In Pursuit of Nursing’s Preferred Future

Actually achieving our preferred future

by Angela Barron McBride

The future we’ve long anticipated may be closer than you think.

Nurse with child patient Suppose you were told that nurses could finally achieve their preferred future—being perceived by patients and professionals alike as knowledge workers, described by the Institute of Medicine (IOM) as providing the leadership essential to quality care, and applauded for their contributions to fiscal health through their clinical use of best practices. Would you believe you had died and gone to heaven? Such a heavenly scenario just may be possible in this, the “Decade of Health Information Technology.”

The truth of the matter is, professional nursing has long held goals that were never fully achievable before the informatics revolution currently taking place (McBride, 2005). We’ve long been held responsible for ensuring safety, coordinating care, utilizing research findings and evaluating outcomes, but we have not had the systems in place to make that really happen.

The emphasis in nursing, heretofore, has been largely on the individual nurse interacting on a one-to-one basis with patients and their families to meet their particular needs. If a mistake was made or a need unaddressed, the nurse was personally responsible, not the system. Though nurse managers and executives were expected to facilitate the work of individuals, those administrators were themselves hampered by a lack of standardized measurements and outcomes that would enable them to encourage their staffs to be accountable for their practice.
A new way of thinking is taking shape, and it is full of enormous promise. Without discounting the importance of individual responsibility or one-to-one relationships, quality care is increasingly seen as a matter of healthy work environments. The IOM’s report To Err Is Human (2000) noted that individuals can only be successful if processes are in place that enable them to succeed.

To do no harm, historically regarded as an individual responsibility, should be updated to emphasize safety as a system property (IOM, 2001). To make that happen, utilizing informatics was described in subsequent IOM reports as a core skill all health care professionals should have in the 21st century (2003), and nurses were urged to provide leadership in establishing safety as a system property (2004).

Soon thereafter, the American Association of Critical-Care Nurses (2005) published standards to promote such healthy work environments. Skilled communication, with particular emphasis on access to communication technologies and proficiency in their use, was listed as the first standard because the number one root cause of serious mistakes is poor communication.

Nurses have a long history of mastering technology, e.g., using countless machines and surveillance systems. What makes the current situation dramatically different are several things: 1) technology heretofore was largely an “add on” that did not change core practices; 2) it was always possible to work in a part of nursing in which technological advances were minimal; and 3) nurse informaticians seemed a rarified group not absolutely necessary to nursing’s day-to-day work.

Information technology (IT) is no longer an “add on.” It is essential to functioning as a knowledge worker and facilitating health literacy in patients and their families. The electronic health record (EHR) is on its way, making all aspects of assessment, intervention and evaluation electronic as well. Consumer and professional education is increasingly Web-enhanced or Web-based. Critical-care nurses and hospitalists consulting electronically are teaming up with ICU staff on the floor to provide seamless services.
No setting will escape the changes ahead. Smart technology will unobtrusively monitor at a distance changes in an elder’s daily living activities, permitting seniors to obtain watchful help without leaving their homes. Not only is nursing education making use of the full array of information technology to provide access and interactive learning—e.g., webcasting, simulations, personal digital assistants (PDAs)—but consumer education is doing the same. The nurse executive may hire others to manage the specifics of technology, but he or she still needs to know enough to write job descriptions and make IT purchasing decisions.

All nurses need to be able to:

1) communicate electronically through e-mail, listservs, file transfers and the like;

2) employ word-processing, presentation and data-analysis software to transform ideas and data into information and knowledge;

3) make decisions using internal information systems and data available on the Internet;

4) understand security, ethical and legal issues related to information technology; and

5) increase access to reliable information for patients and providers.

In addition to these generic competencies, we need to increase exponentially the number of master’s and doctorally prepared nurses specializing in informatics, so they can represent nursing’s
clinical perspective when new systems are designed and installed.

It would be a mistake to see the changes ahead as an intrusion, though they may feel that way to those already leading too-full lives. They will surely be an intrusion if existing practices are merely automated, because changes in service that maintain the status quo are not likely to realize our preferred future. But more of the same is not the promise of either IOM’s quality reports or the informatics revolution.

The changes ahead represent an opportunity for nursing to achieve its preferred future, because the paradigm shifts taking place reflect the ascendancy of longstanding (but not always realized) nursing values, e.g., a systems orientation, support of patient self-management, care that is coordinated across settings, cooperation among clinicians as a priority, an emphasis on just-in-time learning, and care that is customized according to patients’ needs and values.

The chart below summarizes some of the shifts in emphasis currently taking place in health care. Note that the focus is on patient safety, quality improvement and best practices. While nursing has long subscribed to those values, the profession has not always emphasized practices that lead in those directions.

Health care’s shifting paradigms

From process orientation (what professional is doing)
to outcomes orientation (value of what professional is doing)

From focus on provider-patient relationship
to focus on work setting as a learning organization

From do no harm as an individual responsibility
to safety as a system concern

From caregiving that is time and place bound
to caregiving with time and place limitations removed

From focus of care that emphasizes patient compliance
to focus of care that emphasizes best practices

From workarounds being the norm
to crucial conversations being the norm

From decision making based on training and experience
to evidence-based decision making

From organizations that encourage professional silos
to organizations that encourage interdisciplinary collaboration

From seeking cost reductions
to continuously decreasing waste

From emphasis on discharge planning
to emphasis on lifestyle change

For example, the emphasis on the nursing process and the nurse-patient relationship may have inadvertently made us less prepared for today’s emphasis on outcomes and the obligation we have to transform our work settings into learning organizations. Our pride in being “high touch” may get in the way of seeing opportunities in telehealth.

The informatics revolution is an opportunity to really achieve our preferred future. Developing and using information systems to our patients’ advantage are more important than many of the tasks that we have come to believe constitute the essence of nursing. Lest we feel undone by the changes ahead, we would do well to recall that most of what Florence Nightingale did in establishing modern nursing involved promoting healthy environments. We are being asked to do the same. RNL

Angela Barron McBride, RN, PhD, FAAN, recently received two honors: the Lifetime Achievement Award (at left) from the Association of Fundraising Professionals, Indiana Chapter, and the 2005 Indiana Women of Achievement Award from Ball State University. She is distinguished professor and university dean emerita at Indiana University School of Nursing.

References:

American Association of Critical-Care Nurses. (2005). AACN standards for establishing and sustaining healthy work environments: A journey to excellence. Aliso Viejo, CA: Author.

Institute of Medicine. (2000). In L.T. Kohn, J.M. Corrigan, & M.S. Donaldson (Eds.), To err is human: Building a safer health system. Washington, DC: National Academy Press.

Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.

Institute of Medicine. (2003). In A.C. Greiner & E. Knebel (Eds.), Health professions education: A bridge to quality. Washington, DC: The National Academies Press.

Institute of Medicine. (2004). In A. Paige (Ed.), Keeping patients safe. Transforming the work environment of nurses. Washington, DC: The National Academies Press.

McBride, A.B. (2005). Nursing and the informatics revolution. Nursing Outlook, 53, 183-191.