MEDICINE
Nursing troubles
JOHN ROWAN WILSON
Without attracting much public attention, an alarming development has been taking place in British hospitals over the last twelve months. The pattern of nursing care initiated in this country by Florence N:ghtingale, which has been adopted in one form or another by practically the entire civilised world, is being quietly organised out of existence.
One of the fundamental principles of the Nightingale system of nursing was that it was based on the hospital ward. This was the key unit of medical care, since it was here that the patient was being looked after. And in the ward, the nursing sister was supreme. She took personal responsibility for everything that happened on a nursing level, and dealt as an equal with the consultants responsible for the medical and surgical treatment. She had absolute authority over her nurses and psychological dominance over junior doctors as a result of her experience and the prestige conferred on her by the system.
Matrons and other nursing administrators did not try to sit in authority over senior ward sisters, at least not if they were wise. The custom was to treat them with a traditional deference which recognized their special position in the life of the hospital. While the atmosphere within the ward was highly authoritarian (and logically so since, when dealing directly with patients, carelessness and indiscipline cannot be permitted), above this level there was a highly complex interrelationship between doctors, nurses, and administrators. Largely because of a shared ethical code, the arrangement on the whole worked remarkably well.
The damage to this structure has come about as a result of the so-called Salmon Report, which recommended to the Ministry certain fundamental changes in the approach towards nursing as a career. The general implication of the Salmon Report was that the most important job was not nursing itself, but administration and management; the basic unit was not the ward but the hospital. The matron should represent the top of a pyramid, with a whole series of grades under her, starting with deputy and assistant matrons, and going down to the junior probationer. The ward sister was just over half-way up this pyramid. Remuneration should be allotted according to grade. If the ward sister wished to increase her status or earn more money, she must abandon ward work and go into administration. Otherwise she would stay in a relatively junior grade all her working life, which would mean less money, lower status and a lower pension. The object of the new system was the entirely .commendable one of providing an improved career structure for nurses and improving recruitment. Unfortunately it seems likely to have entirely the opposite result. For the attraction of nursing, as of medicine, is not the possibility of being promoted to an administrative position. It is the treatment of patients. This activity has now been devalued. The result is that instead of an improvement in nursing, what we have is the sidetracking of some of our best ward sisters into office jobs. Few of them wish to leave the wards, but they have been placed in a position where they simply canot afford to stay.
This situation is causing serious concern throughout the nursing and medical professions. Indeed, the implementation of the Salmon proposals is probably the main influence behind the recent coolness of the BMA towards Sir Keith Joseph's business-efficiency ' approach towards the Health Service. There is now a belated realisation that while management consultants may have their value in reorganjsing straightforward administrative structures like business or the Civil Service, they can get hopelessly off the track when dealing with something as complicated as medicine.
The main problem about organising medicine (as Miss Nightingale understood instinctively) is that it consists of two distinct activities, the aims of which frequently come into conflict. One of these is purely administrative. It consists of supply, the organisation of staff of admissions and discffarges, cleaning laundry, accountancy, and so on. For this aspect of the operation the hospital is the correct unit of management. The other aspect is the care of the individual patient, which must be carried out in the ward. The second function is not only the more important of the two but also the more difficult. A sick individual presents a more complex problem than an off-duty rota or a syllabus for teaching student nurses. There is more responsibility in preparing the surgical list for one afternoon's operating than in organising the Nurses' Home for a month.
No organisational system can succeed within the hospital service unless it recognises this basic fact. You will never make anybody in medicine believe that administration is more important than nursing care. What you can do, however, is to force nurses to leave the wards by, in effect, bribing them to do so. For it is an unhappy fact that every incentive carries within it its own disincentive; every time you decide in your generosity to regard one form of activity, you may penalise the alternative by implication. And in this case the alternative is what the whole process is about.
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