We are living in very interesting and tumultuous times with respect to healthcare. There are gads of unanswered questions remaining regarding problems that have plagued us from the beginning of time, it sometimes seems.

Let's look at how far we have come with education. Since I was in basic nursing school back in the seventies, I have heard discussion about the baccalaureate degree becoming the minimum entry into practice. It's now 2011 and we still have multiple entry points-no wonder it is difficult for nursing to be thought of as an equal with other healthcare professionals. If we do not have comparable educational preparation, it will remain impossible to interact as equal partners on interdisciplinary teams.

Everyone knows what a physician or an engineer is, however, there is no standard recognized definition for what constitutes a nurse.1 Rather than being concerned with which department or specialty the nurse is involved in, the hospital should be granting recognition for the educational credentials the nurse has garnered. Although there has been some movement toward a baccalaureate prepared staff, there are associate degree schools of nursing opening across the country, justified as needed to address the projected nursing workforce shortage. So, a nurse who graduates successfully from a 1-year technical program, a 2-year associate's degree, a 3-year diploma program, or a 4-year baccalaureate degree program is recognized by the public and healthcare institutions as a "nurse." Blurring all together ignores the huge discrepancies in educational preparation and thus, the competencies, skill functions, and responsibilities each type of "nurse" brings to healthcare. And if our healthcare colleagues and hospital administrators are this confused, just think of what the public's general opinion on what exactly a nurse is. The time to become a real profession has long been past. At a minimum, a registered nurse must have a baccalaureate degree as preparation for the high-acuity patient, population-based and community-based care, changes in technology, evidence-based practice, patient safety, and improvement of the work environment.

Perinatal and neonatal nurses tend to have strong personalities, making them often very good at socializing new staff members to adapt to the internal values and beliefs of their units. Attitudes and behavior toward safety are also strong influencers such that there is an identifiable climate of work processes.2 Improvement of the work environment would be a major step in decreasing unintended harm and medication errors, and improving patient safety. Decreasing resources may translate into an excessive workload that affects both patient safety and the well-being of the nurse. However, workload is typically defined in terms of staffing ratios and patient acuity, despite the fact that these factors are not representative of what nurse believe or perceive their workload to be.3 Why not gather staff nurses together and ask them what their construct or concept of workload is? There are days when I feel like I have worked my butt off, but not because I am providing "hands-on" care constantly. Trying to track down laboratory values, find a pneumatic tube, run to the main supply area, contact the blood bank because blood products still are not here, calling the pharmacy for the third time because a medication hasn't been delivered, and having a pod-mate that doesn't volunteer to assist is all exhausting and frustrating.

I can definitely tell you about workload! Taking care of the baby sometimes is the easiest part.

One of the biggest improvements in patient safety that I would personally like to see made is to stop interrupting a nurse while she/he is delivering patient care. I am not sure when that became acceptable or typical behavior. No one would simply walk into my academic office and just start talking while I was engaged with a student. Do pilots get interrupted as they begin to focus in on the landing strip? If the hospital institution really believes that patient care is a priority, then it should not have a policy in which a nurse is to answer the phone within 3 rings. To do this, the nurse must stop what she is doing, close the incubator doors, remove the gloves, alcohol sanitize her hands, and then answer the phone. I have heard "Now what was I doing?" too many times after the phone conversation ends. Keeping patients safe is really a basic nursing responsibility. The risk for an untoward event is increased, especially if the nurse was in the midst of administering medications or providing a treatment. I have looked at the literature and can't find information related to interruptions-a field ripe for nursing research.

There are numerous other areas that are just calling out for nursing research as they relate to patient safety and the work environment. For example, why aren't known risks acted on, when do overworked staff make the most clinical errors, how can inadequate communication between nurses and healthcare providers be improved upon, and what strategies can best identify early warning signs of an impending error such that effective responses can mitigate the error? Human factors research is a very important part of patient safety and the nursing work environment that may be best investigated by doctorally prepared nurses familiar with the risks and the flaws of these patient care systems.

We are also challenged today by the changing healthcare environment. The astute nurse must be aware of the controversies surrounding the Affordable Care Act. One of the changes is moving to value-based purchasing, which will link payment to performance.4 The exact details of implementation are as yet unknown, but there will be rewards or penalties based upon relative performances to quality metrics. Hospitals voluntarily report to the Hospital Compare database (also known as the Reporting Hospital Quality Data for annual Payment Update program) data related to process-of-care measures, outcome-of-care measures, patient survey data, and Medicare payment and volume.4 This process is likely going to cost some money, as hospitals attempt to improve their quality scores to achieve bonuses. In this time of fiscal restraint, where in the hospital budget is this money going to be found? My fear is that the cost of nursing, often seen as a fiscal liability because it comprises the largest part of the operating budget, will be the target. Over the years, there has been less and less money spent on continuing education for nurses. In addition, salaries for senior bedside nurses are really not all that much different from the novice nurse, and supplies and hospital resources are often time diminished. Will strides to attain added quality cost so much that the quality of nursing care, the work environment, and patient safety be at risk?

In this 25th anniversary year of JPNN, I want us to be proud of the advances nursing has made. However, many of the 25-year-old issues are still the same. I challenge you to examine your thoughts regarding entry to practice, the work environment, patient safety, and the changing politics of healthcare. I want you to begin to think of solutions to our 25-year-old problems, and begin testing those ideas and implementing strategies that encourage positive change, so that when another 25 years comes around, we can proudly say those problems have been laid to rest. Then we can concentrate on the opportunities and challenges with nursing and patient care controversies we haven't even begun to think about.

-M. Terese Verklan, PhD, CCNS, RNC

Neonatal Clinical Nurse Specialist

Neoconsult

Misspuri City, Texas

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