Nurses' voices.Abstract In this paper we analyse an·a·lyse v. Chiefly British Variant of analyze. analyse or US -lyze Verb [-lysing, -lysed] or -lyzing, aspects of the qualitative data from open-ended questions A closed-ended question is a form of question, which normally can be answered with a simple "yes/no" dichotomous question, a specific simple piece of information, or a selection from multiple choices (multiple-choice question), if one excludes such non-answer responses as dodging a included in the RN Survey 2002. We discuss the changes wrought by New Public Management (NPM NPM National Poetry Month NPM National Postal Museum NPM New Public Management NPM National Association of Pastoral Musicians (Silver Spring, Maryland) NPM Network Processor Module NPM National Project Manager ) in the Australian and WA health sectors. We argue that the requisites of NPM and managerialism In the field of administration, observers can characterise as managerialism those systems where they perceive a preponderance or excess of managerial techniques, solutions and personnel. are not necessarily consistent with the historical role of professionalism in the delivery of health care and of nursing as a health profession. In analysing the nurses' qualitative responses, we use the framework from NPM and managerialism as a means to develop understanding of the issues and concerns expressed by nurses. The paper identifies three areas of dissonance: professional dissonance, career choice dissonance and ideological dissonance. It argues that, as a result, nurses emotionally and professionally resist what has been termed 'the instrumental motivations of managerialism'. Introduction Nurses in Australia, the USA, Canada, New Zealand New Zealand (zē`lənd), island country (2005 est. pop. 4,035,000), 104,454 sq mi (270,534 sq km), in the S Pacific Ocean, over 1,000 mi (1,600 km) SE of Australia. The capital is Wellington; the largest city and leading port is Auckland. and the UK have, since the early 1990s, gone through a period of considerable workplace change. Significant in the change experienced in this period throughout the health industry has been the introduction of New Public Management (NPM) and related trends towards market based discipline, 'managerialism' and budgetary stringency (Cline cline, in biology, any gradual change in a particular characteristic of a population of organisms from one end of the geographical range of the population to the other. , Reilly and Moore 2004; Ferlic, Ashburner and Fitzgerald 1995; Malin, Wilmot and Manthorpe 2002; Newman and Maylor 2002). This workplace change is identified in a number of qualitative studies of nurses' work satisfaction and workplace attitudes as significantly changing the nursing role in practice (Bone 2002; Cline et al. 2004; McNeese-Smith 2001; Newman and Maylor 2002; Sharmian, O'Brien-Pallas, Thomson, Alksnis and Kerr 2003). A key unifying issue for nurses in the qualitative studies cited above has been that, in the process of workplace change, the relational or 'emotion work' (Bone 2002, James 1989) which nurses hold as an important part of their role has given way to the technical aspects of their role and the administrative demands of management. The studies cited provide evidence that this results in workplace dissonance for nurses, who in many cases express the feeling that these demands are in conflict with their own professional values and the sources of their workplace satisfaction. Bone argues that nurses interviewed for her study expressed feelings of loss, and remembered workplace satisfactions no longer possible under current working conditions (Bone 2002,). The other theme which emerges in these qualitative studies is a strong expression by nurses that 'management' fails to listen to or respond to their concerns, to communicate effectively with them, to offer support following events such as patient abuse, or to provide feedback (Cline et al 2004, McNeese-Smith 2001, Newman and Maylor 2002, Daiski 2004). Management deficiencies are also invoked by nurses in these studies in relation to issues such as inflexibility in·flex·i·ble adj. 1. Not easily bent; stiff or rigid. 2. Incapable of being changed; unalterable. 3. Unyielding in purpose, principle, or temper; immovable. in dealing with shifts, hours, insecurity Insecurity Inseparability (See FRIENDSHIP.) Insolence (See ARROGANCE.) Hamlet introspective, vacillating Prince of Denmark. [Br. Lit.: Hamlet] Linus cartoon character who is lost without his security blanket. in the workplace, high workloads. They complain, too, of failure to deal with workplace issues such as bullying Bullying Chowne, Parson Stoyle terrorizes parish; kidnaps children. [Br. Lit.: The Maid of Sker, Walsh Modern, 94–95] Claypole, Noah bully; becomes thief in Fagin’s gang. [Br. Lit. , discipline and discrimination. Qualitative data collected as part of the RN Survey 2002 of Western Australian (WA) nurses, and detailed in this article, found evidence of similar responses to those reported in the USA, UK and Canada. The sense of anger was palpable Easily perceptible, plain, obvious, readily visible, noticeable, patent, distinct, manifest. The term palpable usually refers to some type of egregious wrong, such as a governmental error or abuse of power. in the responses, as was the apparent dissonance between the expressed professional nursing values and what nurses perceived as the employer/management values expressed through resources allocation in the health system. These responses are explored further in this article and linked to issues raised in the management of institutional and organisational change in the health industry. In Australia, the UK, New Zealand and Canada particularly, changes in the health industry are largely driven by public sector imperatives and ideologies together with the funding issues for public services Public services is a term usually used to mean services provided by government to its citizens, either directly (through the public sector) or by financing private provision of services. . In what follows we briefly outline the changes wrought by NPM in the Australian and WA health sectors and some of the issues raised in the critical debate of NPM. We then follow with a discussion of the historical role of professionalism (Malin et al. 2002) in the delivery of health care and of nursing as a health profession. We outline the methodology adopted in this paper and discuss the strategy used in analysing the data from the open-ended questions in the RN survey 2002. We then consider the results of the RN survey qualitative data, using the framework from NPM and managerialism as a means to develop understanding of the issues and concerns expressed by nurses. The paper identifies three areas of dissonance: professional dissonance, career choice dissonance and ideological dissonance. We argue that, as a result of these dissonances, nurses emotionally and professionally resist what Bolton (2004, p. 318) terms "the instrumental motivations of managerialism". New Public Management, Managerialism and Health in Australia New Public Management (Aucoin 1990, Hood 1991, Hood 1995, Malin et al. 2002) and its alter ego A doctrine used by the courts to ignore the corporate status of a group of stockholders, officers, and directors of a corporation in reference to their limited liability so that they may be held personally liable for their actions when they have acted fraudulently or unjustly or when 'managerialism' became the prevailing orthodoxy or·tho·dox·y n. pl. or·tho·dox·ies 1. The quality or state of being orthodox. 2. Orthodox practice, custom, or belief. 3. Orthodoxy a. within public administration in the 1980s. Miller and Rose (1990) use the concept of 'technologies of government' to represent the new methods used by the state to maintain rule in an apparently non-coercive way. They argue these 'technologies' lead to the atomising of power and, as a result, implementation rather than policy becomes the focus of resistance. These technologies progressively permeated the Australian public sector, including health services health services Managed care The benefits covered under a health contract , in the 1980s and 1990s and were generally introduced without health sector consultation (Germov 1995). Hood (1995) characterises NPM as associated with seven dimensions of change: unbundling A regulatory requirement that enables a competing service provider to purchase parts of the incumbent local exchange carrier's network in order to provide service to its customers. See ILEC. service units into corporatized units, greater competition in provision of service including the use of quasi-market mechanisms, stress on private sector styles of management practice, discipline in resource use (do more with less), visible and accountable hands-on top management, explicit and measurable standards and performance measures, and emphasis on results. Embedded Inserted into. See embedded system. within these seven dimensions are trends which have been differentiated as 'managerialism' (Beattie 2000, Baum 1996, Malin et al. 2002) involving generic, not sector-specific, management, detachment detachment /de·tach·ment/ (de-tach´ment) the condition of being separated or disconnected. detachment of retina , retinal detachment of policy advice from management, disaggregation dis·ag·gre·ga·tion n. 1. A breaking up into component parts. 2. An inability to coordinate various sensations and a failure to observe their mutual relations. of the public sector within a regulatory framework, with tightly specified outcomes-focused contracts, focus on quantifiable Quantifiable Can be expressed as a number. The results of quantifiable psychological tests can be translated into numerical values, or scores. Mentioned in: Psychological Tests outcomes as opposed to qualitative processes, and customer or client focus as opposed to 'the public'. Hood (1991, p. 15) argued that NPM could be understood 'mainly in the direction of cutting costs and doing more with less as a result of better-quality management and different structural design.' He noted that there was tentative tentative, adj not final or definite, such as an experimental or clinical finding that has not been validated. empirical support for improvements in productivity but that final evaluation on values of fairness, trust, reliability and adaptability a·dapt·a·ble adj. Capable of adapting or of being adapted. a·dapt  a·bil required further investigation.
Barnett and Barnett (2003) reflected these concerns when they concluded that in New Zealand 'market approaches to health care have major limitations and that the ultimate goal of a health system should be the equitable equitable adj. 1) just, based on fairness and not legal technicalities. 2) refers to positive remedies (orders to do something, not money damages) employed by the courts to solve disputes or give relief. (See: equity) EQUITABLE. , efficient and effective provision of care, not the profitable sale of commodities' (Barnett and Barnett 2003, p. 145). Hood (1995, p. 96) identifies the 'erosion of self-management by professionals' (with concomitant concomitant /con·com·i·tant/ (kon-kom´i-tant) accompanying; accessory; joined with another. concomitant adjective Accompanying, accessory, joined with another movement away from trust in professional standards and expertise) and 'less producer friendly style' (contract employment, discipline and parsimony par·si·mo·ny n. 1. Unusual or excessive frugality; extreme economy or stinginess. 2. Adoption of the simplest assumption in the formulation of a theory or in the interpretation of data, especially in accordance with the rule of ) as two of the operational issues resulting from NPM. Each of these issues resonates with the health services workforce generally. More specific issues raised by Baum (1996) and Beattie (2000), which are seen as the outcomes (albeit unintended) of NPM and in particular 'managerialism', include: the focus on readily measurable outcomes to the detriment Any loss or harm to a person or property; relinquishment of a legal right, benefit, or something of value. Detriment is most frequently applied to contract formation, since it is an essential element of consideration, which is a prerequisite of a legally enforceable contract. of those less amenable AMENABLE. Responsible; subject to answer in a court of justice liable to punishment. to quantification quan·ti·fy tr.v. quan·ti·fied, quan·ti·fy·ing, quan·ti·fies 1. To determine or express the quantity of. 2. ; increased volume of paperwork at the expense of service provision; rule bound rather than providing for flexibility and responsiveness; responsive to the logic of cost rather than care; increase in the amount of management/hierarchy rather than reduction; elevation elevation, vertical distance from a datum plane, usually mean sea level to a point above the earth. Often used synonymously with altitude, elevation is the height on the earth's surface and altitude, the height in space above the surface. of processes and reorganisations rather than outcomes. Professionalism and the Delivery of Health Care Professionalism stresses the importance of the intervention of expert judgment in what are otherwise seen to be 'indeterminate' social needs and issues (Malin et al. 2002). The community acceptance of a profession's autonomy in exercising this expert judgment is underpinned by this professionalism being based on the 'standardisation of skills through externally controlled training and qualification' (Malin et al. 2002 p. 84). Professionals are assumed to require a level of autonomy in practice, where their professional judgment, for which they are accountable, can be trusted. Health sector work has been largely based on the practice of such professionals including nurses, doctors and 'Allied Health Professionals' (occupational, speech and physio physio Noun 1. short for physiotherapy 2. pl physios short for physiotherapist therapists). These professions have historically exercised considerable autonomy in establishing their own education and training standards and standards of professional practice. The introduction of the significant investment in university qualifications in the 1980s, detailed further in Nowak (herein), was taken as evidence of an enhanced status for the nursing profession. Malin et al (2002) contrast the standardisation Noun 1. standardisation - the condition in which a standard has been successfully established; "standardization of nuts and bolts had saved industry millions of dollars" standardization of skills of the professional with the standardisation of work processes and the delineated de·lin·e·ate tr.v. de·lin·e·at·ed, de·lin·e·at·ing, de·lin·e·ates 1. To draw or trace the outline of; sketch out. 2. To represent pictorially; depict. 3. roles which are bureaucracy's operating strategy. As they have pointed out, in the evolution of the public sector's involvement in the health industry, the activities of the 'welfare professions'-doctors, nurses, and social workers--have increasingly been defined by the state. Fish and Coles (2000, p. 292) argue that this has resulted in the development of tension between the technical/rational approach to professional practice and the professional artistry art·ist·ry n. 1. Artistic ability: a sculptor of great artistry. 2. Artistic quality or craft: the artistry of a poem. approach. The former, where 'delivery' of service to clients follows predetermined pre·de·ter·mine v. pre·de·ter·mined, pre·de·ter·min·ing, pre·de·ter·mines v.tr. 1. To determine, decide, or establish in advance: routines and behaviours, is consistent with the needs of both bureaucratic bu·reau·crat n. 1. An official of a bureaucracy. 2. An official who is rigidly devoted to the details of administrative procedure. bu and NPM or managerial approaches to public sector organisations, while the latter, involving a mix of 'professional judgment, intuition intuition, in philosophy, way of knowing directly; immediate apprehension. The Greeks understood intuition to be the grasp of universal principles by the intelligence (nous), as distinguished from the fleeting impressions of the senses. and common sense' (Fish and Coles 2000, p. 293), is the way these professions view their practice and professionalism. The introduction of Total Quality Management (Morgan and Murgatroyd 1994), with its emphasis on patients as 'consumers' (du Guy and Salaman 1996), together with the case-mix funding process, and the funder/purchaser/provider approach have encouraged the notion of standardisation. The requirements of accreditation accreditation, n a process of formal recognition of a school or institution attesting to the required ability and performance in an area of education, training, or practice. (e.g. Australian Council of Health Standards 'Equip' accreditation for hospitals and the Australian Government RCS (1) (Remote Computer Service) A remote timesharing service. (2) (Revision Control System) A Unix utility that provides version control. RCS - Revision Control System accreditation standards for nursing homes) have compounded this trend. Whilst Morgan and Murgatroyd see this as strength, the very concept of standardisation and commoditisation may constitute what Keenan (1999) sees as an attack on nurses' occupational autonomy. The system of quality audits has served managers' and bureaucrats' needs, whilst labelling many of the results of professional autonomy professional autonomy, n the right and privilege provided by a governmental entity to a class of professionals, and to each qualified licensed caregiver within that profession, to provide services independent of supervision. as 'deviations'. In the USA the notion of standardisation has manifested itself as 'managed care' and in the introduction of nursing case management (NCM NCM National Corvette Museum (Bowling Green, Kentucky) NCM Nordic Council of Ministers NCM New California Media NCM Nomenclatura Común del Mercosur NCM Non-Commissioned Member (Canadian Military) ), which sought to have nurses manage the balance between the conflicting values of 'quality of care' and 'costs of care'. With case-mix funding, case decisions are based on patient types or 'product lines' and risk categorisation (Padgett 1998). Nurses are not the only professionals affected by NPM. Gcrmov (1995, p. 60) argues that attempts to make the medical profession more accountable through a market-oriented policy curtail cur·tail tr.v. cur·tailed, cur·tail·ing, cur·tails To cut short or reduce. See Synonyms at shorten. [Middle English curtailen, to restrict clinical autonomy and erode Erode (ĕrōd`), city (1991 urban agglomeration pop. 361,755), Tamil Nadu state, S India, on the Kaveri River. The city is located in a cotton-growing region, and its industries include cotton ginning and the manufacture of transport equipment. the position of the medical profession. The resistance to the introduction of USA-style managed care in Australia was evident in the debate preceding the 2005 federal budget (Sydney Morning Herald 2005) on in-vitro fertilisation funding. The debate highlighted the potential for the use of financial means to control health provision and to curtail professional autonomy and the resistance to its implementation at this atomistic at·om·is·tic also at·om·is·ti·cal adj. 1. Of or having to do with atoms or atomism. 2. Consisting of many separate, often disparate elements: an atomistic culture. level. Re-conceptualisation of 'deprofessionalisation' in the discourse about managerialism and the professions is needed. Qualitative Data Collection and Analysis In addition to the quantitative survey questions in the RN Survey 2002 of WA nurses, the survey instrument also sought to provide the opportunity for qualitative responses through which greater understanding of the experiences, motivations, issues and concerns of nurses could be gained. Further details of the survey are provided in Nowak (herein). This paper considers aspects of the qualitative data which were collected in two open-ended questions. In one, nurses were asked: 'If you could go back in time would you still choose nursing?' Those who answered 'no' were then invited to respond to the open-ended question: 'Why not? What has changed?' At the conclusion of the survey respondents In the context of marketing research, a representative sample drawn from a larger population of people from whom information is collected and used to develop or confirm marketing strategy. were asked for 'Any comments or suggestions which you would like to make about nursing or other issues in this survey?' In all, 1564 qualitative (written) responses were available for analysis by the research team. With such open-ended data we adopted a qualitative research Qualitative research Traditional analysis of firm-specific prospects for future earnings. It may be based on data collected by the analysts, there is no formal quantitative framework used to generate projections. approach which was based on the constructivist con·struc·tiv·ism n. A movement in modern art originating in Moscow in 1920 and characterized by the use of industrial materials such as glass, sheet metal, and plastic to create nonrepresentational, often geometric objects. view of respondent In Equity practice, the party who answers a bill or other proceeding in equity. The party against whom an appeal or motion, an application for a court order, is instituted and who is required to answer in order to protect his or her interests. data--that is that respondents 'construct' their own view of the world they experience and develop multiple personal meaning. The role of the researcher becomes one of discerning dis·cern·ing adj. Exhibiting keen insight and good judgment; perceptive. dis·cern  ing·ly adv. and interpreting this
meaning. The resulting research process is termed 'constructivist
interpretivist' (Patton 1990). We adopted this approach because we
were interested in understanding and interpreting nurses'
constructed views of nursing (Denzin and Lincoln 2000). We sought to
give nurses a voice.
We developed categories of meaning from initial iterative it·er·a·tive adj. 1. Characterized by or involving repetition, recurrence, reiteration, or repetitiousness. 2. Grammar Frequentative. Noun 1. coding and refined these, using the constant comparative method employed by grounded theorists (Locke 1996). The focus of grounded researchers is to build theory from data (inductive inductive 1. eliciting a reaction within an organism. 2. inductive heating a form of radiofrequency hyperthermia that selectively heats muscle, blood and proteinaceous tissue, sparing fat and air-containing tissues. ) rather than test existing theory with data (deductive de·duc·tive adj. 1. Of or based on deduction. 2. Involving or using deduction in reasoning. de·duc ). The enormous volume of qualitative data (some nurses wrote several pages in response to the last question) was entered into multiple text files. Using NVivo (QSR QSR Quick Service Restaurant QSR QoS (Quality of Service) Satisfaction Rate QSR Quality System Regulations QSR Quality Status Report QSR Quality System Review QSR Quarterly Status Report QSR Quality System Requirement V 2.0, 1999) for the text management system, we carefully analysed the text responses, using qualitative content analysis (Patton 1990, Altheide 1996). The nurses' voices we record here are from nurses in all areas in Western Australia Western Australia, state (1991 pop. 1,409,965), 975,920 sq mi (2,527,633 sq km), Australia, comprising the entire western part of the continent. It is bounded on the N, W, and S by the Indian Ocean. Perth is the capital. : country and metropolitan hospitals; aged-care facilities; psychiatric psy·chi·at·ric adj. Of or relating to psychiatry. psychiatric adjective Pertaining to psychiatry, mental disorders facilities; public and private sectors; and community nursing. There are also some who are registered but not currently practising. While some of the comments are specific to a particular location of nursing practice, such as a country or a teaching hospital, many more reflect what nurses from all fields of practice are saying. Research results: Perceptions of Western Australian Nurses The major results of the iterative and grounded analysis were grouped into four major categories: 'Working in the Health System'; 'Nursing as a Profession'; 'Nursing as a Job'; and 'Being a Nurse'. Each of these categories was in some way affected by two pervasive institutional or structural influences: NPM and Managerialism, and Women's Labour Market Position. [FIGURE OMITTED] In this paper we focus on the outcomes of the rapid changes in the health industry over the past ten or more years. These changes have been identified as consistent with the broad scope of NPM and involve elements of 'managerialism'. We report on nurses' voices as they experience what it is like 'Working in the Health System' and also report on 'Nursing as a Profession'. This latter category includes nurses' focus on patient care, professional leadership, education and support. We discuss each of these findings below, using examples of the participants' reflections. Other views raised by the respondents included issues relating to relating to relate prep → concernant relating to relate prep → bezüglich +gen, mit Bezug auf +acc 'Nursing as a Job' (e.g., pay, conditions and job design issues), and 'Being a Nurse' (work/family balance, stress, self-efficacy and self-esteem). These, together with the impact of women's labour market status, will be reported elsewhere. 'Working in this Health System' Nurses were very concerned about both the general political trend towards a market oriented o·ri·ent n. 1. Orient The countries of Asia, especially of eastern Asia. 2. a. The luster characteristic of a pearl of high quality. b. A pearl having exceptional luster. 3. system and its implementation by management. As workers in this new health system, they perceived generic, hospital level management and nursing management as distant, uncaring of nurses and failing to communicate with or listen to nurses. Their voices on three aspects of this are provided below. 1. Working in a Market-Oriented Health System. Nurses strongly pressed their view that the health industry has changed to be focused on either cost/financial issues or, for the private sector, profits; they were highly critical of this approach. For many, this was the defining reason for quitting nursing or considering doing so. The quotations below provide some of the flavour (jargon) flavour - (US: flavor) 1. Variety, type, kind. "DDT commands come in two flavors." "These lights come in two flavors, big red ones and small green ones." See vanilla. 2. The attribute that causes something to be flavourful. of their comments. /sadly they are only concerned about dollar cost.../I feel very strongly that ... any health care facility should not be 'money making '.../ only interested in making money .../ always battling with management to get increase in staff .../ The government budgets just keep cutting health budgets more and more .../ It's a pity the money crunchers, senior management outside nursing, seem intent on destroying systems established over years of good practice .../ I hate the growth of luxury private health and the profiteers in the health system .../ Some of the strategies of NPM and managers are blamed by nurses for what they see as a failure to remedy problems in the health system. /since the creation of business divisions in hospitals it is all very disjointed .../ With individual budgets in departments ... there is not a global approach to what is best for the most productive outcomes for patients/hospital/staff .../ the perceived lack of long term solutions management and governments seem to be implementing .../ Waste money on a bypass plan and don't institute any measures--not thought out .../ I have no faith in managements abilities to see the BIG PICTURE'(emphasis in original) .../ 2. Working Under Managerialism. Many nurses saw disconnect disconnect - SCSI reconnect between the rhetoric and the practice of managers; that is, they did not see management 'walking the talk'. /Health service management needs to believe the rhetoric that they give out and implement it, i.e. a whole cultural change is needed .../ There is much lip service given (but) .../ Management level 4 and up do as they please. Ask your thoughts and opinions and don't follow through .../ the buck never stops anywhere .../ Nurses perceived an explosion in the ranks of management, particularly 'non-nursing management', with a consequent con·se·quent adj. 1. a. Following as a natural effect, result, or conclusion: tried to prevent an oil spill and the consequent damage to wildlife. b. rise in meetings and administration generally. They see these trends as unproductive and draining healthcare of resources. .../ the growth of administration in the last 20 years .../ too many chiefs and not enough Indians .../ I see so many people doing, applying out of 10,000 buckets of money .../ special project officers ... health teams who prepare research papers .../ increasing bureaucracy .../ growth of administration ... they hold the purse strings and set the priorities ... new admin and clerical areas while patients waited .../ disproportionate amount (of resources) allocated to higher levels of management/non-clinical aspects of nursing ... /Health institutions are becoming top heavy with office workers .../ Despite the perceived increase in management at all levels, there was a strong view that management did not communicate adequately with, or listen to, nurses' issues, concerns and suggestions. /nurses should be seen and heard by management .../ unit managers willing to toe the line would sacrifice nurses for bonuses .../ after consulting with management and receiving no support .../ management expect loyalty ... but are not prepared to give it in return .../ behaviour of patients ... this is rarely addressed by management .../ no one in power ever listening to what nurses have to say .../ hierarchy does not respect or value its nurses .../ little encouragement ... of "job well done thank you" ... / little discussion with workforce prior to change in role, working area, equipment .../ 3. Doing the 'Paperwork' of Accountability. Many, many times respondents decry de·cry tr.v. de·cried, de·cry·ing, de·cries 1. To condemn openly. 2. To depreciate (currency, for example) by official proclamation or by rumor. the 'paperwork', especially in the aged-care sector. They react angrily to the increase in documentation associated with both certification and audits, and the accountability requirements of the purchaser/ provider models of service delivery. /too much documentation .../... administrators increase (waste) with all their paperwork .../ drowning in documentation. The documentation and auditing requirements of the RCS are ridiculous and hinder nursing practice .../ RCS and accreditation systems place an enormous and increasing burden on staff .../ ... we are covering our decisions with intense documentation .../ documentation is duplicated and repetitive .../ The overall dilemma identified for nurses working in the health system is expressed by one nurse who claimed 'I no longer believe the health system supports clinicians'. 'Nursing as a Profession' Respondents to the RN survey were in the main committed to their profession; at the same time, they expressed 'management play a huge role in degrading TO DEGRADE, DEGRADING. To, sink or lower a person in the estimation of the public. 2. As a man's character is of great importance to him, and it is his interest to retain the good opinion of all mankind, when he is a witness, he cannot be compelled to disclose the enthusiasm of nurses to continue to care'. Many of their experiences reflected the implementation issues In the Business world, companies frequently set-up a connection between which they transfer data. When the connection is being set-up, it is referred to as implementation. When issues occur during this phase, they are known as implementation issues. associated with working in a health system which no longer reflects, values or nurtures their professional values. 1. The 'BUT' of Nursing. Nurses' qualitative responses reflect ambivalence ambivalence (ămbĭv`ələns), coexistence of two opposing drives, desires, feelings, or emotions toward the same person, object, or goal. The ambivalent person may be unaware of either of the opposing wishes. towards their current roles as professionals as a result of the changes in the health care system described above. They repeatedly qualified their positive comments with a 'but'. This is well captured by the following; /... intention of leaving nursing but I never made it /... I love nursing. But ... sadly .../ I have enjoyed my career and have been happy to go with change (but)... if I started out now I would not consider nursing /... I have enjoyed the years I've worked as an RN. However .../ I do love nursing or should I say I did love nursing .../ The tensions between their roles as hands-on patient carers and workers in the NPM health care system are reflected in their comments on 'paperwork'. This tension lessens their self-perceptions of being a 'professional nurse'. /I went into nursing to nurse ... not lots of paperwork, computer work .../ paperwork ... WHERE IS THE TIME TO BE WITH THE PATIENT (emphasis in original) .../ accreditation demands ... have lessened hands-on time with patients .../ the paperwork has taken time away from the patient .../ and the paperwork has increased 'to prove' we have been thinking of patients' needs leaving less time for connection (with patients) .../ I chose (nursing) because I had visions ... where I could offer support/compassion ... but .../ The elevation in importance of technical aspects of the job compared with the more traditional caret role was decried by some nurses. This elevation, as with the increase in paperwork, is an expected side-effect of the increased emphasis on measurable outcomes, which is a major focus of managerialism and NPM. /too technical or doctor oriented and the basic nursing skills of care being forgotten or haven't time to carry out .../ the modern RN is not a bedside nurse but a highly skilled technician .../ 2. Loss of Professional Autonomy and Compromised Professional Practice. There was a dominating theme which goes to the heart of the potential for conflict between NPM, managerialism and a workforce which sees itself as professional and adhering ADHERING. Cleaving to, or joining; as, adhering to the enemies of the United States. 2. The constitution of the United States, art. 3, s 3, defines treason against the United States, to consist only in levying war against them or in adhering to their enemies, to a view of appropriate professional practice and professional autonomy. We heard the repeated clash between the personal and professional value systems of nurses and the culture of their health care organisations operating in a climate of managerialism. This seems to us likely to probe the deepest vein of discontent. /... at the end of the shift feeling guilty that you have not (been able) given people good care .../ my ethics/values differed from those in senior positions .../ care falls short of comprehensive/ holistic approach learnt during training ... results in feelings of frustration, dissatisfaction, inadequacy .../ I entered nursing because I care and I can nurture, however these skills are not valued .../ main stressors for me include ... not being able to give my patients great care .../ I was taught problem solving and decision making and ended up having to follow orders from management .../ nurses are not involved enough in ethical decision processes .../ I left ... because my ethics/values differed from those in senior positions .../ I now try to continue good health care and pure nursing ethics by keeping people away from hospital ... system fundamentally flawed .../ The dilemma associated with providing sub-standard care weighs heavy .../ The capacity to provide 'care', 'good quality care' was one issue at the heart of what nurses saw as the assault on their professionalism. 'Care' in this context is partly bound up with the concept of 'emotional labour' already discussed (Bone 2002, James 1989). It is useful to allow the nurses themselves to define what they understand by 'care'. /to sit and talk with patients, to give all-encompassing care, physical, emotional and spiritual .../ where I could offer support/compassion to those in need .../ talking to patients and families, hands-on patient contact .../ to see people more holistically and not just dish out pills .../ only essential medical/surgical care (can be given), falls short of comprehensive holistic care .../ time for good old fashioned 'tlc'..../ find out how your patients feel or what is really bothering them .../ Nurses in the study understood 'care' to require a holistic approach holistic approach A term used in alternative health for a philosophical approach to health care, in which the entire Pt is evaluated and treated. See Alternative medicine, Holistic medicine. , providing for the simple physical comforts (hygiene, personal grooming
Personal grooming, or simply grooming, is the art of cleaning, grooming, and maintaining parts of the body. , feeding) for those unable to meet their own needs, and emotional support and understanding in addition to medically determined tasks. This accords with James' (1989, p. 26) definition of caring; Caring ... could be described as having emotional labour, physical labour and organisation as its component parts (James 1987), so that the emotional labour is carried out within the context of the organisation and the physical labour. The overall call from these nurses is well summed up by the nurse who said that 'we (in health care) have lost sight of the fact that our priority is to give clients/ patients the best care possible.' 3. Nursing is Managed by Non-nurses One of the historical characteristics of a profession was self-management; in the case of nurses, nurses were managed by other nurses. Today this has changed in the health system and nurses are unhappy about the lack of understanding of their profession. Nurses perceived that generic management, a strong feature of managerialism and NPM, was not able to encompass an understanding of the needs and issues for nurses. /turmoil created by non-nursing, non-medical staff .../ Too many non-nursing managers and other admin people telling nurses how to do their work .../ the use of generic management ... to reduce 'nursing costs' has made most of us resentful of our uncaring administration .../ nursing is now managed by non-nursing personnel ... they are only concerned about dollar cost .../ decisions made further up the managerial line which make my working life stressful .../ 4. Nurse Managers No Longer Play a Professional Role. These nurses are concerned at what they see as the demise Death. A conveyance of property, usually of an interest in land. Originally meant a posthumous grant but has come to be applied commonly to a conveyance that is made for a definitive term, such as an estate for a term of years. of nursing leadership in the face of the major changes which had assailed them. /nursing is divided they need to get their house in order .../ there is no longer a clearly identifiable culture or spirit that enables nurses to be unified and forward looking .../ support of nursing leaders has been eroded .../ very few dynamic contemporary leaders .../the few highly skilled and knowledgeable nurses in leadership positions are used up .../ the system is sick and the leaders absent .../ They also complain that nursing management positions are lost to management. Issues included loss of experienced mentors at the hands-on level and the absorption of nurse managers into the broader management culture. /... The L3 is a combined manager/clerical position and their main job is management ... we desperately need L3 ... who can set standards for others to work to .../ a lot of nurses are now in management dealing with budgets, staffing issues, quality issues, OHS .../ CNMs, once they move into this position ... become puppets of nursing management, hospital management, CEOs and the Health Department .../ One of the important issues for nurses was the feeling that no one in a management or leadership position ever expressed appreciation to them, encouraged them or showed understanding of the pressures and stresses under which they worked. In general, nurses did not feel supported by or within their workplaces. As one nurse expressed it, there was a 'lack of empathy' from management. 5. 'Customer Focus' Rhetoric Does Not Mean Better Patient Care. The focus on the customer/client is a key element of NPM and Total Quality Management. The perspective of many nurses, however, is that patient needs are not being met and that, more importantly from the perspective of NPM, the customers are expressing dissatisfaction, sometimes in unorthodox ways. It is notable that nurses rarely used the language of the new discourse hegemony hegemony (hĭjĕm`ənē, hē–, hĕj`əmō'nē, hĕg`ə–), [Gr.,=leadership], dominance, originally of one Greek city-state over others, the term has been extended to refer to the dominance of one , preferring 'patient' to 'customer' or 'client'. /you find yourself everyday doing a catch-up job, no wonder they (our patients) get angry and depressed .../ patients are neglected and complaining .../ I quite often hear patients saying their needs have not been met .../ There are huge gaps between public expectations and what the health service provides ... nurses bear the brunt of peoples' frustrations .../ Nurses are critical of the impact of cost savings and related financial requirements on what they see as their ability to provide professional and safe levels of care to patients. /closer to profit making 'business' management our workplace becomes the more difficult it will be for us to provide care .../ now nursing is all about cost saving and not those in need .../ I find private hospitals are only interested in making money for their investors. They cut staff to a dangerous level .../ always having to trade off conditions ... and still the Health Department and Government bitching over staffing levels / Discussion of Findings: In this research we followed in the path of other interpretivist researchers who, like Edwards (2002), have sought to share the research participants' experiences and understanding of those experiences. We have sought to 'amplify the voices encountered in the research, present them fairly.... place them in context' (Edwards 2002, p.81). Four themes emerge from the critique nurses have of their 'vocation' rather than 'industry' and their role as professionals in health workplaces. 1. Professional Dissonance In essence, the basis for professionalism and the intervention of expert professional judgment (Malin et al. 2002) is the existence within human and social contexts of situations, problems and issues which involve uncertainty; i.e. it cannot be assumed that there is a linear and certain cause/effect relationship for predicting outcomes. Hence the emphasis on professional 'practice', which develops and supports the necessary accretion The act of adding portions of soil to the soil already in possession of the owner by gradual deposition through the operation of natural causes. The growth of the value of a particular item given to a person as a specific bequest under the provisions of a will between the of information to support expert professional judgment for decision making in uncertainty. With this expert judgment goes the necessity for autonomy in the exercise of judgment and professional accountability for that (Malin et al. 2002). There is very apparent dissonance expressed by the responding nurses resulting from the tension between the workplace processes, roles and accountability requirements ensuing en·sue intr.v. en·sued, en·su·ing, en·sues 1. To follow as a consequence or result. See Synonyms at follow. 2. To take place subsequently. from the hegemony of managerialism, and their own professional values and expectations of appropriate professional practice. This resulted in the nurses expressing feelings of guilt, frustration and inadequacy in regard to the 'care' they provide. We have developed from the nurses' voices an understanding of what they mean when they talk of 'care' in this context. For nurses, 'care' requires a holistic approach to the person, providing the simple physical comforts for those unable to meet their own needs plus emotional support and understanding in addition to medically determined tasks. These nurses underline underline an animal's ventral profile; the shape of the belly when viewed from the side, e.g. pendulous, pot-belly, tucked up, gaunt. the loss of professional autonomy; '... skills are not valued'. They were frustrated frus·trate tr.v. frus·trat·ed, frus·trat·ing, frus·trates 1. a. To prevent from accomplishing a purpose or fulfilling a desire; thwart: by the downgrading downgrading A reduction in the quality rating of a security issue, generally a bond. A downgrading may occur for various reasons including a period of losses, or increased debt service required by restructuring a firm's capital to include more debt and less of, or inability to exercise, professional judgment; '... not involved enough in the ethical decision Real life ethical decisions are studied in sociology and political science and psychology using very different methods than descriptive ethics in ethics (philosophy). Not ethics proper processes', 'reduced capacity to progress and offer services that might best address community need...'. Above all, there is a refrain from the responding nurses that 'care' as they define it is substandard substandard, adj below an acceptable level of performance. or below the standard they believe appropriate and that they constantly face ethical dilemmas An ethical dilemma is a situation that will often involve an apparent conflict between moral imperatives, in which to obey one would result in transgressing another. This is also called an ethical paradox in the decisions the system requires of them. The last word goes to a nurse who described an occasion of health care, concluding: 'This is very poor care in our society and I am ASHAMED (emphasis in original) to be part of it.' The nurses provided evidence that they felt a sense of disarray dis·ar·ray n. 1. A state of disorder; confusion. 2. Disorderly dress. tr.v. dis·ar·rayed, dis·ar·ray·ing, dis·ar·rays 1. To throw into confusion; upset. 2. To undress. in the face of challenges to the profession. One recent response from the profession is to seek to rebuild and re-engage its leaders in the debates on healthcare directions in ways similar to the medical profession. The report of the Steering Committee steer·ing committee n. A committee that sets agendas and schedules of business, as for a legislative body or other assemblage. steering committee Noun of the West Australian West Australian commonly refers to people or things from Western Australia. Specific things to which it may refer include:
n a small amount of chewing tobacco (snuff) an individual takes to use the substance for its desired effect. A “pinch” is called a quid in Britain. and Della 2001, p. 7) argued that this will require nurses to be included in strategic decision making, have enhanced career paths and a comprehensive transition from education to practice as well as develop a visionary leadership and an investment in the long term future of the profession. This is a response which holds to the professional identity and seeks to strengthen it. 2. Career Choice Dissonance The nurses' responses provide clear evidence that, in the process of workplace change, the relational or--in Bone's (2002) terminology--the 'emotion' work, which nurses hold as an important part of their role, is neither valued nor given space within the workplace requirements of NPM and managerialism. The workplace dissonance this creates for nurses is very evident from nurses' responses in the RN Survey 2002. Respondents are very insistent in·sis·tent adj. 1. Firm in asserting a demand or an opinion; unyielding. 2. Demanding attention or a response: insistent hunger. 3. that they went into nursing to provide care. This is consistent with the quantitative data reported in McCabe, Nowak and Mullen (herein). 'Ability to help others' and 'Ability to work closely with people' are ranked by the respondents to the RN Survey as two of the top three reasons for choosing to be a nurse. These two reasons had similar levels of importance to student nurses (also reported by McCabe et al. and Dockery and Barnes herein) and were significantly different from the stated reasons for choosing a course by other first year tertiary tertiary (tûr`shēârē), in the Roman Catholic Church, member of a third order. The third orders are chiefly supplements of the friars—Franciscans (the most numerous), Dominicans, and Carmelites. students. This desire to help others and to work with people has been increasingly at odds with the actual workplace experience of the responding nurses. As one nurse responded, 'WHERE IS THE TIME TO BE WITH THE PATIENT' (emphasis in original). Nurses report their efforts to continue to provide care through unpaid overtime and increased intensity of work. As one nurse said, '... you find yourself everyday doing a catch-up job.' It is apparent, however, that concern at the decline in the 'care' component of their role is a significant cause of stress to nurses. One nurse expressed it thus: 'Main stressors for me include ... not being able to provide my patients great care.' 3. Ideological Dissonance Nurses identify a clash between the commercial and clinical cultures in the WA health system. Nurses in this study do not support the use of the profit motive or the commoditisation of health care and, to this extent, experience an ideological dissonance with their environment. This dissonance is evident not only in the private hospitals and aged-care facilities but also in the public sector hospitals, which have imported private sector financial management protocols as a result of market-oriented reforms imposed by government. These WA nurses appear to share the view of Barnett and Barnett (2003, p.45), who condemn To adjudge or find guilty of a crime and sentence. To declare a building or ship unsafe for use or occupancy. To decide that a navigable vessel is a prize or is unfit for service. the market approaches to the delivery of health care, preferring instead that 'the ultimate goal of a health system should be the equitable, efficient and effective provision of care, not the profitable sale of commodities'. 4. Resistance to the Implementation of Managerialism Nurses in this study clearly felt the burden of several of the elements in NPM and managerialism (Beattie 2000, Baum 1996, Malin et al. 2002) such as quantifiable outcomes and process focus, responsiveness to cost rather than care and quantifiable performance-based contracts. They were faced with the implementation of these measures without any apparent capacity to influence the original decisions prior to implementation. They felt that even nurse managers were impotent im·po·tent adj. 1. Incapable of sexual intercourse, often because of an inability to achieve or sustain an erection. 2. Sterile. Used of males. or not supportive. The consequent expressed burden of 'paperwork', 'audit documentation' and too much time on what they perceived as 'administration' was evidence of this. Nurses contrast the rhetoric of reducing waste while observing increasing managerial superstructures. This corresponds with the political analysis by Miller and Rose (1990), where compliance at an atomistic level with the new 'technologies of government' becomes the centre of resistance. Nurses emotionally and professionally resist what Bolton (2004, p. 318) terms 'the instrumental motivations of managerialism'. In this study there was little evidence of nurses acknowledging benefits of the new management practices. WA nurses clearly felt a resistance to these burdens but, under pressure, complied at the cost of patient care or through an acceptance of work intensification in·ten·si·fy v. in·ten·si·fied, in·ten·si·fy·ing, in·ten·si·fies v.tr. 1. To make intense or more intense: . This experience reinforced nurses' feelings of powerlessness pow·er·less adj. 1. Lacking strength or power; helpless and totally ineffectual. 2. Lacking legal or other authority. pow similar to those reported by Daiski (2004) in a Canadian study. 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The rate of occurrence of habitual absence from work or duty. , Stress and Workplace Injury: What Are the Contributing Factors and What Can/Should Be Done about It?', The International Journal of Sociology and Social Policy, vol. 23, pp.81-103. Sydney Morning Herald (2005) 11 May. 'High risk tax cuts sweeten sweet·en v. sweet·ened, sweet·en·ing, sweet·ens v.tr. 1. To make sweet or sweeter by adding sugar, honey, saccharin, or another sweet substance. 2. To make more pleasant or agreeable. lost opportunity'. (http://smh.com.au/artciles/2005/05/10/1115584964211.html) accessed 18 May 2005. Margaret Nowak and Maureen Bickley *, Graduate School of Business, Curtin University of Technology * We thank Evan King- Mackasy, whose research assistance on this paper, particularly the coding and text management, is greatly appreciated. We gratefully acknowledge a Curtin Business School Tier 1 grant. |
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