It is my very great pleasure and privilege to contribute this editorial comment for the eleventh issue of the Whitireia Nursing Journal. From its beginning the journal has been a valuable resource for facilitating the publication of nursing research and scholarship that is of particular relevance to our own context in Aotearoa New Zealand.
The context for all health professionals has been brought into sharp focus by the Health Practitioners Competency Assurance (HPCA) Act, which was passed in 2003 and is currently being implemented. One of the major implications of this Act was to separate Nursing and Midwifery as two distinct professions that are now regulated by the Nursing Council and the Midwifery Council respectively.
Nurses will be aware that the Nursing Council has been preparing for the changes signalled in the HPCA Act and which will be ready for implementation by 18 September 2004. A number of documents including ‘Scopes of Practice’, ‘Education Standards for Nursing Registration’, ‘Continuing Practice Competencies for Registered Nurses’ and ‘Guidelines for Competency Based Practising Certificates’ have recently been circulated to provide an opportunity for the profession to have their input into how the profession will be regulated in the new environment. While we all may groan as yet another consultation document hits the desk, it is well to remember that the purpose of all this activity, indeed the rationale for the HPCA Act itself, is not whether the changes serve the profession, but to ensure that the public can have confidence and trust in the competency and safety of anyone who calls themselves a nurse.
One can of course challenge whether increasing levels and layers of regulatory control will achieve any greater degree of confidence in the nursing profession than is currently held by the public. However, greater levels of bureaucracy and regulatory control seem to be the symptomatic curse of our times, as anyone who works within our public health system or in our tertiary education system can attest. I have been reflecting on why it is that our complex institutions, such as health and education, seem to be expending more time and energy in monitoring performance and less in creating environments that enable good practice to occur. The bureaucratic response of course would be that institutions must monitor performance in order to validate claims of quality and/or safety.
O’Neill (2002) argues that modern society is characterised by institutions (including professionals) developing more and more complex systems to monitor compliance in an attempt to manage risk, because of a perceived lack of trust by the wider public in these institutions and/or professional groups. She does make the point that while the public may be somewhat suspicious of institutions, that is not in itself evidence that there is a wholesale loss of trust.
Nothing follows from examples of sporadic untrustworthiness, however flamboyant, except the sober truth that today – as always – not everyone is wholly trustworthy and trust must be placed with care (p. 17).
As a profession, I believe we should consider the proposition that trust may be one of the first casualties of an increasingly diverse society.
The question must be asked whether it is true that the public has lost trust in nursing and nurses. Will responses such as those embodied in the HPCA Act make nurses more trustworthy in the public’s view? I am inclined to think not. As a profession, I believe, we should consider the proposition that trust may be one of the first casualties of an increasingly diverse society. The spaces between divergent groups within our society are where doubt and suspicion manifest themselves. Professionally, we need to develop the skills and knowledge to stand in those spaces and deliver safe and competent care in ways that transcend difference. As a profession, and as individual practitioners, it is our ethical responsibility to build trust. Actions that undermine the public’s confidence affect the way they access health care. A range of strategies can be adopted by the profession to address the needs of a diverse society. Not least of these is ensuring that nursing itself is truly reflective of this diversity. I believe Whitireia Community Polytechnic is leading the way in this respect. Each practitioner has a responsibility for recognising that every encounter with a patient and their whanau holds the potential to build trust or to build doubt and suspicion.
Creating learning and practice environments that encourage and sustain nurses as they develop trusting relationships with patients and their families and the broader community is more likely to ensure the public’s faith in nursing competence than institutional measurement of competency. Indeed, the over assessment of competency is more likely to negatively impact on performance than anything else. Let me conclude with this quote from O’Neill:
Perhaps claims about a crisis of trust are mainly evidence of an unrealistic hankering for a world in which safety and compliance are total, and breaches of trust are totally eliminated. Perhaps the culture of accountability that we are relentlessly building for ourselves actually damages trust rather than supporting it. Plants don’t flourish when we pull them up too often to check how their roots are growing: political, institutional and professional life too may not flourish if we constantly uproot it to demonstrate that everything is transparent and trustworthy (p. 19).
This is the core challenge for nursing, both in education and practice. How do we enable competency to ‘flourish’?
O’Neill, O. (2002). A question of trust. The BBC Reith Lectures 2002. Cambridge, United Kingdom: Cambridge University Press.
Dr Margaret Southwick
Dean, Faculty of Health, Education and Social Science Whitireia Community Polytechnic
Copyright School of Nursing and Health Studies 2004
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