A qualitative study of health service reform on nurses' working lives: learning from the UK National Health Service (NHS).

摘要

BACKGROUND AND OBJECTIVES: The need for efficiency and cost effectiveness in healthcare is of international concern and has been an important influence to changes in nursing skill mix in Organisation for Economic Cooperation and Development countries. This article investigates the impact that the British Government's strategy designed to reform the NHS has had on nurses' day-to-day working lives. Nurses have been presented as key players in changing the culture of the NHS and the government has sought to provide them with greater empowerment primarily through skill mix changes. However, government policy may have resulted in greater productivity not greater empowerment for nurses who have often been required to compensate for loss of medical capacity as a consequence of the reductions in junior doctors' hours in line with the European Working Time Directive. Furthermore, what constitutes 'genuine' nursing has been difficult to define and 'caring' difficult to measure. Thus even without work intensification nurses may believe that health service reform has been disempowering by its focus on quantitative targets. METHODS: This article is based on data from interviews with nurses in three English hospitals providing acute care. It compares and contrasts the perceptions of ward sisters, specialist nurses and staff nurses. RESULTS: Uncertainty concerning what is the proper task of a nurse has been reinforced by skill mix changes which have resulted in staff nurses and ward sisters perceiving that they are 'losing nursing'. However, the article shows distinct intra-occupational outcomes. In particular specialist nurses believe that NHS reform has provided greater empowerment by increasing their authority in clinical decision-making. CONCLUSION: The findings suggest that the consequences of government strategy have been inconsistent for front-line staff often combining empowerment, disempowerment and work intensification. This article provides empirical evidence which contributes to a debate about whether and why 'caring' may have become a lost art in nursing. It also demonstrates the possible effects on nursing of using skill mix change as a method for gaining greater workforce efficiency and as a response to medical staff shortages.