Setting the political agenda - Insights from cancer policy in Europe and the US
EONS Past-President Danny Kelly sets out the challenges facing health systems across Europe and looks at some possible solutions for overcoming them.
EONS Past-President Danny Kelly began his talk by setting out the challenges facing health systems across Europe. At present these include:
- rising demand
- cost control measures
- demographic changes
- workforce shortages
- increasingly sophisticated treatments
- rising public expectations
- huge differences in how cancer care is delivered; including the role & scope of nursing.
At the same time, politics is also having a large impact on the morale of nursing in different countries. Danny highlighted a few key issues of our time around pay and workload that were resulting in nurses taking strike action in Portugal and demonstrating in the UK; there is also the huge matter of Brexit to consider.
On top of these complex issues, across Europe there is huge variance in the incidence and treatment of cancer, and little recognition of the importance of specialist cancer nursing, borne out by the lack of detailed statistics in this area. This itself is a stark reflection of the lack of recognition of the important role of cancer nursing today, given that we:
- provide expert care, co-ordination, treatment and psychosocial interventions; beyond the biomedical.
- work within complex MDT models, promoting cultures of patient wellbeing & safety.
- work across hospital and community sectors at all phases of the cancer experience
- respond to new treatments with patient-centric models of care.
Moreover, there are concerning issues within the care setting. Danny took a hard and honest look at the cancer nursing situation as we currently find it. Patients, he argued, were not always having a good experience of nursing care, something indicated by feedback such as this from a breast cancer patient who sought a more personal connection: “Nurses were competent but disengaged. They never asked me how I was and sometimes barely spoke to me. There was no co-ordination, I did it all myself. It was not a good experience of nursing.”
Of course, this by no means represents the universal view, but we must acknowledge that it is a true reflection of the experience of many of our patients, because of the huge pressures on European cancer nurses.
So, what is at the bottom of these sorts of failings? Danny drew on his own deep experience of cancer nursing in the UK for some possible answers that are recognisable across the continent.
In the UK, there is a chronic shortage of nurses: OECD data shows that the UK, for example, trains many fewer nurses than comparable countries. In 2014, the UK had 29 nursing graduates per 100,000 population; the OECD average was 45 per 100,000. The US trained more than twice that of the UK (63), while Australia trained even more, at 76 per 100,000 population.
Pay and recognition: In the UK nurses pay has fallen behind by 14%, and there are issues around a registered and unregistered nursing workforce. This is not making nursing an attractive career choice to attract the brightest young people (76% of British public say nurses are paid too little).
Education and training There is variation in the scope and development of the cancer nursing role across Europe, with some education opportunities widely available in some countries but not in others.
New and more complex therapies, side-effects and treatment often happen at a distance from centres making follow up more of a challenge for patients living some distance form treatment centres (e.g. oral chemotherapy agents).
So, what do we find is the consequence of all this? The risk of cynicism, sadly:
- Nursing has been found to be one of the occupations that display the highest levels of cynicism (Leiter et al 2010).
- Nurses can feel frustrated, pessimistic, distrustful or even contemptuous towards their job and employers (Wanous 2000).
- Some researchers have suggested that this can include excessive and unrelenting job demands, lack of resources and low levels of trust in managers (Kim et al 2009).
From this we have to conclude that the reality of nursing today is very different from the idealised version – and what are the consequences on the ground, in the wards? A challenging situation where safety is often compromised.
Key theoretical positions to consider around how safety is threatened and undermined
- Failures of foresight: disasters preceded by long incubation periods typified by signals of potential danger being ignored or misinterpreted by organisations (Turner 1976).
- Normalisation of deviance: incremental process involving a gradual erosion of normal procedures and standards that would never be tolerated if proposed in one single, abrupt leap (Vaughan 1996).
- Deaf effect: When a decision maker doesn’t hear, ignores or overrules a report of bad news to continue a failing course of action (Jones & Kelly 2015)
Danny focussed on another challenging reality: absenteeism. Sickness absence costs around $27 billion in the UK and up to $25.8 billion in the US (Roelen et al., 2013). If not addressed, the deteriorating health of nurses and socio-economic problem for healthcare organisations will undoubtedly affect the overall quality of patient care (Gao et al., 2012).
The reality of absenteeism and other failings in the culture often results in what has been termed ‘care left undone’. When 12-hour shifts are more prevalent these are associated with more adverse events, poorer performance, poorer quality of care or higher risks to patient safety. Adverse events may include, for example, drug errors or ‘care left undone’ (Ball et al 2013). Less easy to measure is the impact on the caring attitudes and motivation of nurses.
To tackle these issues, we need awareness of workplace culture: how things work, what people do, what is permitted (good and bad) – Is innovation encouraged? What is the style of leadership? What role does nursing play here? How does it feel to be led by others, and what are we seeking in our nursing leaders?
Here, Danny presented an important if uncomfortable fact for consideration: If you always do what you’ve always done, you will always get what you’ve always got!
Hope for the future
Danny told the audience, EONS is taking major action to try and change some of this – most importantly through its RECaN project.
At its 2016 conference, the European CanCerOrganisation(ECCO) announced its intention to make the cancer nursing workforce the focus of its work across Europe:
“Specialised cancer nursing continues to be frustrated by a continuing lack of uniform regulation and recognition across Europe. Yet, despite this situation, cancer nursing provides an undeniable added value in terms of patient outcomes.”
ECCO position statement
Through the RECaN project, ECCO supports the following:
- Cancer nurses as core members of the multidisciplinary team.
- Cancer nursing should be a recognised speciality across Europe based on a mutually agreed educational curriculum.
- Education for specialist cancer nurses (across all tumour types and phases of care) should be made available.
- Enhanced free movement of cancer nurses across Europe should be promoted and facilitated to help address rising demand.
RECaN project – in stages:
- Systematic review led by members of the EONS Research Working Group.
- Data collection from leaders, cancer nurses and managers in four country on roles, working conditions, education, leadership, communication and safety by Annette Lankshear, Danny Kelly, Lena Sharp.
- Work with EU / national policy makers to explore & address issues raised; all EONS working groups, with a strong advocacy focus.
You can find out more about RECAN at http://www.cancernurse.eu/research/recan.html
Finally, Danny concluded his talk with the following key realities which we need to be aware of as we take cancer nursing forward:
- Nursing is a finite resource across Europe
- Working longer hours not necessarily a smart answer – well-rested, motivated, nurses work better!
- Safety is a key concern in oncology & in the workforce
- Complexity of cancer therapy is rising: education is central to effective care
- Understanding the scope and potential of cancer nursing across Europe is key: RECaN project
- Nursing is shaped by social expectations derived from historical, gendered and professional factors
- Nostalgic views of nursing present a simplistic view of the past, and belie today’s complexity
- The health workforce is now a global commodity that is mobile and is in demand
- Education, appropriate work environments, leadership and patient safety are topical, nurses are leading research agendas
- Leadership is key to achieving change.
The final point from this talk was that politics is personal as well as being about national or local issues. At this leadership summit, EONS emphasised that every nurse is a leader; to achieve this the political dimension of cancer nursing must be considered if we are to improve our working conditions, so as to to recruit and retain and motivate nurses. This, in turn, can only benefit patient care.
Daniel Kelly is Royal College of Nursing Chair at the School of Healthcare Sciences, Cardiff University, United Kingdom.