Malone: a woman in a hurry

Beverly Malone, RCN general secretary, is committed to getting nurses’ feet
under the table at every level of the decision-making process.  Nurses should no longer just make the
decision handed down to them, they deserve a centre-stage position, by Nic

It would have taken someone of exceptional prescience to predict that the
failure of Al Gore to win the presidency of the US back in November 2000 would
have a profound impact on UK nurses. But his loss to George W Bush has been
Britain’s gain because it brought Dr Beverly Malone, current general secretary
of the Royal College of Nurses, across the Atlantic.

At the time of the election, Malone was President Bill Clinton’s deputy
assistant health secretary – the highest position a nurse has held in the US
government – but the continuation of her role depended on a Gore win. That’s
why, in June last year, she found herself taking over the reins of the RCN from
Christine Hancock, when the latter moved on to become president of the International
Council of Nurses.

Impressive credentials

With two terms as president of the American Nurses Association under her
belt, a seat on Clinton’s Advisory Commission on Consumer Protection and
Quality in the Health Care Industry and two listings in Ebony Magazine’s list
of the 100 most influential African-Americans, in 1996 and 1998, there is no
question that Malone is a big hitter.

Yet she has come from humble beginnings. Raised in Elizabethtown, Kentucky,
she grew up in a southern area of the US that was still racially segregated,
before, following integration, making it to the University of Cincinnati in
1970 where she studied for a Bachelor’s degree in nursing.

This was followed by stints as a psychiatric clinical nurse specialist as
well as studying for a doctorate in clinical psychology from the same
university. She took on a number of further roles with the university, such as
setting up a department of clinical nurse specialists and nurse clinicians to
provide in-house and external consultancy. She also established a midwifery
nurses programme and started her own private practice in personal therapy and
professional consultation.

In 1986 she moved to become dean of the School of Nursing at North Carolina
Agricultural and Technical State University, during which time she served on
various public bodies. By 1996 she had made it to the ANA, a body that
represents180,000 nurses across the US. The call from Clinton came four years

Firm believer in the NHS

Now, sitting in the RCN’s Cavendish Square headquarters in London, Malone
comes across as warm but polished, very sharp and absolutely committed to
battling hard to get nurses a voice at the top tables of the NHS – a health
structure she evidently admires deeply.

"Back in the States the history has been that you fight and grab and
scratch for every penny that you can on an individual basis. But I consider the
NHS to be the system to have. I believe wholeheartedly in the principle that
care needs to be free at the point of delivery and that it should be
universally accessible to everyone.

"I am delighted to be able to wake up in a country where this issue is
not the one I have to go out and fight a war about every day, as I had to in
the US – about the underlying, philosophical basis of the system of
caring," she says.

The RCN has long been a trade union associated with radical demands on pay
and conditions and a tough, battle-hardened approach to dealing with
governments. While more than prepared to fight these battles, Malone, as
someone with the clear view of an outsider, is adamant about the need to think
beyond the next day’s tussle.

"I really believe that if we can get nurses into decision-making places
– and I’m talking leadership here – at the table where decisions are made. Then
there would be less need to be out there scrounging around about pay or other

"Nurses would be shaping the system. That is what I am looking for, not
for us to do things in isolated splendour at the top of a hierarchy. I want to
be around the table with colleagues and I want nurses’ input to be there,"
she argues. "I am so discouraged when I see us only taking decisions that
are handed down to us and responding to those in a very reactive way, not able
to shape what it could be like for our patients," she adds.

Greater power for nurses

Both the Government and doctors seem, finally, to be heeding her call.
Health Secretary Alan Milburn has long recognised the need to give nurses
greater power and autonomy.

In February, for instance, he unveiled a raft of new prescribing powers for
nurses while Prime Minister Tony Blair pledged greater flexibility in working
practices for frontline staff and a "highly charged debate" about how
healthcare should be funded.

Malone says she believes "wholeheartedly" that the Government is
listening to nurses and the medical profession, not least because there is now
so much at stake politically. Perhaps more surprisingly, the BMA in a
discussion document the same month said it might be prepared to abandon the
hallowed role of GPs as "gatekeepers" to the NHS in favour of a more
nurse-focused approach.

It proposed nurses could co-ordinate the care around a patient, so that in
primary care, for instance, nurse practitioners would be the first port of call
with doctors only being called upon when their skills are needed. BMA chairman
Dr Ian Bogle even conceded that those working in the NHS needed "to take a
long, hard look at how they work".

Shortage of nurses

This, of course, is all well and good in principle, but if the nurses are
not there to do the job – and 25 per cent of nurses are now aged over 50 – it
is simply not going to work. The shortage of nurses, and the need to stop the
exodus from the profession is already one of the biggest issues policymakers
need to address, Malone asserts.

"How do you convince nurses who feel undervalued that they should stay
in the profession maybe another five to 10 years?" she asks.

"I think you have to find new ways of working. I really believe that
there should be newly developed opportunities for nurses who are older so they
do not have to do the same type of work that they did when they were 21, 28 or

The age of nursing students is getting older, with the average now 25 to 27
rather than the 18-to-20-year-olds of a few years back, making issues of pay
and opportunities for career progression and lifelong continuing education even
more critical.

"The pay is the single most effective determinant of why nurses stay in
nursing," she stresses. Despite all the extra money the Government is
putting into the NHS, Malone says she is still "appalled" at how low
nurses’ pay remains.

"There has to be a big boost for nursing pay to get better. It’s not
something that can be done in little increments – I have a saying ‘it’s a cinch
by the inch but it’s hard by the yard’ – but when it comes to pay we need the
yard," she asserts.

She is also horrified by how little thought appears to go into workforce
planning for nurses, something that she believes should be top of the agenda
when there is a recruitment and retention crisis .

"I am hoping that the RCN will be able to work with the Government in
putting something together that could actually start monitoring workforce and
workforce issues. Whether it’s why people are coming back into nursing or why
they don’t come back, those sorts of questions and research opportunities need
to be available," she says.

Occupational health nurses

Despite asking for Carol Bannister, the RCN’s OH adviser, to sit in on the
interview, it is obvious that, even with all her other areas of responsibility,
Malone has made an effort to brief herself closely on some of the key areas of
concern for occupational health nurses.

"I believe occupational health nurses are some of the most required
systems thinkers there are," she argues, arguing that they often need to
take a holistic approach to decision-making.

"They have to continually assess the environment and the community.
They have to be thinking about how they can shape the response of their
corporation so that it is more accessible to the people who work there."

Not enough of this type of thinking takes place in the NHS, she adds, and
occupational health nurses could be used more to pass on best practice thinking
to, say, acute care nurses.

"What can we do in the system to make sure our patients’ stay is as
infection-free and healthy as possible, for instance. How do we make sure that
it is not complicated by other things?"

Ultimately, nurses need to stop thinking of themselves as people who simply
carry out the orders of the great and good and realise they have something of
value to contribute to the decision-making process, she argues. She cites the
example of some private finance initiative-built hospitals that have been constructed
with corridors too narrow to turn trolleys around, or where nurses cannot see
patients from their nursing station.

Malone would like to see the new strategic health authorities being set up
"clearly reflecting nursing input at every level" and primary care
trusts similarly putting nurses centre stage in the decision-making process.

"I’m talking about making sure that nurses are involved in
decision-making, shaping how care is delivered, how buildings are built and how
systems are managed. And it is not just for the glory of nursing, it is for
patient care and that’s why I feel we cannot be patient about this and use it
as a long-term goal," she says.

"I think that we should do some knocking of heads together, in a very
polite and courteous but nevertheless very clear and dramatic way, to say that
if you are really talking about building a patient-centred environment, whether
it be in a workplace or a PCT or acute care trust, it has to be that the
patient is central. Because nurses are advocates for patients and deliver 80
per cent of their care, they need to be involved in that decision-making

"It’s a wake-up call, but it’s a win for everyone. At times some people
may say ‘oh those nurses they just want more’ but it really is about changing
the system and making sure patients get what they need."

When Malone visits nurses around the country – which she does frequently –
the most common complaint is the sense of being undervalued and
under-recognised, she says. There’s a disparity between the high perception in
which nurses are held within the public eye and the attitudes of doctors,
ministers and administrators to their nurse colleagues.

"There’s a real gap between how the public views nurses and how we are
treated. There is nowhere that I go when I talk to nurses that this issue is
not raised," she explains.

For occupational health nurses this would mean being in a position where
their decisions are affecting the way their company operates, either because
they are on the board or because they have access to it.

"I would like to hear about some occupational health nurses who were
sitting on the boards of their companies having a direct way of feeding back
information about health and safety, how they save that organisation money, how
they get people back into employment and how they are planning and working to
do that successfully. To me that would be a measure of success," she says.

With the political clock ticking loudly, Blair and Milburn are men in a
hurry to see real improvements in the NHS. Equally, for Malone, getting nurses
to the table where decisions are made is a vital part of this process. It needs
to sit beside the battle for this percentage pay rise or that number of extra

"I believe it has to be short-term goal. I want to see, soon, nurses at
the decision-making table, with communities, regardless of who they are, having
an appreciation that nurses are the ones who are managing the system of care. I
think we need to be very impatient about this," she stresses.

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