in their area is
good (down from 86% in 2005 to 79%)
• The number of NHS nurses who feel proud
of their organisation has fallen dramatically
to 42%
• The number of nurses who feel their work
is valued has fallen to 50%

Nursing morale
• “I’ve never seen morale so low, you get little or no
management support,you’re expected to grin and
bear it, get on with it, no-one backs you up. They’re
taking the piss, you get no support, no back up. You
ring up and say you’ve no staff and the response is
‘Tough, it’s the same everywhere’.” (Staff
Nurse )

• “Morale is low because of the pressure people feel
under…. it’s partly to do with management, partly to
do with staffing levels. There is an overspend on the
unit, we’re not allowed to book bank or agency unless
we’re absolutely desperate. People feel finance is
more important than patient care.” (Ward
Sister/Charge Nurse )

Shields and Watson 2007-
forecast the 'demise of nursing'

• Need to end fragmentation of care
• Need to promote whole person care above
protocol based assembly line care
• Need to show we value care
• Need to invest in well educated registered
nurses at bedside
• Need to end drive to increase throughput

The implications of healthcare reform for the future

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