There is no cure without care

Even if we find the perfect cures for all the ills in the world, we would still need to care. Our COVID vaccines were on strategy, but health professionals still had to provide the life saving personal or fundamental care that restored and healed people. This observation that curing requires care is a truism that tends to get lost. The reason I'm raising this is simple. Think of what's happening across the world post pandemic: worldwide shortage of nurses, nurses on strike in the UK; disillusionment from experienced nurse leaders in Sweden, the Netherlands and Denmark to mention but a few countries (Kitson, Conroy, et al., 2022); nursing leaders in Canada, the US and Australia building back confidence and self-belief in a profession that aspires to tackle such issues as health inequality and the social determinants of health (National Academies of Sciences, Engineering and Medicine, 2021; Registered Nurses' Association of Ontario, 2021). Governments scrambling to solve the qualified nursing supply problem by thinking of job redesign, substitution, international recruitment, use of technology and other ways to provide an adequate workforce, or to reduce the reliance on people (in this case qualified nurses) to do the caring work. Health and care systems trying desperately to cope with the mounting pressures of more older vulnerable people needing more time to recover, more complex co-morbidity creating even more need for health and care systems to be integrated and take a holistic approach to managing peoples' health and care needs. We have to provide solutions to these challenges and start to generate new ways of embracing the ‘care’ challenge and in particular how we take responsibility for fundamental care delivery (Feo et al., 2018). Essentially, we have three options to determine how essential, basic, fundamental care delivery for patients is going to unfold over the next few years and how we as nurses ought to be shaping the agenda. Option 1: Stop doing and being responsible for fundamental care delivery (Less Care). Option 2: Do more and be more responsible for fundamental care delivery (More Care). Option 3: Be responsible for fundamental care delivery redesign (Better Care). In this option, the nursing profession would explicitly state that it is no longer responsible for the personal (essential, basic, fundamental) care of patients and clients across all health and care delivery systems. Nurses instead would become ‘clinical protocol managers’ and co-ordinators of clinical interventions aimed to cure patients. They would follow medical orders, monitor complex patient groups, manage safety and quality systems and help patients navigate their way through a range of health and care system boundaries. Nurses would not ‘do’ or deliver fundamental care nor would they be responsible for those carers who would be recruited to do it. Personal or fundamental care (eating, personal hygiene, mobilizing, etc.) would be delegated to healthcare assistants, family members, the patient themselves or a mix of all three. Clinical interest in personal care would manifest itself in Activities of Daily Living Assessments in order to set goals and instruct the patient and their care network on managing their recovery—pursuing their own cure. The attractions of this option would be to deregulate care within the health and care systems hence addressing the nursing shortages. It would mean that nursing roles would be defined more around clinical interventions and supporting medical activity. This re-definition could address the chronic nursing shortage by creating more specialization and devolving the ‘care’ work to assistants and others. It would mean that qualified nurses would not have to manage the moral distress of having to take responsibility for fundamental care delivery when systems are lacking resources to do so and do not value fundamental care as a contribution to successful recovery. It would mean that health systems would be explicit that they were not responsible for patients' fundamental care needs being met by professional healthcare staff. The disadvantages of option 1 are that despite the attraction of saving on nursing salaries, and creating more specialist clinical roles (leading potentially to greater job satisfaction) research evidence shows that safety incidents increase with fewer qualified nurses and that many basic nursing care activities such as pressure area prevention, mobilization, adequate nutrition and hydration and oral hygiene help prevent hospital acquired complications and readmissions (Stemmer et al., 2022). So, to separate the doing of and /or being responsible for fundamental care delivery would greatly increase the risks to patients. We know this to be the case from a number of well documented failures in care. In addition, denying the centrality of fundamental care delivery would mean ignoring the growing demographic and morbidity changes in patient populations—more people need more help with their daily fundamental care needs in order to optimize recovery. In this option, we embrace the professional ideal to fulfil our goal to deliver person-centred fundamental care as well as lead in clinical excellence (Kitson, Feo, et al., 2022). The practice of nursing is a humanistic, relationship-based activity, therapeutic in its own right (Feo et al., 2018). It integrates the relational, psychosocial, physical care with the ontological, sense-making experiences of patients and people in our care. In essence, this option embraces the person-centred care movement that builds on notions of dignity, respect, partnership and empowerment. Person-centredness as one of the six aims of the safety and quality movement (along with safety, effectiveness, timeliness, efficiency and equity)(Institute of Medicine, 2001) becomes the central tenet of fundamental care delivery and is central to nursing's social contract with society. The attraction of option 2 is that where hospitals and health and care systems have the right leadership and adequate resources they can achieve very positive experiences for both patients, their families and nursing staff (and indeed the whole healthcare team). Nurses report feeling more empowered and able to provide the sort of care that they want and there is less burnout and staff turnover (Bloemhof et al., 2021). Schemes such as Magnet (Friese et al., 2015) summarize the macro, meso and micro requirements for such philosophies of care to flourish and the consequent benefits. The disadvantages of option 2 are that most health systems are not nor have they been designed to recognize, value and support a person-centred approach to care. Equally dominated by a strong biomedical bias striving for cure and an efficiency cost-based model, it's difficult for policy makers and executive leaders to give anything more than lip service to these laudable aspirations. Health systems are classically siloing and hierarchical (Feo & Kitson, 2016) and find any sort of integrated working beyond challenging. Health and care systems worldwide are finding the dual challenges of aging population profiles with accompanying chronic comorbidities profoundly challenging as their systems are not built to deal with such volume and types of patients and of course are built on the promise of cure rather than recognizing the interdependence of cure and care excellence to advance recovery and healing. Hence, if the health systems do not have the visionary leadership and the resources, nursing staff who work to this ideal will find themselves quickly burnt out, disillusioned and will choose to leave not just the organization but also the profession. And this indeed is what is happening globally post-pandemic. In this option, we commit to not throwing the fundamental care ‘baby’ out with the ‘bathwater’ of the impending crises of global nursing workforce shortages and exponential demand for care due to population age profiles, chronic co-morbidities alongside changes to the social structures of informal care. Nursing needs to think of care as the connecting and healing force across our health and care systems and this understanding must begin with a deep respect for getting person-centred fundamental care right in each encounter. This requires new ways to talk about, measure and evaluate fundamental care delivery. We will need to reconnect care with cure and demonstrate to health system leaders the benefits of maintaining this close integration. It will demand better ways of integrating fundamental care assessment and management with clinical diagnosis, assessment, treatment and evaluation. We will need to tackle our methods of recording and monitoring fundamental care needs and interventions—not just as adjuncts to electronic medical records (EMRs) or parts of a safety and quality audit but an integral part of the patient's personalized (clinical and social recovery) care plan. Executed and documented at the care transaction/interaction level we can then build up an understanding of what actions, information, data, policies, procedures need to be in place at departmental, organizational, and system level in order to move cure and care forward together. We have some great examples of nurses taking on new integrated ‘navigator’ roles to manage the flow of patient information across health and care systems and to address some of the complex social determinants of health (SDOH) challenges. Particularly, in integrated care setting with older co-morbid patients and with patients living with chronic disease or surviving cancer, navigators reflect the need to understand a person's self-care (and self-management) capability and capacity as well as understand their care and support network (Kitson, Feo, et al., 2022). This sort of innovation which recognizes the care as well as the clinical protocol management role of the nurse needs to be profiled much more explicitly and enabled to go beyond the prototyping into mainstream system transformation. Like better use of nurse practitioners and nurses leading integrated teams to deliver that appropriate mix of clinically informed, person-centred fundamental care management. Imagine if nursing took responsibility for looking at a person's self-care capability and capacity, working with them and their immediate ‘care network’ which would include, family, friends, volunteers, and formal carers would generate a personalized care plan fit for purpose (in other words taking account of the care needs generated by the illness, the clinical plan as well as the wider social circumstances of each person). And do this proactively rather than at arbitrary transition points such as discharge from one system to another. While many of these ways of thinking and working exist, there are still huge gaps in the flow of information, accountability and delivery of fundamental care. It may be that one of the reasons for this is that nursing has become ‘stuck’ on an individualized notion of what fundamental care delivery looks like—i.e., it is transacted between the nurse and the individual and personal characteristics such as relationship, trust and respect are used to describe the encounter. How this scales up and is delivered in health and care systems to an equivalent quality is something we are all grappling with and something that Allen called re-conceptualizing holism—moving from the individual to organizational relationships (Allen, 2014). My contention is that if we were able to more clearly describe the micro elements of the fundamental care encounter, we would then be able to start scaling them up across systems and organizations. Of course that would also depend on the systems themselves acknowledging the central importance of care in delivering and supporting curative activity. We would then be able to do the necessary work using artificial intelligence (AI) to understand the patterns of personalized care that support different patient populations. We would feel more confident in using AI and care robots and relevant technologies to aid people's self-care plans. So rather than burdening an already beleaguered nursing workforce, the conscious, deliberate embracing of fundamental care as the cornerstone of nursing policy and practice could be the turning point. It would mean that we have to step up and claim the importance of getting fundamental care right, come up with a range of safe, novel, realistic, cost-effective ways of changing practice that addresses the growing needs of patients in the system. It would also require redefining relationships with patients, their informal care networks and with other professional groups and teams to start to create much more integrated models of (holistic) care delivery building from the strong base of getting fundamental care right. In addition, it requires new workforce plans, ways to understand what current practices need to be changed and how we are going to equip our newly graduated nurses with the technology and AI utilization skills that will be needed in the future. There is no cure without care. Let us take the route that will lead to better care (and cure) for people and better health and wellbeing for nurses around the world who still want to care. And by that I mean embrace fundamental care as a core building block for nursing and society and use this to modernize and transform our caring practices.

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