My nursing vision: NZNO AGM 2014 panel debate

2014.09.17-18 NZNO AGM SC D3100 301 Grant BrookesAt the NZNO AGM last year, I was invited to take part in a panel debate, on the topic “that substitution is good for nursing”. I joined the team arguing the negative.

In my five-minute speech to the assembled AGM delegates, I explained why substitution is not good for nursing. In doing this, I gave an overview of my nursing vision.


‘The steamer ‘Chelmsford’ trading between Parengarenga and Auckland, left at 10 o’clock a.m. on Tuesday with myself, the only passenger. As soon as we got out of the heads it started to rock… [We] reached Parengarenga Harbour at 10 a.m. Thursday… I was only too glad to get up and go ashore, as this was the first time I put my clothes on since I left Auckland. Mrs. Yates… received me so warmly that I soon forgot the horrors of my trip on the boat. After half-an-hour’s conversation with her, I learned that there was sickness in the Pah across that Harbour…

“I went round to all the houses, and in each of these there was a sick person, children mostly…

“Next morning after breakfast I walked to another Pah, about four miles, saw eight patients there, got back to the school-house at 7 p.m., too late to get across, and at 9 p.m. a Maori came to get me to see a man who was very bad with coughing, he said, and was spitting up blood… On my arrival there at 11 p.m. (you have to feel your way carefully, or you may land on your head, as the place is full of gum holes) I found he was suffering from acute pain in right side every time he coughs. On examining the sputum I found it was rusty, and the temperature was 101.4, pulse 144 respiration 48… I left the old man much easier… After breakfast I went to see him again… after seeing 23 patients in the Hapua settlement I came away feeling very much depressed I wish I could have done more for them… I left on horseback, with a guide, a distance of eighteen miles. It poured all the way there, and I was drenched to the skin.”

Hearing these excerpts from a letter to Kai Tiaki, dated July 1909, we begin to see why the name of Akenehi Hei remains synonymous with excellence in nursing practice over a century later.

What stands out from her letter is the enormous effort she made to be with the patient, to be physically present. And the way that nursing, for her, meant being in a caring relationship. “Feeling” and “wishing”.

These essentials of nursing come up again and again, across cultures, across generations.

Writing in California in the 1980s, nursing theorist Patricia Benner famously derived the elements of the helping role from interviews and observations of expert nurses.

“the expert nurses here had the self-esteem and self-confidence to see the value of their presence for their patients”, she said. “They point to the importance of touch and person-to-person contact between patient and nurse.”

It’s this closeness, and this time spent with the patient and their family – what has been called “the privileged place of nursing” – that allows holistic nursing assessment and holistic care.

So, if substitution is good for nursing, then you would expect it to increase our person-to-person contact with our patients and their families. You’d expect it to increase the time we spend with them, and make care more holistic.

But we’ve already experienced substitution of nurses in the healthcare team, haven’t we? We’ve seen the proliferation of unregulated caregivers such as Health Care Assistants. What has it brought us, in reality?

It’s turning nurses into directors and delegators. Instead of spending time in contact with our patients and their families, we’re spending it instructing and supervising staff. We are growing ever more distant from those we care for.

As we assess what can be safely delegated, the holistic vision of nursing care disappears into a set of tasks, to be shared out around the healthcare team – each one to be completed as quickly as possible.

As more tasks are delegated, we are losing the ability to actually “know the patient”.

And it’s turning us from nurses, into documenters. Instead of nursing the person, we spend more and more of our time operating this computer keyboard. And we hate it!

Don’t you agree…?

On the NZNO facebook page last month, there was a lengthy discussion about the high profile roll-out of the Releasing Time to Care programme in Auckland. One comment from a Waitematā DHB nurse got more likes than any other by far: “My job is pretty much data entry”, she said, “with random acts of nursing!”

Who here can relate to that….?

Substitution is not good for nursing. It is destroying nursing.

To return to Akenehi Hei, nursing is first and foremost about human contact, face to face, kanohi ki te kanohi.

Nō reira, rurea, taitea, kia tū ko taikākā anake.

In the words of this Māori proverb, strip away the bark and expose the heartwood.

See substitution for what it is. At its core, substitution is bad for nursing in New Zealand.”

• The NZNO AGM 2014 panel debate was also reported in Kai Tiaki Nursing New Zealand.

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