Contribution to 2020health’s recent report ‘Too posh to wash? Reflections on the future of nursing’
By Samantha Walker, RGN PhD, Executive Director, Research & Policy, Asthma UK
Adapting to uncertainty
Now that the Health Bill has passed into the statute books (Department of Health, 2012), it is perhaps opportune to consider the role of the nurse in the new landscape it represents. Clinicians have been tasked with commissioning or delivering top quality health services for their local communities, on the assumption that they a) know what their local communities need and b) that there is a ‘best’ way of providing it. Terms like ‘clinical leadership and responsibility’ and ‘evidence-based, costeffective care’ are used to describe the skills, drive and confidence needed to implement change, and the knowledge to differentiate between those interventions that work and those that do not. The sheer pace of change within the NHS and the current pressure to deliver better service and improved patient outcomes at reduced cost are constant and compelling drivers.
Historically, leadership and the ability and confidence to appraise, judge and implement research findings in practice are not skills that nurses have necessarily been able to prioritise in day-to-day clinical practice. However, the explosion in online health information and the rising public expectations of 21st century healthcare mean that nurses’ opinions, recommendations and advice are being sought and challenged at a previously unprecedented scale.
Addressing uncertainty; critical appraisal and understanding of evidence-based healthcare
The last twenty years has seen a step change in the way that researchers evaluate the impact of nursing interventions. In many areas, there are now significantly extensive bodies of research evidence available to enable systematic reviews and meta-analysis of nursing interventions to take place (The Cochrane Library, 2012) and to allow practice to be improved as a result. However, the lack of literacy, numeracy, and critical appraisal skills among many nurses remain significant barriers to widespread implementation of research findings and therefore to improvements in delivery of care. On an individual clinical basis this is arguably less important, but if nurses are to work effectively and equally within the multi-disciplinary team environment, then nurses must be able to base their recommendations on sound evidence that stands up to scientific scrutiny. Differences of opinion between professions about what the ‘right’ care is for a specific patient will always exist, but nurses need to develop the skills to articulate an evidence-based case for a specific course of action that they can use to challenge their professional colleagues when necessary. As an eminent nurse researcher has said, “Opinion is the child of subjectivity and subjectivity is the child of sloppy methods. Therefore, opinion is the grandchild of sloppy methods” (Watson, 2003). Similarly, healthcare service re-design should be based on best evidence where appropriate. It is well recognised that research can take decades to translate into changes in clinical practice, but the same can be said of the National Health Service’s inability to take successful pilot studies and translate them into widespread clinical practice.
There may be many reasons for this, but an important factor may be front-line clinicians’ inability (or unwillingness) to search out, critically appraise, consider and develop potential local applications of cost-effective service interventions. If nurses are to develop their roles as commissioners or providers of cost effective health services, then they need to develop skills in service redesign and healthcare improvement that have been developed and applied in clinical settings. As money gets tighter and health and social care services are scrutinised, nurses must collectively become effective advocates for high quality healthcare, wherever it is delivered, based on the needs of their patients and not by the political landscape of their local community (Walker, 2011).
Leadership based on knowledge and evidence of what’s right rather than opinion
Whilst there is more to clinical leadership than the implementation of evidence-based practice, this remains an important factor. Despite managerial re-organisations nurses have a greater degree of control over their actions and behaviour on a daily basis than those who seek to influence and control their behaviour from the top. Given that nurses represent one of the largest groups of healthcare professionals with day-to-day contact with patients, then learning to make individual evidence-based improvements to daily practice could raise standards of services significantly. It is worth noting that ‘leadership’ does not always have to be defined by highly skilled, high profile management roles (although there are now fantastic opportunities to develop such skills (National Institute for Health research, 2012) but can also be achieved through the sharing of individual self-reflection, acquiring basic skills in accessing and appraising summaries of research evidence (e.g. https:// http://www.evidence.nhs.uk/) and making changes to every day clinical practice.
However, there is a significant role for nurses to develop roles in educating, influencing and leading others although again, these are skills that may not always sit comfortably with the traditional nursing model of care. This type of leadership requires confidence, knowledge of best practice in relation to the local community and the effective engagement of nurse teams. These nurse leaders also need the time and space to question their own practice and to consider the introduction of new and more effective way of delivering services. All this needs supporting by access to information about clinical practice and the development of organisational cultures that value such information and encourage it use as a vehicle for improvement of performance.
All of this may sound complex and challenging to deliver, but the sheer size and diversity of the nursing workforce should mean that there are a sufficient number who have or could develop the skills to take on these roles. This is the challenge for our community….
Summary and recommendations
Nurses have a powerful voice in the NHS which is often under-used and underrepresented. Collectively, we have the power and the potential to deliver great improvements to the care of the patients we seek to represent. The ability (and willingness) of nurses to differentiate between (cost-) effective and (cost-) ineffective healthcare, to develop the skills and knowledge to change and improve their practice as a result and to use that knowledge to influence others are vital factors in the delivery of high quality patient care in the future.
Department of Health, 2012, Health & Social Care Act, 2012 [online] Available at http://www.legislation.gov.uk/ukpga/2012/7/contents/enacted
The Cochrane Library, 2012, Home page, [online] Available at http://www.thecochranelibrary.com/view/0/index.html
National Institute for Health research, 2012, [online] Available at http://www.nihr.ac.uk/faculty/Pages/Leadership_Programme_competition.aspx
Walker, S, 2011, The Times, Monday 20th June 2011
Watson R. 2003, Debate: “That scientific method is the only credible way forward for nursing research” RCN Research Conference