The Department of Health is conducting a value-for-money audit on the four-year nursing degree course. Pat O'Brienargues that while not without merit, it is important that its objectives are clear
The Department of Health's decision to commission a review on whether the programme to make nursing a degree-entry profession has represented value for money for the taxpayer is timely and welcome. However, there are a number of points to be addressed.
Firstly, how can value for money be measured in this context? What precise criteria will the commission use to measure objectives outlined?
Indeed, the fundamental question to be addressed would be: Is it possible to measure quality of care (which one presumes is what nursing and, indeed, medicine is essentially about), using quantitative (economic) criteria - input and output measures?
Care cannot be quantified in mathematical and statistical terms - in other words, using book-keeping techniques. Care is concerned with such human variables as patient experience, happiness, comfort, alleviation of pain and distress, psychological wellbeing and, inter-alia, diminution of anxiety levels.
Care in the aforementioned context can be evaluated using psychological tools but not economic ones. Accordingly, talking about a "value for money" review is, in my view, a somewhat futile and inherently flawed exercise. Likewise, referring to the Department of Health's "business plan" in the same context is equally illogical, very simplistic and daft.
Yes, of course, as the department and the HSE argue, the new development should be driven by service needs and by contribution to greater efficiencies within the health services as a whole but, just as importantly, it should be driven primarily and fundamentally by high quality patient care.
It is essentially toward this end that finite taxpayers' financial resources should be invested in terms of the relevant and appropriate research.
Nurses, like all public servants such as teachers and doctors, must, with absolute justification, be held personally and corporately accountable for their practice in terms of their professional modus operandi, including answerability for judicious economic use of precious and expensive resources such as time, equipment and human resources.
Inherent in this accountability must be a requirement to produce concrete evidence of good clinical practice by rigorous adherence to the planning, development and use of top quality individual patient care plans, including proof of ongoing review and modification as patient requirements dictate.
In this context, the well-known practice of oft-time wastefully and ritualistically spent endeavours on useless paperwork - merely for its own sake and without a sound clinical rationale - should be eliminated.
Clinical record-keeping is a sine quo non in sound medical and nursing practice, both for practical and legal reasons, but the practice of spending a lot of clinical time documenting realms of repetitious waffle in patient case notes, to satisfy the whims of some nursing administrator in relation to some abstract American nursing model is wasteful in the extreme and quite indefensible from either a professional or a scientific perspective.
The Minister for Health's spokesman said more than €700 million has been spent on the nursing degree project since the government decided in 2002 that nursing students in Ireland should be educated to degree level (HealthSupplement, July 31st).
He also suggested that €250 million has been invested in capital facilities, while revenue costs are running at €120 million.
Bearing those figures in mind, it is imperative the Minister and Department of Health should commission the forthcoming review, as justification for the spending of such a vast quantity of taxpayers' money must be made absolutely transparent.
The nursing unions - the INO and the PNA - have made the point in their recent submission under the benchmarking process, for salary increases of more than €6,000 annually, that nurses and midwives as professionals "deserve fair recognition for qualifications and work done".
The unions also emphasise that nurses are "therapeutic practitioners".
I, as an experienced former clinician and current teacher and university lecturer in nursing, have no dispute with the claim that nurses and midwives are highly professional and deserving of fair recognition for their qualification and work done.
I do, however, take issue with the PNA assertion relating to the concept of "therapeutic practitioners" for those who practise in the psychiatric services.
There are, of course, a number of highly skilled professional nurses in psychiatric practice who are very competent, distinguished and accomplished therapeutic practitioners. They are, however, in the minority.
The majority of clinical psychiatric nurses are practising at the staff nurse grade and are the product of the "old" apprenticeship training model, having acquired their certificate qualifications on completion of three years' training in a school of nursing attached to a traditional mental hospital.
In my experience, the majority of those people are good, decent and competent professionals but, as in every other profession, there are many who do not measure up.
The old apprenticeship model did not educate and train psychiatric nurses to be "therapeutic practitioners" - neither, alas, is the current university model achieving this goal. Thus, it is, I would argue, fundamentally flawed.
Present day psychiatric nurses continue to occupy a largely custodian role - essentially comprising security, prevention from self-harm and predominately task-centred activities such as administration of drugs, preparation for and assistance to doctors with ECT (electro-convulsive-therapy) and other forms of "therapy" used in the so-called medical model.
The education of nursing students, in our colleges and universities, in preparation for practice in psychiatry, remains grossly over-inflated with theory, to the sad and lamentable lack of any significant input on psychological skills development which, I believe, constitutes the essence of valid psychiatric nursing practice.
Without the planned and dedicated input and development of those critical skills, waffling about psychiatric nurses as "therapeutic practitioners" is about as far removed from reality as the human mind is capable of conjuring.
Certainly, as far as psychiatric nursing practice is concerned, the imminent Review Commission would be well advised to get its priorities right during its task in evaluating psychiatric nursing practice.
Patrick J O'Brien. M.Ed, (NUI) DIP Ed., (Leeds) DIP. N. (Lond), RNT, SRN, RMN., Lecturer Emeritus, in psychiatry and psychiatric nursing, Trinity College Dublin, He is also a visiting lecturer in psychiatry and psychiatric nursing, Dublin City University.