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You've been working in nursing since
the early '70s. Can you comment on the changes you've
seen in health care in the last 30 years?
Three major things have occurred. [The first] is clearly
technology. Perhaps the greatest impact of technology
has been the shortened length of stay, increased outpatient
services and decreased intensity of treatment and care
following most of these procedures.
Secondly, the increasing intensity of those who are
institutionalized. And third, the complexity of the
health care system has grown considerably-complexity
at all levels: complexity of payment, service, relationship,
care and therapeutics, so that the notion of "the
captain of the ship" is simply today no longer
viable or sustainable.
"The captain of the ship"
referring to doctors?
That's right-the physician, the person who somehow
is capable by knowledge, position or role to control
all the elements of the patient's journey through the
health care system.
Much of your academic work, including
your dissertation, has focused on the idea of "shared
governance." How does this tie in as nursing looks
forward?
We could begin by observing that, structurally, the
health care system is designed to support the physician
in doing his or her work. Now the work is multifocal,
multidisciplinary and complex over a continuum where
the characteristics and the services that are offered
are so fragmented that the historic infrastructure of
health care just doesn't work.
It clearly doesn't work, and so the issue here is,
how then do we change the structure to begin to build
the kinds of relationships that are necessary in order
to respond to the need for a continuum of decision-making?
So, a less hierarchical structure?
Exactly. Eliminate the hierarchical nature and establish
relationships based on contribution, on role, on action.
And build it on accountability. Not "What did you
do?" but "What difference did it make?"
The reason I mention this is that nursing is a process-heavy
profession. You talk with nurses and you can always
hear them say what they do, how much they do. So the
volume and content is important to nursing, because
it's a part of our historical journey.
… Especially for a group accustomed
to a more subordinate role.
The fact is, we're owners in this journey. Each of
us, if we are active in it, has some ownership for it.
We're not passive, we're not subordinates, we're not
employees. We're partners in this process.
One of the disheartening things about the union movement
in nursing (not that collective bargaining isn't appropriate;
I support it 100 percent) is the whole notion that nurses
bring to collective bargaining: That "somebody
will take care of me."
And their reason for saying that is a hidden agenda
that "I really can't take care of myself. And because
I can't, let me find a third party that can take the
risks of taking care of me and prevent the obligation
that I have to fully participate and own that part which
is mine." And that's not an adequate reason for
collective action.
These are no small issues.
No, it's not a small world anymore, is it? Those four
principles: partnership, equity, accountability and
ownership are the cornerstones of the unfolding structure
of health care and of the profession's obligation to
fully participate in it. And without embracing them,
the profession becomes subordinate, loses steam and
I think places itself on a questionable agenda in terms
of our ability to be sustained in an age where the whole
process is changing.
As a nurse, my crisis is, most of what I know, most
of what I do, requires residency. Most of what's happened
in medicine doesn't require residency.
Let me give you an example: I had my appendix out when
I was 13. I stayed for 14 days. That's where you healed,
where you got care, what the technology permitted. My
nephew had his appendix out last week. He was in at
9 a.m. and home at 1 p.m., no scar, a Band-Aid over
the hole and back to school tomorrow. The question is,
where is he going to do most of his healing?
That story is representative of the major shift in
how health care is delivered and the possibilities that
are included in health care that simply didn't exist
during most of the careers of most of the nurses in
practice today.
Remember, the average age of nurses is 46, 47 years,
which means that they have spent most of their practice
years in a residency-based model of nursing care delivery.
You hear nurses mourning the loss of what was rendered
during those longer stays with phrases like "I
can't do everything I was once able to do." "The
patient can't get all the things they deserve."
And if you listen to the content of that language,
it's rife with the conflict between one model of delivery
and an emerging model that's demanding a different set
of clinical relationships. And we're struggling to make
that shift.
Another classic example: In California, where they're
establishing nurse-patient ratios … that's important
work and I would not diminish it, but I think our emphasis
on it is a classic example of misplaced energy, of passive
avoidance of the real issue. Because it's not really
how many nurses there are per patient, it's how short
a term of tenure the patient has in the institution
and what are the tools they are going to have to be
able to heal in an environment for the most part where
the nurse is not going to be.
Some of these things will be difficult
for nurses to hear. What practical words would you offer
to today's staff nurse?
I'd try to be straightforward and honest, because you
can't deal with your issues if you're not facing them.
There are three things staff nurses need to focus on.
One: "My world is changing. What does it
mean to me?" The nurse has to know that she can't
do what she once did. That's no longer a secret.
Two: "I don't have the time to do the things
I once did, because people aren't staying around long
enough for it."
Three: "I have to begin to focus on what
a person needs in the context of a short stay. How do
I unbundle the dependence on me for everything? How
do I transfer the skills I have for caring for the patient
to the patient and others in a way that allows them
to survive and heal in an environment where I am not
going to be the key player?"
These will have to be personal but
also structural and institutional changes to enable
this to happen.
Exactly. I practice on Fridays; I'm a gerontologist
and my specialty is wound care. I have to see to it
that the skills necessary for healing are in the hands
of those either who can do it themselves or who have
significant others who will be able to help.
You've said, "If you're not changing, you're dead."
Is there not some core of nursing practice that is abiding?
In this time of transformation, we have to think about
"What am I taking with me? What are those core
things in my own practice?" For me, the language
is: I have to take "care" with me.
The one thing that isn't going to change, the universal
that I am taking with me, regardless of the context,
is that I am taking this notion that "care"
is the heart of what I do. Now, what I have to realize
is that the vision and the application of care now has
changed. But care hasn't. That goes with me. But now,
I have to redefine that.
… A lot of soul searching.
That's what things are about in a time like this. And
I think this is exciting.
I hear people say that health care is worse. Health
care isn't worse. There are things that are chaotic
and complex, but if you look at the average availability
of care and service and technology, the options and
opportunities for health, long life and quality of life
are greater now than at any other time in the history
of humankind.
We have to stop saying, "Things are worse."
We have to start saying, "Things are different."
That's the bottom line.
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