The money or the nurse?

As health care costs continue to rise, providers of care are examining ways to achieve high quality care at a lower cost. Because nursing is seen as a high cost item, pressure is placed on nurses and nurse leaders to examine all aspects of care and determine methods of care delivery that are cost effective. The competing ideologies are those of nursing and economic rationalism.

This is a time of great uncertainty and change that affects every aspect of society. The health care industry is not exempt from these changes. In fact, the health care industry is poised to reflect these changes in the most dramatic fashion. Society is experiencing transformations that are more comprehensive and revolutionary than have ever been seen before. As health care is a central structure within society the flow on effects of these changes are felt in all areas. These call for change in our paradigms of thought. We need a new paradigm.

Advanced technology and computerisation have opened the doors of knowledge in medicine, nursing and health to an increasing number of consumers. Health care providers are challenged to provide top quality care to increasingly knowledgeable consumers. Nurse leaders are challenged to ensure their practice and those of their nurses are of a standard to meet these demands. Strict hierarchies are changing to multi-disciplinary teams - though some would suggest that the role of nurses in these teams is yet to be fully recognised. We have moved from jobs for life to careers for life through multiple jobs. Professionals are called on to be more flexible and may be required to work on a number of different projects within a short period of time. Organisations are required to be global as well as local. Workers are asked to be autonomous while being part of a team. Market forces are producing dramatic changes in the way health care is financed and delivered. The pressure is on to contain costs while providing a top quality service.

Some of the central paradoxes facing society are those of justice, intelligence, organisation and ageing. The paradox of justice lies at the core of the health system as it tries to balance economy with equity. This is reflected in the process of trying to distribute resources and provide services equitably among various populations. The health care system is dependant on intelligence and advanced professional knowledge. This knowledge, though essential, is very difficult to control, measure or tax.

In the paradox of ageing we see that every generation perceives itself as unique and different from the previous generation but prepares for the future as if the future generation's needs will be the same as their own. Rapid changes in this postmodern era are demanding that this time we prepare differently for the future. To achieve this it is necessary to understand our own worldview as well as the worldview of the next generation.

Complexity, though still poorly defined, has been partly described by M. Waldorp in the Journal of Advanced Nursing as “a phenomenon consisting of a great many interactions among independent agents that are changing constantly vis a vis themselves, their surrounding, and their observers”. A further observation was that it was futile to try to break down a complex system into various parts in order to analyse or understand it. In health care today, however, we are still trying to do this.

Within the ideology of nursing lie the core values of professionalism, holism, caring and advocacy. Economic rationalism favours a greater role for markets and espouses a model of competition. One of the central beliefs of this ideology can be seen as obsession with “best cost”. This is often reflected in the assumption that what is good is cost-effective; what is cost-effective is good - with little else being seen as "good". Competitive markets are said to create better efficiencies with health care seen as a product to be marketed as any other product. There is a reliance on economic models for any decision making expressed by indicators for performance, efficiency and productivity, and a belief that objective measures can “fully and properly evaluate performance”. It is not difficult to see evidence of the Newtonian paradigm of thought in this ideology.

Professionalism incorporates autonomous practice, accountability and the development of a unique body of knowledge. It is this that helps to protect the profession from such things as role substitution - thus providing a defence against economic rationalism. If nursing is to remain a player in the transforming health care scene, the values espoused by the profession should be brought forward continually in all decision making.

Holism is seen as nurses being the providers and coordinators of care and is used as a defence against fragmented care and unskilled workers and technicians. The concern is that substituting unskilled workers or technicians will deliver a lower quality product by delivering care they are not qualified or ready to do.

Caring is seen as central to our values. But caring is under attack because it is difficult to measure and therefore cost. Some argue that caring is “proof of humanity and concern” and that it is an indispensable human service. Others call for nurse leaders to “refuse to silence the values of caring”.

Advocacy is a value that obliges us to represent the interests of others and ourselves. We need to remember where we came from and what we stand for. We need to look for ways to support each other within the profession as well as enter into discussions on racism, classism and social change, and continue to critique economics as the one and only reference for social policy.

How do we achieve this? There is a phrase in common use in society today - “be real”. Is this meant as a challenge to all people to manifest integrity in their everyday life? If so, it could well apply to nurse leaders today.

Research is needed into the development of nursing sensitive measurement tools. Because we remain uncomfortable about fitting human care into an empirical framework it is crucial that nurses learn the skills to develop appropriate processes that will ensure nursing's survival in this post modern era. Economics demand measurement, dollar values and numbers. Nurse leaders need to develop an understanding of these factors in order to balance nursing and administration.

Nurses need to be aware that education does not stop upon completion of their degrees but continues for the duration of their careers. Nurses need to be educated to have the confidence and competence that will take them from the classroom to the boardroom. We may need to be more innovative and creative about how we are educated and how we develop our practices within an economic framework, but our focus should remain on nursing. This may help put more nurses into decision-making levels in government and private organisations. Nurses need to learn how to avoid the trap of the “tyranny of niceness” that some authors believe is keeping nurses from confronting the difficult issues that are inherent in health care today.

Advocacy must be for ourselves as health care professionals as well as for others. As a profession we need to promote the core values amongst ourselves first, and then take them to the wider community. Only if nurses are consistent and persevere in the promotion and ongoing development of their values based system of practice will outside forces, governments and economists, be influenced. Leadership for today and tomorrow needs to be developed, promoted and practised. To do this we need to understand our own leadership style and ask whether this style is suited to today's health care scene. As workplaces today consist of people from different generations, cultural backgrounds and value systems it is imperative that those in leadership positions, or who aspire to those positions, develop an understanding of leadership itself, reflect on their own style and then alter or develop that style as necessary.

Leadership through advocacy is a model suited to health care today. As nurse leaders we could be seen to be the last line of defence of our profession. We must be aware of the wishes of the creators of our nursing values and, through advocacy, bring that information to the attention of all nurses. This process can only be successful in an environment where collaboration and trust exist. Trust needs to be earned not given. Trust is an interactive process that cannot take place behind closed doors.

All instruments play an essential part in delivering the complete sound of an orchestra. Its music is incomplete and would not meet the composer's requirements unless all the different instruments are involved in delivering the music. Imitations and substitutions of synthesised music may be cheaper but is it real music? As nurse leaders we need to promote harmony between the different aspects of our profession. Nurse leaders need to ensure clinical practice models protect the profession from the advent of unskilled workers and technicians. Nurse leaders should develop the unity of purpose required to ensure the music of caring is played the way we want to hear it and reaches the heart of the audience intact.

The world of nursing leadership is challenging and complex and requires diverse expertise and skills. Nurse leaders need excellent interpersonal capabilities combined with critical thinking skills and knowledge. There is no 'best' place to deliver nursing care. The venues may be different and change over time but the music remains the same. As the health care scene moves from the acute setting into the community and patient homes, nurse leaders will be called on to develop programs to support nursing practice in these vastly different areas.

Leadership through advocacy requires nurse leaders to have a voice in the issues that effect nursing and the broader health care arena be it in economics, politics or social policy. It calls on all nurse leaders to become self-aware and develop the skills required to promote nursing through empowering others. But it is this leadership style that may best help us to address the complex issues inherent in the question - “The Money or The Nurse?” Nurse leaders are challenged by it but through this challenge let it be seen that nurses dare to care in a corporate world.