Abstract
This 200th anniversary of the birth of Florence Nightingale, social reformer, statistician, iconoclast and founder of modern nursing, presents an opportunity to revitalise her legacy for today’s ‘Nursing Now’ challenge.1,2 Recognising Nightingale’s influence and impact, the World Health Organization has designated 2020 and 2021 as the ‘International Year of the Nurse and Midwife’.
Since Nightingale, nursing practice, education and research have advanced inexorably. This has been enabled largely by the move from hospital-based schools of nursing into the higher education sector in the late 1980s. This move was controversial for some, and to this day, we still see Neanderthal views that nurses, alone among health professionals, do not need a university education, as the only qualities required it seems are kindness, common sense and robotic obedience, enforced by Sandhurst-style military training and sergeant-major matrons. 3 A degree-based education has, however, been largely advantageous for both nurses and the public. For example, a major European study (RN4CAST) 4 showed the improvements to mortality that accrued when nurses had a bachelor’s degree education and where they cared for six rather than eight patients. Nurse-led care and Nurse Practitioners are also demonstrably effective in many settings. 5 Today’s nurses are not ‘overqualified’ or ‘too posh to wash’. If mainstream media need another superficial soundbite, ‘Nurse Boffins Save Coffins’ would be more accurate and less demeaning.
As nurses make up the largest healthcare workforce in the world, 5 they assuredly have the potential to take on 2020’s ‘Nursing Now’ challenge to ‘equip and empower the next generation of nurses and midwives as leaders, practitioners and advocates in health’. The major ‘State of the World’s Nursing 2020’ report 5 provides ample evidence that nursing is ideally placed to tackle major forthcoming contemporary health challenges. Regrettably, nursing’s progress and achievements have often been accomplished, not with managerial and political support, but in the face of their opposition. Long-established, institutional and professional impediments exist that thwart nursing’s attempts to be in the same room, let alone at the same table as other key health and service decision makers. Achieving Nursing Now’s goals will not be easy. The ‘empowerment of nurses’ sought will not be willingly handed to us. When Dr Martin Luther King Jr said that ‘Freedom is never voluntarily given by the oppressor; it must be demanded by the oppressed’, he spoke a timeless truth about power and the need for all health professionals to demand and wrest this from those who would keep nursing forever subservient and invisible.
Given the incontrovertible value of nursing and the need for a strong nursing voice at every health service level, why are nurses still pleading for a ‘seat at the table’ in health services? In the throes of a major pandemic such as COVID-19 that has united health professionals as never before and that has upended the workings of bureaucracies previously deemed ‘impossible to change’, nursing continues to be rendered invisible and not by accident. Never, in our lengthy careers, have we heard a senior manager say ‘Whoops, I completely forgot to make sure I have nursing input into this process’. We teach people how to treat us, and by deference, acquiescence and obedience, nurses perpetuate this situation. Jane Salvage's influential work on ‘The Politics of Nursing’ depicted such wholesale disempowerment over 35 years ago. What has prompted nurses like her to ask yet again in 2020, ‘Why shut nurses out of decision making?’ 6 As The Lancet stressed earlier this year, ‘Giving nursing and midwifery the status they deserve is long overdue’ (p.1167).7 ‘Nursing Now’ and indeed the current COVID-19 pandemic give every nurse and every doctor an opportunity to turn this situation around.
What can be done to rectify this institutional diminution of nursing that causes such collateral damage to our medical colleagues and to genuine teamwork? Rather than being surprised to see a nurse interviewed or quoted as an expert in any health story, we should be seeing regular media appearances and hearing major clinical and health promotion advice from key nurses everywhere. Yet, the same nurses, who for 18 years have been voted the ‘most trusted professionals’, are routinely forbidden by corporate apparatchiks from talking to the media. 8 No hospital, health service or government should convene service meetings or health policy groups in 2021 that do not have a nursing voice at that table. It defies belief that this ‘demand’ has to be made in 2021. The history of ‘medical dominance’ makes painful reading 9 but we contend that nursing’s prime oppressor today is not medicine, but the managerialist corporatism and systemic malevolence that disfigures many health and education services and that threatens medicine as much as nursing. 10
Nursing cannot remedy this situation on its own. We need the support of our medical colleagues at our side, not above us in the traditional hierarchy that has been so damaging 10 for all involved. Imagine if every doctor refused to sit on any working group or committee where there was no nursing voice. Imagine medical colleagues insisting on key nursing input at every case conference, clinical review or adverse event assessment. Imagine if every CEO understood that nursing input at every organisational level was not an optional extra to be ‘allowed’ at their whim. Nursing’s involvement in health decision making will never be ‘granted’ as a favour and we condemn another generation of nurses to waiting for the crumbs from the table if we imagine this. Assuming that involvement and inclusion are privileges our masters allow us internalises the exclusion and subservience that nursing has endured since Nightingale’s era.
Nursing needs support from our medical colleagues, but we cannot and should not expect anyone else to solve this problem for us. This buck stops with us and the actions needed to end this invisibility blight must start with us. Nurses, from the newest student to the most senior nurse manager, need to stop waiting for invitations or permissions from power that may never come. It is up to us to ‘take our rightful place at the table’ with the emphasis on ‘take’. This will not be easy and nurses need to step into roles and arenas that may be outside of our comfort zones. So be it. When have nurses ever been restricted to comfort zones? If training in lobbying, politics (with a small or large ‘p’), media work or Board membership is required, we need to access it. Imagine nurses worldwide rising up to this challenge in 2021 ‘International Year of the Nurse’.
We also need to stop perpetuating nonsense about nurses ‘leaving the bedside’ as if this were some professional affront. This infernal ‘bedside’ obsession has stunted our development and stymied our ability to take our rightful place at so many fora and decision-making groups from which nursing is excluded. Of course, nursing, like medicine, is about direct care, but it is about so much more. Nurses do not ‘abandon’ nursing because they manage a service. They do not suddenly ‘forget about clinical care’ when they become a nurse educator. They do not ‘betray nursing’ when they work with doctors or other colleagues in an interdisciplinary research team. They do not become ‘know-it-alls’ when they obtain a higher degree. This self-inflicted demeaning of nursing is worse than anti-intellectualism, it is a determination to ensure that nursing’s potential and possibilities are forever limited. Nurses must confront and end this destructive rhetoric whenever it raises its ugly head.
What would happen if nurses insisted that they would be attending all crucial clinical and executive meetings and fora where nursing input was important. What would happen if nursing and medical leaders in every hospital and health service announced that nursing presence in key deliberations and practice and policy matters was a core organisational principle and value as important as patient safety and service quality? What would happen if systemic nursing involvement and participation and demonstrable, collegial teamwork between doctors and nurses were assessable criteria in every hospital or health service audit or review? What would happen if Ministers of Health worldwide announced that such nursing representation was to become integral to all health services by the end of ‘International Year of the Nurse’? What would happen if nurses took the ‘Nursing Now’ empowerment challenge seriously, rather than having yet another ineffectual ‘leadership programme’ foisted upon them? 11 What if our medical colleagues fought beside us to accord nursing and midwifery their long-overdue place in healthcare1 that would benefit nursing, medicine and the public we all serve? What if this was nursing’s and medicine’s opportunity to jointly speak truth to the powers who render nursing voiceless? What if 2021 truly did become ‘The Year of the Nurse’? What indeed.
