Winter 2006

One of the major struggles of the time is the failure of leadership at every level of clinical practice to develop a clear vision of the future and undertake the activities necessary to make that vision real in the lives of the staff. Nurses and other providers are stuck in service models that no longer reflect the character and content of the contemporary delivery of health service. In the past decade, much of therapeutics have become so mobile and digitalized that procedures can now be done in a fraction of the time they once were and completed with less complications and recovery time than ever before. Much of clinical practice reflects a time when patients had to stay over longer lengths of stay in order to receive excellent care enabling their recovery and return to their own lives. Today, clinical processes can be done in hours or minutes with no recovery time and an immediate return back to the activities of daily life.

These emerging models of portability and mobility require a different frame for clinical practice than many practitioners learned in their educational programs. So much of the emerging content of practice doesn’t “look’ like the practice that most practitioners know and have experienced over the life of their careers. The challenge in this scenario is that the emerging realities are creating a demand for a different foundation for practice. This new foundation assumes that the patient will not stay long and that most of the healing experience will be done in settings other than where nurses and other providers work. The chief caregiver in these settings will be significant others and other related individuals, many of whom will have no formal training in the very care they will be asked to provide. Patients will be leaving the institution and falling into the hands of these other caregivers and will be at risk with regard to the knowledge and skill these people will have to offer. Nurses and other caregivers have to recognize that their roles have changed and that offering good care to patients is not nearly as important as seeing that these patients go home and can receive competent care from those caregivers who will be providing those services in their home setting. The question for nurses and other caregivers today is no longer “ how well did I care for my patients”, instead it will be “how well informed are their caregivers and do they have access to the information and support they need to provide the necessary care and support to their loved one?”

It’s a big question for the professional caregiver regarding what the future holds for practice. Without any clear script, it is difficult for individual practitioners to be clear about role expectations. The historical behavior has been to wait for others to define the expectations for work and to simply perform within the context of these expectations. The issue in the contemporary set of circumstances is that the script is unclear and undefined and that clarity now depends on engagement by all stakeholders in a dialogue out of which will emerge some certainty regarding role and performance expectations. In addition is the consideration that emerges out of an evidence-based framework. The inexorable move toward evidence-driven systems reflects the growing dependence on the emerging digital infrastructure in health care. As information systems become more comprehensive and pervasive, the potential for establishing a clear relationship between action and outcome becomes possible. This potential places great pressure on the caregiver, establishing and evidencing a relationship between action and outcome. The problem with this potential is the demand for clarity with regard to caregiving activities and patient impact and value. The problem for most caregivers is the fact that there has been little relationship established between clinical action and direct value impact on patient outcomes. This reality creates the necessity for the caring professions to establish clear foundations in their behaviors and practices and tie those actions to impact and value with regard to patient outcomes. When that relationship is not clear, practitioners must be willing to surrender these actions and replace them with new practices that appear more relevant. This practice relativism and tenuousness is a foreign experience to most nurses and other caregivers increasing a sense of uncertainty and insecurity. However, that uncertainty is conditional and cannot be relieved simply by retreating into past practices or recidivism. The challenge of the time is to be willing to risk and test practices and establish a stronger relationship between these behaviors and patient outcomes. Informed by the veracity of the resulting data, the professions can get a better handle on those practices that are relevant and important and build an evidence-base database that can act as a testament to those practices and the value of the profession.

Fully participating in this emerging reality assures the disciplines the opportunity to evidence their value and contribution to patient outcomes. This participation must occur at every level of the health system and of the professions. Patient care is essentially local. Therefore, it is important for every practicing nurse and caregiver to more fully engage in the investigation of value-driven and relevant practices and in determining the actions that are most directly related to advancing patient care and achieving sustainable patient outcomes. The foundations of practice are bound to the technology and innovations related to clinical therapeutics. It is incumbent upon every practitioner to fully engage the issues that affect the point-of-service and demand changes in the functions and actions there. This redefinition calls every practitioner to fully participate, to engage the issues there. Someone else cannot do it for them. And to wait and hope someone else will handle the problems or issues for them without having to enter into the mix of redefinition and changing expectations is to assure certain failure. Change simply cannot be successful if the stakeholders are not a considerable part of the driving force for acting upon it.

So many times it is heard that people simply say they just want to be left alone to do their jobs. The problem with this plea is that jobs are changing and the work now includes redefining content, processes and practices. Failing to do this assures that the work these people seek to do simply won’t be there to do. Holding onto current or past behaviors simply because they are known and practitioners are comfortable doing them is a formula for failure. Depending upon one’s experience alone during a time of great change or during a paradigm change, can be the greatest impediment to creativity and to innovation and will keep people operating within the context of their historic reality, preserving the patterns of experience that may no longer fit the environment or context of work. The only way not to be imprisoned or crippled by the barrier of past experience is to couch experience in the context of contemporary demands and ask what should be sustained and what needs to be surrendered. The only way to do that is to fully invest one’s energy in the questions of the time related to work and value and to make new decisions that reflect a shifting context, new technology and evidence of value. For every practitioner, this is a clarion call for full engagement in constructing a viable and meaningful future for practice and assuring that patients continue to get what they need. Assuring the future health of those we serve is a critical foundation for all clinical practice. In the 21st Century, caregivers are presented with a new age, a changing context for practice, and a new medium for the expression of care. To thrive in these times and to assure the future of the caring professions, it is vital to embrace the obligation to participate in writing and living the new script. The future is inevitable but not guaranteed. What it becomes depends on the energy and insight creators bring to it. Don’t be left out or you just might be left out.

 

Tim Porter-O’Grady