Feature

The right medicine for nursing?

Nursing is changing fast, and runs the risk of fragmenting into a thousand allied professions, says Barry Clifton

friend, who is developing links with European nursing, reports that French nurses are amazed to find how articulate and ambitious British nurses are. In France, they say, the doctors do not want well-educated, and thus potentially independent and argumentative nurses, and they take pains to ensure that nursing does not develop challenging structures.

In this country, however, that development of nursing is already under way. Project 2000, with its promise of registered nurses educated in the human and social sciences, not just trained in mechanical procedures, and PREP, which is designed to guide nurses into development of their knowledge and skills, are both intended to further this development.

Here we have a different way for the male-dominated medical and managerial health care professions to deal with the potentially revolutionary enfranchisement of the largest group of health service workers. Nurses are to be marginalised and automatized.

Project 2000 and PREP are being, and will be, praised and encouraged at every level of government and administration. They are not being, and will not be, properly funded. Part-time nurses with families, who necessarily form a large part of the profession, finding themselves expected to bear the costs of periodic registration and compulsory updating will find the costs too heavy to bear and will let their registration lapse. Wherever possible, the increasingly costly, well-educated registered nurse will be replaced by unqualified or semi-qualified care assistants, or declared redundant as staffing levels are eroded. Other smaller paramedical professions will move into areas presently occupied by nursing.

A friend, nursing in a hospital which attained trust status in the first wave, has described how, by the time she left, aspect after aspect of nursing had been taken over by care assistants, physiotherapists and occupational therapists, until the main job of nurses was to hand out pills. Self medication, advised by pharmacists, will soon put an end to that.

There are areas in which hospital nurses can expand. Those who are skilled in the intensive part of acute care can become technical specialists, skilled in the mechanical and physiological procedures by which intensive care is characterised. Others may specialise in areas such as the care of diabetic or oncology patients, the incontinent or those with stomas. In due course, they will form specialist associations, and after a period new departments with their own professionals will arise like the Department of Stomatherapy.

Another area that nurses will develop - my own regional health authority has started a project to make it look like progress - is their traditional one of taking over from doctors, and especially junior doctors working shorter hours, all those chores that are no longer interesting to the doctors. In the past, registered nurses have in this way taken on physiotherapy, blood pressure monitoring, pressure area care and even taking of temperatures, to pass most of them on in due course to more narrowly specialised or less qualified staff.

The next wave of activities registered nurses will undertake to safeguard their jobs will include, and in some places already includes, intravenous cannulation, phlebotomy (there is already a group of technical specialists outside nursing moving in here), certifying routine deaths, defibrillation, minor surgery and prescription of run-of-the-mill medications.

Nursing, as it was intended to develop through Project 2000, would bring into the health service increasing numbers of people who instead of merely being trained in a range of practical activities designed to make them useful assistants to doctors, would be educated, often to degree level and beyond, in human and social sciences, enabling them to become advocates of the new emphasis of health care. In this, people are provided with the information and resources to enable them to take charge of their own health, with professionals serving as repositories of information and ideas.

That shrinking proportion of newly-qualified nurses who actually get jobs, will in practice have to abandon the ideals which their broader education has engendered about the nurse’s role as patient advocate, and must become some sort of medically dependent technician, as they have until recently always been. They will not be allowed to forget all the nurses who have not got jobs and could replace them.

All this is in keeping with the treatment of health as a commodity which can be sold like any other, and enables hospital nurses to be managed as interchangeable and disposable machine minders, rather than autonomous professionals. The rhetoric about enabling and empowering patients to protect and promote their own health is there, but the will of the managers to implement it is not.

With this sort of gulf between nurses’ expectations and those of doctors and managers, we can expect future cohorts of newly-qualified nurses to find their position difficult to maintain, if they are able to gain a position at all.

Perhaps the doctors’ handmaidens of France will hang on to their dependent status and be grateful when they look across the Channel one morning and find that British nursing has vanished in a cloud of allied professions.