From celebration to rage

We close 2022 with a celebration of the JRN Veroncia Bishop Paper of the year and the publication of this edition which includes five papers and their associated commentaries – all of which, for me, provide important insights into the contemporary circumstances of nursing and healthcare.

But first we celebrate. Moving and handling care of bariatric patients: a survey of clinical nurse managers by Sara Dockrell and Graham Hurley was identified by our panel of three independent judges as the paper published in JRN last year that was most likely to influence policy and practice. One judge remarked:

The significance of multidisciplinary management of this important patient demographic has been poorly addressed in the past. Given the increasing policy emphasis on multidisciplinary teamwork and the development of flexible role boundaries, the application of this framework could make a crucial contribution to interventions which address the escalating global incidence of obesity. The identification of the barriers to moving and handling care for these particular patients is also crucial in reinforcing the evidence-based arguments for improving access to appropriate equipment, the provision of caring guidelines etc.

Many congratulations to Sara and Graham who receive £100 of Sage book vouchers and the potential to work with us to develop and publish a graphic interpretation of their paper. Our aim here is to support the further dissemination of their work and increase the potential of engaging a wider range of audiences.

Early next year we’ll be calling for nominations for our 2023 paper of the year – the paper published in 2022 most likely to impact on nursing practice and/or health and social care policy. Please follow us on Social Media @JRN_latest for our latest announcements or send your nomination(s) to us via jrn@sagepub.co.uk. But before you do, you might like to take a look at the papers published here.

Four papers and associated commentaries provide insights into the experience of living with a long-term condition and the nursing response. The first considers the impact of the symptom of fatigue on the health-related quality of life of people living with irritable bowel disease (IBD) and provides new insights into a poorly researched area. The second paper focuses on the experiences of men living with chronic lymphoedema, a long-term condition which predominantly manifests in women (80%) and is therefore under researched in men. This qualitative systematic review powerfully illustrates how men’s experiences of living with lymphoedema impacts on all aspects of their lives. The third paper provides insights into the experiences of people living with and managing cystic fibrosis related diabetes. In setting the scene, the authors explain how the effectiveness of treatment has meant that people with cystic fibrosis are living longer. Consequently, the incidence of co-morbidities is on the rise with diabetes among the most common. Although cystic fibrosis related diabetes shares aspects of ‘standard’ diabetes, it is a pathologically different, distinct condition where appropriate interventions may seem counter-intuitive. The fourth paper is related to HIV, a long-term condition, the management of which has been transformed over time through the development of new knowledge which has given rise to innovative diagnostics and treatments. The consideration in this paper is the feedback from men who have ordered a self-test diagnostic kit through an online platform, ostensibly to improve the experience for those who follow. These papers and their associated commentaries bring into sharp focus the value of nurses with specialist knowledge and expertise in the care of people living with long-term conditions, the benefits that can be realised from research and the necessity for life-long learning in practice to improve patient outcomes.

Firstly, the nature of nursing care is often temporal because, for example, technological innovation, whether by design or necessity, impacts on nursing. When commenting on the first paper, for example, Stanfield acknowledges the limitations of assessing fatigue in patients with IBD when a consultation is undertaken over the phone. And similarly, when commenting on the fourth paper, Watson highlights the risk of missed opportunities for treatment, support and counselling when people with the potential for asymptomatic HIV are required to self-manage their testing and self-report their results. These nursing experts are not Luddites, they are experienced nurse-clinicians who can clearly articulate the positive and potentially detrimental impacts of introducing specific technologies into practice from both a nursing and a patient/service-user’s perspective. I am minded of a recent Tweet highlighting the absence of a nursing voice in the development of policies around digital innovations in healthcare. What a missed opportunity that was!

And of course, the temporal nature of nursing care is a direct result of the temporal nature of the knowledge that informs that care, and often, as can be seen here, adds another layer of complexity and nuance that specialist nursing care encompasses: new insights into the impact of fatigue on the quality of life of people living with IBD have the potential to inform and shape specialist nursing care in the field; new insights from a review of the evidence into the impact of lymphoedema on men living with this long-term condition that has a significantly higher incidence in women call for the gender-based tailoring of specialist nursing care; new understanding of the impact of one long-term condition on another – in this case living with the co-morbidities of cystic fibrosis and diabetes – highlights the need to tailor patient education and care accordingly; and how advances in the care and treatment of people confronted with the potential of an HIV diagnosis have, over time, dramatically impacted on the context and the timeliness in which that might take place. New knowledge continually shapes the nature of specialist nursing in the care of people living with long-term conditions, it serves to highlight the complexity of nuanced symptom management and the support and education required by people living longer with, and increasingly self-managing, their long-term conditions. The impacts of long-term conditions are far reaching. They don’t start and end with the health and well-being of an individual, they impact to varying degrees on those around them and society at large. They impact on individuals’ and carers’ potential to engage in education and employment. They impact on the wider health and social care economy. Specialist nursing care is both complex and far reaching and the expert nursing voice has, by definition (or default?), an important contribution to play in shaping research, policy and practice for people living with long-term conditions.

In this context, the Editors of JRN have joined forces with Dr Alison Twycross the Editor of Evidence-Based Nursing and our colleague and former editorial board member Dr Elaine Maxwell. Our purpose is to explore with nurses who have nursing expertise in caring for people living with long-term conditions, our collective understanding of the potential of the nursing contribution in the care of the people living with the long-term sequelae of a COVID-19 infection. And this is why here, at JRN, we have issued an associated call for papers published on the final page of this edition and online. ¹

In the final paper in this edition, it is sobering to read the author’s report that in their study on nursing students, the nature and indeed the complexity of nursing was poorly understood by them at the start of their course. It was also reported that when the student nurses reached the end of their undergraduate education, they expressed a sense of disconnect between what they had learned at university and their experiences in practice.

Some argue that 21st century nursing is poorly articulated by nurses, and therefore, by definition, this is the fault of nurse leaders if not nurses themselves. That leads me to question, might there be vested interests both within and beyond nursing that are served either purposefully or subconsciously, by subjugating nurses, especially those in clinical roles, and silencing, or at least temporarily muting, the voice of professional nursing? Why is nursing most often represented by nurses who no longer practise nursing? Why did some nurses, and why do they still, uncritically embrace managerialism (Traynor, 1999). Why are bright, articulate nurses, who challenge the status quo, often perceived as a threat by their peers and unsupported by those with the power to enable them to make a difference?

I was struck by Allan’s commentary on this paper where she argues that the notional ‘theory-practice gap’ describes a false dichotomy which ignores the thinking in doing. Her argument that in this context we project our discomfort of such a tension by blaming or projecting the blame onto someone or something else is clearly transferable into other contexts.

Can we collectively empower our profession by surfacing and acknowledging vested interests, agreeing our common purpose and building alliances? The account of the emergence of the specialist nursing role in the care of people living with IBD in the commentary by Stanfield is illuminating. Written by a senior clinical nurse with vast experience of caring for people living with IBD, Stanfield provides a first-hand account of the development of nursing expertise within the specialty. She reflects on how the starting point for the early specialist nurses like herself was to follow a biomedical model of practice, focussing almost universally on the management of a patient’s physical symptoms. However, over time a more holistic focus that included patients’ experience of living with the disease has come into play. Why did the classic ‘biomedical model’ shape the development of specialist nursing in this field and how has nursing made this role their own? I suggest that the emergence of specialist nursing roles like the one described here, that makes a clear and purposeful nursing contribution, in partnership with other disciplines who respect and understand each other’s roles, would indicate that given the right conditions, yes we can.

Yet, I write this at a time when our profession is on its knees. For the first time in the 106 year history of the Royal College of Nursing of the United Kingdom (UK), nurses have indicated their willingness to take strike action across the four countries of the UK. The arguments are (at least) two-fold. Firstly, nursing salaries have materially decreased since 2010 and there are reports of nurses using food banks to feed themselves and their families. Secondly, there is an unsustainable shortage of healthcare professionals across the UK. Despite repeated calls and promises, at the time of writing, there is still no workforce plan in place in England.

When a senior clinical consultant nurse (see commentary by Stanfield, p. 703) reflects on research that informs her practice and candidly reflects on whether she and other nurses are currently equipped with the knowledge, skills, expertise and time to surface and address the insights this important research raises, we know we are in trouble. Enough is enough.

The working conditions for nurses have become intolerable, nurses are leaving the profession because their own health and well-being is suffering, attrition is at an all-time high and patient care is no longer considered safe. And while these issues have been steadily growing over several years, they arguably have been exacerbated more recently in the UK by the decision to leave the European Union and have come to a head globally in the midst of the COVID-19 pandemic. In 2020, we hosted a debate on nurses’ well-being in partnership with the Foundation of Nursing Studies and one contributor reported:

Nurses’ emotional labour has clearly been exacerbated during the coronavirus 2019 (COVID-19) pandemic. With hospitals overcrowded and supplies running short, the risk of contracting the disease we were fighting was very real. In some places, nurses were being recognised by the population, clapping us as heroes, yet in others were getting spat at or evicted for being a front-line worker and a risk to the general public. (Smith et al., 2021)

It is unsurprising that in these conditions, nurses and other healthcare professionals are reporting burnout which can manifest as a perceived absence of empathy (Loft et al., 2022) and is a major cause of attrition (Hunt et al., 2017). In their review of burnout and its relationship to empathy, conducted before the pandemic, Hunt et al. (2017) identified the responsibility of employers to identify nurses at high risk of burnout before they leave the profession and to provide a supportive environment. The imperative now is for Governments to do the same.