Nursing Issues: Putting Patients First: The Role of Nursing Caring
Congratulations to Hospital Quarterly for launching a nursing column. I am honoured to be invited to share my thoughts. Several of the articles in this issue provide a perfect springboard to address what I believe is a key challenge for hospitals: a thirst for caring while the resources required for caring continue to dwindle.
Three of the articles highlight the need for quality nursing services while new data from the Canadian Institute for Health Information (CIHI) confirms a shrinking supply. Tranmer speaks about the different perceptions that patients and nurses have regarding what is important to patients as they receive nursing care. Ferguson-Paré and colleagues explore best practices in the care of elderly persons in hospital settings. Fitch stresses that treatment for individuals with cancer must be interwoven with supportive care so that "the cancer tumour is attacked and the human spirit upheld." While these three articles point to the need for excellence in nursing services, the CIHI data reveals that Canada's registered nurse workforce is aging, full-time employment is shrinking, and the number of registered nurses per capita is declining.
These articles not only point to the increasing gap between need for, and supply of nurses, but also shed light on key elements that help explain this worrisome gap. In my view, this gap is a reflection of the struggle between a caring paradigm that requires providing appropriate nursing resources to enact care, and a healthcare system conceptualized as an industry where cutbacks dominate. Not surprisingly, nurses leave the profession in frustration and fewer people are attracted to join.
"Nurses care" is an expression often used to describe the essence of nursing practice. There are distressing signs however, that the economic forces guiding the management of healthcare services make it difficult, and at times impossible, for nurses to maintain a caring practice. We know that nurses, patients and their families are not willing to dispense with caring. Public poll after public poll attest to the fact that nursing has the full support and the highest trust of the public. In fact, the public says that RNs are the key to ensuring quality healthcare.
Several aspects within the re-engineered healthcare system have impacted on the ability of nurses to care. The diminished managerial role of nurses is one principal element. Eliminating formal nursing structures, and in some agencies taking nurses out of their administrative roles altogether, has made it too easy to implement strategies which have proven to be problematic.
One of these strategies was the move away from full-time positions to part-time and casual ones. Today in Canada, 45.3% of registered nurses work part-time or casual. For four years the re-engineering machinery conveyed to nurses a message that they were expendable. The psychological implications of this message on the nursing workforce have been deep and the consequences far-reaching. Many nurses chose to leave the profession, and fewer men and women are choosing to join. What began as a misconstrued cost-saving exercise is now turning into a full-blown crisis, as more and more nurses are opting to remain in part-time or casual employment status. If you cannot get a full-time position with the conditions necessary to enact excellence in caring and advance a satisfying professional career, why bother? At least, a part-time or casual position allows for more flexibility in your life.
Another mistaken initiative has been the unbundling of nursing care into a series of tasks and their distribution to various care providers. Although administrators implementing this approach are careful to ensure that the appropriate caregiver is providing the appropriate level of care the overall impact of this strategy has been underestimated. Despite the best intentions and the most conscientious application of this strategy, there is a basic flaw in this method that good intentions cannot overcome. The approach shifts the attention away from the patient as a person, as a whole, and places that attention onto a series of tasks to be successfully completed in the most efficient way. It is the antithesis of patient-centred care.
The fragmentation of patient care is deeply troubling since it leads to a separation of the thinking, being and doing of nursing care. It is also a predecessor for clinical errors. This fragmentation of nursing care greatly limits registered nurses by denying them opportunities to enact caring practices with patients. It prevents meaningful relationships from flourishing. Registered nurses have experienced a dramatic decrease in the time they have available to be with patients.
Putting patients first and attending to patients in a way that is meaningful to them requires work environments that respect and adequately support caring practices. Being asked to work one day and not the next, having only some component of the total care of a patient, being understaffed and overworked - all these limit the ability of nurses and other healthcare providers to engage in caring practices. No nurse is exempt - whether in the hospital, the home, or the community at large.
The key strategy for putting patients first and for solving a potentially dangerous nursing shortage, is resolving the paradox in which patients and nurses seem to be caught: a thirst for caring relationships in a system that refuses to support and resource caring practices. What needs to be done?
Hospitals should greatly increase the ratio of full-time to part-time nursing positions to about 70:30. They should all but eliminate casual positions. They should strengthen the role of nurses in administration and leadership positions. They should implement models of care delivery that emphasize continuity of care and continuity of caregiver. They should provide staffing ratios that allow nurses to spend time with their patients and families who expect nurses to engage in caring relationships.
What is at stake is the fundamental role of caring in our institutions. Neither administrators nor healthcare professionals can morally allow this caring to slip away. I am certain that consumers will not allow it. The time is right and the stakes are high: action is needed now!
About the Author(s)
Doris Grinspun, RN, MSN, PhD (cand.), is the Executive Director of the Registered Nurses Association of Ontario.
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