INNOVATION IN NURSING: ONLY RADICAL CHANGE WILL DO
For several decades the most prestigious health and human service organizations, both public and private, have called for significant restructuring and revisioning of how health services are delivered. Likewise, environmental scientists have doggedly tried to make the case for a global response to impending environmental and ultimately increasing human, read-human health-disaster. Nursing as both an organized body of professionals and a disciplinary body of knowledge has as yet failed to address major change through major innovation. Radical change is called for, change that is not incremental or a rehashing of traditional perspectives and methods, but the change that is dramatic and abrupt, creative and feeling like a risk, one that is threatening to all stakeholders in the way great change feels at first.
Woman's suffrage, civil rights, same-sex marriage, legalization of marijuana, LGBTQ in the US military, and immigration reform are examples of areas in which only swift and abrupt change either eliminated or set in motion a path to eliminate barriers to people's needs. Ultimately, incrementality, while somewhat helpful, did not create the vast changes required in these examples. In nursing, we are well past the point for which disparate, incremental innovation is keeping up with the health needs of people and their communities. Radical change is required.
The quality of ideas and the breadth of innovation is a notion that is not given enough attention in nursing. I admire the authors whose innovations are included in this issue of ANS and nurses everywhere who struggle to make things better. Many nurses, perhaps most nurses, working today have a critique of their workplace, and they have ideas for improving or changing how things are done for patients-some things to improve patient outcomes and some things to improve the working conditions of nurses. Many are frustrated, seeing persistent problems that are not addressed, and feel unable to create change; many, most, were inadequately prepared for becoming change agents in school; most lack the key elements for change and that is the ability to critically analyze the social, political, and cultural milieu in which they work, the power dynamics of the setting, and their own power to make change. However, nurses would have to be educated during their time in school to have the skills and confidence to become real innovators. Or, practicing nurses need to form "study groups" where they can develop the knowledge, skills, and confidence to innovate. Emphasis on critical social theory, feminism, social justice, and the political, social, and economic basis of nursing and more generally, health care, would be needed. Nurses could effect greater change and greater good outcomes for a greater number of persons and communities by learning to be, and rewarded for being, imaginative, creative, and critical.
Not all ideas are good enough or innovative enough or potentially efficacious enough to achieve desired outcomes. There is a lack of imagination and creativity in advancing new ideas for how nursing is accomplished and particularly, from my perspective as a nurse educator, how nursing education gets done. There are thousands of ways to meet any desired goal. There seems to be a lack in creating truly progressive nursing care delivery and education. Even indices such as healthy people goals are chronically underaddressed and not given their due as primary foci for the profession and for professional education. We continue to support the biomedical industrial complex and fail to reject its greed-inspired tenets and inadequate solutions to human health and illness. We continue to take a back seat and not forward the nursing philosophies and holistic, humanistic, and caring agenda that most nurses value.
If so-called innovative programs such as Magnet Status Programs and the essentials by which we educate students according to accreditation standards are indicative of progress, change, and innovation, we may be in trouble. While achieving institutional recognition for indices-oriented quality improvement programs brings some changes that nurses recognize as desirable in terms of safety, quality, and improved outcomes, the primary beneficiary is the hospital. The intention is not to overhaul the infrastructure to provide innovative patient care and an environment for actual professional nursing to occur guided by nursing's extensive body of knowledge. Similarly, teaching to the test and basing nursing education standards on outmoded ideas of what the majority of persons and communities need (acute care in hospital) rather than ideas of what evidence has indicated most persons need (nonroutinized, holistic, socially critical care in community) is dangerous. We have an unhealthful and in-need populace that clearly demonstrates this position. Radical change is required.
Indeed, the focus on another "innovation" such as electronic medical records and the seeming acceptance by many nurses as they turn their face away from patients and clients toward the computer screen is a serious example of nurses not speaking up and pulling the plug on a lousy idea (or at least lousy implementation of a good idea). There may also be a widespread blind acceptance that those designing and selling these systems provide safeguards for the ethical issues of confidentiality and privacy. However, presently, electronic medical records may be a technology that is running ahead in terms of sales and implementation without necessary addressing of the ethical dimension and unthought-of potential problems for confidentiality and privacy. The motivation for institutions and organizations to accept and initiate electronic medical records primarily for cost-cutting measures trumps potential risks to patients and families. As demonstrated by the inequitable and fragmented infrastructures and systems dominating health services, it is clear that protecting profit is more important than protecting patients and improving health outcomes, safety, and quality. If designed and implemented with the patient as the clear recipient of benefit, electronic medical records could indeed be an enormous help in the continuity and comprehensiveness of health care. A large part of the "fix" would have to be disconnecting the nurse and doctor from the computer during their interactions with people so they can provide the simplest of human-human endeavors: looking at and listening to the recipient of their care.
Moreover, the money and time and effort to establish and expand simulation in education may be a misguided use of the processes of imagination and innovation. Many will not agree with this statement despite a lack of empirical evidence that demonstrates that better student outcomes are without a doubt associated with the use of simulation and not other factors of enhancing the teaching-learning process, There is no denying that practice in the simulation laboratory may be helpful to some, perhaps many students, and boosts their confidence for traditional hospital-based nursing care. However, this emphasis has trapped nursing into an acute care model, one that we need to end, and instead create a process of education and practice that is more in keeping with the ideals, values, and goals of the discipline and profession. I advocate for nurses to practice outside the hospital setting and create well person, chronic illness, and acute care community nursing venues established by, designed by, and run by nurses.
It would be innovative for nursing as a profession and for nurses to act on its/their own goals and values-those that promote health and quality of life in humanistic and socially critical ways to the majority of persons who require care where they live-in the community. Nursing innovation is when nurses take a critical approach to their enormous knowledge and talent in healing and caring and reject the biomedical industrial complex and the biomedical model for the many philosophical and scientific frameworks that reflect the reasons most nurses went into the field in the first place. My students tell me that they did not go into nursing to sit at a computer and not face the other human who has come to them at a time of health with questions and concerns or times of illness, suffering, and perhaps experiencing loss. They did not come into nursing to achieve a hospital's increased prestige achieved on the backs of nurses who are still positioned to follow doctors' orders, an archaic remnant of misogyny, classism, and professionism (professional bias, entitlement, and dominance) if there ever was one. Others came into nursing only on the basis of the cultural stereotype of the hospital nurse in white doing exactly that-following doctors' orders. However, the focus for many students is more on the opportunity to "work with people" and "care for people" but most arrive at, as well as complete, their education without any critical social analysis or awareness of the importance of such practices as working with and caring for people while being socially critical. Many graduates proceed to work and have only a vague notion of cognitive dissonance (they are not really able to be with people as they had wished) and that something is not right once they begin work in settings dominated not by nursing goals and knowledge but rather, those of the corporation and of corporate medicine.
Only radical change brought about by big innovative ideas and action can deliver a health care system and nursing care delivery that really works for both patients and nurses. And, only by becoming adept at social and power analysis can we hope to create real change. This critique requires a deep examination of the social relationships and power relationships that drive the political and economic patterns and infrastructures of health care. All nurses need to learn this in school; it should be an essential-or several essentials. The current standards lack in making nursing a critical study field, while preparing nurses to uphold their charge as care providers, healers, advocates, teachers, and reformers by the absence of social critique, and the use of social justice and nursing frameworks as the primary focus of education and thus of practice.
In 20 to 30 years, the only relevant nurses will be those who know how to organize and provide safety and urgent/chronic community care, food and water, and disaster relief supported by a sound knowledge of environmental health and disaster response and sustainability measures. This one essential aspect, recognition that the greatest threat to human health this century is environmental, is blatantly nonexistent in current preparation and practice of nurses. The number of nurse scholars developing knowledge around environmental health and sustainability is scant. However, they are disciplinary leaders, and they are innovators. The failure of most nursing leaders to imagine the future based on current environmental evidence and respond creatively and urgently toward innovation that represents radical change is indicative of how deeply ensconced we are in the agendas of big business and the accompanying greed and self-promotion of most organizations and agencies charged with the health and well-being of our citizens, nursing organizations included.
Innovation does not mean tweaking or repositioning the puzzle pieces of nurse education, practice, and research to form seemingly novel approaches. Innovation means taking a profoundly critical look at where we are and how things are done and taking the risk to abandon habits of thought and action toward true change and accomplishment that betters human health and quality of life.
-Paula N. Kagan, PhD, RN
Associate Professor
DePaul University
Chicago, Illinois