The Changing Shape of Nursing Practice

The Role of Nurses in the Hospital Division of Labour

Davina Allen

• Publisher: Routledge
• Year: 2002
• eBook ISBN: 9781134605958
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

Bringing together sociological theories and nursing practice this text develops a dynamic conceptualisation of the nursing role which is rooted in the work setting. It looks at the factors which have shaped nursing work in the past and those which are likely to shape it in the future.Nurses' work is changing in two respects: the place nursing occupies in the health care division of labour and the routine shifting of work boundaries that nurses experience in their daily work. Drawing on her detailed observations of the reality of nursing work in a district general hospital, Davina Allen explores these linked themes, focussing on five key work boundaries: *nurse: doctor
*nurse: manager
*nurse: support worker
*nurse: patient
*nurse: nurseThe text provides new insight into many of the tensions and dilemmas nurses routinely face and the processes and constraints through which their work is fashioned. It offers a new way of thinking about the nursing role which is particularly relevant at a time when the scope of nursing practice is expanding and when the integrated approach to health and social care is seen as the key to provision and improved services.

1 PROFESSIONALISM AND MANAGERIALISM

Project 2000 will bring out highly-trained professionals who we will have to use properly […] Nurses are locking themselves in too tight a definition. What’s a doctor and what’s a nurse? There’s work to be done, you get the work done by the people who are best qualified to do it […] Hands-on care is below nurses’ level of competence. The nurse will become the overall assessor of the care that the individual needs to have […] A higher quality, cheaper service, with a competitive edge will be achieved by those who make the most improvement in their labour costs. It’s just common sense.

(Eric Caines¹ in an interview with Naish 1990,
quoted by Naish 1993: 25)

It may appear that many nursing activities can be performed by untrained people … Nurses use (bathing, washing and other forms of personal care) … to perform other vital activities. Bathing is an ideal opportunity for observation of the skin and pressure areas. Counselling, reassurance and health education are carried out in a variety of settings when patients are relaxed and feel able to talk. Replacing trained nurses with untrained ones wherever possible will save money in the short term, but will prevent trained nurses having the vital and regular informal contact with patients and will affect the quality of total holistic care that nurses strive to deliver.

(Rosemary Gillespie, letter to the Guardian, 15 May 1993,
quoted in Davies 1995: 89)

These extracts were precipitated by developments that were taking place in the UK in the 1990s in which changes in health policy (DH 1989a) and medical and nursing education (DHSS 1987; UKCC 1987; GMC 1993) had created vigorous debates about the future shape of the nursing role. They suggest very different versions of nursing and are assembled in rhetorically distinctive ways. Caines uses the language of management with its emphasis on quality, economy, efficiency, and competition. Gillespie employs a professional discourse that stresses the importance of holistic care and the value of combining physical tending with counselling, reassurance and health education. Both are oriented to a ‘common sense’ understanding of nursing work. Caines makes an appeal to the (self-evident) mundaneness of hands-on care, whereas Gillespie aims to counter ‘what everybody knows’ by making visible the indeterminacy and complexity of nursing practice.

The interaction of the discourses of professionalism and managerialism has had a major historical influence on the definition of nursing as an occupation and on the evolution of its jurisdiction. At the end of the nineteenth century, for example, Nightingale’s vocational vision of nursing as a ‘moral métier’ (Rafferty 1996) vied with the professional model advocated by Mrs Bedford Fenwick founded on scientific skills. The struggle over nurse registration centred on the very different visions of nursing they proposed and was infused with the politics of gender and economic interest.

Nightingale advocated a ‘domestic academy’ model of nurse training in which the education of nurses was principally about the formation of ‘character’. Rafferty (1996) argues that the roots of this approach can be found in Victorian ideas about the role of middle-class women as guardians of morality in the home. Improving the morals of nurses was seen as a route to the reform of the working class. The Bedford-Fenwick group, committed to a professional version of nursing, adopted a strategy that emphasized technical and scientific skills based on the model of the medical profession. While not denying the importance of character, Mrs Bedford-Fenwick insisted that the good nurse was both technically competent and morally virtuous.

At the end of the nineteenth century, nursing was tightly linked to particular hospitals and the knowledge nurses gained was not readily transferable to other types of patient or institutional context. Nightingale’s conception of nursing as a calling akin to a religion, coupled with a strategy of on-the-job training, provided hospitals with a cheap, disciplined and compliant labour force (Witz 1992). The registrationists were anxious to break the monopolistic control of the hospitals over the career prospects of nurses. Mrs Bedford-Fenwick proposed a private-practice model of nursing, based on a generalizable training that would prepare nurses to work with a wide range of patients in and outside the hospital. The absence of a national scheme of accreditation meant that the voluntary hospitals enjoyed a series of captive labour markets. Mrs Bedford-Fenwick’s proposal threatened to remove this control and place it in the hands of an autonomous professional body; instead of nurses working on terms set by the hospitals, the hospitals would have to employ nurses on terms set by the occupation (Dingwall et al. 1988).

Opposition to nurse registration was expressed in gendered terms. Emphasis was given to the importance of the training institution in instilling an appropriate character in nurses so that they did not abuse their intimate relationship with patients. Books and theory could be no guarantee of virtue it was argued. This anti-intellectualism was further underwritten by arguments that stressed nurses’ uneducatability and that derived a gloss of scientific legitimacy from evolutionary biology. Rafferty (1996) cites the example of Dyce Duckworth’s address to the Scottish Society of Literature and Art in which he cautioned against higher education for women lest it should disrupt ‘the natural evolution of perfect womanhood’ (p.).

In the event, the 1919 Nurses Registration Act proved to be a hollow victory for Mrs Bedford-Fenwick’s professional vision. As Dingwall et al. (1988) and Rafferty (1996) have argued, it appeared to have been influenced by the government’s intention to create a national health service after the war that would require some rationalization of nurse training, rather than sympathy for the registrationist case. The Act established a register of trained nurses and a General Nursing Council (GNC) charged with its maintenance and the determination of conditions. The Bedford-Fenwick group fought within the GNC for a system based on the model followed by the medical profession in which standards for recruitment and training were independent of the staffing needs of the hospital (Rafferty 1996). They were a minority voice, however, and in the early years of the Council priority was given to the development of a wider dispersion of skills and to the encouragement of local arrangements to rationalize training provision (Dingwall et al. 1988). Moreover, although the Registration Act gave nurses a protected title – only nurses on the register could call themselves state registered – this was not a prerequisite for employment as a nurse and, as a consequence, despite their desire for an all-qualified work force, faced with recurrent recruitment crises, the professionalizers were unable to resist the introduction of the EN (enrolled nurse)² in 1943 and the unplanned growth of the nursing auxiliary.

Nursing work is now a long way removed from its Victorian origins, yet this historical legacy remains centrally relevant to our understanding of the shape of the occupation today. While given a contemporary flavour, the struggle between the discourses of professionalism and managerialism is as germane as we begin the twenty-first century as it was at the end of the nineteenth. In the UK in the 1990s, the implementation of Project 2000 and the introduction of general management into the National Health Service (NHS) resulted in a revival of these divergent visions of nursing jurisdiction, marking a critical point in the occupation’s development.

Nursing and the new managerialism

In the late 1980s and early 1990s, the UK, like other countries in the developed and developing world, witnessed major reforms of its health care system. Signalling the start of a period of profound change in the nature of public administration, ‘new public management’ (Hood 1991) in the NHS began with the publication of the Griffiths Report (DHSS 1983) and was further consolidated in the 1990 NHS and Community Care Act. This ‘management revolution’ (Klein 1995) was part of a systematic attempt to refashion the relationship between public sector professionals and the state by exercising greater control over their practice and use of resources. It was the medical profession that was the principal target of the government’s agenda for change in the health sector, but the reforms that they instituted also had important implications for the shape of nursing work.

At the time, these were arguably the most radical policies instigated by any administration, but concern with NHS governance was by no means new. The search for improved management has been a persistent feature of the NHS’s evolution (Harrison et al. 1990), reflecting two linked tensions that arise from its organizational form. The first is the relationship between central government and local provision and the difficulties of reconciling central funding and accountability with the need for sufficient autonomy to meet local needs (Ranade 1994). The second is the product of an historical bargain struck between the state and the medical profession at the NHS’s inception (Klein 1995), which accorded doctors a privileged place in administering the new system (Ranade 1994). Although government controlled the budget, doctors controlled what happened within the budget. This was a double-edged arrangement for both parties. On the one hand, operating within tightening financial constraints, the medical profession was left to do the government’s dirty work in rationing service provision. On the other hand, the considerable clinical autonomy doctors enjoyed meant less central control over how resources were utilized. Klein (1995) describes this as a truce rather than a final settlement and, from the 1960s onwards, these strains became increasingly apparent.

These linked tensions constitute the so-called NHS management ‘problem’, which has been the basis of successive reforms of the service. Interest in improved management gathered momentum in the late 1960s and early 1970s, reflecting rising concern with the alleged poor performance of the ‘government machine’ (Harrison et al. 1990) and changing management ideologies in relation to the whole of the public sector (Flynn 1990). Previously, service organizations had been seen as unique but this was replaced by the belief that they were equally amenable to the principles of economic rationality associated with business organizations. Planning was seen as a neutral tool. Targets could be set and progress made towards them (Allsop 1984). The emphasis on achieving greater efficiency and rationality through planning was common to both main political parties (Klein 1995) and these ideas were manifest in a number of health policies throughout the 1960s and 1970s.

By the end of this period, however, there was mounting concern over the NHS. Spiralling costs and a series of industrial disputes led to the questioning of existing health policies. The 1979 Conservative government, in strong contrast to its 1970s predecessor, was not committed to the ideology of rational planning (Klein 1995). In the reorganization it instituted in 1982, decision making was devolved to local level although interestingly, they did not propose any fundamental reform of management. Indeed, ministers were emphatic that this was to remain firmly in health professionals’ hands. Launching Patients First Patrick Jenkin, then Secretary of State for Social Services, argued:

I believe that doctors and other professional people in the NHS are trained to take professional decisions off their own bat, and do not need the torrent of advice to which in recent years they have been subjected. It is doctors, dentists and nurses and their colleagues in the other health professions who provide the care and cure of patients, and promote the health of the people. It is the purpose of management to support them in giving that service.

(Allsop 1984: 139, quoting DHSS and Welsh Office 1979)

This was a view that was to be short-lived.

The publication of the Griffiths Report in 1983 marked a clear turning point in NHS management policy. In the past, the main preoccupation had been with the structure of the NHS; attention now shifted to its organizational dynamics (Klein 1995). Griffiths proposed major changes to NHS organization, duties, responsibilities, accountability and control. A general management structure from top to bottom was prescribed (Dingwall et al. 1988) with a number of in-built mechanisms to ensure accountability to central government. Although the introduction of general managers was, to a considerable extent, a mechanism for changing doctors by bringing them into the managerial process and instilling managerial values, it had a devastating effect on nursing. Nurses already had a management structure, and since the 1974 reorganization had been directly responsible for the enormous budgets that covered the provision of nursing staff (Davies 1995). ‘[A]t a stroke’, however, ‘the 1984 reorganization removed nursing from nursing’s own control and placed it firmly under the new general managers’ (Strong and Robinson 1990: 5).

Griffiths challenged many of the assumptions that had shaped the NHS since its inception. Consumerism emerged as a key theme in response to the criticism that services were oriented to the needs of providers rather than its users.

The NPM [new public management] claims to speak on behalf of taxpayers and consumers and against cosy cultures of professional self-regulation. Taxpayers and citizens, rather like shareholders, are the mythical reference points that give the NPM its whole purpose.

(Power 1999: 44)

The rhetoric of this period cast the general public as knowledgeable consumers of health services and emphasis was given to information and issues of communication. The period saw a dramatic increase in the number of complaints about health services provision and the implementation of local systems for measuring user satisfaction. Working at the ‘front-line’ of service delivery, it was frequently nurses who found themselves at the sharp-end of this new consumer consciousness (Annandale 1996).

The reforms were underpinned by a very particular view of ‘management’ (Flynn 1990). Many of the changes were introduced by people from the private sector and the managerialist ethic that developed was grounded in the belief that managers should ‘manage’, that they should be in control of their organizations and be proactive. ‘Active’ management was to replace ‘passive’ administration. The demand for greater ‘value for money’ generated a raft of techniques for management evaluation and control of clinical activity (Elston 1991) and signalled the beginning of an era in which the provision of care became subject to continuous scrutiny. In the NHS, as in other areas of public service provision, audit and accounting practices assumed a decisive function (Power 1999).

In addition to encouraging health professions to embrace a more ‘business-like’ approach, the new managerialism was also underpinned by a belief that it was possible to manipulate organizational cultures in a more direct way (Ouchi 1981; Deal and Kennedy 1982; Peters and Waterman 1982; Schein 1985). Commonly referred to as the ‘corporate culture’ paradigm, exponents of this view claim that ‘excellence’ is dependent on organizational members sharing common values and goals (Hughes and Allen 1993a). Although many NHS managers did not embrace these ideas uncritically, their influence was nevertheless evident in the discourse they adopted (Pettigrew et al. 1988; Traynor 1999). Pettigrew et al. (1988), for example, write of the spread into NHS management of a new language of ‘product champions’, ‘visionaries’ and ‘change agents’ (Hughes and Allen 1993a).

But Griffiths was only a beginning. In 1990, as a consequence of increasing concern with cost containment, the health service was reorganized again. The reforms introduced as a result of the National Health Service and Community Care Act 1990 were in many ways a logical development and strengthening of the Griffiths management philosophy, but their ‘kernel’ – the creation of the quasi-market – was a radical new departure (Ranade 1994). The crucial components of the Act were:

• the creation of a split between purchasers and providers of health care;
• the institution of a contracting process whereby providers would present tenders to purchasers;
• the creation of ‘self-governing Trusts’ that, following the Conservative victory at the General Election in April 1992, became the normal means for the provision of secondary and community health care; and
• other related policies, such as budgets held directly by general practitioners for certain services.

(Paton 1993)

Consonant with the consumerist trend was the introduction of the Patient’s Charter, one of a series of citizen’s charters that aimed to ‘improve and modernize the whole range of public services and to set standards that the general public can expect and demand’ (Robertson 1994: 86, quoted by Lyne 1998). Standards were specified in relation to matters such as waiting times for outpatient appointments and surgery (Hughes and Griffiths 1999). Aggregate data was used as the basis for ‘league tables’ by which Trusts’ ‘performance’ could be assessed. Health Authority contracts for clinical services often included ‘penalty clauses’ which resulted in reduced...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Acknowledgements
• Abbreviations
• Transcription Conventions
• Introduction
• 1. Professionalism and Managerialism
• 2. Conceptualizing the Nursing Role
• 3. The Study
• 4. The Intra-Occupational Division of labour
• 5. The Nurse– Support Worker Boundary
• 6. The Nurse–Management Boundary
• 7. The Nurse–Doctor Boundary
• 8. The Nurse–Patient Boundary
• 9. Conclusions
• Notes
• Bibliography