My husband is a rabid football fan. I am not! I find it difficult to tune out the play-by-play commentary during the Sunday, Monday, and Thursday night games. This past year, for the first time, I paid attention. I was fascinated with the critique of a defensive coach who took his team on a stunning losing streak because he lacked the flexibility to adjust his theory of defensive plays to the talents of his players and to the strength of competing teams. I listened to every post-game analysis, imagining that the defensive coach would soon change his strategy. He is not with the team any longer. Someone in the front office confronted "stupidity."
James Welles1 defined stupidity as the failure to change or adjust one's cognitive schemas in the face of the ever-changing contingencies of reality. In other words, "Don't let the facts or data interfere with my theory and don't ask me to change in the face of mounting evidence." Oddly enough, stupidity is not a "lack of intelligence" or "being dumb." Intelligence is the innate ability to learn and process knowledge. There are many highly intelligent professionals in health care, but intelligence does not preclude stupidity, which occurs as a function of rigid schemas (belief systems or mental models) that do not adjust or open to divergent points of view or even to frank data. Let's examine how stupidity works in some arenas of health care.
Fifty years after the development of the nurse practitioner (NP) role and ample evidence of NPs' efficacy in generating quality patient outcomes, many physician groups and organizations still believe that NPs should be directly supervised by physicians because of a perception that NPs cannot "diagnose complex illnesses."2 This "collective schema" of some physician groups ignores the 16 states in which NPs are practicing independently and the expanded scope of practice legislation in many other states. To be fair, there are many other physicians who have embraced NPs as colleagues in providing high-quality health care and others are understandably concerned about the decline of reimbursement rates that will compromise the maintenance of practices. The complexity of this situation is astounding; problems of tradition, turf, control, economics, and quality of care. Such complexity demands a loosening of the "belief systems" and a critical examination of data so that we can move the system beyond stupid.
I am old enough to remember long discussions about whether or not a licensed practical nurse should be permitted to remove a patient's intravenous drip by order, of course. This issue related to perceived lack of quality and danger to the patient, level of education and preparation, and threats to the RN's license. And, there used to be concerns by NPs about the knowledge and skill base of physician assistants, although this seems to have dissipated with the Affordable Care Act3 and the shortage of primary care physicians looming.
My point is that we all engage in stupid thinking, in hanging on to unfounded and untested beliefs. We need to become students of our own stupidity, to question ourselves, to become more open to exploring even quirky ideas such as Florence Nightingale's use of statistics to demonstrate efficacy of nursing care. So, who ever heard of statistics in the 1860s? Nightingale raised a lot of hackles, but she had data and the will to promulgate it. So, when was the last time you were stupid? Let's see, for me it was yesterday!
-Gloria F. Donnelly, PhD, RN, FAAN
Editor-in-Chief
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