Nursing Inquiry 2015; 22(1): 74–83
Feature
Shaping the future of nursing: developing an appraisal framework for public engagement with nursing policy reports Ann Bradshaw Faculty of Health and Life Sciences, Oxford Brookes University, Marston, Oxford, UK Accepted for publication 10 May 2014 DOI: 10.1111/nin.12072
BRADSHAW A. Nursing Inquiry 2015; 22: 74–83 Shaping the future of nursing: developing an appraisal framework for public engagement with nursing policy reports It is accepted that research should be systematically examined to judge its trustworthiness and value in a particular context. No such appraisal is required of reports published by organizations that have possibly even greater influence on policy that affects the public. This paper explores a philosophical framework for appraising reports. It gives the reasons why informed engagement is important, drawing on Popper’s concept of the open society, and it suggests a method for appraisal. Gadamer’s concept of the two horizons and Jauss’s reception theory offer a methodological framework to enable the individual citizen, whether professional or lay, to engage in debate about policy that affects him or her. By way of a worked example, the framework is applied to two international reports on nursing. Conclusions suggest that nursing policy should be subjected to robust interrogatory appraisal by both profession and public for a democratic debate and creative discourse. Although this analysis is related to international nursing policy, it has a wider relevance and application beyond nursing. Key words: appraisal, Gadamer, Jauss, nursing, policy, Popper, reports. Nursing world-wide accepts that research must be critically scrutinized if it is to form a valid and reliable basis for patient care (Mitchell 2004). The Cochrane Collaboration (2013) states that independent, authoritative and reliable information is vital for informed choice in health-care. The Critical Appraisal Skills Programme (2013) argues that the process of carefully and systematically examining research to judge its trustworthiness, value and relevance in a particular context is crucial for the same reason. This paper suggests that reports which determine nursing policy should be subjected to a similar analysis not only by the profession but also by the public, upon whom nursing policy impacts, to engage in informed debate and make choices. The paradigm of Popper (1945) is argued to
Correspondence: Ann Bradshaw, Senior Lecturer in Adult Nursing, Faculty of Health and Life Sciences, Oxford Brookes University, Jack Straw’s Lane, Marston, Oxford, OX3 0FL, UK. E-mail:
support this requirement. The objective of this analysis is to highlight how the readership of nursing reports can receive, read, engage and participate in policy formation and debate, given the powerful leverage of reports in policy change. While policy appraisal frameworks for public policy assessment are numerous (Nilsson et al. 2008), it seems that there is a paucity of appraisal frameworks for critically appraising policy reports. This paper will draw on the methodology of reception theory, as proposed by Continental philosophers, Jauss (1982), developed from Gadamer (1975), to suggest questions that may help the reader, whether professional or lay, appraise individual reports.
THE CONTEXT AND STRUCTURE OF THIS PAPER This paper has developed from the author’s academic interest in changes to UK nursing, in which highly influential UK © 2014 John Wiley & Sons Ltd
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nursing reports 1972–2014 were found not to have been subjected to public scrutiny and debate. This has led the author to a broader analysis, and to consider whether philosophical and ethical arguments require public scrutiny of reports that shape policy, and if so, how this can be achieved. This analysis is in three sections. In the first section, the paper illustrates the significance of reports by describing an historical example of their use to effect UK nursing change, 1972–2014. In the second section, the paper examines the philosophical argument for the need to open reports to public scrutiny and debate, and proposes an appraisal framework, developed from underlying theory. In the third section, the framework is applied to two current major nursing reports, from the European Union and the United States, to demonstrate international applicability and relevance.
1. AN HISTORICAL EXAMPLE FROM THE UK: THE USE OF REPORTS TO CHANGE NURSING Reports have shaped UK National Health Service nursing policy (Rafferty 1996). In 1972, the government’s Report of the Committee on Nursing [Briggs Report] (1972), recommended major educational and organizational change. The Briggs Committee did not consult the general public. Instead, it assumed prior knowledge of public opinion, stating without any supporting data, that the public held an inherited, romanticized image of the nurse, with which it disagreed. The only data the committee gathered on nurses’ attitudes showed clearly that nurses themselves did not want educational and organizational change (Morton-Williams and Berthoud 1971a,b). But these detailed two volumes of data were disregarded by the report’s recommendations. The Briggs Report (1972) led to the 1979 Nurses, Midwives and Health Visitors Act. The Royal College of Nursing (RCN), the UK professional body and also its main Trade Union, set up a commission on nurse education, The Education of Nurses: A New Dispensation (Judge Report) (RCN 1985) chaired by an educationist who was not a nurse. This report acknowledged in its introduction that the British public would want to retain the current system of nurse training, and would not want change, but rejected this lay opinion: One initial difficulty must be openly acknowledged. The layman will need to be convinced that anything very much is wrong. He is likely to believe that the nurse in our society may indeed be undervalued and under rewarded, but not that she is irresponsible or ill-prepared. His experience suggests that the public has confidence in the quality of practical nursing, and prompts the question “if the system
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of training is wrong, why are the products so good?” He will, moreover, be disposed, in a spirit of traditional Anglo-Saxon pragmatism, to favour a system which embeds tradition on practice and eschews fancy notions of theories of “Education”. He will be sceptical of any attempts to move the training of nurses from its present base. He will, if pressed, want his bedside nurse to be trained and practical rather than educated and questioning. He will certainly not wish to be cared for after an operation by an amateur psychologist or (still worse) sociologist. Told that nurses learn their craft by being engaged from the beginning in the delivery of care, he will grunt his heartfelt approval. (Royal College of Nursing 1985, 7)
And a third report set up by the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC), headed by a sociologist who was not a nurse, also proposed radical changes to nurse education in a report entitled Project 2000 (UKCC for Nursing, Midwifery and Health Visiting 1986). This report to make nurse training more academic, also ignored the public and grass roots nursing view. It was accepted by government, but with provisos (Moore 1988). In 1998, the government commissioned a review of these policy development (JM Consulting Ltd 1998a,b). This review found notable weaknesses in the new system. These included the relative lack of attention given to professional attitudes and standards in education programmes and the still imperfect integration of theory and practice education, and the feeling by many observers that practice education was given a lower priority than intended. The government (Dobson 1999) recommended that nurse education be reviewed. Despite political agreement (Bottomley 1998; Keen 1999), this review did not happen. Ten years later, the Prime Minister’s Commission on the Future of Nursing and Midwifery in England’s (2010) advocated a move to an allgraduate nursing profession, which was accepted as the future preparation for nurses by the Nursing and Midwifery Council (NMC) (NMC 2010). The public view was ignored by Briggs (1972), Judge (1985), Project 2000 (1986), The Prime Minister’s Commission (2010) and the NMC (2010). The public was not considered to be the audience and hence receiver for these reports from the UK nursing profession, even though ordinary people were directly affected. Public opinion was well known, as the Judge Report (1985) shows, but deliberately disregarded. Yet public opinion, often unsolicited, was expressed with regard to patients’ experiences of nursing care. This was given in regular reports about poor patient care published regularly in the following decades (Meredith and Wood 1997; Age Concern 1999; Help the Aged 1999a,b,c; Health Service Commissioner 1995, 1997, 1998). These concerns became a political
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focus (Alberti 2009; Thome 2009; Mid Staffordshire NHS Foundation Trust Inquiry 2010; Parliamentary and Health Service Ombudsman 2011; Care Quality Commission 2011; CHRE 2012; Patients Association 2012). This culminated in the Mid Staffordshire NHS Foundation Trust Public Inquiry (2013) (Francis Inquiry) which provided detailed evidence of a loss of UK nursing compassion and competence. The RCN published a preemptive report in response to the Francis Inquiry (RCN 2012) (Willis Commission), which was defensive and discounted public opinion. The heads of UK university nursing departments stated that the poor image of nursing in the UK, compared with other countries, was a perception held by the public that needed countering, so set up a commission (Dean 2014). But the director of an independent healthcare research unit came to a different conclusion (Jarman 2013). He stated that there had been a decade of concerns about the quality of care in UK hospitals; patients had been ignored, the regulatory systems had failed and there had been a culture of denial. This example from the UK shows the fundamental influence of reports on the direction of UK nursing 1972–2014, that was without public scrutiny, debate or indeed, evidence of improved patient care. Moreover, reports seem to have been used by the profession to obscure the public view, as opposed to being open to it. This UK example is relevant internationally. Popper (1947) argues that in an open society ideas and proposals should be critically scrutinized and tested by rational argument by all those who have a stake in it. This includes not only grass roots nurses and other healthcare workers, but also, importantly, the lay person who is affected by the nursing profession, both by funding it and receiving its services. This paper sets out to give the reasons why informed engagement and participation is important, and to suggest a method for engagement.
2. WHY INFORMED PARTICIPATION IN POLICY IS IMPORTANT INTERNATIONALLY IN NURSING AND BEYOND NURSING In science, progress is made by subjecting theories to critical scrutiny and abandoning those which have been falsified. Popper (1945) argues that critical scrutiny should occur at the social level in the same way that it does in science. Popper holds that the open society can only be brought about if the individual citizen evaluates critically the consequences of the implementation of government policies. These can then be abandoned or modified in the light of this critical scrutiny. In such a society, the rights of the individual to criticize
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administrative policies should be formally safeguarded. Undesirable policies would be eliminated in similar ways to falsified scientific theories. Differences between people on social policy will be resolved by critical discussion and argument. Popper’s conception of the open society may be defined as ‘an association of free individuals respecting each other’s rights within the framework of mutual protection supplied by the state, and achieving, through the making of responsible, rational decisions, a growing measure of humane and enlightened life’ (Levinson 1957, 17; Thornton 2013). As Popper (1945, 224–5) argues, an open liberal society means that ideas need to be openly and transparently tested, subjected to rational argument and analysis. Rationalism includes empirical testing and evidence – not just intellectualism. Policies that affect the community need debate, argument and free criticism. This should not need special education or training, but should be openly accessible to each affected person. This cannot be done in isolation. It can only be done by the community, by those who have a stake in it, through informed and reasoned argument. To make this point, Popper gives the example of Robinson Crusoe alone on his island. On his own, he cannot create language, nor argument and reason. He needs human society. This is the audience which tests ideas that influence policies that shape society. In relation to nursing policy, this means that all those affected by nursing policies – whether professional or lay – have a responsibility to engage in debate about policies.
A Method to Enhance and Widen Engagement: An Appraisal Framework for Reports Hans Robert Jauss (1921–97) is the founder of modern reception theory. Jauss supports Popper’s position on the open society. He holds that interpretation of texts involves new ways of seeing, a paradigm shift, in which genuinely creative discourse emerges not at moments of normal routine, but at moments of crisis. The context is both historical, in relation to particular times, and social, in relation to specific groups of people (Thiselton 2012, 290). Jauss’s vision was for interdisciplinary research, and he sought the ‘still-unfinished meaning’ in texts. Jauss draws on Gadamer (1975) to focus on the historical influence of a text (Thiselton 2012, 290). As Gadamer taught, all arguments are influenced by the tradition in which one stands. The past horizon is embraced within the horizon of the present, and understanding is always the process of the fusion of past and present horizons. Jauss
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develops this idea of reciprocity. In the interpretation of texts the reader brings his or her own subjectivity, but also the texts influence the reader’s subjectivity. Successive generations of readers influence the understanding of texts. Jauss draws on Marxist theories of interpretation and on formalism, but goes beyond both. Marxism stresses the socially formative power of literature, and Jauss endorses this. Texts shape readers and their expectations. He draws on formalism for such devices as ‘defamiliarisation’, which is a disruptive device to make strange what is otherwise familiar. Jauss rejects the complacent assumption in formalism that texts are autonomous. The process of communication involves readers. The reader completes the meaning of the text. This means that a ‘text’ is not simply passively accepted by the reader, but the reader interprets the meanings of the text based on his or her individual cultural background and life experiences. In essence, the meaning of a text is not inherent within the text itself, but is created within the relationship between the text and the reader. An acceptance of the meaning of a specific text tends to occur when a group of readers have a shared cultural background and interpret the text in similar ways. It follows that if two readers have very different personal and cultural experiences, their reading of a text will vary greatly. Because Jauss’s reception theory has its origins in interdisciplinary research, it is relevant to nursing. This is the view of Mitchell (2004), a Canadian nursing scholar. She is interested in applying reception theory as a framework for human becoming. According to Mitchell (2004, 107), crucial to understanding reception theory is the term ‘horizon of expectation’. This is used to denote the criteria that readers use to judge literature. It represents the common assumptions attributed to a group or community who share some meaningful history and beliefs. Jauss (1982, 13) referred to the ‘transsubjective horizon of understanding’. The full impact of a text can only be known from some perspective or horizon of shared expectation. Horizons of expectation change over time as each age of scholars interprets works in the light of its knowledge and experience. ‘Specifically the researcher/artist sketches the horizon in the nursing perspective, and the critic who shares the codes and conventions makes a judgment as to how well the horizon was described. It is the horizon of expectation that sets the stage for illuminating the artistic disclosure’ (Mitchell 2004, 7).
Developing the Appraisal Framework Jauss’s reception theory may be drawn on by the reader to appraise texts, and in this case, policy reports. A useful © 2014 John Wiley & Sons Ltd
framework that may help the reader, in Mitchell’s (2004, 7) words, bring to debate his or her own ‘horizon of expectation’, may be adapted from the work of Thiselton (2012). He draws on reception theory as a hermeneutical framework by developing seven points: Jauss (1) dismisses value-neutral objectivism; (2) stresses the reader’s horizon of expectation; (3) sees that this horizon changes and expands with formative effect; (4) stresses the value of question and answer, and appropriation, in actualising potential new horizons; (5) acknowledges the relation between interpretation and the readers’ pre-understandings; (6) takes account of the diachronic or historical and synchronic or contemporary meaning; and (7) re-emphasises formative function of texts and works, and their creative effects on life. Importantly, Jauss argues that question and answer can provide access to the text. And Thiselton’s framework can be developed in the form of interrogatory questions to help the reader see in new ways to access the reports. Although this can obviously apply to any reports on any topic, the following will be applied to the author’s field of nursing: What value judgments and preconceptions about nursing are held by the writers of the report? Is this report accessible to the lay person as general reader? Does the report consider the perceptions of nursing held by the audience, including lay and/or grass roots professional? Does the report aim to change readers’ perceptions of nursing? Is reliable data used in the report? Are historical and current understandings of the nursing role considered? How does this report intend to shape nursing policy? If this framework were applied to reports significant for nursing, then the reader of the policy report – any citizen affected, professional or lay – should be able to bring their individual horizon of expectation to engage in debate, as Popper (1945) considers vital for an open society. And, according to Popper, this debate should be accessible to the general reader, without specialist education or training.
3. WORKED INTERNATIONAL EXAMPLES OF THE FRAMEWORK’S APPLICATION Two major international nursing reports will be examined using this framework. The first is a European
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Union report (2012) which suggests care is in crisis. The second is a North American report on nurse staffing. (2013). What value judgments and preconceptions about nursing are held by the writers of the report?
Is this report accessible to the lay person as general reader?
Does the report consider the perceptions of nursing held by the audience, including lay and/or grass roots professional?
Does the report aim to change readers’ perceptions of nursing? Is reliable data used in the report?
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1 European Federation of Nurses Associations (2012) Caring in Crisis: The Impact of the Financial Crisis on Nurses and Nursing Brussels: Author.
The report from the European Federation of Nurses Associations (European Federation of Nurses Associations 2012) focuses on the effects of the 2008 global financial crisis on European nursing. It believes the effects are obvious: reduction of nursing posts across Europe; pay cuts and freezes, diminished recruitment and retention rates, compromises in quality care and safety; downgrading of nursing and substitution of nurses with untrained assistants. It is written for governments in the European Union, claiming that the 34 National Nurses associations are representative on the nursing profession throughout Europe. It states the intention that the report should be used as a tool and campaigning document to governments. Its key messages are simple political slogans: Remind – Health and productivity go hand in hand. Suggest – protecting health of citizens will boost the economy and provide the means out of recession. Warn – unless action is taken thousands of women will be excluded from the labour market. Urge – protect nurses, protect women, protect health. It is published online, so accessible by the general reader, but it is not intended for the general reader, so gives no general background or context to enable the lay reader engage in debate. The report does not consider audience perception, either lay or grass roots professional. Each country’s association has a page to describe the impact of the financial crisis on its nursing workforce. It would seem that the professional perception of nursing varies between and within countries. The UK profession, for example, as indicated by the Willis Commission (2012) holds a rather unclear view of the nurse’s role, advocating advanced and specialist roles, the nurse as an organiser and leader of care. The professional body accepts that much direct, fundamental care will be given by unqualified healthcare assistants. In contrast, the lay person from the UK expects the nurse to be the giver of fundamental care. This is indicated by the Francis Inquiry (2013), and Patients Association (2013). The title and executive summary of the report are intended to inform readers of a crisis in EU nursing. The report was gathered from input of members at a round table discussion at EFN General assemblies in 2009, 2010 and 2011. Their names and the countries they represent are listed. Each country’s contribution to the body of the report is about a page, but some countries contribute only one or two paragraphs (for example, France, Germany and Luxembourg). Statistics are given in some contributions, but the reliability of these statistics is not demonstrated. France and Germany give no statistics at all. Individual contributions often do not reflect the underlying assumption of the report, that there is a crisis. For example, Austria states that 2000 more nursing posts were created in 2010 and there was a shortage of specialist nurses. Nursing was considered safe employment. Belgium states that it was not feeling negative effects. On the contrary, there were positive developments and increased salaries. Although Bulgaria was affected financially, nurses were not being replaced by nonqualified staff. The Czech Republic did not have a nursing crisis, and nursing numbers were not reduced. There was an increase of nurses in Denmark. Ireland, Hungary and Greece, on the other hand, did have cuts in nursing posts and salaries. So the situation is very mixed.
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Are historical and current understandings of the nursing role considered?
How does this report intend to shape nursing policy?
There is no consideration of the nursing role, education, wider analysis or historical background. There is no consideration of EU standards of nursing education in different member states detailed by the EU (European Commission 2000). There are no references to other sources. Hence, for example, the UK contribution, by the Royal College of Nursing (RCN) General Secretary, gives statistics for cuts and pay freezes, but gives no consideration to wider issues, such as the role or education of the nurse or the quality of care. Both these aspects were being considered at the time by the RCN itself in the Willis Commission (2012), a response to the Francis Inquiry (2013). The report makes no mention of other European Union reports, for example European Union nursing standards (Keighley 2009). Neither is there consideration of nursing outside of Europe. The report intends to inform European Union governments that nursing is in crisis. It is a call for attention. But it is not clear what the report is asking governments to do.
2 National Center for Health Workforce Analysis (2013) The US Nursing Workforce: Trends in Supply and Education Washington, DC: Author. What value judgments and preconceptions about nursing are held by the writers of the report?
Is this report accessible to the lay person as general reader? Does the report consider the perceptions of nursing held by the audience, including lay and/or grass roots professional?
The report focuses on the supply, distribution and education pipeline of US nurses. It highlights the growth in the number of nurses working in the United States. It examines numbers for two categories of nurses, licensed practical nurses and degree-level nurses. It makes no value judgments about desirability or effectiveness of the different levels of qualification. It examines trends but takes no account of factors likely to influence future supply and demand. The report is intended to assist the work of national and state officials, policy-makers, the nursing community, educators and researchers focused on the nursing workforce. It is published online, so accessible by the general reader, but it is not intended for the general reader, so gives no general background or context to enable the lay reader engage in debate. The report does not consider audience perception, either lay or grass roots professional. The professional perception may be indicated by a current report from the Institute of Medicine (2011), which aims to reconceptualise the role of the nurse. This report suggests that: 1 Nurses should practice to the full extent of their education and training. 2 Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression. 3 Nurses should be full partners, with physicians and other health professionals, in redesigning health-care in the United States. 4 Effective workforce planning and policy-making require better data collection and an improved information infrastructure. The lay perception may be indicated in the IOM report by their criticism of political agendas and public opinion that frequently override empirical evidence. Three public forums were held by the IOM. Points that emerged at the forum, may indicate the lay perception (albeit led and interpreted by the IOM): Knowledge of frontline nurses that they gather from their interactions with patients is critical to reducing medical errors and improving patient outcomes. Involving nurses at a variety of levels across the acute care setting in decision-making and leadership benefits the patient, improves the organizations in which nurses practice and strengthens the healthcare system in general.
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Does the report aim to change readers’ perceptions of nursing?
Is reliable data used in the report?
Are historical and current understandings of the nursing role considered?
How does this report intend to shape nursing policy?
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Increasing the time that nurses can spend at the bedside is an essential component of achieving the goal of patient-centred care. High-quality acute care settings require integrated systems that use technology effectively while increasing the efficiency of nurses and affording them increased time to spend with patients. Multidisciplinary care teams characterized by extensive and respectful collaboration among team members improve the quality, safety, and effectiveness of care. So it may be that the US public perceive the bedside nurse to be fundamental, while medical and nursing professionals consider the expanded role of the nurse to be an important reconceptualization. Understanding the supply and distribution of nurses is key to ensuring access to care and an effective healthcare system. This report presents data on the supply, distribution, and education/pipeline of the US nursing workforce. The report is intended to be used by national and state workforce planners, as well as educators, researchers, and policymakers. The data comes from a variety of sources and present recent trends and the current status of the registered nurse (RN) and licensed practical/vocational (LPN) workforces is gathered by Health Resources and Services Administration, Bureau of Health Professions, National Center for Health Workforce Analysis. This is an advisory committees established by law, executive order of the US President and by agency authority. Its primary purpose is to collect data. Sources are from the US Census Bureau and the American Community Survey. Relative Standard Errors are considered. More information about the data sources and methods used in the report can be found in a website ‘The US Nursing Workforce: Technical Documentation’ The report does not consider historical data on US nursing trends, but does consider data from 2001. The report does not consider in detail the content of the training of different levels of the nurse. Nor does it consider the quality of care. Hence, it takes no account of the work of Aiken et al. (2003, 2014), whose own presupposition is that the nursing workforce should be at degree level, and that there is a potential crisis in replenishing the US nursing workforce (Aiken 2011). Aiken’s work, which started in the US has expanded to Europe, and is underpinned by the proposition that a degree level nursing reduces patient mortality. This argument by Aiken et al. (2003, 2014) is itself subject to question by Black (2010) and Lilford and Pronovost (2010), who argue that mortality statistics are an inadequate indicator of quality of care. The National Center for Health Workforce Analysis (the National Center) aims to inform public and private-sector decision-making related to the health workforce by expanding and improving health workforce data, disseminating workforce data to the public, improving and updating projections of the supply and demand for health workers, and conducting analyses of issues important to the health workforce. It does not comment on the future shape of the workforce. It does state that the nursing workforce grew substantially in the 2000s. Growth in the nursing workforce outpaced growth in the US population. So there is no shortage of nurses in the US
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DISCUSSION: DRAWING SOME CONCLUSIONS FROM THE INTERNATIONAL APPLICATION OF THIS APPRAISAL FRAMEWORK This interrogatory appraisal of two reports has revealed similar concerns about nursing staffing that are relevant both to Europe and the United States, but it has also highlighted differences in methods and conclusions drawn. The European report is written in to draw attention to what it describes as a ‘crisis’ in nursing and nurse staffing. It is surprising to discover that this is not supported within the report by data or description from many individual countries in the European Union. On the contrary, most countries report that there is no crisis, thus undermining the purpose of the report itself. The North American report considers the nurse staffing situation to be good. It uses data from specified sources, which can therefore be followed up and validated for reliability. The European report relies on individual contributions. Many do not provide statistics. Those countries which do give statistics, for example, the UK, does not give the sources for the data, so this cannot be followed up and tested for reliability. Although the European report gives individual country’s representatives, and hence it can be assumed, the authors of each contribution to the report, neither report gives the overall authors’ names. Both reports reveal inconsistencies and lack of clarity in the nursing role. These should be vital aspects for public debate. Neither report defines, or even considers, the nurse’s role in any depth, despite the importance attached by the Institute of Medicine (2011) and Aiken (2011). Neither report attends to the education required for the nursing role. In neither report is there consideration of the public’s requirements for nursing. Neither report is explicit about how nursing should be shaped in the future. And neither report reflects on the wider context of nursing in countries beyond the European Union and United States, or indeed, historically. As the Francis Inquiry (2013) found in the UK, nursing care is often performed by unqualified or less qualified staff, but neither report considers the variety of qualification levels in either EU countries or the US. Crucially, there is no discussion on the quality of care internationally, which is a preoccupation in the UK following the Francis Inquiry, and more widely (Aiken et al. 2003, 2014). What has emerged from this appraisal is that, as in the UK, both reports are intended to be received by policy-makers, rather than grass roots professionals or the general public. The organizations that publish the reports do not expect them to be subjected to public critical scrutiny or discourse.
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Rather they expect policy-makers to use them to shape public policy without involving the public voice. Perhaps the most important conclusion revealed by the interrogatory questions of this framework, is that neither report pays any attention to the lay person as general reader as a receiver of the report. Yet, the lay person has a major stake and interest in the policy being shaped by the reports, and should be facilitated to contribute to debate about policies that affect him or her. Contrary to the UK Judge Report (1985), the perspective of the lay person should not be discounted. Instead, according to Popper (1945), Gadamer (1975) and Jauss (1982), the horizon of the lay person is essential to new ways of seeing and therefore to a creative discourse.
POSSIBLE IMPLICATIONS OF THIS FRAMEWORK This framework for appraising policy reports has several possible implications. First, it may open up nursing policy to public critique and engagement. Because the only purpose of the nursing profession world-wide is to serve the public, the public should participate in policies that shape the role and purpose of their nurses. Second, nursing scholarship will benefit from a stronger attention to, and critique of, nursing policy reports. The use of this appraisal framework could widen both discourse and analysis and set nursing research in the context of nursing policy and praxis. Third, a stronger appraisal of policy reports may lead to a more open engagement with policy not only in health-care but more widely, in all public policy spheres. Fourth, the existence of the appraisal framework may encourage authors to address the receivers of their reports and so consider the clarity, accuracy and accessibility of their texts. The ultimate goal of this framework is to improve scrutiny of, and engagement with, public policy and thus improve the quality and relevance of policies that affect people’s lives.
CONCLUSION Following Popper’s conception of the open society, this paper argues that reports affecting nursing policy should be subjected to robust appraisal by both profession and public. This is so that citizens can engage democratically in an informed debate and foster a genuinely creative discourse in policies that directly affect them. Reception theory is proposed as a key resource for developing a framework for appraisal, and applied, by way of worked examples to major international policy reports that are intended to shape nursing. This discussion has relevance beyond the nursing profes-
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sion and health-care into all policy areas that directly affect individual lives. The appraisal framework can therefore be adapted for wider use.
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Gadamer H-G. 1975. Truth and method. New York: The Seabury Press. Health Service Commissioner for England, for Scotland and for Wales. 1995. Third report for session 1994–95: Annual report for 1994–95. London: HMSO. Health Service Commissioner for England, for Scotland and for Wales. 1997. First report for session 1997–8: Annual report for 1996–97, HC41. London: The Stationery. Health Service Commissioner for England, for Scotland and for Wales. 1998. Investigations completed April–September 1998: Ist Report-Session 1998-99, HC3. London: The Stationery Office. Help the Aged. 1999a. The views of older people on hospital care: A survey, January 1999. London: Author. Help the Aged. 1999b. Dignity on the ward: A campaign update – October 1999. London: Author. Help the Aged. 1999c. Failing older people: Flaws in the NHS complaints procedure. London: Author. Institute of Medicine. 2011. The future of nursing: Leading change advancing health. Washington, DC: National Academies Press. Jarman B. 2013. Quality of care and patient safety in the UK: The way forward after Mid Staffordshire. Lancet 382: 574–5. Jauss HR. 1982. Toward an aesthetic of reception trans. Timothy Bahti, Minneapolis: University of Minnesota Press. JM Consulting Ltd. 1998a. The regulation of nurses, midwives and health visitors: Invitation to comment on issues raised by a review of the Nurses, Midwives and Health Visitors Act 1997. Bristol: Author. JM Consulting Ltd. 1998b. The regulation of nurses, midwives and health visitors: Report on a review of the Nurses, Midwives and Health Visitors Act 1997. Bristol: Author. Keen A. 1999. House of commons. National Health Service. Hansard 323, 17: 35–54, January 11. Keighley T. 2009. European Union standards for nursing and midwifery: Information for accession countries. Copenhagen: WHO Regional Office for Europe. Levinson RB. 1957. In defense of Plato. Cambridge: Cambridge University Press. Lilford R and P Pronovost. 2010. Using hospital mortality rates to judge hospital performance: A bad idea that just won’t go away. BMJ 340: 955–7. Meredith P and C Wood. 1997. The patient’s experience of surgery: A selective evaluation of two hospital sites. London: Patient Satisfaction with Surgery Audit Service, Royal College of Surgeons. Mid Staffordshire NHS Foundation Trust Inquiry. 2010. Independent inquiry into care provided by Mid Staffordshire NHS
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Foundation Trust January 2005 – March 2009. Chair Robert Francis. HC 375. London: The Stationery Office. Mid Staffordshire NHS Foundation Trust Public Inquiry. 2013. Report of the Mid Staffordshire NHS Foundation Trust public inquiry. Executive Summary. Chair Robert Francis. HC947. London: The Stationery Office. Mitchell G. 2004. An emerging framework for human becoming criticism. Nursing Science Quarterly 17: 103–9. Moore J. 1988. Letter from the Secretary of State, Department of Health and Social Security, to Miss Audrey Emerton, Chairman of the United Kingdom Central Council for Nursing, Midwifery and Health Visiting, May 20. Morton-Williams JR and R Berthoud. 1971a. Nurses attitude survey, ref. 02.188. London: Social and Community Planning Research. Morton-Williams JR and R Berthoud. 1971b. Nurses attitude survey: Report on depth interviews, ref. 02.194. London: Social and Community Planning Research. National Center for Health Workforce Analysis. 2013. The US nursing workforce: Trends in supply and education. Washington, DC: Author. Nilsson M, A Jordan, J Turnpenny, J Hertin, B Nykvist and D Russel. 2008. The use and non-use of policy appraisal tools in public policy making: An analysis of three European countries and the European Union. Policy Sciences 41: 335–55. Nursing and Midwifery Council (NMC). 2010. Standards of proficiency for pre-registration nursing education. London: Author. Parliamentary and Health Service Ombudsman. 2011. Care and compassion? London: The Stationery Office. Patients Association. 2012. Listening to patients: Speaking up for change. Harrow, Middlesex: Author.
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Patients Association. 2013. Patient stories. Harrow, Middlesex: Author. Popper K. 1945. The open society and its enemies. London: Routledge. Prime Minister’s Commission on the Future of Nursing and Midwifery in England. 2010. Front line care. London: Crown Copyright. Rafferty AM. 1996. The politics of nursing knowledge. London: Routledge. Report of the Committee on Nursing. 1972. Cmnd.5115. Chairman: Professor Asa Briggs. London: HMSO. Royal College of Nursing (RCN). 1985. The education of nurses: A new dispensation. Chairman: Dr Harry Judge. London: Author. Royal College of Nursing (RCN). 2012. Report of the Willis Commission on nursing. Quality with compassion: The future of nursing education. London: Author. Thiselton AC. 2012. Reception theory, H. R. Jauss and the formative power of scripture. Scottish Journal of Theology 65: 289–308. Thom e DC. 2009. Mid Staffordshire NHS Foundation Trust: A review of lessons learnt for commissioners and performance managers following the Healthcare Commission investigation. London: Mid Staffordshire NHS Foundation Trust Public Inquiry. Thornton S. 2013. Karl popper. In Stanford encyclopaedia of philosophy, ed EN Zalta, Spring 2013 edn. http://plato. stanford.edu/archives/spr2013/entries/popper/ (accessed 20 August 2013). United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC). 1986. Project 2000: A new preparation for practice. London: Author.
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Feature
Shaping the future of nursing: developing an appraisal framework for public engagement with nursing policy reports Ann Bradshaw Faculty of Health and Life Sciences, Oxford Brookes University, Marston, Oxford, UK Accepted for publication 10 May 2014 DOI: 10.1111/nin.12072
BRADSHAW A. Nursing Inquiry 2015; 22: 74–83 Shaping the future of nursing: developing an appraisal framework for public engagement with nursing policy reports It is accepted that research should be systematically examined to judge its trustworthiness and value in a particular context. No such appraisal is required of reports published by organizations that have possibly even greater influence on policy that affects the public. This paper explores a philosophical framework for appraising reports. It gives the reasons why informed engagement is important, drawing on Popper’s concept of the open society, and it suggests a method for appraisal. Gadamer’s concept of the two horizons and Jauss’s reception theory offer a methodological framework to enable the individual citizen, whether professional or lay, to engage in debate about policy that affects him or her. By way of a worked example, the framework is applied to two international reports on nursing. Conclusions suggest that nursing policy should be subjected to robust interrogatory appraisal by both profession and public for a democratic debate and creative discourse. Although this analysis is related to international nursing policy, it has a wider relevance and application beyond nursing. Key words: appraisal, Gadamer, Jauss, nursing, policy, Popper, reports. Nursing world-wide accepts that research must be critically scrutinized if it is to form a valid and reliable basis for patient care (Mitchell 2004). The Cochrane Collaboration (2013) states that independent, authoritative and reliable information is vital for informed choice in health-care. The Critical Appraisal Skills Programme (2013) argues that the process of carefully and systematically examining research to judge its trustworthiness, value and relevance in a particular context is crucial for the same reason. This paper suggests that reports which determine nursing policy should be subjected to a similar analysis not only by the profession but also by the public, upon whom nursing policy impacts, to engage in informed debate and make choices. The paradigm of Popper (1945) is argued to
Correspondence: Ann Bradshaw, Senior Lecturer in Adult Nursing, Faculty of Health and Life Sciences, Oxford Brookes University, Jack Straw’s Lane, Marston, Oxford, OX3 0FL, UK. E-mail:
support this requirement. The objective of this analysis is to highlight how the readership of nursing reports can receive, read, engage and participate in policy formation and debate, given the powerful leverage of reports in policy change. While policy appraisal frameworks for public policy assessment are numerous (Nilsson et al. 2008), it seems that there is a paucity of appraisal frameworks for critically appraising policy reports. This paper will draw on the methodology of reception theory, as proposed by Continental philosophers, Jauss (1982), developed from Gadamer (1975), to suggest questions that may help the reader, whether professional or lay, appraise individual reports.
THE CONTEXT AND STRUCTURE OF THIS PAPER This paper has developed from the author’s academic interest in changes to UK nursing, in which highly influential UK © 2014 John Wiley & Sons Ltd
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nursing reports 1972–2014 were found not to have been subjected to public scrutiny and debate. This has led the author to a broader analysis, and to consider whether philosophical and ethical arguments require public scrutiny of reports that shape policy, and if so, how this can be achieved. This analysis is in three sections. In the first section, the paper illustrates the significance of reports by describing an historical example of their use to effect UK nursing change, 1972–2014. In the second section, the paper examines the philosophical argument for the need to open reports to public scrutiny and debate, and proposes an appraisal framework, developed from underlying theory. In the third section, the framework is applied to two current major nursing reports, from the European Union and the United States, to demonstrate international applicability and relevance.
1. AN HISTORICAL EXAMPLE FROM THE UK: THE USE OF REPORTS TO CHANGE NURSING Reports have shaped UK National Health Service nursing policy (Rafferty 1996). In 1972, the government’s Report of the Committee on Nursing [Briggs Report] (1972), recommended major educational and organizational change. The Briggs Committee did not consult the general public. Instead, it assumed prior knowledge of public opinion, stating without any supporting data, that the public held an inherited, romanticized image of the nurse, with which it disagreed. The only data the committee gathered on nurses’ attitudes showed clearly that nurses themselves did not want educational and organizational change (Morton-Williams and Berthoud 1971a,b). But these detailed two volumes of data were disregarded by the report’s recommendations. The Briggs Report (1972) led to the 1979 Nurses, Midwives and Health Visitors Act. The Royal College of Nursing (RCN), the UK professional body and also its main Trade Union, set up a commission on nurse education, The Education of Nurses: A New Dispensation (Judge Report) (RCN 1985) chaired by an educationist who was not a nurse. This report acknowledged in its introduction that the British public would want to retain the current system of nurse training, and would not want change, but rejected this lay opinion: One initial difficulty must be openly acknowledged. The layman will need to be convinced that anything very much is wrong. He is likely to believe that the nurse in our society may indeed be undervalued and under rewarded, but not that she is irresponsible or ill-prepared. His experience suggests that the public has confidence in the quality of practical nursing, and prompts the question “if the system
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of training is wrong, why are the products so good?” He will, moreover, be disposed, in a spirit of traditional Anglo-Saxon pragmatism, to favour a system which embeds tradition on practice and eschews fancy notions of theories of “Education”. He will be sceptical of any attempts to move the training of nurses from its present base. He will, if pressed, want his bedside nurse to be trained and practical rather than educated and questioning. He will certainly not wish to be cared for after an operation by an amateur psychologist or (still worse) sociologist. Told that nurses learn their craft by being engaged from the beginning in the delivery of care, he will grunt his heartfelt approval. (Royal College of Nursing 1985, 7)
And a third report set up by the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC), headed by a sociologist who was not a nurse, also proposed radical changes to nurse education in a report entitled Project 2000 (UKCC for Nursing, Midwifery and Health Visiting 1986). This report to make nurse training more academic, also ignored the public and grass roots nursing view. It was accepted by government, but with provisos (Moore 1988). In 1998, the government commissioned a review of these policy development (JM Consulting Ltd 1998a,b). This review found notable weaknesses in the new system. These included the relative lack of attention given to professional attitudes and standards in education programmes and the still imperfect integration of theory and practice education, and the feeling by many observers that practice education was given a lower priority than intended. The government (Dobson 1999) recommended that nurse education be reviewed. Despite political agreement (Bottomley 1998; Keen 1999), this review did not happen. Ten years later, the Prime Minister’s Commission on the Future of Nursing and Midwifery in England’s (2010) advocated a move to an allgraduate nursing profession, which was accepted as the future preparation for nurses by the Nursing and Midwifery Council (NMC) (NMC 2010). The public view was ignored by Briggs (1972), Judge (1985), Project 2000 (1986), The Prime Minister’s Commission (2010) and the NMC (2010). The public was not considered to be the audience and hence receiver for these reports from the UK nursing profession, even though ordinary people were directly affected. Public opinion was well known, as the Judge Report (1985) shows, but deliberately disregarded. Yet public opinion, often unsolicited, was expressed with regard to patients’ experiences of nursing care. This was given in regular reports about poor patient care published regularly in the following decades (Meredith and Wood 1997; Age Concern 1999; Help the Aged 1999a,b,c; Health Service Commissioner 1995, 1997, 1998). These concerns became a political
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focus (Alberti 2009; Thome 2009; Mid Staffordshire NHS Foundation Trust Inquiry 2010; Parliamentary and Health Service Ombudsman 2011; Care Quality Commission 2011; CHRE 2012; Patients Association 2012). This culminated in the Mid Staffordshire NHS Foundation Trust Public Inquiry (2013) (Francis Inquiry) which provided detailed evidence of a loss of UK nursing compassion and competence. The RCN published a preemptive report in response to the Francis Inquiry (RCN 2012) (Willis Commission), which was defensive and discounted public opinion. The heads of UK university nursing departments stated that the poor image of nursing in the UK, compared with other countries, was a perception held by the public that needed countering, so set up a commission (Dean 2014). But the director of an independent healthcare research unit came to a different conclusion (Jarman 2013). He stated that there had been a decade of concerns about the quality of care in UK hospitals; patients had been ignored, the regulatory systems had failed and there had been a culture of denial. This example from the UK shows the fundamental influence of reports on the direction of UK nursing 1972–2014, that was without public scrutiny, debate or indeed, evidence of improved patient care. Moreover, reports seem to have been used by the profession to obscure the public view, as opposed to being open to it. This UK example is relevant internationally. Popper (1947) argues that in an open society ideas and proposals should be critically scrutinized and tested by rational argument by all those who have a stake in it. This includes not only grass roots nurses and other healthcare workers, but also, importantly, the lay person who is affected by the nursing profession, both by funding it and receiving its services. This paper sets out to give the reasons why informed engagement and participation is important, and to suggest a method for engagement.
2. WHY INFORMED PARTICIPATION IN POLICY IS IMPORTANT INTERNATIONALLY IN NURSING AND BEYOND NURSING In science, progress is made by subjecting theories to critical scrutiny and abandoning those which have been falsified. Popper (1945) argues that critical scrutiny should occur at the social level in the same way that it does in science. Popper holds that the open society can only be brought about if the individual citizen evaluates critically the consequences of the implementation of government policies. These can then be abandoned or modified in the light of this critical scrutiny. In such a society, the rights of the individual to criticize
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administrative policies should be formally safeguarded. Undesirable policies would be eliminated in similar ways to falsified scientific theories. Differences between people on social policy will be resolved by critical discussion and argument. Popper’s conception of the open society may be defined as ‘an association of free individuals respecting each other’s rights within the framework of mutual protection supplied by the state, and achieving, through the making of responsible, rational decisions, a growing measure of humane and enlightened life’ (Levinson 1957, 17; Thornton 2013). As Popper (1945, 224–5) argues, an open liberal society means that ideas need to be openly and transparently tested, subjected to rational argument and analysis. Rationalism includes empirical testing and evidence – not just intellectualism. Policies that affect the community need debate, argument and free criticism. This should not need special education or training, but should be openly accessible to each affected person. This cannot be done in isolation. It can only be done by the community, by those who have a stake in it, through informed and reasoned argument. To make this point, Popper gives the example of Robinson Crusoe alone on his island. On his own, he cannot create language, nor argument and reason. He needs human society. This is the audience which tests ideas that influence policies that shape society. In relation to nursing policy, this means that all those affected by nursing policies – whether professional or lay – have a responsibility to engage in debate about policies.
A Method to Enhance and Widen Engagement: An Appraisal Framework for Reports Hans Robert Jauss (1921–97) is the founder of modern reception theory. Jauss supports Popper’s position on the open society. He holds that interpretation of texts involves new ways of seeing, a paradigm shift, in which genuinely creative discourse emerges not at moments of normal routine, but at moments of crisis. The context is both historical, in relation to particular times, and social, in relation to specific groups of people (Thiselton 2012, 290). Jauss’s vision was for interdisciplinary research, and he sought the ‘still-unfinished meaning’ in texts. Jauss draws on Gadamer (1975) to focus on the historical influence of a text (Thiselton 2012, 290). As Gadamer taught, all arguments are influenced by the tradition in which one stands. The past horizon is embraced within the horizon of the present, and understanding is always the process of the fusion of past and present horizons. Jauss
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develops this idea of reciprocity. In the interpretation of texts the reader brings his or her own subjectivity, but also the texts influence the reader’s subjectivity. Successive generations of readers influence the understanding of texts. Jauss draws on Marxist theories of interpretation and on formalism, but goes beyond both. Marxism stresses the socially formative power of literature, and Jauss endorses this. Texts shape readers and their expectations. He draws on formalism for such devices as ‘defamiliarisation’, which is a disruptive device to make strange what is otherwise familiar. Jauss rejects the complacent assumption in formalism that texts are autonomous. The process of communication involves readers. The reader completes the meaning of the text. This means that a ‘text’ is not simply passively accepted by the reader, but the reader interprets the meanings of the text based on his or her individual cultural background and life experiences. In essence, the meaning of a text is not inherent within the text itself, but is created within the relationship between the text and the reader. An acceptance of the meaning of a specific text tends to occur when a group of readers have a shared cultural background and interpret the text in similar ways. It follows that if two readers have very different personal and cultural experiences, their reading of a text will vary greatly. Because Jauss’s reception theory has its origins in interdisciplinary research, it is relevant to nursing. This is the view of Mitchell (2004), a Canadian nursing scholar. She is interested in applying reception theory as a framework for human becoming. According to Mitchell (2004, 107), crucial to understanding reception theory is the term ‘horizon of expectation’. This is used to denote the criteria that readers use to judge literature. It represents the common assumptions attributed to a group or community who share some meaningful history and beliefs. Jauss (1982, 13) referred to the ‘transsubjective horizon of understanding’. The full impact of a text can only be known from some perspective or horizon of shared expectation. Horizons of expectation change over time as each age of scholars interprets works in the light of its knowledge and experience. ‘Specifically the researcher/artist sketches the horizon in the nursing perspective, and the critic who shares the codes and conventions makes a judgment as to how well the horizon was described. It is the horizon of expectation that sets the stage for illuminating the artistic disclosure’ (Mitchell 2004, 7).
Developing the Appraisal Framework Jauss’s reception theory may be drawn on by the reader to appraise texts, and in this case, policy reports. A useful © 2014 John Wiley & Sons Ltd
framework that may help the reader, in Mitchell’s (2004, 7) words, bring to debate his or her own ‘horizon of expectation’, may be adapted from the work of Thiselton (2012). He draws on reception theory as a hermeneutical framework by developing seven points: Jauss (1) dismisses value-neutral objectivism; (2) stresses the reader’s horizon of expectation; (3) sees that this horizon changes and expands with formative effect; (4) stresses the value of question and answer, and appropriation, in actualising potential new horizons; (5) acknowledges the relation between interpretation and the readers’ pre-understandings; (6) takes account of the diachronic or historical and synchronic or contemporary meaning; and (7) re-emphasises formative function of texts and works, and their creative effects on life. Importantly, Jauss argues that question and answer can provide access to the text. And Thiselton’s framework can be developed in the form of interrogatory questions to help the reader see in new ways to access the reports. Although this can obviously apply to any reports on any topic, the following will be applied to the author’s field of nursing: What value judgments and preconceptions about nursing are held by the writers of the report? Is this report accessible to the lay person as general reader? Does the report consider the perceptions of nursing held by the audience, including lay and/or grass roots professional? Does the report aim to change readers’ perceptions of nursing? Is reliable data used in the report? Are historical and current understandings of the nursing role considered? How does this report intend to shape nursing policy? If this framework were applied to reports significant for nursing, then the reader of the policy report – any citizen affected, professional or lay – should be able to bring their individual horizon of expectation to engage in debate, as Popper (1945) considers vital for an open society. And, according to Popper, this debate should be accessible to the general reader, without specialist education or training.
3. WORKED INTERNATIONAL EXAMPLES OF THE FRAMEWORK’S APPLICATION Two major international nursing reports will be examined using this framework. The first is a European
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Union report (2012) which suggests care is in crisis. The second is a North American report on nurse staffing. (2013). What value judgments and preconceptions about nursing are held by the writers of the report?
Is this report accessible to the lay person as general reader?
Does the report consider the perceptions of nursing held by the audience, including lay and/or grass roots professional?
Does the report aim to change readers’ perceptions of nursing? Is reliable data used in the report?
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1 European Federation of Nurses Associations (2012) Caring in Crisis: The Impact of the Financial Crisis on Nurses and Nursing Brussels: Author.
The report from the European Federation of Nurses Associations (European Federation of Nurses Associations 2012) focuses on the effects of the 2008 global financial crisis on European nursing. It believes the effects are obvious: reduction of nursing posts across Europe; pay cuts and freezes, diminished recruitment and retention rates, compromises in quality care and safety; downgrading of nursing and substitution of nurses with untrained assistants. It is written for governments in the European Union, claiming that the 34 National Nurses associations are representative on the nursing profession throughout Europe. It states the intention that the report should be used as a tool and campaigning document to governments. Its key messages are simple political slogans: Remind – Health and productivity go hand in hand. Suggest – protecting health of citizens will boost the economy and provide the means out of recession. Warn – unless action is taken thousands of women will be excluded from the labour market. Urge – protect nurses, protect women, protect health. It is published online, so accessible by the general reader, but it is not intended for the general reader, so gives no general background or context to enable the lay reader engage in debate. The report does not consider audience perception, either lay or grass roots professional. Each country’s association has a page to describe the impact of the financial crisis on its nursing workforce. It would seem that the professional perception of nursing varies between and within countries. The UK profession, for example, as indicated by the Willis Commission (2012) holds a rather unclear view of the nurse’s role, advocating advanced and specialist roles, the nurse as an organiser and leader of care. The professional body accepts that much direct, fundamental care will be given by unqualified healthcare assistants. In contrast, the lay person from the UK expects the nurse to be the giver of fundamental care. This is indicated by the Francis Inquiry (2013), and Patients Association (2013). The title and executive summary of the report are intended to inform readers of a crisis in EU nursing. The report was gathered from input of members at a round table discussion at EFN General assemblies in 2009, 2010 and 2011. Their names and the countries they represent are listed. Each country’s contribution to the body of the report is about a page, but some countries contribute only one or two paragraphs (for example, France, Germany and Luxembourg). Statistics are given in some contributions, but the reliability of these statistics is not demonstrated. France and Germany give no statistics at all. Individual contributions often do not reflect the underlying assumption of the report, that there is a crisis. For example, Austria states that 2000 more nursing posts were created in 2010 and there was a shortage of specialist nurses. Nursing was considered safe employment. Belgium states that it was not feeling negative effects. On the contrary, there were positive developments and increased salaries. Although Bulgaria was affected financially, nurses were not being replaced by nonqualified staff. The Czech Republic did not have a nursing crisis, and nursing numbers were not reduced. There was an increase of nurses in Denmark. Ireland, Hungary and Greece, on the other hand, did have cuts in nursing posts and salaries. So the situation is very mixed.
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Are historical and current understandings of the nursing role considered?
How does this report intend to shape nursing policy?
There is no consideration of the nursing role, education, wider analysis or historical background. There is no consideration of EU standards of nursing education in different member states detailed by the EU (European Commission 2000). There are no references to other sources. Hence, for example, the UK contribution, by the Royal College of Nursing (RCN) General Secretary, gives statistics for cuts and pay freezes, but gives no consideration to wider issues, such as the role or education of the nurse or the quality of care. Both these aspects were being considered at the time by the RCN itself in the Willis Commission (2012), a response to the Francis Inquiry (2013). The report makes no mention of other European Union reports, for example European Union nursing standards (Keighley 2009). Neither is there consideration of nursing outside of Europe. The report intends to inform European Union governments that nursing is in crisis. It is a call for attention. But it is not clear what the report is asking governments to do.
2 National Center for Health Workforce Analysis (2013) The US Nursing Workforce: Trends in Supply and Education Washington, DC: Author. What value judgments and preconceptions about nursing are held by the writers of the report?
Is this report accessible to the lay person as general reader? Does the report consider the perceptions of nursing held by the audience, including lay and/or grass roots professional?
The report focuses on the supply, distribution and education pipeline of US nurses. It highlights the growth in the number of nurses working in the United States. It examines numbers for two categories of nurses, licensed practical nurses and degree-level nurses. It makes no value judgments about desirability or effectiveness of the different levels of qualification. It examines trends but takes no account of factors likely to influence future supply and demand. The report is intended to assist the work of national and state officials, policy-makers, the nursing community, educators and researchers focused on the nursing workforce. It is published online, so accessible by the general reader, but it is not intended for the general reader, so gives no general background or context to enable the lay reader engage in debate. The report does not consider audience perception, either lay or grass roots professional. The professional perception may be indicated by a current report from the Institute of Medicine (2011), which aims to reconceptualise the role of the nurse. This report suggests that: 1 Nurses should practice to the full extent of their education and training. 2 Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression. 3 Nurses should be full partners, with physicians and other health professionals, in redesigning health-care in the United States. 4 Effective workforce planning and policy-making require better data collection and an improved information infrastructure. The lay perception may be indicated in the IOM report by their criticism of political agendas and public opinion that frequently override empirical evidence. Three public forums were held by the IOM. Points that emerged at the forum, may indicate the lay perception (albeit led and interpreted by the IOM): Knowledge of frontline nurses that they gather from their interactions with patients is critical to reducing medical errors and improving patient outcomes. Involving nurses at a variety of levels across the acute care setting in decision-making and leadership benefits the patient, improves the organizations in which nurses practice and strengthens the healthcare system in general.
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Does the report aim to change readers’ perceptions of nursing?
Is reliable data used in the report?
Are historical and current understandings of the nursing role considered?
How does this report intend to shape nursing policy?
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Increasing the time that nurses can spend at the bedside is an essential component of achieving the goal of patient-centred care. High-quality acute care settings require integrated systems that use technology effectively while increasing the efficiency of nurses and affording them increased time to spend with patients. Multidisciplinary care teams characterized by extensive and respectful collaboration among team members improve the quality, safety, and effectiveness of care. So it may be that the US public perceive the bedside nurse to be fundamental, while medical and nursing professionals consider the expanded role of the nurse to be an important reconceptualization. Understanding the supply and distribution of nurses is key to ensuring access to care and an effective healthcare system. This report presents data on the supply, distribution, and education/pipeline of the US nursing workforce. The report is intended to be used by national and state workforce planners, as well as educators, researchers, and policymakers. The data comes from a variety of sources and present recent trends and the current status of the registered nurse (RN) and licensed practical/vocational (LPN) workforces is gathered by Health Resources and Services Administration, Bureau of Health Professions, National Center for Health Workforce Analysis. This is an advisory committees established by law, executive order of the US President and by agency authority. Its primary purpose is to collect data. Sources are from the US Census Bureau and the American Community Survey. Relative Standard Errors are considered. More information about the data sources and methods used in the report can be found in a website ‘The US Nursing Workforce: Technical Documentation’ The report does not consider historical data on US nursing trends, but does consider data from 2001. The report does not consider in detail the content of the training of different levels of the nurse. Nor does it consider the quality of care. Hence, it takes no account of the work of Aiken et al. (2003, 2014), whose own presupposition is that the nursing workforce should be at degree level, and that there is a potential crisis in replenishing the US nursing workforce (Aiken 2011). Aiken’s work, which started in the US has expanded to Europe, and is underpinned by the proposition that a degree level nursing reduces patient mortality. This argument by Aiken et al. (2003, 2014) is itself subject to question by Black (2010) and Lilford and Pronovost (2010), who argue that mortality statistics are an inadequate indicator of quality of care. The National Center for Health Workforce Analysis (the National Center) aims to inform public and private-sector decision-making related to the health workforce by expanding and improving health workforce data, disseminating workforce data to the public, improving and updating projections of the supply and demand for health workers, and conducting analyses of issues important to the health workforce. It does not comment on the future shape of the workforce. It does state that the nursing workforce grew substantially in the 2000s. Growth in the nursing workforce outpaced growth in the US population. So there is no shortage of nurses in the US
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DISCUSSION: DRAWING SOME CONCLUSIONS FROM THE INTERNATIONAL APPLICATION OF THIS APPRAISAL FRAMEWORK This interrogatory appraisal of two reports has revealed similar concerns about nursing staffing that are relevant both to Europe and the United States, but it has also highlighted differences in methods and conclusions drawn. The European report is written in to draw attention to what it describes as a ‘crisis’ in nursing and nurse staffing. It is surprising to discover that this is not supported within the report by data or description from many individual countries in the European Union. On the contrary, most countries report that there is no crisis, thus undermining the purpose of the report itself. The North American report considers the nurse staffing situation to be good. It uses data from specified sources, which can therefore be followed up and validated for reliability. The European report relies on individual contributions. Many do not provide statistics. Those countries which do give statistics, for example, the UK, does not give the sources for the data, so this cannot be followed up and tested for reliability. Although the European report gives individual country’s representatives, and hence it can be assumed, the authors of each contribution to the report, neither report gives the overall authors’ names. Both reports reveal inconsistencies and lack of clarity in the nursing role. These should be vital aspects for public debate. Neither report defines, or even considers, the nurse’s role in any depth, despite the importance attached by the Institute of Medicine (2011) and Aiken (2011). Neither report attends to the education required for the nursing role. In neither report is there consideration of the public’s requirements for nursing. Neither report is explicit about how nursing should be shaped in the future. And neither report reflects on the wider context of nursing in countries beyond the European Union and United States, or indeed, historically. As the Francis Inquiry (2013) found in the UK, nursing care is often performed by unqualified or less qualified staff, but neither report considers the variety of qualification levels in either EU countries or the US. Crucially, there is no discussion on the quality of care internationally, which is a preoccupation in the UK following the Francis Inquiry, and more widely (Aiken et al. 2003, 2014). What has emerged from this appraisal is that, as in the UK, both reports are intended to be received by policy-makers, rather than grass roots professionals or the general public. The organizations that publish the reports do not expect them to be subjected to public critical scrutiny or discourse.
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Rather they expect policy-makers to use them to shape public policy without involving the public voice. Perhaps the most important conclusion revealed by the interrogatory questions of this framework, is that neither report pays any attention to the lay person as general reader as a receiver of the report. Yet, the lay person has a major stake and interest in the policy being shaped by the reports, and should be facilitated to contribute to debate about policies that affect him or her. Contrary to the UK Judge Report (1985), the perspective of the lay person should not be discounted. Instead, according to Popper (1945), Gadamer (1975) and Jauss (1982), the horizon of the lay person is essential to new ways of seeing and therefore to a creative discourse.
POSSIBLE IMPLICATIONS OF THIS FRAMEWORK This framework for appraising policy reports has several possible implications. First, it may open up nursing policy to public critique and engagement. Because the only purpose of the nursing profession world-wide is to serve the public, the public should participate in policies that shape the role and purpose of their nurses. Second, nursing scholarship will benefit from a stronger attention to, and critique of, nursing policy reports. The use of this appraisal framework could widen both discourse and analysis and set nursing research in the context of nursing policy and praxis. Third, a stronger appraisal of policy reports may lead to a more open engagement with policy not only in health-care but more widely, in all public policy spheres. Fourth, the existence of the appraisal framework may encourage authors to address the receivers of their reports and so consider the clarity, accuracy and accessibility of their texts. The ultimate goal of this framework is to improve scrutiny of, and engagement with, public policy and thus improve the quality and relevance of policies that affect people’s lives.
CONCLUSION Following Popper’s conception of the open society, this paper argues that reports affecting nursing policy should be subjected to robust appraisal by both profession and public. This is so that citizens can engage democratically in an informed debate and foster a genuinely creative discourse in policies that directly affect them. Reception theory is proposed as a key resource for developing a framework for appraisal, and applied, by way of worked examples to major international policy reports that are intended to shape nursing. This discussion has relevance beyond the nursing profes-
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sion and health-care into all policy areas that directly affect individual lives. The appraisal framework can therefore be adapted for wider use.
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