Focus on staff stability: its role in enhancing ward nursing practice

Abstract

Our papers (Adams & Bond 2003a,b), which are published in this edition of Journal of Nursing Management, highlight a number of important messages for NHS Human Resources (HR) Directors aiming to achieve strategic targets set out in successive HR-related policy documents (Department of Health 1998, 2000, 2002). We focused on wards in acute hospitals and examined relationships between nursing staff resources, organizational practice and nurses’ perceptions of their work environment. Work environment included the quality of nurses’ working relationships, job satisfaction, their influence and the standard of nursing practice. In previous research, the impact of staffing resources and systems of ward nursing organization on care processes have been considered separately. By including all of these elements, our work provides a missing synthesis. Using a national sample of wards, conditions associated with a positive work environment for nurses and with a positive care environment for patients have been identified. Few nurses are available for providing care and a weak grade mix was associated with adopting hierarchial organizational practices and attitudes to care provision. Wards where this was the case were characterized by a lack of devolution of authority for patient care decisions, less teamworking and an atmosphere in which nurses felt undervalued by managers and medical colleagues. When there were more nurses, authority for patient care decisions was more likely to be devolved to individual nurses working in autonomous teams. Their perceptions of multidisciplinary collaboration, ability to cope with the ward workload, influence over ward management and job satisfaction were more positive. These results are perhaps not surprising. Procter (1989) has long since argued that when staff are sparse and when agency staff substitute for permanent staff (as they do increasingly), nurses revert to functional nursing as the only safe means of ensuring that essential care is provided. However, what stood out in our findings was the importance of achieving stability in staffing complements. It was relative staff stability, irrespective of clinical grade, which was found to be associated with achieving a positive ethos of nursing care, which embraced the elements of innovation, research-based practice, an interest in staff development, and patient and family involvement in care decisions. These positive aspects of practice have received endorsement in government policy related to modernizing and improving the quality of NHS care (Department of Health 1998, 2000) and to enhance nurses’ contribution (Department of Health 1999). Achieving stability through retention of experienced nursing staff is one of the biggest challenges faced by the NHS. Our data were collected at a time when the depth and scale of the recruitment and retention difficulties affecting nurses were coming sharply into focus. Against a background of financial constraint, and in the absence of concerted national strategies to overcome nursing staff shortages, NHS Trusts responded to their staffing crises in different ways throughout the 1990s. Some adopted business process re-engineering strategies, focusing on the nature of health care work and how and by whom it was accomplished. Health care working practices were analysed and streamlined wherever possible, often leading to the creation of new work roles as well as reductions in numbers and grades of nurses. Others looked at multiskilling initiatives, such as patient-focused care. With its blurring of traditional professional boundaries, it sought to enhance continuity of care with reduced staff numbers. In the community, increased emphasis on this type of approach is manifest in the call to embrace integrated working (Department of Health 2001). Yet other Trusts sought to replace like with like, and embarked on recruitment programmes involving overseas nurses. This solution, which continues to be widely used, brought with it the need to examine the comparability of training programmes and to retrain and re-educate overseas nurses where necessary. Nurses from overseas bring with them different cultural perspectives on health and illness and the relocation of immigrant nurses and their families has significant economic and sociocultural consequences. Anecdotal evidence suggests that recruitment drives in some parts of the world have been more successful than others, but the long term effects of successive waves of overseas recruitment on patient, staff and organizational outcomes are yet to be evaluated. The most common and less innovative solution adopted by the majority of NHS Trusts involved systematic grade mix dilution, replacing professional nurses with health care assistants within a set budget. Comparative evidence of the relative effects of these different solutions to overcome staff shortages is not available. NHS HR Directors told us that they lacked sufficient time, research tools and expertise to carry out evaluations of the often profound staffing changes they had made (Adams et al. unpublished data). However, the different approaches have one thing in common. All attempt to provide nursing services by means other than developing the stock of UK nurses. Redesigning work processes and work roles, and substituting UK nurses by overseas or less qualified staff or less skilled staff may provide short term staffing solutions. But these strategies do not address the more fundamental, long term problems underlying the shortage of nurses in the UK. There will always be criticisms that insufficient action has been taken to remedy the situation, but the current government has instituted concerte national strategies to tackle the causes of recruitment and retention problems. Making A Difference (Department of Health 1999) provided some ‘joined-up’ thinking. A new pay system for nurses improved both rewards and removed the artificial ceiling to career advancement, and pay is again under review with the Agenda for Change. Nurse consultant posts aimed at retaining experienced nurses in senior clinical posts, instead of rerouting them into management and increasingly out of the NHS. Related initiatives include a concerted recruitment drive; making increased numbers of training places available; commitment to provide a post registration education and continuing professional development framework; implementation of supportive, family-friendly employment practices; better retirement and pension packages; a supply of affordable housing; and extended roles for nurses to make better use of their knowledge and skills. These initiatives are now becoming mainstream NHS practice through the Improving Working Lives initiative. Such measures represent a realistic and creative approach to trends in women's participation in the labour market. Evidence from pilot schemes suggests that these strategies will go some way towards enlarging the pool of UK nurses and may result in greater staff stability. However, certain aspects of the government's plans may need careful surveillance. Extending nurses’ roles is very much in line with the profession's own aspirations. Witness the burgeoning number of consultants, specialist and advanced nurse practitioners in recent years. But research shows that piecemeal development of such posts at Trust level can be far from satisfactory. Furlong & Glover (1998) described the stresses experienced by the incumbents of extended nursing roles arising from variable job descriptions and expectations, unclear lines of accountability and the idiosyncratic nature of posts even within the same Trust, making job transfers and career development difficult. Our own recent research (Adams et al. 2000) examined the consequences of role changes for nurses in a range of clinical settings and found that while many nurses had gained a greater range of clinical skills, this did not necessarily provide any sense of job enrichment. It remains to be seen whether the directive to shift the balance of power to front line staff (Department of Health 2001) alleviates or adds to nurses’ experience of increasing work intensification, isolation from professional colleagues and resentment that while their roles are expanding, this occurred in the absence of reciprocal help from other disciplines. Increases in clinical responsibilities without concomitant developments, enabling greater influence and authority over clinical decisions, is a recipe for disenchantment. If the outcomes for both nurses and patients are to be good, care will need to be taken to ensure that future extensions to nurses’ roles take place in sufficiently healthy organizational infrastructures. In line with our research published here, the government has recognized that investing in generating a greater supply of human resources is as, if not more, important than investing in ways to try to make the existing resource ‘go further’. Providing sufficient nurses may break the persistent and vicious circle of burnout, disenchantment and staff turnover. If greater stability can be achieved, our research suggests that nurses are more likely to have opportunities to develop their practice and patients more likely to benefit from better quality care.