Mind the Gap: rhetoric and reality

By Jill White and Mary Chiarella
Jill White is Professor of Nursing and Dean of the Faculty of Nursing and Midwifery, University of Sydney. Mary Chiarella is Professor of Nursing and Midwifery, University of Sydney.

Redundancies, nursing positions replaced with administrators, more nursing assistants. Welcome to NSW post-Garling.

The recommendations of the Garling Inquiry in New South Wales held the potential to make a difference to the outcomes of care in NSW hospitals - for patients and staff. They were based on an enormous body of research evidence and the testimony of many expert clinicians. Now well past the initial excitement about the potential for change, some of the current initiatives being rolled out in the name of a “response to Garling” are puzzling at best.

Commissioner Garling acknowledged the pivotal role of the Nurse Unit Manager (NUM) in patient safety and the quality of care, and was concerned at the progressive clinical detachment of this role. He suggested the introduction of a role of “clinical support officer” to support NUMs in the administrative tasks that were taking them away from expert overview of clinical care at the unit level and the supervision of unit nursing care. What was never foreseen was that in implementation, the clinical support officer roles would be introduced at the expense of nursing positions rather than as a complement to them. The Inquiry was sparked by a growing public concern for patient safety and particularly, the recognition and action around the deteriorating patient. Watchful practice and early detection fundamentally rely on well educated, experienced nursing staff in sufficient numbers to be able to provide care.

But what are we seing?

We are seeing clinical support officers replacing nursing positions, and very high numbers of assistants in nursing being introduced in substitution – not as adjuncts – to registered nurses. Perhaps the most worrying, we are also seeing many nursing positions in several Area Health Services (AHS) being made redundant. These redundancies extend across a wide spectrum of RN positions, including Clinical Nurse Consultants who provide expertise and support to clinical nurses. Two of the area health services in which this is taking place are areas of significant socio-economic hardship and that have traditionally had difficulty in attracting and retaining RNs. We understand that a number of these redundancies have been offered to very experienced 8th year RNs who arethe backbone of the experienced clinical ward based workforce.

What a perplexing contradiction!

The public rhetoric about a dire skilled nursing shortage and its impact on bed availability, the call for the government to educate more nurses, the department’s drive to recruit overseas prepared nurses, the introduction of leadership programs such as “take the lead” and practice improvement programs such as “essentials of care”. These, juxtaposed with the clinical reality of redundancies, substitutions and the introduction of a large cohort of assistants in nursing. In small numbers, assistants may
be an adjunct to the care team but should by no means be a substitution. This situation has been compounded recently by a significant decrease in the number of available places in NSW public hospitals for new graduates in new graduate transition program, leaving many well prepared and eager newly registered nurses disenchanted and disenfranchised and who may never now enter the public health system.

The rhetoric around evidence-based practice is brought into sharp relief with actions such as these, which run contrary to the findings of a strong body of international research (Aiken et al, 2002,2003) and even to that commissioned by NSW Health itself, the major research project Glueing it Together, (Duffield et al, 2007). This NSW based research demonstrated that, at ward level, for every 10% increase in degree-prepared RNs in a unit, there is a concomitant 27% reduction in adverse events. It further
showed that skill-mix (the proportion of RNs) is more critical to patient outcomes than the hours of care provided.

Commissioner Garling sought to improve clinician engagement, to improve flagging clinician morale and to reassert the place of the experienced multidisciplinary team at the centre of care. These redundancies, with their loss of experience and expertise, and the substitutions of uneducated pairs of hands are not only further demoralising for the workforce but are potentially compromising for patient care. The deteriorating patient – at the centre of Garling’s concern – may be at further risk if we are not vigilant about changes related to cost savings, made in the name of patient care improvements, cloaked in the name of implementation of the recommendations of the Garling Inquiry.

Article published in Radius December '09