Portal de Periódicos da CAPES

Editorial: Bring back the veil!

2009; Wiley; Volume: 18; Issue: 6 Linguagem: Inglês

10.1111/j.1365-2702.2008.02584.x

1365-2702

Christine Duffield,

Healthcare professionals’ stress and burnout

Walk on to any unit in a hospital today and you are likely to be confronted by a ‘wall of people’ in the corridor. Confusing as it is to those of us who work in health, imagine what it must be like for patients and their families. They might well pose questions such as: Are all these people in the corridor hospital staff? If they are staff do they belong on this unit? Are they nurses, cleaners, pharmacists, managers, medical or allied health staff? If they are a nurse are they my nurse? Is my nurse a registered, enrolled or endorsed enrolled nurse, an assistant in nursing or a clinical nurse specialist? Does this matter to my care? There was a time when it was easy to identify staff in a hospital, particularly nurses and doctors. The nurse was in a white uniform wearing a veil and medical staff wore white coats with a stethoscope around their neck. The veil disappeared many years ago as did the traditional white nurses’ uniform. More recently, in response perhaps to generational changes in the workforce, many hospitals have endeavoured to ‘modernise’ the nursing image as depicted by the uniform. Nurses’ uniforms now are found in an array of colours, prints and styles. In any one institution the assortment of apparel worn by nurses can range from theatre scrubs in a variety of colours, to ‘corporate’ suits. Nurses and their work have become less visible (Gordon 2005) and we may have inadvertently contributed to this by changing nurses’ uniforms. Consider the patient being diagnosed and treated in the emergency department by a health professional in navy theatre scrubs with a stethoscope around his or her neck. The patient and family are more likely to assume that the individual is a medical practitioner rather than a registered nurse, nurse practitioner or clinical nurse consultant/specialist. The work that nurses do has become less identifiable because nurses themselves are less identifiable in the healthcare team. This in turn, is likely to have altered the public’s perceptions of our role and value and whether we like it or not, uniforms play a part in these perceptions. Skorupski and Rea (2006) found in the USA that wearing a white uniform conveyed an image of professionalism and the wearer was perceived to be a registered nurse rather than another category of nurse. However, a nurse in a white uniform was also more likely to be chosen as the person patients would not like to take care of them. A nurse in a print uniform suggested an image of a more informal and friendly approach to care (Skorupski & Rea 2006). The idea that a uniform can act as a barrier between nurses and patients is not new. In a seminal piece of work Menzies (1961) studied the anxiety experienced by student nurses during their hospital-based programme which led to them leaving their training. She proposed that to function effectively an organisation develops socially structured defence mechanisms to protect staff, in this case a hospital and its employed student nurses. In her analysis, she concluded that the core of the anxiety for a nurse lies in his/her relationship with patients. The more a nurse gets to know a patient, the greater the potential for increased stress and anxiety. To prevent this hospitals establish mechanisms to distance the nurse from the patient. Uniforms are one example. By wearing a standardised uniform distinguished only by an arm stripe (for a second year student) or a cap (third year student), a student nurse loses his/her individuality (Menzies 1961). ‘Blanket’ decisions are then made by a category of employee (e.g. nurses) rather than individuals (Nurse X), thus minimising an individual nurse’s anxiety. However, creating a sense of detachment between nurses and patients is not consistent with open disclosure and accountability for individual actions, cornerstones of the patient safety agenda in most countries today. Hospitals are more complex and busier than ever before. To illustrate, in New South Wales (Australia), patients move 2·26 times in an average length of stay of about four days (not including intra-ward transfers) and an average of 1·25 patients pass through each medical-surgical bed every day (Duffield et al. 2007). Coordinating patients’ care with this degree of patient ‘churn’ requires great skill. However, in addition to these patient movements, there are also quite unusual workforce pressures which may threaten staffing stability, thereby threatening patient safety. Some of these factors include a workforce comprising 44% part-time employees (Duffield et al. 2007); the use of more casual, temporary and agency (labour hire) staff; changes in ward staff of up to 100% over a 4–17 month period (Duffield et al. 2007); and multiple different staff rosters (schedules) on the same ward comprising four, six, eight, 10 and 12 hour shifts, necessitating multiple handovers and the reassignment of patients (Kalisch et al. 2008). The potential for a lack of continuity in care and compromise to patient safety is clear. Given the now well established positive relationship between a rich skillmix (a greater proportion of registered nurses) and improved patient outcomes (Aiken et al. 2001, Tourangeau 2002, Duffield et al. 2007, Kane et al. 2007, Rafferty et al. 2007), patients and families have a right to know who is responsible for co-ordinating or providing their care – is it a registered or enrolled nurse or an unregulated worker. They also have a right to know to whom they divulge at times, very sensitive and personal information. They need to know that this information is then handled professionally under a nursing code of conduct and shared with other health professionals as appropriate to ensure the best possible care. The UK took an historic decision with their Patient’s Charter when they advised patients that they would be told the name of the qualified nurse, midwife or health visitor responsible for their care (Department of Health 1996). Patients and families also want to know that they are asking the right person for help. Asking the pharmacist for assistance walking to the shower may not be met with a positive response! Making nurses and nursing work less visible makes this task more difficult. The current emphasis on restructuring in hospitals has all too frequently led to a loss of or changes to the nurse executive role and this has also contributed to the decreased visibility of nursing and its critical role. Frequently, these positions take on responsibility for a larger and more diverse range of staff and services, resulting in some cases with less direct representation of nurses and their issues, at both institutional and policy levels. The lack of involvement of nurse executives in organisational decision-making has left nurses with limited power to influence change or create positive nursing work environments, both of which are critical in ensuring patient safety (Patrick & Laschinger 2006). Nurses generally have been slow to recognise and acknowledge the negative impact that devaluing these roles has had both professionally and for patients. Recently, in an enquiry to investigate patient complaints of inadequate and unsafe care in New South Wales (Australia), a key recommendation was that the ‘role of Director of Nursing be reviewed as a matter of urgency, with a view to restoration of management responsibilities so that the most senior nurse on staff has authority to make decisions and can provide leadership and support for the nursing staff’ (Joint Select Committee on the Royal North Shore Hospital, 2007, p. xv). It is perhaps again a sign of our invisibility with the public, politicians and policy makers that it has taken a Parliamentary Enquiry for the loss of this most senior position to be made known more generally. We need to ensure that there are strong nurse leaders at all levels. They need to be involved in a real way in decisions about resource allocation to recruit and retain nurses and facilitate the development of their future careers. Ensuring nurses continue to make a contribution to the population’s health relies very much on the leadership they see and experience. This lack of ‘public face’ flows through to all levels of nursing management. Unfortunately, many nurses in charge of wards or units, the real clinical interface between patients and nurses, are novice managers with little experience in the role (Duffield et al. 2001). Management positions are not keenly sought after. However, the work environment of nurses, largely influenced by a first-line nurse manager, is critical in staff satisfaction and retention (Duffield & Franks 2002, Duffield et al. 2007). Strong leadership from the nursing unit manager is also very important to patient safety (Duffield et al. 2007). However, the role of these managers has also changed considerably in recent times. Restructuring has resulted in a loss of many middle and senior managers in all disciplines, which means first-line nurse managers have been required to undertake more ‘general’ management functions (human resources, payroll). This has been at the expense of providing clinical leadership, again eroding the importance and visibility of nursing. As the leader of the unit or ward the nursing unit manager has the capacity to instil a sense of personal and professional pride in being a nurse through his/her own role modelling. This requires being visible to staff and patients. Of course the title for this paper is meant to be tongue-in-cheek. Anyone who has worn a veil would say it was hot and uncomfortable, got in the way of patient care and was a harbinger of infection. However, by perhaps trying to ‘move with the times’, changing nurses’ uniforms has had an unintended consequence. We may have unconsciously achieved what Menzies (1961) defined as a conscious decision many years ago by organisations. We have socially structured defence mechanisms to protect nurses by making them less visible. It is time to rethink our approach. The veil identified who was the registered nurse. Nursing was visible. Patients and staff knew who they were dealing with. We now know as a profession that nurses play a critical role in ensuring patients are safe, but perhaps we have not communicated this message effectively to the public. It is time that patients and the public know who we are. They need to understand the critical role nurses and nursing play in their safety and well-being. A uniform will not necessarily achieve this but it does make nurses and our work more visible.