The silence of the nurses

Following a remarkable surgery to separate conjoined twins, the media were keen to report on the children’s recovery. Every report was prefaced by “Doctors worked for nine hours … Doctors say … Doctors are humble about their contribution …”

The health professionals present with the twins every hour of that event were nurses. Nurses were a key part of the surgery, a critical part of supporting the parents minute by minute and would have been at the bedside of the twins every moment of their recovery. Nurses in the community will support their integration into life as separate entities and the huge needs of the parents in managing that process.

Yet nurses’ voices are never heard and rarely sought by the media. We speak as professors of nursing and former nurses. Our colleagues and former students have been present in the widest range of health service contexts and we are critically aware of the impact of political and policy changes on patient and community wellbeing.

Nursing was at the centre of the response to the Whakaari Island disaster, the Christchurch massacre, the Christchurch earthquakes, and the Covid-19 pandemic. The Royal NZ Nursing Corp has been present in every war and military intervention since WWI. Nurses have died providing care during influenza epidemics and local outbreaks of typhoid. But despite being present at every critical health and health-related event, our enormous profession has suffered from an enduring and offensive silencing.

Right now the situation is perhaps the worst it has ever been. Nurses striking for safe staffing to ensure patient safety and wellbeing are told by Health Minister Simeon Brown, who has no experience in health care, that they should put patients first. Chief nurses are blocked from speaking publicly about organisational issues that risk patient safety, all the while being held accountable for failures of care often exacerbated by lack of staff, lack of resources, and chaotic interrupted working environments.

The impact of this silencing is in effect a silencing of patient voices and supports the ever-increasing focus on costs and the commodification of care. Nurses have been consistently told (explicitly or implicitly) that what they know is neither real nor valued.

The Trump administration in the US effectively no longer deems nursing a professional degree. There is also a weird animus against degree-qualified nurses in the United Kingdom, with newspaper columnists suggesting such nurses were “too posh to wash” patients. A similar disregard was found in Sir Peter Gluckman’s university advisory group final report, which questioned, without any evidence of a problem, whether nursing needed to be within the university system.

And now nursing has been excluded from the Minister of Health’s primary care advisory group, a group that includes six doctors, one accountant, and one community pharmacist. No nurses, and also notably, no Māori or Pasifika voices among them.

Nurse practitioners work in primary care, covering general practice, rural practice, elder care, community health, and youth health. Designated nurse prescribers also work in primary care, as do practice nurses. They each have their defined roles, which are independent of doctors, although they may also work in collaboration with doctors.

The minister is absenting these voices and their experience of primary care provision. It would be laughable, were it not so obvious, that the minister expects that medics can convey nursing’s views and expertise. We hope that is not the expectation of the medics themselves, and that they will argue for an expansion of the advisory group. Approaches have been made. The current homogeneity of this advisory group will attenuate any innovative advice about primary care provision.

Nursing holds an extensive range of hard data that counts and costs the consequences of poor staffing, the impact of lack of post-graduate education and the persistent view that nursing is a cost to be contained rather than an investment that generates reward.

Politicians, policy wonks and organisational managers are ignoring that data at their ongoing peril. That ignorance is measured in preventable admissions to hospital and in costly adverse events including wound infections, pressure sores, patient falls, and prolonged lengths of hospital stays. The systematic silencing of nursing was not surprising in a long-gone era when women were seen as wives and mothers, and nursing work regarded as a public expression of that role regardless of the sex of the nurse. That this has persisted into the 21st century is astonishing, but sadly, unsurprising.

The distribution of, and the 24/7 presence of nurses in critical environments, means they hold a wealth of knowledge and awareness about what works, about what is needed and most of all about what does not work. We continue to ignore or marginalise those nursing voices at our peril.