A seminal virtual debate, co-hosted by FoNS and the Journal of Research in Nursing
Dr David Foster, Chairman, Foundation of Nursing Studies
They were thoughtful and thought-provoking, powerful and persuasive. In debating the motion that ‘This house believes that a natural facet of nursing work is that it depletes nurses’ well-being’ the panels drew on evidence, both empirical and experiential. At the start of the debate 65% voted for the motion and 35% against. After the arguments were heard this changed slightly with 55% for the motion and 45% against. It was a vital and vibrant debate.
The panels were led by eminent nurses. Leading the panel speaking for the motion was Pam Smith, the doyenne academic whose seminal work is on the emotional labour of nursing. Leading the panel against the motion was Jos de Blok, the charismatic founder and chief executive of the Buurtzorg model of neighbourhood nursing. With Pam were Danni Castillo, Radha Adhikari and Gearóid Brennan. With Jos were Judith Verhoef and Joost de Blok. You can find out more about them here. What was striking to me about all these panellists was that, despite their relative youth, they had already had rich, diverse and global careers. We heard specifically about nursing in Chile and Nepal as well as in the Netherlands. And so much of the debate was illustrated by their potent personal stories. I am not going to rehearse their arguments (the full debate can be seen here https://www.youtube.com/watch?v=ncgtYMBhbiU) but I will reflect on some aspects of the presentations that particularly struck me.
So, does the nature of nursing work naturally deplete nurses’ well-being? Well, yes and no. It often does but it need not. The crux of the matter seems to be about control: control of your personal workload and control of the system around you, the system that controls your work.
The culture in which nurses work makes such a difference to how they work and how they cope with their workload and the pressures of that work. The UK system is diverse. It is a health and care system that is not really cohesive and is subject to different political drivers and policies in each UK country. In the perception of the public, and often in the minds of politicians. the system is dominated by NHS hospitals: nursing is so much bigger than NHS hospitals, bigger than the NHS and the majority of the care is in the community.
In such a system nursing work is often invisible and under-valued. Nurses themselves have little control over their workload, the skill mix and staffing levels. They appear to be so dis-empowered that their only option is to play the hand they are dealt. Changing the system does not seem to be an option for them. Neither do nurse managers or nurse leaders systematically protect nurses from these stressors. There is a sense that nurses should develop techniques for being more resilient (which is in preference to managing the system to reduce the pressures so that the stressors are reduced and developing greater resilience becomes unnecessary).
In pondering this issue of resilience I turned to the dictionary. I found that it means to readily recover from shock, to be buoyant and have the power to recuperate. However, I think it is more commonly used to suggest a Teflon, non-stick robustness in which people are expected to be unaffected by stress and so protect their own well-being. The two are very different.
The diverse NHS and care system is in complete contrast to the Buurtzorg system. Clearly neighbourhood nursing is a contained specialty and probably not representative of a whole, nationwide system. However, it is one in which nursing is valued, in which there is a great deal of nursing autonomy and control. The lack of a hierarchical structure means there are no extraneous managerial pressures being exerted on clinical practice. The close knit teamworking creates a natural atmosphere of support in which experienced nurses nurture and coach the newer generations who have the freedom to flourish. Political influence is positive because the politicians have been nurtured as allies and are not seen as impediments to progress or developing new services. Of course, the nature of nursing work is still stressful but it is perceived that nursing with a high degree of autonomy and in a supportive culture actually enhances nurses’ well-being. It is a lack of autonomy and people’s perceptions of nurses that might lead to a depletion in nurses’ well-being – not the work itself.
Nurses’ well-being is crucial to the safety and quality of care. Having supportive, nurturing and enabling leaders can create the right climate to protect nurses from workload pressures, burnout and from becoming jaded. But there is also an opportunity for nurses to create such a climate for themselves – not necessarily as individuals but as a cohesive, collegiate community working for the well-being of nurses and, as a natural consequence, their patients, clients and colleagues.