Deconstructing the nursing shortage: the idea that the nursing shortage has been constructed and thus can be deconstructed, has been cogently argued by nursing author Suzanne Gordon. Here a nurse with a particular interest in safe staffing examines the argument and is convinced nurses" collective strength is the key to changing the work environment.

Last year, after 23 continuous years' nursing, I embarked on a 12-month careerbreak from my clinical role as an emergency nurse at Waikato Hospital. This time provided me with a priceless opportunity to draw breath and reflect on where I have come from, who I am now and, most importantly, where I am going with the next 20 working years I have to offer.

At the beginning of my break, I had no idea whether or not I would be going back nursing, or whether it was the beginning of a whole new rife outside nursing. The first six months felt like recovery time, stepping back from the relentlessness and frustration of modern clinical nursing. While I missed my colleagues, I felt in no hurry to throw myself back into the fray. Over the second half of my break, however, I found myself increasingly drawn back. The thought of never again experiencing the joy of coming to the end of a day where I had used my technical caring, analytical and humanistic skills to make a rear difference to a patient's experience was not something I was ready to give up. I also reflected, though, on how rare this experience had become in my practice. What had changed so very fundamentally over the quarter century I had been nursing to eliminate many of the intrinsic rewards of my profession?

Safe staffing inquiry

Around the same time my career break was due to finish, I was asked if I would be prepared to be nominated to the Safe Staffing/Healthy Workplaces Committee of Inquiry, which had been agreed to during last year's district health board multi-employer corrective agreement negotiations. Despite a reluctance to take on more new things, I strongly believed that if we were to have any hope of reclaiming our work environments as places where we can deliver safe, effective and satisfying care, then we must grab this opportunity with both hands.

The committee of inquiry is now up and running and will present its recommendations by June 2006. As part of my preparation for participating on this committee I read widely around the subjects of safe staffing and healthy workplace environments. One book, Nursing Against the Odds (1) by Suzanne Gordon stands out as a comprehensive commentary on why we are experiencing a world-wide nursing shortage, falling standards of patient safety and widespread dissatisfaction within the nursing profession. Gordon is an experienced hearth reporter in the United States, who has long hen an interest in nursing's contribution to health care; she is not a nurse.

The key message I drew from the book was that although we refer to the current "nursing crisis" as a phenomenon, it is anything but. A phenomenon suggests an "act of God", something beyond our control. Gordon shows clearly, through meticulous analysis of the evidence, that the problems we face are more of a construct--something that came about through a series of concrete actions (or inactions). If we accept this notion that the situation was constructed, then we can also accept that there is the possibility of de-construction, ie of undoing much of the harm caused. To do this we need to be able to "unpack" the components of what happened, try to understand them better, and then develop strategies to repair and rebuild.

The key themes Gordon articulates through her work are: the historic and ongoing dysfunctional state of the nurse/doctor relationship; the invisibility and stereotypes with which nursing is publicly viewed and portrayed; the disastrous outcomes of widespread health reforms; the contribution nurses themselves make; and finally conclusions and ideas for action. The book is more than 450 pages and it is not possible to do justice to the depth of Gordon's analysis. However, there are many insights that helped to shape my thinking around the issues, and these are worth sharing with a wider audience.

Gordon is highly critical of the perpetuation of unequal nurse/doctor relationships and the medical monopoly that means the critical contribution that nursing makes is not given due weight and consideration. She makes no judgment about which party is responsible for this but provides compelling evidence that the outcome is detrimental to patients. For example, she challenges the way there are two "languages" in use--medical and nursing.

In providing an historical perspective, Gordon had this to say: "Although nurses and doctors depended on o shared language, it was a language many nurses felt they were not allowed to use. If a nurse used a medical term, it would suggest she had medical knowledge and could thus intelligently form a medical opinion. How, one might wonder, could nurses "intelligently cooperate with the physician" and report to him without using medical knowledge? Only by engaging in a fascinating game of hide and seek. The nurse had to hide her conclusion in a sea of verbiage, describing the diverse aspects of what she says, bit by frustrating bit, while never reaching a conclusion about the phenomenon she has observed or reported."

Sadly this game still goes on today. In two very interesting sections titled "Dropped from the Picture" and "Missing from the News", Gordon looked at a range of television programmes and current events where nursing is intrinsic to the story fine. Time and time again, the doctor was portrayed at the cutting edge, making life-saving, critical decisions, white the nurses (if they were seen at all) were shown either in comforting roles to patients or support roles to doctors.

Societal perceptions

Recently in the New Zealand Herald there was an article relating to health care where there was one photo of a doctor and one of a nurse. The doctor was auscultating a patient's chest, while the nurse was holding the hand of an elderly patient. This is not just about nurses saying "poor us, we're not understood". The significance of this is that it reinforces a societal perception that the work nurses do is "nice to have", not "critical to have". When decisions are being made about cost-cutting or levels of service provision, it does not help that our work is seen as much less intrinsically important to patient outcomes than it really is. Interestingly, Gordon also found that, even when nurses were given the opportunity to express professional opinions, there was a great reluctance to do so. The body of the text gives an in-depth review and analysis of the effects of health care reform on the work of nurses and the outcomes for patients. There is no good news. We are all well aware that during the health reforms of the 1990s in New Zealand, real nursing numbers were reduced and nursing management systems were dismantled.

Gordon provides compelling evidence of the appalling outcomes this had for patients and on nursing morale and retention. Nurses, says Gordon, are being asked to integrate themselves into the business dialogue and obey institutional imperatives. The result is that "because it is much harder to attack the real enforcers of a bad system--who sit in offices in administrative wings ... nurses may subtly delegitimise the very real needs of their patients, who become the symbols not of illness and its tragedies, but of the relentless demands that have become impossible to acknowledge, much less fulfil". Gordon also traces the effects of reform to the loss of teamwork, innovation and collegiality. "The nurse's voice within the institution was muted. Patient loads increased and educational resources disappeared."

Despite the bleak picture painted, the overall tenor of the book is not meant to be a message of despair. In the final section, Gordon looks for examples of good ideas, initiatives and practices surviving against the odds and puts out some challenges for nursing. The three areas that struck a chord with me were around collectivism, how we articulate what it is that we do, and the imperative for positive action around workloads.

Gordon illustrates that internationally, the sectors of nursing that have managed most successfully to "hold back the tide" are invariably where there is a strong collective industrial and professional representative voice, such as we have in New Zealand, Australia and Denmark. Gordon also cautions nursing about over reliance on what she calls the "virtue script". She argues that while we continue to choose slogans and words to describe our work that focus society only on the caring, nurturing aspects of our role, we will struggle to make traction in securing a greater understanding of the contribution of nursing. Gordon also advocates strongly for positive action that seeks to manage nursing workloads. She is of the opinion that "while nurse/patient ratios can certainly be refined and are not the final solution to the nursing crisis, they are an important tool that managers can use to create stability and predictability. ... The first condition for easing the nursing crisis is to assure that the workload of working nurses will not crush them--that they will have the time and the psychological and physical energy to be effective on the job, to empathise with patients and to keep them safe from harm".

Seeking sustainable ways to manage workloads is precisely the work NZNO is engaged in through participation in the committee of inquiry. As I contemplate my imminent return to the clinical environment, I take heart from this Donna Diers quote in the book; "Nursing is two things--the care of the sick and the tending of the environment within which care happens." (1) My role, as I see it, is to continue to do the best I can in my clinical environment, but also to work with my colleagues at the political level to turn back the tide of deterioration in the environment within which care happens. At both levels I must be prepared to articulate what I do as a nurse, challenge those things that threaten the integrity of skilled nursing care, and advocate for the changes that are needed. If we focus our collective strength towards this goal, it can be done--it must be done.

Nursing Against the Odds is available for members to borrow from the NZNO library.

References

(1) Gordon, S. (2005) Nursing Against the Odds: How Health Core Cost Cutting, Media Stereotypes, and Medical Hubris Undermine Nurses and Patient Care. Ithaca, New York: Cornell University Press.

Jane Lawless, RN, is a practice development facilitator in the nursing research and development unit at Waikato District Health Board and a casual staff nurse in the emergency department at Waikato Hospital. She is the NZNO member representative on the Safe Staffing and Healthy Workplaces Committee of Inquiry.