More than a decade ago I participated in a workshop which was part of a large international conference on nursing informatics held in the US, and hosted by one of the big multinational health informatics companies.
Care home payment row case ‘reveals urgent need to define nursing’
We were invited to suggest and discuss scenarios about what nursing would look like 20 years hence.
One of the most influential informaticists (who was not a nurse) suggested that in future what we now call nursing would be divided among a new breed of medical technicians and an army of low-qualified generic carers.
Professional nursing as we know it would have disappeared, said the informaticist. I laughed: it couldn’t happen – could it?
But it looks like it could – and my fear is that we are letting it happen now.
A recent court case in Wales, in which local councils and NHS health boards were arguing over how much money they should each pay for nurses’ time in care homes, has shown this may be becoming a reality.
The health boards said they should not be required to fund nurses’ time spent doing tasks such as dressing and washing, because other staff members could do this instead – but the local authorities disagreed and said the NHS should pay for everything done by a registered nurse in a care home.
One problem is that discussions about the “role” of the nurse misuse the term “role”. The terms “role”, “function”, “activities” and “tasks” are not synonymous.
When we talk about a “role” this means the part played by a person in relation to others.
It is not defined by a list of activities. For example, a doctor, a nurse, and a support worker may all perform the same activity, even with the same patient, but their three roles are very different.
What worries me is that, in the present rhetoric about who should pay for “social care” - what we call basic nursing care – , this is being taken away from nursing by calling it social care and making it the responsibility of people who do not have the necessary underpinning nursing knowledge.
“What worries me is that, in the present rhetoric about who should pay for ’social care’ - what we call basic nursing care – , this is being taken away from nursing”
As a result, all that is left for nursing is a list of tasks which over time will be allocated to lesser qualified people who are cheaper to train and employ.
This will mean nursing will continue to be undervalued and the nursing needs of frail older people, especially in residential care homes, will not be identified or met.
As the judge in the recent Wales Supreme Court ruling said, it all comes down to the definition of nursing.
In 2003 the Royal College of Nursing published a document entitled Defining Nursing, which I helped to develop. The work was led by a steering group of council members and former presidents; members were widely consulted, and the definition redrafted accordingly. The document’s stated purposes included:
- describing nursing to people who do not understand it;
- clarifying the role of the nurse in the multidisciplinary health care team;
- influencing policy agendas at local and national levels;
- informing decisions about whether and how nursing work should be delegated to other personnel;
- supporting negotiations at local and national levels on issues such as nurse staffing, skill mix and nurses’ pay
“All that is left for nursing is a list of tasks which over time will be allocated to lesser qualified people who are cheaper to train and employ”
But for reasons that I have never understood, the RCN establishment has never promoted or used it – or an updated version in 2014 - for these purposes, and the confusion around the definition of nursing continues today.
I believe that personal care, which is currently being defined as social care, should be recognised as part of the “unique function of the nurse”, as defined by Henderson as “to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that the person would perform unaided given the necessary strength, will or knowledge”.
This does not mean that personal care can only be undertaken by nurses. But it does mean that the assessment of need and the prescription of care is based on nursing knowledge.
“We must urgently promote the provision of personal care as a responsibility that belongs to nurses”
Not only that but, when it comes to who pays, personal care should be free to those who need it – regardless of who provides it – and the RCN should stand up and say so.
Without a clear understanding of the nature of nursing we are at risk of seeing the informaticist’s prediction come true. To stop this from happening we must urgently promote the provision of personal care as a responsibility that belongs to nurses.
Dame June Clark, emeritus professor of nursing at Swansea University and former president of the Royal College of Nursing