Letting go of our past to claim our future

For more than 100 years, most countries have structured the leadership of health service delivery predominantly from a biomedical perspective. The seemingly natural leadership of medicine and doctors has assumed hegemonic status. It is therefore salutary to reflect that across the world following this period of leadership we now have shared and widespread global problems. These include epidemics of long-term conditions, resurgence of infectious diseases, antimicrobial resistance, major disparities in health outcomes and the steady rise in what many are calling the diseases of despair including anxiety, depression and high suicide rates especially among young people (Case & Deaton, 2017). I am proposing in this editorial that we are viewing and managing health through the wrong lens and that health systems are long overdue for a revolutionary change of focus led by nursing.

It is time to consider different approaches and to heed the World Health Organization calls for new models of health delivery (WHO, 2008). A well-supported argument could be made that a health system should be led by people educated from a health rather than an illness focus. Such a change of direction would support countries to think outside the box when considering new models of care or service delivery.

Changing direction makes intuitive sense because medicine focuses on repairing the damaged or dysfunctional body which perhaps contributes to 10%–20% of health outcomes. The remainder can be attributed to the social determinants of health (Lleras-Muney, 2018; Marmot, 2015) and the degree to which people are supported towards good health within their particular constraints. In direct comparison to medicine, nursing equals partnership with individuals and communities, enablement (Frost, Currie, Cruickshank, & Northam, 2018), attention to health literacy, supporting people to stay well, helping people to live with illness or disability and to die with dignity and comfort. As such, there is, or should be, a direct and deep connection to the social determinants of health in every encounter between nurse and client or patient (Villeneuve, 2008).

Regardless of any international movements such as Nursing Now, the levels of unmet need for health care in almost all locations should create significant impetus for nursing to step out from behind the shadow of medicine and to claim our space as the natural leaders of healthcare delivery. Despite remarkable development in our levels of scholarship, we have yet to be taken completely seriously as the largest health workforce across the world. I suggest that if nursing is to seize the opportunities and responsibility being suggested, and which our communities need from us right now, we have work to do to resolve our internal contradictions as a discipline. Our internal conflicts seemingly prevent us from stepping forward in a unified fashion, and they allow external stakeholders to excuse our absence at decision making tables.

Recently, I conducted a simple discourse analysis of a wide range of nursing grey literature texts. Unfortunately, it has not been published but sharing it with nurses in multiple forums has confirmed that the findings are quickly recognised by nurses from many settings.

As is known in the theory of discourse analysis, discourses by their very nature are historically, locationally and context-dependent with one or more being dominant and others marginalised at any point in time in any particular discursive field.

A gendered discourse celebrates the caring side of nursing and frequently infers that this comes naturally without recourse to research or education. Reverby (1987) has written powerfully about the ordering of nurses to care in an environment that does not place great value on caring. Nurses as women are positioned to use their “natural abilities” in mothering and domestic skills, to support and care for the wider community. This discourse is deeply embedded in our history. Closely related but with subtle differences is the holistic discourse which seeks to differentiate nursing from medicine by noting with some pride that nurses consider the psycho-social, cultural and context aspects of a person's presentation rather than just their bodily ailments.

As is true of any discursive field, there are some elements of reality in all of these discourses. Over the course of time and within individuals in the profession each of these ways of understanding, nursing is accorded prominence or marginalised. Different nurses take up different subject positions within one or other discourse and as a result different voices or images are projected to the public, to politicians and to policy makers. This renders nursing vulnerable to decision-makers who find it easy to wring their hands and suggest that engaging nursing around the policy table is pointless because “they can never agree about what is needed”. In particular, when the worker bee and techno-rational discourse prevail it is hard to argue, for example, for better funding for postgraduate education or significant engagement at the executive table.

The impact of the gendered discourse remains a powerful deterrent for nursing in the strongly neo-liberal environments that accord significant value to that which can be counted and measured and anything that can improve efficacy and the strength of the bottom line (Griffith & Smith, 2014b; McGregor, 2001). In this context, we are long overdue in successfully challenging the belief that nursing is a cost to be rigorously pruned to instead recognising the substantial evidence that nursing is a vital resource worthy of investment in order to achieve good returns not to mention patient safety.

Unfortunately, our conflicts and lack of power are clearly displayed in the micro-behaviours through which nursing presents itself to the public, to colleagues and to media. In NZ at least, nurses sport name badges which reveal a christian name only (albeit with a formal identification in a less obvious place) and correspondence often fails to name or credential the nurse author. Many nurses practice in unnamed consulting rooms or cheerfully accept the anonymous title of nurse 1 and nurse 2. An informal scan of General Practice (primary care clinic) websites shows that whilst doctors have surnames and qualifications, the nurses have neither, referred to in one alarming example noted as “our Yvonne”. A more insidious process is the tendency of nurses who move outside conventional roles to actually divest their identity or origin as nurses. A current doctoral student interviewing self-employed nurses in business doing largely project work notes their reluctance to be identified as nurses citing the risk that they will not be seen as intelligent and will be less likely to be contracted. Similarly, nurses working in Government or as chief executives almost never note their nursing credentials in correspondence or role description. Medical practitioners are rarely so reticent and thus make clear the scope, breadth and value of their contribution and leadership in multiple settings.

Nursing needs once and for all to discard these residues of our religious, militaristic and highly gendered history and to take our rightful place as leaders of health service delivery. Reasons for so doing include our value to the health sector, our relevance to health outcomes and the knowledge we hold which cannot inform policy direction if we are not around the table. Health leadership needs to come from a health rather than a medical lens if we are to really make a difference to individuals and communities and to maintain sustainable services. Regardless of our own personal thoughts about this, our consumers now and in the future need us to take power over our own practice and assert greater leadership of the health system from policy level to executive leadership of organisations.