Elizabeth C Percival
RN, Dip.App.Sc(Nsg Mgt), BN, FRCNA FCN (NSW)
December 1996
The University of Adelaide
Department of Clinical Nursing
Joan Durdin Oration
Paper Series Number 2
Published by the University of Adelaide, Adelaide South Australia 5005
Distributed by the University of Adelaide, Department of Clinical Nursing
Designed and Typeset by the University of Adelaide, Department of Clinical Nursing
Printed by the University of Adelaide Printery
National Library of Australia
Cataloguing in publication data
Percival, Elizabeth (Elizabeth C.)
Nurses driving policy.
ISBN 0 86396 407 9.
| 1. | Nursing-Australia | 2. | Medical policy-Australia. |
| I. | University of Adelaide. Dept. of Clinical Nursing. | ||
| II. | Title. (Series:Joan Durdin oration.:Paper series;no.2). | ||
362.173094
The Joan Durdin Oration is an annual event initiated and sponsored by the Department of Clinical Nursing at The University of Adelaide. It is intended to serve as an occasion of celebration of nursing's past achievements and to focus on a vision for the future. Orators are distinguished nurses who have made a major contribution to the development of Australia's vibrant nursing profession.
As well as focusing on nursing as a profession which is central to effective health service delivery, the Oration honours the contribution of Joan Durdin, a South Australian who has played a major role in uncovering the historical legacy of nursing and in the advancement of nursing through the development of advanced education in the higher education sector.
The Joan Durdin Oration brings together all nurses of South Australia as well as leaders from all fields associated with health and well being of South Australians to celebrate nursing's past achievements and anticipate the further evolution of nursing in the future.
Elizabeth Percival has been a registered nurse for over 30 years. Her formal qualifications include a Diploma of Applied Science (Nursing Management) and a Bachelor of Nursing. She is presently completing a Master of Science in Primary Health Care at Flinders University. From 1985-1988 she was the Foundation Director of Nursing, Philip Kennedy Centre in Adelaide. From 1988-1994 she was Chief executive Officer and Registrar, Nurses Board of South Australia. In 1992 she was appointed Adjunct Associate Professor, School of Nursing, The Flinders University of South Australia and she was Chair (Foundation Chair), Australian Nursing Council, 1992-1994. Over the years she has sat on numerous government advisory committees and Councils both in South Australia and at the Federal level. She has addressed numerous conferences and meetings in Australia and overseas on topics as diverse as quality assurance, nursing ethics, licensing and registration of nurses, professionalism and best practice, and innovations in age care. Elizabeth Percival is presently the Executive Director of Royal College of Nursing, Australia.
The Department of Clinical Nursing was established in 1995 as an initiative of the Royal Adelaide Hospital. Specialising in graduate studies in clinical nursing, the Department focuses on field based learning, clinical specialties and the rigorous pursuit of nursing knowledge through scholarship and research at the Masters and Doctoral level.
I am proud and delighted to have been invited to give the second Joan Durdin Oration. Through out my career Joan has been a source of inspiration to me. This began when she was my senior Tutor Sister at the Royal Adelaide Hospital in the early 1960s.
South Australian nurses have been fortunate to have somebody of Joan's stature, vision, intellect and ability. Over the years her leadership has given us signposts for quality practice and pride in our nursing activities.
I was fortunate to have studied under Joan, and under her guidance to have been awarded a gold medal as a graduating nurse of Royal Adelaide Hospital. One of my most treasured possessions is the letter of congratulations signed by Joan on my achievement.
Over the time span that Joan has been a leading figure in nursing we have all experienced significant and monumental change, and we witness it every day in our profession. When we think of where nursing was 20 years ago, and compare it to now, we have made tremendous advances.
We are not the only ones who have made advances. There have been advances in all aspects of technology, but let us focus on just one area of change - change in motor vehicle engines. Car engines today are so much more sophisticated than they were 20 years ago - they get us to our destination more smoothly and efficiently. A 4 cylinder engine today performs much better than a 6 cylinder engine of 20 years ago. Let us consider those elements driving the advances in nursing as the nursing engine. For the engine to do its tasks, to work efficiently and smoothly in getting us to our destination, it needs to fire on all cylinders, and needs to be kept lubricated, to minimise the friction that is inevitably part of the process. If one part of the engine is not working, there will be resulting wear and tear on the whole mechanism. As we observe changes in the nursing engine the technological change has been tremendous, and as Palmer and Short (1989:137) point out, education and industrial gains have occurred as a result of strategic political action by nurses. Most of the cylinders seem to be firing!
First of all, we have made clinical advances, and innovated with, adapted to and used a variety of new technologies. Let us think of this as the first cylinder of the engine.
As Sandra Speedy documented so well in the first Joan Durdin Oration last year, we have made crucial advances in education and research. This is the second cylinder
The third cylinder comprises formidable advance in the industrial arena, where nursing is now taken seriously.
What I want to talk about tonight is a fourth area, where we still have some way to go. That fourth cylinder is policy development and advice. I want to examine the importance to nursing of making a contribution to policy development, and of nurses being regarded as legitimate and consequential contributors to health policy.
In his 1986 keynote address to the Leadership in Nursing, at the Health for All Conference, Dr Halfdan Mahler, Director General of the World Health Organisation claimed that nursing was a vital group for the success of the Health For All concept (WHO 1987:5). It was also claimed that the nursing profession needed to produce leaders to unleash the potential driving force, and that it must voice its opinions at policy and decision making levels. The conference which was held in Tokyo, was attended by international nursing leaders who considered the immediate and long term needs of the nursing profession to provide it with the impetus, skills, knowledge and confidence to direct and lead change in nursing for the achievement of the Health for All goal. It was seen that it would be necessary for nurses to address relevant social, economic and health policy issues affecting health care delivery systems.
Participants at the conference indicated that there was a lack of knowledge and skills in the nursing profession in relation to policy-making and planning processes at a political and government level. (WHO, 1987:10)
That important international nursing conference was held 10 years ago, and it is urgent that we make the effort to review nursing's achievements in health policy development over the past decade.
A few years later the message of that conference found its way into the Australian landscape. The Nursing Research Targets, (RCNA et. al 1992a) stated that nursing research will be fostered by (inter alia) "incorporation of research findings into nursing and health care policy development, planning and decision making for the benefit of health care consumers". Discussion during the workshops that formed part of the National Nursing Research Targets Project suggested that priorities should be ordered according to (inter alia) "strategic research by trained nursing researchers which applies a nursing perspective to health services issues, which informs and influences policy"(Pearson 1992:64). The words are there. The actions are slower in coming.
The core activity of nursing is providing care - this is the framework - the body of the car which is driven by the 4 cylinders. I am not for a moment suggesting that health policy development should occupy every nurse's time, any more than I would suggest that industrial issues or education and research issues should occupy all of OUI time. A car trying to run on one cylinder won't get far!
But as nurses who are oblivious of new research, continuing education, or the industrial environment have a gap in their practice, so too do nurses who are oblivious to policy. Nursing leaders have an important role in policy because policy issues fundamentally affect the core activity - provision of care. The quality of care that is delivered is influenced as much by policy as it is by education and research, and by industrial matters. For example case mix funding is intensely policy oriented, as is residents' rights policy which has transformed aged care.
As health issues affect all of us, and are shaped by various practices and expected outputs, why does the policy process result in one type of policy rather than another? Why does the car, regardless of how many cylinders it is running on, go down a certain road? Depending on the circumstances, the answer may lie in the realm of ideology, or in the realm of pure expediency, or somewhere in between, where ideology and expediency temper each other, however unsatisfactorily.
As nurses, we need to ensure that our intimate involvement in providing holistic care, our historically long commitment to better health for all, and our grasp of technological innovation are reflected in health policy - policy that shapes our public well being.
I am not suggesting that tomorrow we all start preparing Cabinet documents. Health policy covers a very broad spectrum, of which Cabinet processes are but one aspect. As I see it there are no nurses in Federal Cabinet today, nor are there likely to be many in the foreseeable future. Nurses are not alone in all the occupational and interest groups that have no seat in Cabinet, and just because a Cabinet member is of a particular occupation does not mean that there is necessary acceptance by the occupational group. Last month Dr Wooldridge took a lot of flack from members of his profession, and I'm sure he'll take more as time goes by.
There are many policy roles for nurses. They drive, they navigate, they repair faults, they lubricate the engine, but they don't often design new engines.
In any form of policy analysis it is necessary to distinguish:
One way of thinking about it is that a service might be part of a program which in turn is part of a policy. For example, nurses as immunisation providers deliver a service and develop procedures which are part of the broader immunisation program, which itself is part of public health policy.
Much has been written by academic political scientists about policy analysis and policy development. I am not going to dwell tonight on definitions and theoretical issues, other than to suggest that very few nurses have been provided, either in their formal education or in professional development activities, with this theoretical knowledge. As a result most nurses are probably not adequately prepared for a policy role.
Academic commentators provide us with a six lane highway of policy definitions. Mason, Talbott, & Leavitt (1993: xxxii) define policy as a political and value-laden process that includes decisions about what gets on the policy agenda, what policy is adopted and how and by whom the policy is evaluated. Richard Titmuss (1974:23) saw policy as the principles that govern action directed towards given ends; Kalisch & Kalisch (1982:62) see policy as a consciously chosen course of action (or inaction) directed towards some end
It is a plan, direction or goal for action. It is authoritative decision making according to Stimpson & Hanley (1991:12), while Davis et al (1993:15-16) see policy as the interaction of values, interests and resources guided through institutions and mediated by politics. Policy analysis, they say requires the "puzzling out" of this interaction of values, interests, and resources.
To work towards the achievement of desirable goals and to make the best use of resources in doing so, involves a process of planning. This according to Gilbert & Specht (1977:1) is a conscious attempt to solve problems and control the course of future events by foresight, systematic thinking, investigation and the exercise of value preferences in choosing amongst alternative lines of action.
All of these authors make policy seem reasonably simple, and Lindblom, for example lays out a classical formulation of policy as a rational model.
Faced with a given problem rational persons first clarify
It all sounds like a lot of common sense. What stops this part of the engine from working?
Let us go back to Joan Durdin for a moment. I was again to experience her leadership and support when I returned to study in the early 1980s at the then Sturt College of Advanced Education, now the Flinders University of South Australia. It was during this period of my career that I became interested in public policy development and analysis, and in nurses' input and influence in these processes. As a student undertaking a Diploma of Applied Science, Nursing Management, I was introduced to these concepts when I enrolled in a subject entitled the History and Politics of the Health Care System in Australia.
At that time I was the Deputy Director of Nursing at Southern Cross Homes and we were fighting a battle with the Commonwealth Government about funding for the staffing mix in the nursing homes. The policy of Southern Cross Homes at that tune was to employ only Registered and Enrolled nurses to provide nursing care. This commitment by an aged care service provider was unusual, as most private operators, state and charitable organisations staffed their facilities with large numbers of unqualified people to deliver nursing care. Clearly Southern Cross's policy decision about the staffing mix would have an impact on Commonwealth aged care policy.
The big questions about the allocation of resources, about equity, about values and about who wins and who loses were complex. The nurses involved did not see it from the Government's perspective. In a naive way we looked at it firstly from our point of view, and secondly from the aged person's perspective - they deserved qualified care, and that was that! We were concerned about delivering quality nursing care; about how we were going to maintain our standards; and of course we did not like the thought of change and the possibility of job losses. These issues of staffing mix, change and possible job losses were very real to us, just as they are real today to nurses in our acute hospitals and in community settings.
This policy dilemma was relevant to my study. When the time came for students to undertake a project for assessment it was clearly obvious that I should focus my intellectual effort on examining policy development around the skill mix and delivery of nursing care to the elderly. Together with a fellow student I researched the issues and identified who would be the winners and losers. We examined the policy process in which values, interests and resources compete to influence government action. It was hard work as we were on a steep learning curve and discovered that we needed to look at things in a very different way - in a more policy oriented manner.
A few years later, this time enrolled in a Bachelor of Nursing and undertaking an individualised program, I was keen to increase my knowledge of public policy in Australia, but the student demand wasn't there, so the courses were not offered. A kind lecturer let me do an individualised reading course, but I felt clearly disadvantaged, as I did not have a cohort of colleagues with whom I could debate and discuss issues. The fact that other students (many of whom held senior positions) could not be attracted to enroll in these political and policy units, I believed was quite profound. At this point I became a zealous observer of nurses' role in policy. I have, since then been conscious of how nurses responded to policy initiatives, and how badly prepared we have been to drive policy, or to critically analyse policy proposals.
Today in my job as the Executive Director of Royal College of Nursing, Australia I am constantly told that nurses should be involved in the development of health policy. I am constantly quoted facts and data suggesting that nurses make up the largest component of the health care work force, and that nurses are at the coal face of patient care, and they are pivotal in providing input to health policy development and analysis. Furthermore, nurses make strong claims that they should be involved in all levels of policy development and analysis.
The important questions to ask and to answer are - how well prepared are nurses to do this? What has to be done to make sure they do it well? Should all nurses take on this role? Which nurses should do what, when it comes to policy roles?
The College places such importance on the nurses' role in health care policy, that in the Strategic Plan a complete program of activity, and therefore resource allocation is directed to public policy. One of the primary reasons the headquarters the College were relocated to Canberra was to be physically close to the centre of government and to better position itself to fulfill its public policy program.
In preparing this oration I sought assistance from a librarian who undertook a literature search. It was interesting that she came up with very little Australian literature in the area of policy work by nurses. Furthermore, it is essential to my role to keep abreast of current issues and trends in nursing, and therefore I have to allocate time to scan the nursing literature. As I mentioned earlier I have become an observer of nurses and their policy role so I always have an eye open for any policy work undertaken by nurses in the many publications that come across my desk.
The journals have considerable content focussing on nursing's achievements in education, management and practice, and indeed those achievements have been significant over the past two decades. The literature review revealed commentaries about clinical and organisational policy formulation by nurses, for example, ~e Australian Nursing Federation's (Australian Nursing Federation, 1990:21) and Royal College of Nursing's (1992) policies on the Environment and Health provides a point of reference for nurses when developing organisational environmental policies.
Nursing's achievements in broader health and public policy development are hard to find in the literature. Specific and strategic policy- research written up by nurses was disappointingly scarce. Nursing input into the policy development of the Australian Resuscitation Council, for example, is clearly evident. The policies, however, are more of a procedural nature, but they are enhanced by nurses' contribution. At an organisational and practice level, nurses' input into policy is much more evident.
My direct experience in working with nurses on policy development has provided me with more enlightening information as I continue to monitor the developments in this area. Over the past three years the College has provided input to a range of different policy papers and members have been provided with the opportunity to comment, and be involved in the decision making process. Many of the comments were more of an editorial nature, and demonstrate little analysis of the issues and the impact of proposed policy concepts. Policy proposals are often treated sceptically or resisted by nurses. If more nurses were better attuned to the impact of policy development and to the flow on from good policy, then a whole new world of opportunity arises, opportunities to blend our practice into policy. There is strong evidence to suggest that nurses are advancing in this area. A review of our policy work at the College shows that in 1994 the College provided input to seventeen pieces of policy. In 1995 to fifty eight, and so far in 1996 (to October) to fifty one.
I am aware that the College's register of expertise shows that few members have expertise in health policy development or analysis, or claim to have an interest in public health policy. It is timely to examine nursing's education programs at undergraduate and post graduate level to clarify if nurses are provided with any theoretical background relating to policy developments and in particular to health care policy.
Is it realistic to expect that nurses working at the bedside should incorporate these concepts into their practice? Should we expect a nurse working in accident and emergency or in theatre to be focussing on employment policy in the north of Adelaide, or job displacements in the timber industry as environment and industrial policy confront each other? Are nurses working in our hospitals prepared to and are they competent to comment on proposed health policy and are they willing to be involved in the decision making process? Or is it up to nurses in leadership positions and nurse academics only, to grapple with these complex policy concepts? A cooperative policy development effort is essential.
To support the claim that nurses lack the preparations for their role in policy one need only turn to the Australian Nursing Council INC. (ANCI) competencies which neither refer to policy in the role statement for Registered Nurses, nor mention health policy development in the competencies statements. Competencies developed for advanced or specialist practice gloss over the policy role of the specialist nurse, though the competency standards for specialist critical care nurses lists as one of the performance criteria "participates in policy and decision making", and a similar point is found within the mental health nurses standards.
Regardless of their education, nurses deal with health care policy in their day to day activities. They are affected by this policy in the workplace, in the community and in professional organisations.
But to make sense of it all, we can look at policy from three different perspectives:
This view sees nursing policy as a set of general principles - as a series of desirable states. Often the principles are articulated in abstract terms but there is a search for enduring solutions to identified problems.
The sorts of philosophical issues at the forefront are a commitment to quality; this is shaped by a strong belief in holism and this takes place against a philosophical backdrop of integration of activities and services. An ethical stance of commitment to equity, and recognition of rights frames the notion of policy as a philosophical concept.
As a product, nursing policy can be seen as a series of conclusions or recommendations concerned with selective or general social improvement, and the practices and procedures to back them up. Often the vehicle is a formal document that is the result of an expert study or evaluation of a program or service setting out the intended policy for an organisation or care unit. Such products proliferate in Australia and the library shelves are full of reports - each comprising an analysis and set of suggestions, prepared by an expert team, recommending the improvement of a particular set of conditions and suggesting courses of action to be pursued.
Manufacturing a product is no guarantee that the product can work, will work, or will even be tried out. Industrial history is littered with stories of products that were never used, were hidden to prevent their interfering with other established products, or even ridiculed before they ever had a chance. Administrative history is similar, one topical example being the National Nursing Research Targets Project, 1992. Another is the national review of Nursing Education in the Higher Education Sector, 1994. Both products are awaiting full implementation.
Our best product is a quality outcome - but the policy path towards that is not always smooth, not if the engine is not fully in tune.
As a process, policy is the means by which existing organisations attempt to do what is required by them. The focus is on programs, procedures and activities and mechanisms for the attainment of the product, which in turn is based on the philosophical concept. It is largely an implementation process. Organisations want the highway to be carefully graded, so that the engine does not have to strain, and blow out harmful emissions.
If we are serious about nurses having a role in the development of health policy then we need to ensure that they are provided with the appropriate tools, that they are educationally prepared. They will need to fully understand and make a demonstrative commitment to the importance of an equitable distribution of health services, community involvement in health policy decisions, a focus on illness prevention and health promotion, the appropriate use of technology, and a multi sectoral policy approach which recognises the importance to a healthy community of adequate education, employment, housing and transport.
Do we all readily recognise that the determinants of many common health problems lie in society itself, and that a policy approach limited strictly to the health sector at government level is inadequate? Other actions taken outside the health service sector may have greater effects on health than the interventions undertaken within the scope of health departments. Social policy developments in areas related to health policy but not strictly considered as health policy, including income security, welfare services, education, recreation and cultural programs have a profound effect on the health of populations. Policies that affect the distribution of income, fiscal policies that influence the levels of employment, and industrial policies that affect conditions of work also have a dramatic effect on health (Sax 1990: 3-4).
It is now time to focus our attention on the fourth cylinder. It is time for nurse researchers to undertake strategic policy research, it is time for nurse academics to consider nurses' contribution to health policy, and it is time for nurse leaders to mentor others in the profession. Nurses' role as policy makers, policy researchers, policy implementers policy evaluators and policy communicators requires development. Much work remains to be done to ensure that the diverse voices of nurses and their values are represented in the policy process. If we achieve this we will be firing smoothly on all four cylinders.
Let us look forward to the next 20 years. Let us identify the sign posts, the mentors, the leaders with the vision for the future of nursing, as Joan Durdin did in South Australia with the transfer of nursing to the Higher Education sector. Let us however, never forget that the core activity of nursing is the provision of care.