Has contemporary nursing been sabotaged by political interference?

I retired from my substantive nursing role at the end of 2019, just before the advent of the COVID-19 pandemic. Distracted by the conditions in which we found ourselves, I unintentionally let my professional registration lapse last year. I had been on the register for the best part of 40 years.

Nevertheless, at the end of last year I decided to apply to be a nurse vaccinator and make a small contribution to the vaccination programme within my community. The UK nursing regulatory body, the Nursing and Midwifery Council (NMC), set up a temporary register at the outset of the COVID-19 pandemic, specifically to bring people like me, back into service. I duly joined the temporary register and, taking into account my other commitments, I indicated I would be able to contribute 6 hours a week to the vaccination programme.

I’m currently in the process of carrying out the required preparation to take up this role in the autumn. This includes completing and passing a minimum of 13 online learning modules, in advance of a ‘corporate’ induction day. I’ve also been advised I am required to attend a session on lifting and handling, to build on the theory covered in one of the online modules. I don’t doubt that this will be followed up with more learning and practice, specifically related to the role of a vaccinator.

Health services across the UK are currently at breaking point. There are a whole host of reasons for this including years of underinvestment along with the backlog of unmet non-COVID related patient need and COVID-related staff burnout. Consequently, there are repeated media reports of insufficient staffing in nursing and medicine. In the face of this, for reasons for which I cannot fathom, the NMC is closing the ‘temporary register’ at the end of September this year. Therefore, I’m obliged to go through the processes required to re-register before I can practice. ¹

It’s fair to say, at this stage of the process, I can’t help feeling that the amount of work required to prepare for the role feels disproportionate to the demands of the job. It’s perhaps too early for me to say this categorically but what I can say is that I am not alone. I know others, in a similar position to me, who have simply given up when faced with so many hurdles to cross.

Assuming therefore that my gut feeling is right, and the requirements are disproportionate, why might this be so? One theory I have is that it is an unintended, and indeed paradoxical consequence of the introduction of the then ‘new’ public sector management (NPM) in the 1980s.

The prevailing belief of the Government of the day was that the public sector was neither swift of foot, nor value for money. The solution, according to the then Conservative Government, led by Margaret Thatcher, was to privatise every aspect of the public sector, where deemed politically expedient. In some cases, such as the National Health Service, this was considered too much of a political risk. The next best policy solution was judged to be the introduction of the values of the private sector, and in particular the management approaches employed, into the public sector. A better managed service would be more efficient, more effective and provide equitable standards and access (Klein, 2001).

One consequence of this was that a ‘quality culture’ was ‘introduced’ ostensibly to reflect the ‘discipline of the market’ (Loughlin, 2004). For example, standards were drawn up and introduced at pace, across the piste. There were undoubtedly some benefits in doing so, but, depending on your standpoint, this approach was not without its challenges. For example, professional autonomy was threatened and weakened in the name of accountability (Timmermans and Berg, 2003), and in some contexts, measures that were introduced lacked validity, reliability and relevance.

Indeed, the New Labour government, led by Tony Blair, who came into power in 1997, actively pursued this particular policy strategy across public services, with a focus on the introduction of targets as a means of measuring performance and ratcheting up standards of services and care (Barber, 2007). Once again, whilst perhaps laudable in intent, this has not been without its problems in practice. As Laughlin wryly acknowledged in 2004,

‘The result is that those of us who actually do the work in the public services find we are spending ever more time demonstrating quality and less time actually doing what we used to think of as our jobs’ (Loughlin, 2004: 26).

Twenty years later this culture has been normalised and it is my contention that a legacy of these developments is services overburdened with measures and processes of questionable value, often applied uncritically, by personnel without the authority to use their discretion. It takes a great deal of courage and energy to push back against a system of some 30 years’ standing, that has processes in place, ostensibly to assure quality and safety, that have the capacity to be counterproductive. Equally, I am left questioning, what does the current generation of nurses actually think of as their job?

We currently have a global nursing shortage and in the UK it is recognised that we have a considerable retention problem. My starting point to address this would be to empower nurses to think critically about what they actually think of as their job and then question and challenge the systems and processes that burden them, but don’t appear to add perceptible value.

With that in mind, each of the papers I have selected for this edition say something about the contemporary circumstances of our profession. The first paper examines nurses’ roles in modern healthcare; the second examines the moral distress experienced by neonatal intensive care and paediatric care nurses in northern Ghana; the third examines the impact of a visitor ban as a consequence of the COVID-19 pandemic on patients relatives; the fourth asks whether the involvement of registered nurses in improving healthcare services influences their intention to stay and the final paper explores attitudes and the perceived benefits of nurse managers participating in policy making.

I hope you find these papers, and their associated commentaries, as informative and thought provoking as I have.