Episode 8 - How to Make the Nursing Profession Disappear


Published: 28 August 2016

Welcome to episode eight of the new Ausmed Handover podcast: How to Make the Nursing Profession Disappear

Welcome to episode eight of the Ausmed Handover podcast. In this episode I’ll be examining how a simple and seemingly innocent trend in healthcare management actually threatens the continued existence of the nursing profession.




Hello and welcome to the Ausmed Handover podcast, my name is Darren Wake, and in this episode, I’m going to tell you how to make the profession of nursing disappear forever. Oh, and it’s already happening.


“We need to cut back to the essentials, Johnson. We really need to improve healthcare by getting rid of the superfluous like…”

“Free newspapers?”

“Yes, free newspapers…”


“Free parking?”

“Yes, free parking, we’ll put meters in.”


“Coffee, tea and biscuits”

“Yep, they can go.”


“Hot breakfasts”

“Yes, cornflakes will do.”


“What else Johnson?”



“Excellent: Nurses”



That’s funny isn’t it. Well, I thought so, but what’s really scary to me is that’s pretty much taken verbatim from a senior healthcare management meeting I went to about ten years ago in a country that shall not be named, and a city that will forever be anonymous.

During this meeting, which was attended by a whole swathe of high level healthcare managers, nurses, doctors, financial managers and a lot of CEO’s, someone actually delivered a hypothetical that may as well have been called “how to get rid of nurses”, which essentially laid out a fictitious process to narrow and reduce, but not entirely eliminate, the presence of registered nurses in their particular healthcare facility.

Now, there was no suggestion at the time that there was a concrete plan to get this underway: it would have been industrial suicide to enact what the presenter was suggesting: it was more of an intellectual cum financial thought experiment on reducing costs by reallocating human resources, but what has interested me over the ensuing years since that workshop, is that many of the core aspects of the proposal seem to have been very subtly creeping into the healthcare services on a global scale.

Now, I’m not a conspiracy theorist, and I’m not saying that there’s an agenda out there to extinguish the nursing profession, but what I am definitely saying is that there is an active global agenda to rationalise healthcare, and changing the role nurses have to play within healthcare facilities is very much on the cards.

Again, this isn’t a conspiracy I’m talking about. Actually having an overt agenda to remove nurses from the healthcare system would be akin to pulling the pin out of a hand grenade to see what happens.

There’s no illuminati-like elite out there that has designs on the position nurse’s hold in the healthcare system, but rather it’s a kind of unconscious management global zeitgeist: a very large bunch of healthcare managers and bean counters are acting independently and very probably unknowingly to collectively threaten the identity and consequently the existence of the nursing profession.

It’s kind of like a thousand children all playing in the same yard independently and unaware of each other. Each one taking just a single brick from the foundation of a very large house, and each thinking: one brick, what would that matter to anyone else, or to the house itself for that matter; aren’t there are thousands of bricks in the foundations?

But brick by brick things are changing, and probably not in the best interests of the building, if you get what I mean.

But, let’s get back to the root causes before we discuss how this is happening. The first question we should ask is why. What reason would the senior movers and shakers of the healthcare systems have to degrade the contribution that nurses make to the healthcare service?

BRIDGE (00:10)

It’s money. It all revolves around cash, budgets and profits. And as we shall see, it’s about power.

Nurses are a highly trained commodity and as such are expensive, whether you think you are well paid or not, with on-costs such as insurances, leave replacement and shift loading, the average full time shift working nurse in Australia costs their employer over $100 000 a year. Now, that’s a million dollars for every 10 FTE, and if your ward employs 30 FTE nurses, that’s 3 million dollars a year spent on wages: that’s bound to be a tempting target for any cash-conscious financial operating officer.

These days, economic rationalization is the catch phrase and driving agenda for many healthcare facilities and institutions, and once they have looked to save money by changing the brand of toilet paper they buy, any employer will, sooner or later, ask themselves whether they can deliver the same standard of care in their facility without using so many nurses.

But that’s not so easy to do: it tends to upset the unions and it’s dreadful for public relations: nurses have a very strong emotional and ethical relationship with their public and you can’t easily remove nurses from healthcare because of this. Polls in a number of countries have shown repeatedly that the public regards nursing as the ethical nexus of the healthcare system: far more trustworthy than doctors or anyone else, for that matter, so no matter what form rationalization takes, nurses have to remain: the public would not tolerate otherwise.

But from a managerial perspective, although they have to remain as part of the service, there is certainly an opportunity to reduce their number, and consequently their power within the service.

So, if you were a healthcare manager and wanted to reduce the expense of your nurse’s wages and reduce their power base, how would you go about it without upsetting anyone?
Well, there is a subtle and very effective methodology you can employ, and it involves the following elements:

Deconstructing the role of the nurse.

Emphasising skills, but in a very narrow range.

Change the meaning of roles within the service.


Outsourcing or re-distributing responsibilities to cheaper human resources.

Let’s look at each of these in turn, and see how they affect our profession.

Deconstructing the role of the nurse.

This involves breaking down the role of the nurse into its constituent parts. Generally, the more specialised the area within which nurses work, the easier this is to do, but essentially, we simply list all the things that nurses ‘do’ as part of their daily job, and separate them into their component parts. So patient care can (at a very basic level, be kind to me) be divided into hygiene, mobility and eating.

Then, once we have that list, we can split off all the aspects of the role that, once separated from the whole, can be performed by lesser qualified, or equally qualified but cheaper, or unqualified staff, and we put these aside.

Essentially, we remove these jobs from the scope of the nurse, and from their job description. We aren’t concerned about combined tasks or holism (like assessing a patient’s skin during a bed bath): just separating the parts from the whole.

Emphasising skills, but in a very narrow range.

In step number two, we take those aspects of the nurse’s role that remain, and we enrich, build on and focus these aspects.

By that, I mean we, as managers, actually emphasise the importance and value of the depth of knowledge and expertise that is commonly held by nurses. In this respect, we focus on those core areas of competency that are associated with the initial training that every nurse undergoes, that is unique to the profession.

This most commonly is viewed by managers as the roles of assessment, planning, and to a greater or lesser degree, medication administration. So we would really emphasise these skills and talk a lot about elevating the nurse into ‘specialist roles’ that exemplify these skills in practice. We may even reward people who have this advanced level of expertise by, paradoxically, giving them more pay. And since we have liberated them of many of their lesser tasks, we really don’t need as many on the floor.

Changing the meaning of roles within the service.

Now in part 3 of this process, we work some semantic magic.

We take all those aspects of the nurse’s role that we have split off that, independently, don’t require formal registration, or even training of any depth, and we cobble them together to create new jobs.

Since the core elements that only a nurse is legislated to do are absent, we don’t use the word ‘nurse’ to describe any of these new roles. If we did, we would imply that the role falls into the realm of nursing, that nursing had a claim on it, and so can only be done by a nurse. And we don’t want that: we want something less qualified, because that means cheaper.

What we are doing here is changing the power base and identity of nurses. Once, we might have employed nurses in broad reaching healthcare roles, where we could take advantage of their knowledge of patient care, nursing staff, logistics and so on, and they did things like manage human resources for a clinical area: we’re talking about nurse unit managers, directors of nursing, and so forth.

But now, we’ve created a situation where there’s no specific requirement in the job description for many of these positions for the incumbent to be a nurse, and no mention of nurse in the title.

Rather, we carefully craft job titles that specifically describe some the role without any implication that a certain profession or having a certain qualification is a prerequisite to filling the role. We want the job title to be as generic as possible.

We call these roles things like personal hygiene assistants, aged care facilitator, wound technician, pulmonary technician, continence champion, medication dispenser and so forth.

But in the meantime, we emphasise the value of nursing expertise, albeit now in a very narrow, highly qualified range, stripped of all it’s less technical aspects, and many of its emotional aspects, even though nurses have, over perhaps the last millennium, worked out ways to efficiently incorporate these seemingly lesser tasks into their everyday practice in a way that is very much to the patient’s benefit.

So, what we have done, is take the nurse’s role, stripped it down to the bare, but very specifically qualified bones, and repackaged what we stripped away into generic roles that make no mention of nursing, and carefully avoided incorporating any element in the job description that might require some person who is formally registered.

And we’ve changed the name of a whole bunch of jobs that were once done by nurses.

In one fell swoop, by deconstructing the role of the nurse and outsourcing the component parts of their job, we’ve reduced their power base and influence on the healthcare system, and created a specialist role that although it retains the name of a nurse, really no longer fulfils that broad clinical role that it once did.

Outsourcing or re-distributing responsibilities to cheaper human resources.

And now, we can move on to step four, which is to distribute these newly created, generic jobs to non-qualified, or cheaper or less qualified staff.

Now, let’s not forget about our nurses. We’ve focussed on their core competencies, at least the ones that we have to acknowledge, and promoted them: our nurses now perform highly specialised, expert roles, but, since about 50% of their former job is now performed by non-nurses, we simply don’t need to hire as many.

Seemingly, a fiscal job well done.

Imagine walking into a ward where the personal care and observations are performed by personal care assistants, wounds are tended by the wound care tech, discharge planning is done by a home care facilitator, and there, in their office is the one nurse rostered on for the shift who acts in a kind of consultative role.

Nurses are still part of the health system, so the public is satisfied, their role is very much visible, but their involvement in patient care is significantly diminished.

I mentioned I wasn’t a conspiracy theorist, that there was no grand master orchestrating the demise of the nurse’s role, but what I have described here in this episode has happened in the past, and is happening everywhere as we speak, in management, in clinical environments, in education.

In 1988 in Perth, Western Australia nurses negotiated the introduction of a new EBA based on the primary nursing system. The management of several hospitals agreed to this move, but since it was a radical departure from the existing nursing model of care, insisted that all nursing management positions be rewritten, the incumbents spilled, and the jobs opened to all applicants.

It was assumed that the incumbents would be walk-ins to their old jobs, but management had rather sneakily removed all use of the word ‘nurse’ from the job descriptions, and subtly removed the requirement that any applicants be registered with the nursing board of Western Australia.

They had deconstructed the role to its bare human resource and financial elements.

Given this, the job descriptions completely suited a whole range of applicants, especially those with business experience and never you mind if you understand your nursing staff and skill mix, or what kind of disposables need to be ordered on the ward if there is a hospital wide gastro outbreak, if you had experience with budgets and drawing up a roster: you were completive in the recruitment process.

The fact that you were qualified as a nurse didn’t even come into it.

Consequently, a lot of wards found themselves being managed by people who had no experience I healthcare or any knowledge at all of patient needs, but could do fantastic activity reports, or being managed by accountants who could do beautiful budgets and order stationary efficiently.

It was disaster, and thankfully, over a long time, many of these hospitals saw sense. But those days were better funded than now, and it’s on the horizon again: offer nurses a highly specialised place in the healthcare system, but reduce their power base and numbers.

I’ve also worked in a hospital, on a high dependency unit in the United Kingdom, where the patients were looked after by six unqualified carers, and one registered nurse. The carers all used colour coded obs charts, and if the patient’s blood pressure deviated above or below certain coloured lines, for example, they asked the nurse to review the patient. No clinical reasoning whatsoever. But where there were once six nurses, there were six much cheaper carers, and one highly specialised RN.

No offence to our brethren in theatres, but the introduction of operating department personnel is the perfect example of what I have discussed today: taking the work nurse out of a job title, and filling the role with a cheaper, or less industrially powerful option.

And of course the perfect example these days is aged care. It’s not uncommon now to work in large aged care establishments where there is just a single registered nurse employed: working Monday to Friday day shifts in a role called something like aged care nurse consultant, or nurse manager. The rest of the roles are usually filled by far less qualified or even unqualified staff undertaking jobs that were once part of the nurses role, and are making decisions about wound care, mobility and incontinence, and deferring only to the nurse if they feel they need to.

And before you put up your hand to mention safe staffing levels, please remember that the core reference model for all safe staffing guidelines comes from the legislated Californian model, which indeed states that a certain number of staff should be present on any ward to prevent adverse events, but it doesn’t really state that those staff should be nurses.

This is happening now.

BRIDGE (00:10)

What I’ve been talking about today is something the philosopher Michael Foucault would call cultural imperialism. The need for nurses in the healthcare system is being changed for the worse by something as simple as changing a job title: if it doesn’t say “nurse”, does it have to be a nurse? Change a job title, you change identity, change identity and you change the role of the incumbent. Change the role and every opportunity is there to reduce the influence of a group of people on a given context.

Do it smartly, and you can extinguish that identity entirely.

Yet nursing has a distinct identity that encompasses a broad range of duties, some of which to the layperson seem trivial, but they always inform the nurse in terms of designing a more complex plan of care for the patient, and putting it into practice.

That’s something we’ve refined over several hundred years, and we perform a role the public regards as essential.

But not in a token form. It would not be good to reach a position where a medical ward has one single token nurse on to oversee the shift.

Nurses need to get territorial: fractured care is cheap, but it doesn’t do those we are mandated to care for any good at all.

This is the Ausmed Handover podcast, my name is Darren Wake, and thank you for listening.

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