GUEST EDITORIAL: Nurses look beyond the health sector crisis through nursing research

Merian Litchfield

About the author: Merian Litchfield, RN, PhD, is an academic-at-large, researcher, educator and consultant.

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IN THE CURRENT HEALTH sector crisis, various research studies inform those funding and employing nurses about what is needed to immediately boost the workforce. But it is now quite clear that the current ways and systems – and the workforce for them – are not sustainable or fit for purpose. Immediate action without future direction and possibilities in mind merely reinforces the status quo – where the traditionally protected place (roles) of nurses in the services now seem to be heading towards costly burnout.

So, just as urgent as the research for immediate action is the research and scholarship that present the substance of new thinking about health (including ill-health) and health care to address it. Our mahi is to place (re-create) essential nursing at the core of the health service system for the future. How we envisage the significance of nursing, and will act beyond the crisis, is surely a focus for our research: it is our professional responsibility and our political clout. My comment here is about the need for nurses to be scholars as well as practitioners and to undertake nursing research.

Our nursing predicament

Recently when I was visiting my family in Ontario, Canada, an item in the daily newspaper made me reflect on our nursing predicament in Aotearoa New Zealand. The heading was as evocative in Canada as any in the media here: “Staff shortage leads to ICU’s closing; Strain at [one hospital] highlights continuing crisis in Ontario health care system”. And it is the shortage of nurses particularly that feeds the crisis, aggravated by the “fallout from the pandemic”. On the surface, the issue is the same in our two countries: the number of nurses essential to maintain service delivery. In Ontario, the solution was to get relevant laws changed, which would remove politicised barriers to employment of nurses and thus fill the gaps.

In Ontario, just as if in Aotearoa, the newspaper reporters took their stance primarily focused on the workforce: “services can’t keep up with demand for care” because of the shortage. The source of their information was the hospital agency, the employer. The way the issue was construed caught my attention. The journalists reported: “lt [the hospital] said . . . we are constantly making adjustments to support our staff, physicians and patients during this ongoing health human resource shortage” (emphasis mine). We can assume nurses are incorporated in the frame of “our staff”. That is, they are employed into the roles cast by the impersonal hospital body as those it requires to achieve its mission; nurses are acquired as a quantified component of a generic workforce.

From this vantage point, nurses are among the cogs of the exhausted wheel of health service delivery that must and will be superseded. Because the sector has evolved conventionally around the advancements of medical science and technology (heavily weighted to personal medical care at the expense of population health), the current flow of funds assumes the primacy of the medical and surgical script. We can see that nurses continue to be cast as the assistants of the medical/surgical practitioners: the hegemony of the medical purpose (with its ethos and methodology) in design and delivery of health care. That nursing is a profession with a distinct and vital social purpose for its contribution, whatever the involvement of medical practice (albeit complementary), is not noticed; all are homogenised as the “medical workforce”.

Hence the potential for nurses to be free to nurse, or contribute creative analyses and proposals for improving health care, is lost in the efforts to prove parity, and argue employment concerns, that might hold the status quo on a highly-charged competitive stage. The direct significance of nursing for health and people’s lives – the health of the nation – beyond just sustaining the services as they exist, is neither expected nor even imagined. The distinct and essential contribution of nursing is inevitably missing at the table of health sector review and development. Surely the public have the right to be nursed when their health-related circumstances, their suffering, vulnerabilities and lack of knowledge, require it? Surely the availability of nursing is a marker of modern civilised societies?

The critical shortage of nurse numbers to sustain the traditional workforce is recognised as an international trend, and this brings us an overwhelming sense of helplessness and inevitable burnout. But as nurses in Aotearoa, we are very conscious of our particular orientation of the nursing needed to address the complexity of health need and predicaments of our citizens. Irihapeti Ramsden coined the terms Kawa Whakaruruhau and “cultural safety” (Ramsden, 1990), identifying our national, cultural approach to the practice of nursing. So whereas the crisis is global on the surface (workforce inadequacy), our historical and cultural roots give us our own way to review, look ahead and show the actual health significance of nursing practice for our own people, as it could be. The crisis and analysis of its causes and implications are contextual. The distinctly relevant statement of social relevance of the nursing profession in Aotearoa, gives us the lens through which to envisage health care beyond the crisis. Research that brings the focus of the lens to health and people’s lives can substantiate the potential. This is research addressing the practice of nursing and its significance.

Most importantly, it is nurses only who can and must undertake this research concerning nursing practice. Early in the pandemic here in Aotearoa, I read a newspaper item written by GP Dr Cathy Stephenson, explaining what happens to patients admitted to the ICU with COVID-19. In language readily readable for the public, she succinctly outlined the technologically intensive hospital treatment that is the medical prescription. As illustration, an excerpt was: “To be as safe and comfortable as possible, all patients on ventilators are sedated, and are given a muscle relaxant via a drip to ensure they remain drowsy. The ventilator may remain in place for days or weeks if needed, and is then ‘weaned down’ and stopped if there are signs of recovery”. The public are interested and grateful to have such information. But it is nurses who know the intensity and complexity of the nursing that is not mentioned. The continuous nursing engagement with each patient, whānau and family (even if the nurses change) is a coherent practice in itself, not just the performance of protocols and specified tasks and sets of skills ordered for the implementation and success of the medical prescription. What nursing involves – the wisdom of the practice – that has implications for health and lives well beyond that episode of critical clinical care, is what calls for nursing research. This requires a particular form of research that is nursing research.

Practice and research have social purpose

Nursing research distinguishes nursing as a profession. Practice professions have an agreed, acknowledged social purpose. Clarity of purpose gives practitioners as members of the profession their ethical stance and focuses their knowledge development. In recent times, nurses of Aotearoa, through membership of NZNO, have looked to the past and future and stated professional commitment to Te Tiriti o Waitangi, expressed as manaakitanga, whakawhanaungatanga, rangatiratanga, wairuatanga (Clendon, 2020). This identifies the relational nature of nursing as fundamental to its social purpose: the humanness of expression of cultural safety necessary for nursing for health (in its broadest meaning). Nurses’ understanding of these themes shapes their performance of all the technical and prescriptive activities they might include in their practice (Litchfield, 2021). That is, who the nurse is in practice matters . . . experience as a nurse matters . . . as well as the knowledge and skills for competencies.

The stated professional social purpose of nursing is the reference point (at least for the moment) for any nurse engaging in research and writing academic papers intended to inform and explain nursing practice; it is the basis of a sort of contract between the profession and the public to which we all commit to become registered. I argue that such nursing research relevant for the health and lives of the people of Aotearoa, assumes nursing methodology: the wisdom of nursing practice. The methodology is participatory in form. The wisdom unfolds through the research process that is as-if practice, and the product is an explanation (Litchfield, 2021). The researcher is practitioner, to be able to explore and substantiate the practice. As for other practice disciplines, the process of research is the process of nursing practice.

The wisdom of practice

Of course nurses as students do delve into other disciplines and select their methodologies through which their research contributes to the extensive body of objectified knowledge: the knowledge available to all in the workforce. This is important. But it is only through nursing research by experienced nurses that there can be development of and presentation of the wisdom of practice, and new thinking about how nursing practice might have its significance for health as part of the evolving health-care system. Union arguments for better work conditions gain traction and strength when there is nursing research to explain the direct health significance of nurses in practice, and further when there is scholarly analysis of the political and fiscal implications of practice. Nursing research is the coherence of a practice and systemic approach to innovation.

Nursing research is future-oriented

Given the rapidly advancing technology in the health sector and the enormous fiscal issues impacting everything about health care as we know it and see it in this crisis, the need for nursing research can only increase – alongside the more traditional research projects. It is timely for us as nurses to take our own lead in proposing how health might be addressed, when the number of nurses needed and who does what could be looked at quite differently. Such proposals require at least a group of articulate nurses who can explain and substantiate the significance of their nursing practice for health and people’s lives.

This is the challenge for nurses taking up the postgraduate education opportunities available. It is through nursing research and scholarship that nurses can confidently convey the significance and relevance of nursing for the people of Aotearoa – as a distinct practice in the changing context. I believe this future orientation to advancing one’s nursing practice brings much needed vitality to our outlook: the recognition of an expanding horizon for career possibilities beyond the bleakness of constraint in the current health sector crisis.

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References

Clendon, J. (2020). 2020 and beyond: A vision for nursing. New Zealand Nurses’ Organisation.

Litchfield, M. C. (2021). Nursing is – and has – a methodology: A nursing voice. Kai Tiaki Nursing Research, 12(1), 66-72.

Ramsden, I. (1990). Kawa Whakaruruhau: Cultural safety in nursing education. Ministry of Education.

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Note: “Nurse” refers to registered nurses. “Practitioner” refers to all nurses who are professional practitioners of nursing, not limited to those who are certified by the Nursing Council of New Zealand with the title “nurse practitioner” (NP).