Expert nursing: a necessary extravagance The Inaugural Bob Tiffany Annual Nursing Lecture: The Royal Marsden Hospital, UK, 2 February 1995

JUNE CLARK, Social Work ed Health Sciences, University of Middlesex, Enfield, Middlesex EN3 4SF, UK

Many people in this room knew Bob Tiffany as a colleague and friend, but none was ever prouder of that relationship, or owed more to it, than me. I therefore regard it as a tremendous honour and privilege to have been invited to give this, the inaugural Robert Tiffany Annual Nursing Lecture.

Bob’s life and work are recognized and celebrated in many ways. For example, you will have been as delighted as I was last week to hear the announcement at the Annual Dinner of the Royal College of Nursing of the UK that a new award in Bob’s name is to be added to the awards which the Nursing Standard gives each year to recognize excellence in the major fields of nursing. But I think Bob would especially approve the idea of an Annual Nursing Lecture in his name, here at the Royal Marsden Hospital. Indeed, you could almost say it was all his idea in the first place. It was, of course, Bob who established that wonderful programme of lectures here at the Royal Marsden which enable us to hear some of the world’s most outstandmg nurses4 particularly remember listening to Virginia Henderson, Vernice Ferguson, and Miriam Hirschfeld. I so enjoyed being in the audience on chose occasions, but I never thought I should ever be on this side of the microphone. For me, and I guess for many of you, Rob is right hcre now among us as the Master of Ceremonies that he always was.

I believe that Bob lives on most significantly, and most importantly in the ideas about nursing which he held passionately and promoted constantly, and which are increasingly expressed in the practice of nurses not only here at the Royal Marsden but all over the world, not only in cancer nursing but in the best nursing practice in any speciality.

When I chose the title for this lecture, I felt that Bob would have approved it. He was always for me the champion of expert nursing and, on a more personal

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lcvcl, I loved his ‘nccessary extravagance’-I think he would have liked that phrase too. But it was not really until I began the research and preparation for this lecture that I realized just how significant were Bob’s ideas on this theme. I suppose my immediate association of ideas around the word ‘expert’ in relation to ‘nursing’ led me to Pat Benner’s work and her book From Novice to Expert, which has made such an impact on the thinking of nurses in this country and elsewhere. But while that work-and I shall certainly draw on it in what I have to say-was first published in 1984 and took a little while to cross the Atlantic, I found myself drawing even more extensively on the work which Bob Tiffany was doing here in the Royal Marsden during the 1970s (Tiffany, 1982), on what he was saying in conferences around the world in the 1970s and early 1980s (Tiffany, 19801, and the policy work that he led within the Royal College of Nursing (RCN, 1981, 1988a,b! and, at international level, for the International Council of Nurses (ICN, 1988). And so my thoughts on ’Expert Nursing: A Necessary Extravagance’ turned out to be an even greater tribute to Robert Tiffal-ly than I had thought.

The kind of questions I want to address are these.

What do we mean by ‘expert nursing’? Does it make a difference? How can we foster it? Is it an extravagance! Can we afford it?

WHAT IS EXPERT N U R S I N G ?

The trouble with expert nursing, like expertise in many other fields, is that you know it when you see it or experience it, but it is difficult to describe or to explain in words. And yet since words and language are our common currency for the sharing of ideas and experiences, and especially for the information which is used in formal decision making, if we cannot describe expert nursing (i.e.

JUNE C LA R K Expert nursing: a necessary extravagance

what it is that expert nurses do, in what circumstances, with what effects, and how it differs from ‘inexpert nursing‘, we cannot expect those who have not seen or experienced it to acknowledge it, value it and therefore, in our new finance- driven health care system, to buy it. Moreover, those who have seen or experienced it, even if they had the words, may be reluctant to talk about it.

’The acts that go on between a patient and a nurse are so firmly embedded in the private domain that they are not talked about in the pub or over the dinner table. While everyone will happily &scuss publicly their operation or medical problem, very few are prepared to talk about the sort of things which go on between a nurse and a patient. “I cried, and the nurse comforted me. I wet the bed and she made it alright. I felt dirty and she made me feel clean again” (Vaughan, 1992).

Jocelyn Lawler has analysed ths phenomenon in her fascinating book Behind the Scenes (Lawler, 1991) and she suggests that ‘the essence of these practices has not been regarded as formal knowledge partly because there has been no formal language to describe them’.

Both of these authors go on to link this lack of language with a denial of the knowledge base of expert nursing, and to link both of these to the dominance of the positivist and reductionist approaches to professional practice that are a feature of the medical model of health care. I will return to these ideas about nursing language and nursing knowledge in a moment.

But nurses cannot just blame ‘them out there’ for the lack of value which is attributed to their expertise. Some- times we are our own worst enemies in that we ourselves often denigrate our own expertise. Alison Kitson recounts a story of attending an academic seminar followed by dinner, where the subject of the debate was doctor-nurse relationships. She spent some time in quite fruitful discussion with a consultant colleague about what constituted good doctoring and good nursing, and felt that she had achieved some acknowledgement and respect for the idea that nursing is a complex activity requiring considerable knowledge and expertise. Then, she con- tinues: ‘Our dinner was followed by coffee in another room, where in the rearrangement of guests I was introduced to his wife who was also a nurse, he proudly declared. Encouraged by the successful dialogue I had had with her husband I proceeded to extol the virtues of edu- cating nurses and how important it was to the profession. She looked at me rather surprised and then announced “Oh I don’t believe in all of that nonsense. I’m just an ordmary nurse. Anyway you don’t need a lot of brains to be a good nurse. It’s just basic care and common sense. 1 don‘t know why all these nurses want to go to

university-why didn’t they do medicine in the first place?” I suddenly saw all my sterlmg efforts with this women’s husband vanish into thin air. He would never alter his basic opinion about nursing if h s wife continued to hold and practise these sorts of ideas about her profession. I wondered how many so-called nurses held the same view .... Needless to say my new-found optimism in improved collegial relationship was short-lived. 1 went home cursing my own nursing colleagues.’ (Kitson, 1993, p.26).

I should add that a similar experience of my own-a similar conversation at a dinner soon after I became President of the Royal College of Nursing-led to a slightly different conclusion. M y dinner companion turned out to be the editor of the British Medical Journal, and the conclusion was a lea- article in the BMJ called ’Nursing-an intellectual activity’ (Clark, 1991). I’m afraid it produced just the same kind of responses in the correspondence pages over the following weeks.

So, in establishing the value of expert nursing we have at least three hurdles to overcome: lack of a language, an inadequately formulated knowledge base, and the self- denigration which, as Jane Robinson (Robinson, Gray & Elkean, 1991) among others has pointed out, is behaviour typical of oppressed minorities.

A LANGUAGE FOR NURSING

First, language. As Norma Lang (Lang & Clark, 1990) tells us ‘If we cannot name it, we cannot control it, finance it, research it, teach it, or put it into public policy’. And the reality is that if ‘it’ means ‘nursing‘ we are still at the same stage as when Florence N&tingale wrote in 1859 ‘I use the word nursing for want of a better’.

We have as yet no precise or universally agreed language with which to describe the complexity of our nursing practice, no data to explain how the dimensions and characteristics of nursing practice vary among nurses, across patient groups, clinical settings, or time. Medicine has its international Classification of Diseases, but you will not find listed there, much less defined, those conditions-the ‘human responses to actual or potential threats to health’ [to quote the American Nurses Association’s definition of nursing-which are the speci- fic focus of nursing interventions. And if you look in the International Classification of Procedures in Medicine, you will find that the whole of nursing activity is dismissed in two residual categories in the chapter called A d a r y Procedures. The good news is that work on the language of nursing has now begun and is developing fast.

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The International Council of Nurses is beginning to develop an International Classification for Nursing Practice which involves naming, sorting and linking the phenomena which describe what nurses do, for what human conltions, to produce what outcome: in other words, a language and classification for nursing diagnoses, interventions, and outcomes (Clark h Lang, 1992).

In the UK, the Nursing Terms Project is producing a thesaurus of nursing terms which will be integrated into a multi-disciplinary thesaurus of clinical terms withn the framework of the Read codes. And nurses across Europe are coming together in projects such as the Telenursing Project and a new organization called ACENDIO (Asso- ciation for Common European Nursing Diagnoses Inter- ventions and Outcomes]. However, these are only the very first steps on a long, long road.

As it happens, Bob Tiffany &d not have a lot of patience with this kmd of activity. He saw it (as do many nurses, especially in the UK where I believe, we have a long and strong trahtion of anti-intellectualism in nursing] as the kind of abstract theorizing which has little to do with the real practice of expert nursing. We had many lively arguments about it, because as a member of the ICN’s Board of Directors his support was necessary to get the ICNP project off the ground. And, typically of Bob, he gave that support on the basis of ‘OK, run with it, and convince me‘.

The relevance of this kind of work to clinical practice is becoming increasingly evident. We have to recognize the imperative of information technology-the information super highway-and I believe that, like it or not, nursing will in future be defined, resourced and controlled by the information held about it in computerized information systems. And since what comes out of the computer is only as good as what you put in, we had better be sure that what goes in does adequately and properly describe this phenomenon of ‘expert nursing’.

To take an immediate example, and one directly related to my title, consider the latest Department of Health initiatives on clinical outcomes and clinical effectiveness. You all know the old adage ’The operation was a success but the patient died’. The evaluation of success or effectiveness depends on which dimension of value you choose, and ddferent people choose ddferent lmensions {Clark, 1983). In evaluating a new cancer chemotherapy, for example, the doctor might consider its effect on the size of the tumour, the patient its convenience and side- effects, and the chief executive its cost. The challenge for nursing is to identdy, demonstrate and measure those clinical outcomes which are important to patient well- being and which are achieved by specific nursing

interventions, and especially by expert nursing. For example, if we are considering the outcomes or

effectiveness of treating fractured hips, it is not enough to look at the relative merits of various surgical techniques or types of prostheses on bone healing. We must also consider the matrix of nursing problems, such as confu- sion, mobility, incontinence, pain, sleep disturbance, nutrition, and their associated nursing interventions. And then there are all the contextual factors, such as the carer‘s role-strain, which might otherwise prevent a successful outcome. Ultimately, the clinical effectiveness must be measured not just in the healing of the bone, but in the healing of the person: can they walk, be pain free, manage their personal and social functions at the level they could before the fracture occurred? And it is to those things that expert nursing makes the ddference. But first we have to be able to specify and name our variables before we can test them, and it is the clinical testing of these nursing variables that provides the basis for demonstrating nursing effectiveness. As Benner has pointed out: ‘Until nurses’ language and their documentation of nursing functions match the reality of nursing practice, the recognition lag in nursing will continue’ (Benner, 1984).

KNOWLEDGE FOR EXPERT N U R S I N G

A reference to Benner brings me to the question of the knowledge base of expert nursing and to what she first called ’the uniqueness and richness of the knowledge embedded in clinical practice’. I’m sure most of you will be familiar with Benner’s study From Novice to Expert (Benner, 1984) but, for any who are not, Benner took the model of skill acquisition developed by Dreyfus h Dreyfus (cited in Benner, 1984) in research designed to study pilots’ performance in emergency situations, and applied it to the work of nurses in intensive care units. It is, by the way, important to recognize the field of nursing in which the original work was done, because I believe that the over- enthusiastic and uncritical application of her work to all settings and other kinds of nurses ( e g students) without further validation does Benner no favours. For example, Lauri h Salantera (1994) has shown that this model of clinical decision making does not apply to public health nurses.

Benner used interviews and participant observation with 21 pairs of nurses-beginning nurses paired with nurses recognized for their expertise-to obtain and compare their accounts of patient care situations which they had in common. Her aim was to discover if there were distinguishable characteristic differences in the novice’s and expert’s descriptions of the same critical incident, and,

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if so, how these differences could be accounted for and understood (Benner, 1984, p. 14). There were differences, which enabled Benner to identify and describe five ascending levels of nursing proficiency: the novice, the advanced beginner, the competent nurse, the proficient nurse, and the expert.

The novice, because she has no experience with the situation in which she is expected to perform, has to rely on the context-free rules which she has been taught. The advanced beginner has coped with enough real situations to note recurrent meaningful patterns, but cannot yet reliably sort out what is most important in complex situations. At the level of the competent practitioner the nurse can see and rely on long-range goals and plans to determine which aspects of a situation are important, and is able to cope with and manage many contingencies of clinical nursing, but without the speed and flexibility of the proficient nurse (the fourth level) who now perceives situations as wholes and can home in on an accurate region of the problem. But the expert nurse, at the fifth level, no longer relies on an analytical principle (rule, guideline, or maxim) to connect her understanding of the situation! drawing on her extensive experience, she uses what Benner calls ‘an intuitive grasp of each situation’. Dreyfus & Dreyfus (cited in Benner) describe it as follows: ‘The chess player develops a feel for the game; the language learner becomes fluent; the pilot stops feeling that he/she is flying the plane and simply feels that he/she is flying’. Dreyfus & Dreyfus are describing exactly the same phenomenon as Benner, but they avoid what I believe is a semantic disaster in Benner‘s description. Benner uses the word ‘intuition’ and, although she has analysed and described in detail the level of knowledge and skill which underpin the ’intuitive grasp’, the damage is done. To the hard-nosed positivist ‘intuition’ means what the dxtionary says it means: knowledge whch is ‘instinctive’ (Penguin Concise Dictionary), ’without reason’ (Concise Oxford Dictionary, 1991), and listed in Roget’s Thesaurus as synonymous with ‘second sight’ and ‘sixth sense’. And so, once again, the knowledge base which underpins skilled or expert nursing practice is demeaned as ‘not scientific’ and ’just a mixture of feminine intuition (as opposed to male rationality) and common sense’.

The problem is not in the words ‘scientific’ or ‘intuitive’ themselves but in the way we use them and values attached to them. My classical education, before I became a nurse, tells me that the latin word scientia simply means knowledge. But we limit the use of the word science to knowledge about particular kinds of phenomena and obtained by particular methods. Our positivist traditions

value it as the only ‘reliable’ type of knowledge and therefore ‘good’, while we dismiss ’intuitive’ knowledge about other kinds of phenomena as ‘unreliable’ and therefore ’bad’. This is not the place for an epistemologi- cal attack on the randomized controlled trial, but it is the place to say that the practice of expert nursing and its associated knowledge base, concerned as they are with individual human response, are far more complex than can be understood by any single ‘way of knowmg‘. We need all of the four ways of knowing which Carper (1978) identified in nursing:

0 the empirical or scientific; 0 the aesthetic, sometimes called artistry; 0 the moral or ethical! 0 the personal, or use of self.

It is, as Jose Closs has pointed out, ‘by developing an understanding of science alongside intuition and the empathy which most nurses readily feel for patients, [that] we can equip ourselves to become expert practi- tioners‘ (Closs, 1994).

DEVELOPING EXPERT NURSING

So how do we develop and foster expert nursing? There is currently a great deal of political rhetoric and innumerable glossy publications (Department of Health, 1993a, b, c) about publicizing and fostering what is called ’optimum practice’. Most nurses, struggling just to survive, as repeated recent RCN surveys show (RCN, 1994, 19951, will tell you that there is a huge gap between this rhetoric and their reality. But in spite of, or maybe because of, the prevalent negativism and despair, I do believe we need to keep the vision firmly in our sights and to keep r@t on towards it.

The recent Delphi Survey of Optimum Practice, spon- sored by the Department of Health and undertaken by the University of Manchester, describes the views of some 2000 nominated ‘expert’ nurses on what constitutes and supports good nursing practice (Butterworth, 1993). From the responses the researchers identdied 18 key character- istics about what ‘optimum practice’ and its practitioners require. In the United States a model is provided by the Magnet Hospitals - a group of hospitals identified and characterized by their excellence in nursing, which have been studied over a period of more than a decade (Dean, 1991). But, in fact, we need look no further than right here at the Royal Marsden, and at the policies which Bob Tiffany began to develop here from the 1970s onward.

The expert nurses who are the product of these policies now occupy some of the most important leaderslup

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positions in nursing. They can testify from their direct experience, and I can test+ from what I learnt from w o r h g alongside Bob in the RCN. But when I was preparing for this lecture 1 came across two articles written by Bob: one in the Iournal of Advanced Nursing in 1980 and one in Nursing Focus in 1982 (Tiffany, 1980, 1982). From these two articles, one can identdy several key ingredients which together constitute the recipe which we should follow. ‘First’,he wrote, ‘there must be a rahcal rethink in the way nurses view the four major areas of nursing activity: nursing practice, nursing education, nursing management, and nursing research .... Nursing practice has become the Cinderella of the nursing profession, resulting in an apparently subordmate role for the clinical nurse; a situation that is characterized by routinization of work at ward level rather than persona- lized, dynamic, innovative nursing practice .... Where a phdosophy about extendmg the role of clinical nurses ... has been accepted and developed as at the Royal Marsden Hospital, nursing practice and patient care have become revolutionary and exciting‘ (Tiffany 1980).

Since Bob wrote that in 1980 there has been, I believe, a real flowering of expert clinical nursing. The growth of nursing development units, starting in Oxford but now, with the support of the Kings Fund, a countrywide network, is one example. Paradoxically, the disastrous loss of a whole generation of nurse leaders as a result of the changes in the NHS following the Griffiths report of 1983, has enabled the emergence of a new generation of nurse leaders whose leadership is demonstrated not in organiza- tional management but in clinical practice. In spite of the upheavals in higher education, nurse researchers are uncovering and developing our knowledge base. And Project 2000 is beginning to produce the ‘knowledgeable doers’ who can develop into expert nurses.

Expert nursing means doing nursing, not what Bob called ‘nursing by proxy’, that is, directing others. It means nurs- ing based on expert knowledge, both science for nursing and the science of nursing, which is much more complex. Cancer nurses, for example, as Bob said need to know a lot about cancer, cancer treatment and cancer care, but most importantly they must understand cancer nursing; only when they understand their nursing can they contribute appropriately to the multidisciplinary programme using their own expertise in a way which complements other people’s roles without encroaching on them.

The keys to knowledge are education and research; they need to be part of every nurse’s daily life. What other hospital had, or has now, the kind of education centre which was developed here, and its own Department of Nursing Research? Research is for practice, and if there is

no literature for research-based practice, well the Royal Marsden produced its own: The Royal Marsden Manual of Clinical Policies and Procedures (Pritchard & Wolter, 1984).

Expert nursing also requires experience. Well before Benner’s work-which showed that the development of expertise takes time, and that when a nurse who is proficient or even expert in one field moves to another field, she becomes again a novice or, at best, an advanced beginner-Bob Tiffany was arguing, quite against the prevailing view, that career development should not mean moving around a range of specialities, but should mean staying in one place to develop expertise over time.

Expert nursing needs clinical specialization: ‘If the nursing profession does not avail itself of the in-depth knowledge of specialist nurses’, wrote Bob, ’and continues to believe that the general nurse must know it all, it will continue to be a profession broadly based in knowledge but sadly lacking in depth (Tiffany, 1980). The Royal Marsden pioneered the Clinical Nurse Specialist which Bob defined as ‘an expert practitioner in nursing with considerable knowledge, a high degree of skill, and exten- sive experience in the care of patients in the speciality concerned’. But the speciality concerned, he argued, must reflect nursing functions and patients’ experience rather than the traltional medically defined specialities or simple delegation of medlcally defined tasks. Having put these ideas into practice here at the Royal Marsden, Bob went on to develop the same kind of policy with specific and relevant guidance in the Royal College of Nursing (RCN, 1988) and for the International Council of Nurses (ICN, 1989).

Expert knowledge should be shared with other nurses for the benefit of the wider group of patients. So the clinical nurse specialist should also be a clinical nurse consultant, advising and supporting other nurses-a con- cept which is still less used in nursing than in medicine.

Expertise enables and makes credible autonomous practice. The Royal Marsden also pioneered the nursing clinics that run parallel to, and are complementary to the medical clinics, providing patients with continuity of care from the first outpatient appointment, through admission, treatment, aftercare and follow-up, now not only in cancer care, but also in the care of people with dlabetes, asthma and other conditions.

Expert nursing deserves to be properly rewarded, and it was Bob who led the first RCN work on the development of a clinical career structure for nursing and a proper clinical grading structure. He would have been appalled, as I am appalled, at the current downgrading of nurses in clinical practice, the casualization of the nursing work- force through temporary and short-term contracts, and the

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shifting around of skilled nurses like pawns on a chessboard (Buchan, 19951, all of which militate terribly against the development of expert nursing. The latest Department of Health statistics (DOH, 1994) show that in spite of the considerable and much vaunted increase in the number of patients treated, the number of nurses continues to fall. And worse, while the overall loss between 1991 and 1993 was around 2.5%, the number of G grades fell by 6% and the number of I grades by more than 20%. And the latest RCN evidence to the Pay Review Body (RCN, 1995) shows the dramatic shift among clinical nurses to temporary contracts and bank arrangements.

Finally, expert clinical nursing requires the support of managers who can provide-and this is my last quotation from that brilliant paper--‘an environment in which the autonomy of the ch ica l nurse withm the multidisciplin- ary team is respected, fostered, and developed, so that the prescribing, planning and delivery of nursing care becomes an activity based on nursing criteria, reinforcing the concept of nursing as a professional activity in its own right’ (Tiffany, 1980). That, as many expert nurses here can testig, was the environment which Bob Tiffany created at the Royal Marsden Hospital.

BUT DOES IT MAKE A DIFFERENCE?

It must be clear by now to everyone here that I have a passionate belief, as did Bob Tiffany, in the value of expert nursing. But I have not yet responded to the challenge of the second part of my title. Does it make a difference? and even if it does, is it nevertheless an unaffordable luxury?

The answer to the first question is unequivocal: Yes it does. In 1991 as part of its 75th birthday celebrations, the Royal College of Nursing began a campaign which it called ‘The Value of Nursing’. The campaign was born of the need to demonstrate-in the new financially driven and cost-cutting agenda of the National Health Service, which was being expressed in the replacement of qualified nurses by lesser qualified or unqualified staff-that qualified nurses are not only more effective, but are more cost- effective. The RCN commissioned and published a review of the existing research, mainly at that time from the other side of the Atlantic, which had evaluated the costs and/or benefits of employing qualified nurses and the costs and benefits of specific nursing interventions. Caring Costs (RCN, 1991) stimulated a series of other studies, notably form the Audlt Commission (1991), the Centre for Health Economics at York University (Carr-Hill et ~ l . , 1992), and the Institute of Employment Studies, all of whch have demonstrated that there is a direct correlation between the employment of qualified nurses and better patient

outcomes. The work is being continued and updated as the evidence increases. Fagin has more recently summarized and reviewed the work in three areas: (i) nursing care in hospitals; (ii) the work of nurse practitioners substituting for other providers; and (iii) alternatives to traditional models of care (Fagin, 1992).

On the effectiveness of nurses in hospitals, the research is now extensive and unequivocal: hospitals with a higher proportion of registered and more highly educated nurses provide better quality care and better patient outcomes. In fact, the higher the percentage of registered nurses, the lower are the mortality rates. In the most recent phase of the Magnet Hospitals study-which compared the mor- tality of Medicare patients in the 39 ‘magnet hospitals’ with 195 matched control hospitals-the magnet hospitals’ observed mortality rates were 7.7% lower (9 fewer deaths per 1000 Medicare discharges) than the matched control hospitals (Aiken, Smith & Lake, 1994). In my view, it is a scandal that, alongside the pressure placed on chicians to ensure research-based or evidence-based clinical practice, managers have been allowed to fly in the face of this substantial evidence by cutting the numbers of registered nurses and diluting the grade mix.

Evidence is beginning to accumulate about the effec- tiveness of interventions by expert nurses in specialist fields; for example, the treatment of leg ulcers (Cullum h Robottom, 1995) and other types of wound care, urinary incontinence (O’Brian et d., 1991), and catheter care, stoma care (Wade, 1990) contraceptive services (Newton, 1976) diabetes care (Mallows et ~ l . , 1990), breast cancer and counselling (Wilkinson, 1988; Maguire et d,) Patient teaching by expert nurses has been shown to be par- ticularly effective in a number of fields. Some recent work by Wade (Wade, 1993) shows that expert assessment by nurses is associated with lower drug consumption by elderly people. The contribution of the nurse has been identified as a key factor in the effectiveness of multi- disciplinary programmes in fields such as the management of asthma, diabetes and hypertension, and cardiac rehabilitation. Studies of nurse-led services, such as the N H S nursing homes, the nursing units in Burford and Oxford and, more recently, at I(mgl College Hospital and other places, have all demonstrated better patient recov- ery and lower costs than the matched traditional hospital care.

There is a considerable literature, now from both sides of the Atlantic on the work of nurse practitioners, especially in primary health care (ANA, 1992; SETRHA, 1995). In the USA nurse practitioners have been used as physician substitutes in under-served areas in ways which have not been necessary and probably would not be

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acceptable here. But the UK work on nurse practitioners shows that their true value is not their (demonstrable) ability to perform more cheaply tasks previously carried out by doctors, but in the dlfferent approach and skills which they offer. This raises another issue: as 1 suggested earlier, making a difference means more than profession- ally defined clinical effectivenessj patients like it, want it and need it because it makes them feel better. And I think that is just as important. There are many studies in areas such as health visiting (Health Visitor, 19941, management of ‘chronic pain‘ (Walker, 1994), support of carers in the community (Aiken & Fagin, 19941, health education in schools (Fahey, Ward & Cutting, 1992), and AIDS support (McCann 1991) where the clinical effectiveness is harder to demonstrate, but patient satisfaction is clear.

There is no doubt that expert nursing makes a difference even though, as I earlier complained, we are not yet able to spec+ precisely which elements of expert nursing make the hfference, and why.

BUT IS IT NECESSARY?

In these times of turbulence and uncertainty nurses, like other groups, agonize about their future. With the millen- nium almost upon us, several people have set scenarios of what health care might look like in the 21st century. We have the Chief Nursing Officers‘ Challenges for Nursing and Midwifery in the 21st Century (DOH, 1993a), WHO’S Nursing Beyond the Year 2000 (WHO, 19941, NAHAT’S document on The Future Direction of the NHS (NAHAT, 19921, the Adam Smith Institute’s 20-20 Vision (1994), and we eagerly await Sir Duncan Nichol‘s Healthcare 2000. The interesting thing is the remarkable degree of agreement among them, including, for example, the shift towards care in the community and the death of the District General Hospital as we know it today.

In the new scenarios I see no diminution of the need for expert nursing. On the contrary, I believe that nursing’s particular combination of knowledge and skills are exactly what is required to meet the challenges of the growing demands of an ageing population, with greater disability after heroic treatment, managing chronicity, teaching self- care, teaching healthy living, acting as the person’s advo- cate and guide through the maze of a fragmented and pluralistic health care system, and providing the emo- tional and practical support which patients need which neither the new technology nor multi-skilled technicians can provide.

It is the constant of peoples’s needs as human beings which constitutes the challenge and the focus for expert nursing. The core of nursing practice is not the ability to

take a blood pressure, administer medication, dress wounds, or manage complicated machines. It does not lie in our manual skills, many of which will be as obsolete in 5 years’ time as some of the skills I learnt as a student 30 years ago. It does not even lie in our empathy or caring approach to people, for there are many others who can equal that claim. It lies in OUI ability to diagnose and deal with other people’s human responses to illness, frailty, disability, life transitions, and other actual or potential threats to health, and to do so within a relationship of trust and care that promotes health and healing. And that is expert nursing.

AN UNAFFORDABLE LUXURY O R AN UNNECESSARY EXTRAVAGANCE

But finally, is it an unaffordable luxury or a necessary extravagance? The Concise Oxford Dictionary defines ‘extravagant’ as ‘spending, especially money, excessively; immoderate or wasteful in the use of resources’, and ‘exceeding normal restraint or sense’. Every country in the world is trying to contain, if not reduce, its health care cost. But the paradox is that if you look at the data-both comparative data across countries, and the data to which I have already referred from our own country-it shows that most countries, including ours, would gain better value for their money if they spent more on nursing.

In our own health care system, nursing represents some 80% of direct care. Nurses are often the first, last, and most consistent point of contact that most people have with the health care system. If the nursing isn’t right, the whole system of care fails. Without the right numbers of qualified and experienced nurses, in the right proportions, their expertise recognized and properly utilized, clinical effectiveness is only a pipe dream.

In reviewing earlier the work on the effectiveness of nursing, I deliberately did not make explicit the question of cost, but I’m sure that most of you will have recognized that it was there. I avoided it at that time because I do believe that nursing can and must demonstrate its effectiveness in its own r m t , and I do not relish the reality that nurses come cheap. But in every case the reality is that the effectiveness of nursing is enhanced by its cost effectiveness. Value for money requires considera- tion of cost and quality, and nurses score on both accounts. As Aiken has written: ‘Many believe that increasing nursing compensation 1i.e. salaries) is not affordable given cost constraints. Yet a cursory glance [at the evidence] will debunk that myth and force exploration of where the money for health care is actually going ...’ ’The data are accumulating to attest to the powerful

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JUNE CLARK Expert nursing: a necessary extravagance

contribution nurses are making to enhance the quality of care, promoting health and lowering total system costs. What is very clear is that nursing is a bargain, in and out of hospitals. We need to make the results of these studies available to policy makers’ (Aiken &. Fagin, 1992). I am reminded of one of those lovely animal posters you see on other peoples’ walls. Underneath a picture of a chimpan- zee the slogan reads: ’If you think educations’s expensive, try ignorance’. To our politicians, policy-makers, and the users of our services 1 want to say, ‘If you thmk expert nursing’s an extravagance, try inexpert care’. And to the expert nurses-and I know there are many in the audience-I want to say, with Benjamin Franklin:

‘Hide not your talents They for use were made; What’s a sundial in the shade’

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