Anne Marie Rafferty on the future of nursing

As part of the Green Templeton College 2021 Giving Day activities and Health and Care Studies Series, the college was both honoured and delighted to welcome Professor Dame Anne Marie Rafferty to speak on ‘Nerds and Nightingales: The future of nursing’. Dame Anne Marie is Professor of Nursing Policy at King’s College London, President of the Royal College of Nursing and an alumna of then-Green College. She shared her insights and wealth of experience on the challenges, opportunities and strengths of the nursing and midwifery profession at a lecture on Tuesday 1 June introduced by Principal Sir Michael Dixon and chaired by Honorary Fellow Dr Paul Brankin.

Lisha Jeena, a medical doctor from South Africa currently reading for an MSc International Health and Tropical Medicine at Green Templeton reports:

At the onset of her presentation, the humility and grace with which the speaker has carried herself throughout her inspiring career, was evident as she acknowledged her supervisors and community of support. Dame Anne Marie’s carefully and artistically crafted presentation draws inspiration from the work of Florence Nightingale, famously known as ‘the Lady with the Lamp.’ Dame Anne Marie explored the legacy of Nightingale and the relevance of this legacy today; discussing the important role nurses play in supporting health and government systems; and outlining interventions to positively support the nursing profession both during and after the COVID-19 pandemic.

The enduring legacy of Nightingale

Dame Anne Marie described the life and work of Florence Nightingale, capturing how she was indeed a woman beyond her time. Not only was Nightingale a compassionate nurse, but also an English social reformer, researcher, statistician, author and innovator. Nightingale came to prominence while serving as a manager and trainer of nurses during the Crimean War where she cared for wounded soldiers. Witnessing the poor care and conditions in which care was being delivered, Nightingale advocated for improved healthcare facilities. She collected evidence to support her theories of the importance of hygiene, sewage systems and adequate ventilation to improved patient outcomes. Her famous Coxcomb diagram, also known as the Nightingale rose diagram, illustrated the causes of patient mortality in the military field hospital that she managed. At the time, this was both novel and hugely influential in her advocacy for infection prevention. Dame Anne Marie pointed out that not only was Nightingale inspired by and inspiring to statisticians such as Adolphe Quetelet, but also generations in health academia centuries after her lifetime. Her work remains relevant to current nursing practices and shows the important role nurses can play in contributing to research.

Nightingale was instrumental in founding a professional nursing school at St Thomas’ Hospital in London as well as in the hospital’s floor design – raising issues of patient flow, ventilation, spacing between beds, and overall facility aesthetic to promote psychological well-being. During the COVID19 pandemic, the NHS set up field hospitals across the UK to alleviate the burden on pre-existing healthcare facilities, one of which bears the name ‘Nightingale hospital’. As Dame Anne Marie pointed out, this serves as a reminder of the care and concern Nightingale herself had for hospital design, patient movement and infection prevention measures which are critical to COVID-19 control. Dame Anne Marie drew from Nightingales’ inspiration in advocating for nurses to be embedded within governance and leadership functions in order to exercise their expertise and knowledge and thus further contribute to improved patient outcomes.

Dame Anne Marie also referenced Nightingale’s most famous book Notes on Nursing, published in 1895, which provides simple remedies and advice for at-home care. Dame Anne Marie appraised Nightingale’s insights, noting their applicability to both community- and home-based nursing care structures. Strengthening community-based nursing has been a key lesson of the COVID-19 pandemic – to reduce the pressure on the healthcare system while upholding quality care provision.

Nurses supporting health systems

Dame Anne Marie referenced the United States Bureau of Labor Statistics, which lists healthcare, technology and clean energy as three key contributors to a country’s growth. Nursing, Dame Anne Marie argued, can be found at the heart of all these areas. Healthcare, most intuitively, as guided by the Nightingale Pledge, is an intrinsic pillar of the profession. Accelerated by the COVID-19 pandemic, technological advances that promote remote-based care and tele-consultation are largely managed and/or coordinated by nurses. Even sustainability is a necessary consideration within the profession when thinking about waste disposal of medical equipment such as latex gloves. Dame Anne Marie shared these examples to highlight the multidisciplinary contribution of the nursing profession.

The World Health Organization released its inaugural World Nursing Report in 2020. It is the first time that data from 193 nations has been brought together in one document to describe and better understand the strengths and challenges in the nursing workforce. Despite there being approximately 19 million nurses worldwide, there is still an estimated shortage of 6 million nurses. As Dame Anne Marie illuminated, it is not only the number of nurses, but the level of education of nurses that will be critical to managing the increasing number and complexity of people with multimorbidity who fall ill. Dame Anne Marie furthered these arguments with evidence from her own research, which found that deaths are significantly lower in hospitals with more bachelor’s degree-educated nurses. She stated that up to 3,500 deaths per year might be averted if at least 60% of nurses within the nine hospitals studied had a bachelor’s degree or higher, and if the nurse to patient ratio was no more than 1:6. Dame Anne Marie said that higher educated nurses have more confidence and critical thinking skills, which better prepares them for the quick decision-making necessary to handle challenging patient care situations.

Allowing and enabling nurses to create and challenge the narrative of their profession is fundamental to improving working conditions for nurses and thus patient outcomes. Echoing the sentiments of the World Health Assembly and World Health Organization, Dame Anne Marie stated that nurses are crucial for resilience in the healthcare setting and that it is essential to create a space for their voices to be heard.

Interventions to positively support the nursing profession

Dame Anne Marie presented five elements she believes if aligned and enabled to work together will best ensure a sustainable nursing workforce, particularly during and beyond the COVID-19 pandemic.

First, to ensure that nurses are adequately compensated for their work and level of experience or expertise. There is an increasing movement for fair treatment of nurses as seen with the protests in Northern Ireland in 2019 where better pay and working conditions were demanded. Medical doctors, ancillary healthcare providers as well as the public are increasingly supportive of this plight, acknowledging the key role nurses play within a health system.

Second, to ensure careful workforce planning. While the UK’s target of an additional 50 000 nurses is aspirational, Dame Anne Marie argued that this should be refined to also understand where the shortages are and what level of skill of nurse/s is required at the facilities.

Third, continued professional development. Without structures and opportunities for training, a vast majority of nurses remain within the bottom bandings of the pay-grade, making it challenging to incentivise and retain nurses into and within the profession.

Fourth, to encourage and invest in leadership development and nurses being employed in managerial roles. It is not enough for nurses to be vehicles of health innovations, but should rather be part of the conceptualisation and design process.

And fifth, to support legislative reforms that ensure a safe working environment both in the patient to nurse ratio, and in mechanisms that support nurses’ overall mental and physical well-being.

In her concluding remarks, Dame Anne Marie reflected on the future of nursing with optimism. Through learning from past icons like Florence Nightingale, reflecting upon the strengths and challenges of the COVID-19 pandemic, and building skilled capacity within the nursing workforce, a sustainable future for health and nursing is possible but the political will needs to be there to make it happen. This is a political choice and building the will is crucial in the months moving forward.

Created: 10 June 2021