AACN News—June 2000—Opinions

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Vol. 17, No. 6, JUNE 2000


President's Note: Pioneering in a World of Innovation

Anne W. Wojner, RN, MSN, CCRN
President, AACN

Editor’s note: Following are excerpts from the presidential address delivered by AACN President Anne W. Wojner, RN, MSN, CCRN, at the opening session of the National Teaching Institute and Critical Care Exposition in May 2000 in Orlando, Fla. A printed transcript of the speech is available from AACN. Call (800) 899-2226. Ask for Item # 7010.

Charlie was 21 years old when she entered nursing. She had wanted to be a nurse for as long as she could remember. The reason was simple: Charlie felt a deep, personal connection with what she believed nursing was about—caring
for others.

For more than 20 years, Charlie exemplified the beauty of critical care nursing as she blended the art and science of our role into masterful human caring.

One of Charlie’s patients may have described her best when he said: “Charlie gave me the will to live. She passionately cared for me; she saw beyond all the equipment and machines, and nursed me with her heart and soul. I will never forget, nor will I ever be able to repay the gift of her loving spirit, her tender smile and her ability to comfort me at my darkest moments.”

This tribute came at Charlie’s funeral. She died recently, after a difficult battle with breast cancer.

Charlie asked me to give you this message: “Life is the most wonderful gift, and to be a nurse, touching the lives of so many others, is by far the most significant of roles. You have but a precious small amount of time here on this Earth, and it is not by chance that each one of you became a nurse. Don’t waste your time here in frustration and anger. Pull together, support one another through difficult times and, most of all, stay focused on caring for our patients. You should be so proud of what you do everyday.”

Charlie’s love for our profession permeated everything she did and all that she was. She had an uncanny ability to turn on a dime; to embrace change; and to question practice, while constantly seeking information to improve her performance.

Most of us entered nursing supported by the same values as Charlie. Although some of you are just beginning your careers, most of us have been trekking along this path for quite some time.

We prepared ourselves for our careers as best we could, as we set out to meet an unknown practice terrain. We armed ourselves with education, team spirit and enthusiasm, as well as with a belief that we would make a difference in the lives of others. However, we were unaware of the many challenges, hurdles, heartbreaks and demands that lay ahead.

Entry Into Nursing
We faced one of these hurdles as soon as we graduated from nursing school. Because of the diversity of nursing education programs, some of us, including me, graduated from diploma schools; others from associate degree programs. Some entered nursing with a baccalaureate degree. At the time, we did not know that entry into the profession through diploma and associate degree programs would limit our ability to advance, or that many doors to future career development would remain closed unless we returned to school.

I find it inexcusable that we have yet to resolve our entry into practice issues. Our inability to commit to the baccalaureate degree as the minimum preparation for a career in nursing leads our future colleagues down a frustrating pathway. The entry requirements for nursing are among the lowest of the health sciences. It is time to stop allowing entry through a path that promotes frustration and does little to enhance the science of our work. Let’s stop setting each other up for failure.

Technology and the Pace of Change
The pace of change today is accelerating. The growth of technology in my 22 years as a critical care nurse is breathtaking. The proliferation of technology in critical care settings has, in some cases, blurred the lines between life and death. Many of us struggle each day in our ICUs with ethical issues regarding the delivery of futile care. As nurses, we are often caught between questionable medical care decisions, family crises and inappropriate communication about what can and cannot realistically be accomplished for our patients.

Seasoned critical care nurses can accurately predict which patients will die, in spite of medical science’s best attempts to keep them alive. We know which patients will be left with devastating disabilities because of ambitious and often inappropriate resuscitation attempts. We also must deal with the emotional and physical pain and suffering that is inflicted by fruitless efforts to sustain life at all costs. This type of knowledge is one of the most heartwrenching aspects of our roles.

Hospitals were created to provide nursing care, and it is time that our concerns for quality of life be heard and valued. In trying to cut costs, downsizing nursing staff—the only 24-hour support system that patients and families have—instead of dealing with futile care delivery that promotes suffering and drives annual costs into the millions, just doesn’t make sense. If we truly want to reduce healthcare costs, we must tackle the difficult political problem of substandard medical practices and inefficient systems.

The Science of Nursing
Through the years, we have seen practice myths that we once held “near and dear” replaced by improved techniques and methods. The science governing what we do each day has grown significantly in just a few years.

Although nurses at all levels are scientists, we often fail to think of ourselves, describe ourselves or project ourselves as scientists. Where are you on the novice-to-expert nursing science continuum? I can vividly recall times early in my career when I thought I had achieved expert status. Then, I would meet someone whose ability to synthesize science and integrate it into practice amazed me.

Specialization in nursing has narrowed our boundaries, increasing our need to collaborate with experts in other practice areas. We cannot possibly know everything, so we walk a dangerous path, if we think we do. True expertise is gained only through years of study and practice that include support by expert mentors; a commitment to lifelong learning; a humility that allows us to recognize our boundaries and limitations; and an approachability and willingness to change.

Use Research
Unfortunately our practice doesn’t always mirror current science. For example, why do some of us continue to use saline in endotracheal tubes when we suction? Why do some of us still refuse families access to their loved ones in our ICUs? Why do some of us starve patients for days, when even the layman knows that nutrition promotes healing?

The unfortunate reality is that some of us still are not routinely using the knowledge generated through critical care nursing research, which is tragic for our patients and families. It is time to pull together and learn to reject the proliferation of practice myths.

Often, we avoid using research in practice, because we lack understanding of research design and the statistical processes. However, there are user-friendly resources, many developed by AACN, which can be used to decipher research and determine if it is ready for use in practice.

At times, we avoid basing our practice on research, because the politics of change in our environments may involve a nonscience-based practice standard that has been imposed on us by another discipline.

I just have to ask: “Whose profession is this, anyway? “Nursing must set the standards that support how nursing care
is provided.

We must also commit to showcasing the scientist within us to those in our service. Why don’t we routinely project ourselves as nursing scientists? Why do we hold to a tradition of withholding information that is within the realm of our scientific boundaries until we are given permission to share it? Perhaps, we are too humble. However, our humility does not serve us well when patients and physicians, as well as our own family members, cannot even articulate what it is that we do as nurses. If we are to truly overcome the “bedpan” image, we must make the science base that supports nursing practice visible to our colleagues in complementary disciplines, and to our patients and families.

Master the Art of Nursing
We must also be committed to mastering the art of our profession. The word nursing is derived from the Latin word nutrire, which means “to nourish.” Nurturing implies an ability to care for, sustain and provide for another. Critical care nurses are privileged to care for people at the most vulnerable and intensely private time in their lives.

Nurses share intimate, joyful, painful and fearful moments with highly vulnerable, complex patients and their families. When we judge the importance of care events by their labor intensity, and fail to recognize that every health-related moment is a significant event for the patient, we lose sight of the gift of our art. Patients and families want to share their fears and be supported by nurses. We, in turn, must reflect on our ability to provide this essential service, and commit to mastering its execution.

The Image of Nursing
In her book, Life Support: Three Nurses on the Front Lines, Suzanne Gordon says: “If more nurses insisted on being heard …it not only would transform the public image of nursing, but our view of what is and is not important in healthcare.”

The findings of repeated studies of what patients want most from the healthcare system are no surprise. They want to be acknowledged as individuals who have full lives; they want to be respected; they want to have input into their care; they want clear communication regarding their health status; they want honesty; they want competent caregivers; and they want to feel that someone truly cares about them.

Shortly before his death from prostate cancer, writer Anatole Broyard wrote: “I wouldn’t demand a lot of my doctor’s time. I just wish he would brood on my situation for perhaps five minutes; that he would give me his whole mind just once; be bonded with me for a brief space; survey my soul as well as my flesh to get at my illness … Just as he orders blood tests and bone scans of my body, I’d like my doctor to scan me, to grope for my spirit as well as my prostate. Without some such recognition, I am nothing but my illness.”

Our patients hear us when we dare to really care, even when we don’t say a word. This is a powerful nursing image, not something invisible. It is the image of the nurse I want caring for me; it is the image of a nurse we should all hope to be.

In her book, Nursing the Finest Art: An Illustrated History, M. Patricia Donahue writes: “Nursing is not merely a technique but a process that incorporates the elements of soul, mind and imagination. Its very essence lies in the creative imagination, the sensitive spirit and the intelligent understanding that provide the very foundation for effective nursing care.” Nurses provide safe passage for their patients through an increasingly complex healthcare system.

The Journey Ahead
Although our journey as nurses has taken us far, we still have a long way to go. Nursing is a profession that is concerned about healing and caring. Yet, we are often far from caring to each other.

Falling down and getting bruised are a part of nursing today. However, if we are to reinvent and explore new ways to optimize our practice, we must become adept at taking falls, dusting ourselves off, reassessing our situation and climbing
back into the saddle.

Often, the ones we hurt most are the brave souls who dare to tell the truth about how difficult it is to practice nursing in 2000, as they offer suggestions for improvement. Hospitals could save millions of dollars each year in consulting fees if they would simply listen to their nurses.

At the same time, we need a new breed of administrator, who is willing to don scrubs and spend a day in the practice arena to learn what it is like to walk in a staff nurse’s shoes. Administrators who take the time to know what we know are powerful advocates for excellence in nursing practice. Making changes that affect nursing practice without understanding today’s realities is dangerous to both nurses and their patients.

The bedside nurse should be a partner in constructing practice change, instead of a victim of poor planning.

A Teaching Renaissance
To meet the demands of tomorrow’s world, nurses must commit to an academic renaissance. Because nursing
is a practice profession, nursing educators must demonstrate expertise in the practice of nursing.

Why, in schools of nursing, is status often associated with movement far from the bedside, while, in medical schools, this movement translates into irrelevance and termination?

The greenest, first-semester nursing student who has never touched a patient can easily spot an “imposter” faculty member. If we are to ensure nursing excellence in the future, nursing faculty must be expert clinician-scientists who practice on a
regular basis.

Nurses as Pioneers
There are numerous examples in our rich history of nurse leaders who were truth-tellers and change agents, individuals who risked their lives, public ridicule and their reputation because they believed that change was necessary.

History has generously remembered our great leaders, who recognized that the synchronicity around them was not just happenstance, and who found new meaning in every interaction. They endured and continued their struggles to bring to light a new and better tomorrow for us today.

Nursing needs courageous pioneers who will continue moving forward despite tremendous resistance. We must adopt methods that allow us to celebrate mistakes and be thankful for our progress. Being a critical care nurse requires
tremendous courage.

Tear Down Barriers
In 1861, Florence Nightingale wrote: “… resignation in a nurse [is] contemptible.” We must not be resigned to unacceptable changes that jeopardize our practice. Barriers that limit progress must be torn down.

What are these barriers? Following are some of the barriers that you told me about during my travels as your president the
past year:
• Lost recognition of the importance and significance of holistic nursing care
• Nursing apathy and negativity
• Invisibility of our contribution to patient care
• Stigma attached to nursing’s image
• Lack of a collective voice and support for one another.

The plan to tear down these barriers is simple. Start by caring for each other and celebrating the wonderful gifts we give to patients and families. Congratulate each other for the healing that saved a patient’s life; for orchestrating an environment of comfort for a beautiful, loving death and support for a grieving family; for easing the pain of a recovering patient; and for helping someone cope with the terrifying fear of critical illness. The artist’s loving care, and the scientist’s commitment to improving practice combine to provide the gift of nursing, a gift unparalleled by any other healthcare provider.


A Love of Nursing
In closing, I want to share some final thoughts about Charlie. Over the past few years, we have lost many gallant, dedicated nurses to early deaths from cancer, stroke, trauma and cardiovascular disease. Each of our “Charlies” wanted more from us than passive acceptance of the turmoil and confusion around us. To the end, they stood for a commitment to change, resiliency and love for this profession.

Some of us are fighting Charlie’s fight today. We want our patients to be comforted by the knowledge that we will be their advocates and their light in the darkness of what can be a terrifying and lonely healthcare experience.

As Charlie said, each of us is here for a reason and, for us, being a nurse is a part of the plan.

We love nursing. However, we are unhappy when dangerous decisions, made by forces more concerned with the “bottom line” than human life, affect our practice and our ability to meet the needs of patients and families. Instead of directing our anger at our noble profession, we should use our energy to make clear the value and gifts that are associated with nursing.

Nurses are everyday heroes. However, we often overlook the significance of our heroic acts, because of the regularity with which we perform them. If we would pause to look into our patients’ and families’ eyes, we would see how important and significant a role we play.

You are and always will be the most essential contributors to patient care. Celebrate your failures, rejoice at new learning and, most of all, care for each other as you continue to impart your gifts to the world. Your gifts to the lives of others are a magnificent blessing, and your nursing career is truly a great adventure.

Letters

Quit Following Misguided Rules
To President Anne Wojner:
I applaud your recent “President’s Note,” titled “Why Do We Do the Things We Do? Stop the Carnage of Nursing Research (AACN News, April 2000). I have practiced in critical care for 19 years. The longer I practice, the more of these “misguided rules” I quit following, though not without a great deal of grief from many of my coworkers for not doing things “the way we always have.”

You are a great leader and example for all critical care nurses. Keep up the good work.
Linda Schweke, RN, CCRN
Springfield, Mo.

Never Relax the Standard of Care
I was disappointed with part of an answer to a question in the Practice Resource Network column in the March 2000 issue of AACN News.

The question was whether there are standards for minimum care activities when a critical care nurse is asked to care for three or
more patients. Although I agree with the first part of the response that certain activities must be carried out regardless
of staffing, I believe the writer later lost sight of the question and why we are nurses in responding that “in trying

times such as these, we may need to relax our picture of what ‘good care’ looks like.”

Nurses, not just critical care nurses, have always set high standards for the care they provide to their patients. We work long hours so that our patients receive the best care possible. This is what is expected by the hospitals we work for, by
the physicians and other allied health professionals we work with, by the patient’s family members and friends and, most importantly, by the patients themselves. We cannot relax our picture of what good care looks like, because providing good care is what nursing is all about.

We need an organization that will help us move forward. It is my hope that we can work together to develop a better method to staff our demanding ICUs, so that we don’t have to relax our picture of what good care looks like. Although patients are sicker, our staffing patterns haven’t changed to meet the demand.

If we are asked to relax our picture of what good care looks like, how long will it be before we have to step aside to allow nonlicensed
personnel to automate a non-caring healthcare system?

Thomas A. Hubbard, RN, BSN, CCRN
Middlesex, N.J.