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Women hold up half the sky

2009; Wiley; Volume: 56; Issue: 4 Linguagem: Inglês

10.1111/j.1466-7657.2009.00781.x

1466-7657

Edward J. Halloran,

Primary Care and Health Outcomes

Dr Edward Halloran, RN, MPH, PhD delivers the Virginia Henderson Lecture at the 24th ICN Quadrennial Congress in Durban, South Africa. Edward J. Halloran, RN, MPH, PhD delivered the Fourth Virginia Henderson Lecture at the 24th ICN Quadrennial Congress on 1 July 2009 in Durban, South Africa. The lecture honours Virginia Henderson, an American nurse who made an extraordinary contribution to nursing and health. Like Florence Nightingale, she moved nursing forward as a respected profession based on the science and art of caring. Dr Halloran is a scholar of Henderson's writings and their implications for public policy. Following is an excerpt from the lecture. The English word nurse is used synonymously with the word woman. Most nurses are women and where pronouns are used in the singular, the nurse is invariably referred to as she. This may seem natural to many of you but to me it does not. I am from a very unique situation in both time and place. Ours was a time of enormous privilege for men. Education, pay, position and opportunity were all disproportionately given to men, even when the work was performed by women. Hospitals, the locus of health care in America, were and are dominated by elite men. After 35 years of study of patients, their nurses, and the agencies we work for – I have come to believe that men have failed us. Women offer us all hope for a better future. For centuries women of the world have been denied substantive education, except for nurses. The education has been meager and reluctantly given, but nonetheless, it places nurses in a unique position. If women are to lead, nurses, by reason of their education, must lead women. The thread that holds this essay together is the tension or structured conflict between men and women that exists in health care around the world (Rosenberg 2007). This conflict was to some extent considered by Nightingale (1863), and she described it best in her appendix to Notes on Hospitals, 3rd edition. She said the best interests of the sick were served by a perpetual rub between nurses and doctors and between hospital administrators and nurses. This disagreeable collision keeps all belligerent parties to their duties and reflects beneficially on the interests of the sick. She added that the threat of publicity is the best guardian of the interests of the sick. Her remarks are a far cry from the collaboration and cooperation that many seek from nurses. Four areas, prevention versus cure, modern nursing versus medicine, human needs versus disease classes, and the International Council of Nurses (ICN) versus the World Health Organization (WHO), deserve further scrutiny here. I hope this publicity will serve the interests of both the sick and the well (Henderson 1960). Our health care challenges throughout the world will not be managed by medical science alone (Rosenberg 2007). One need only look at the HIV-AIDS pandemic to see the cost in human misery of waiting for a cure. Dr Sheila Tlou, ICN's second Virginia Henderson lecturer, writes of her frustration with medicine and men when Botswana's citizens suffered while waiting for science to stop the disease. (Tlou 1996, 2001) Dr Tlou knew then and knows now that prevention stops HIV-AIDS. She knew, too, that if the disease were to be prevented, nurses would have to play an enormous role (Tlou 2001a). In the words of Virginia Henderson, the nurses would help people, sick or well, perform activities contributing to health where individuals lack strength, will, or knowledge. We should have brought – we should still bring – our army of nurses and women to bear, specifically with our interventions, encouragement and education. The HIV-AIDS scourge can conceivably be eradicated through prevention in a generation. Who needs a cure when disease can be prevented? Florence Nightingale faced the same obstacles from men of science during her active career. As a sanitarian she observed and participated in sanitary improvements on the health of soldiers and measured the effect of these improvements on the British Army. Her most important writing concerned the protection of the British Army from preventable disease (Nightingale 1858). In America, after Harriet Martineau (1859) published a book based on Nightingale's Notes on the British Army, ladies of the Women's Central Association for Relief formed the United States Sanitary Commission (Halloran 2002). This voluntary agency used Nightingale's sanitary science, along with an inspection form she developed for India, to teach Union officers in the Northern Army to prevent disease (Stille 1866). The disease mortality the Union Army experienced was one fourth of what the British Army had encountered less than a decade before. During this remarkable period of writing and reform, Nightingale (1860) prepared her most famous document, Notes on Nursing. This work has much more to do with prevention than with relief. In the ensuing decades most nursing has stressed relief. Nightingale believed that less relief is needed if illness is prevented. Virginia Henderson knew that the antibiotic changed medicine and nursing. She noted the need to reformulate nursing and distinguish the nurse's role from the physician's. At the end of the Nightingale era, in 1950, Henderson took up the cause. She spent five years completely revising a textbook, Harmer and Henderson's Textbook of the Principles and Practice of Nursing, 5th edition. How was nursing perceived when Henderson began her revision? Mostly, nurses were the performers of skilled procedures learned in apprenticeship training on hospital wards. Henderson's genius not only extended the emphasis on nurses' performance of skills but now contextualized them. Nurses learn to perform procedures for patients but do so only when individuals lack the strength, will or knowledge to perform the tasks themselves; even then, they do so only until individuals gain strength. Henderson's emphasis on rehabilitation and the independence of patients from nurses was one major difference between the 5th and previous editions of her textbook. Virginia Henderson virtually redefined modern nursing yet maintained continuity with the past. We have begun to measure the effect of encouragement and support in randomized controlled clinical trials with some interesting results. Two research teams have more recently used Henderson's formulation as a jumping-off point for more detailed studies. Dorothy Brooten et al. (1986) and Mary Naylor et al. (1999) have published reports of interventions used by nurses to support and educate patients and their families. Their findings are consistent even among such diverse populations as premature infants (and their parent[s]) and old sick people with heart disease. Individuals and their families do better with support and education from visiting nurses than do those who receive more hospitalization, more physician visits and more long term care institutionalization. David Olds et al. (1997) and Harriet Kitzman et al. (1997) and their colleagues are revolutionizing the prenatal, infancy and early childhood experience of first time mothers with home visits by nurses who give encouragement, support and education. Research reports describe families receiving intervention from nurses as being better off according to a number of social measures than are those not provided the service. The Nurse-Family Partnership Program has now been adopted for use in a wide variety of American states and counties (Boo 2006). Both of these investigative teams have been implicitly testing Henderson's theory that support and education reduce dependence. Both teams have prevented problems from developing – problems that have caused control group members to suffer in comparison. Over her very long and active professional life, Virginia Henderson had many opportunities to reflect on her theory and her writing, and she chose not to change the description of nursing she authored for ICN (Henderson 1991). As a textbook author, she relied on writers who were both scientists and clinicians and who used peer review practices to prepare our professional literature. Henderson uniquely knew this literature as she had indexed all the papers by nurses and about nursing written in English from 1900 to 1975 and used her vast intellectual powers for synthesis (Henderson 1963, 1966, 1970, 1972). Henderson read all that was written about nursing in English and organized the material so that it could be taught and learned. Of note here is the enormous amount of professional literature she reviewed. The clinical papers and research reports were written mostly by women who had been deprived of education on anywhere near parity with men. We should all celebrate the depth, scope and richness of our literature, accumulated against all odds for well over a century after Nightingale's informed reports. The knowledge made available to us in our professional literature and her synthesis is what enables nurses to offer a desirable service to patients, with or without doctors, in hospital or not. Nurses must have parity with physicians in accessing and helping people become more independent in activities contributing to health, its recovery, or to a peaceful death. Physicians, too, want independence for patients but use medicines and surgery to achieve it whereas nurses use strength, encouragement and support, and teaching to achieve independence. I agree with the British Medical Association, which recommended that patients see nurses before they see doctors (BMJ News Roundup 2002). Needed now is a system for classifying patients to take advantage of developments in digital communication. Bethina A. Bennett was principal nursing officer for the Ministry of Labor and National Service in Winston Churchill's post-war English government. Responsible for nursing manpower issues in a country that had just adopted the National Health Service, Bennett was required to describe who nurses were and why they were needed. She found her answers in Henderson's 1955 textbook and advocated in Nursing Mirror that British nurses read, understand and consult this ‘most stimulating’ book (Bennett 1956). Bennett went further. As chairwoman of the ICN Nursing Service Committee, she commissioned Henderson to write Basic Principles of Nursing Care. The first draft of this significant document appeared in a seven-part series for the 1958 Nursing Mirror. ICN refined this draft through a feedback process and published it in 1960, 100 years after the appearance of Nightingale's Notes on Nursing. The importance of this intellectual endeavor, coming on the heels of the widespread use of the antibiotic and the development of the National Health Service, cannot be overstated. Henderson expanded her description of nursing by adding 14 fundamental human needs: breathing, eating and drinking, eliminating, moving, sleeping, dressing, maintaining temperature, keeping clean, avoiding danger, communicating, worshiping, working, playing, and learning. ICN's Basic Principles of Nursing Care comprised the depiction of these human needs and the nurses' activities in helping individuals meet them, especially when modified by conditions like age, temperament, social and cultural status, and physiological and intellectual capacity, as well as by pathological states. ICN's Basic Principles of Nursing Care was a sensation, was translated by ICN member states into 30 of their languages, and helped standardize the nature of nursing. Henderson, too, went further and wrote a new edition of her textbook, a job she undertook in her 73rd year. Published in 1978 when she was 81 years of age, the 6th edition of Principles and Practice of Nursing was written around the fourteen-human-needs she had detailed for the ICN. John D. Thompson, RN, my teacher and a Yale nurse, introduced me to Virginia Henderson in 1975. Thompson was known principally as the finder of diagnosis related groups or DRGs, which are used now for budgeting hospitals and health services (White 2003). Henderson was writing the 6th edition of Principles and Practice of Nursing without reference to disease at the same time Thompson was creating the DRG system based on disease diagnosis and treatment (Henderson & Nite 1978). Together, these two great Yale nurses created in me a schizophrenia from which I am only now recovering. Using Thompson's logic, all institutional nursing flowed from disease specificity – when the disease was known and the treatment started, and DRG assigned, the nursing care (and payment for it) was standardized. Henderson thought differently. To her, human needs were fundamental, and needs were always affected by social and developmental factors and sometimes modified by pathological states. These differences in perspectives are no small matter. In some countries nurses do what they are told by physicians, whereas in others nurses see patients independently of doctors and hospitals. Then, as now, it is imperative to describe both what nurses do (their unique function) and how much time it takes the qualified nurse to perform in a predictable way to help people with specific needs become independent in their performance. My own quantitative research addressed both the time spent by nurses with patients and the time patients spent in hospital (Halloran et al. 1988). In both cases, variations in time were better explained by nursing need than by DRG. The results led me to conclude that if patients are admitted to hospital by physicians, nurses should discharge them. I also found further evidence that universal human need triumphed disease. When people neared death they acted more alike than as members of their respective disease groups. Nurses, too, were adept at identifying which hospitalized patients were likely to die. Just as nurses should discharge hospital patients, so too ought they to organize end of life care under ICN's Basic Principles of Nursing Care's mandate on helping individuals experience a peaceful death. Of all health professionals, only nurses have specifically identified peaceful death as a domain for practice. Dame Cecily Saunders of the UK and Florence Wald in America, both nurses, embraced end of life care through their writings on the modern hospice movement. ICD and DRG labels do not explain why nurses spend more or less time with patients. ICN's Nursing Service Committee asked Henderson to explain the standards for the time nurses spend with individuals, measured in hours. In order for any nurses or groups to establish standards for nursing care time, they must first examine the pattern of needs among patients served by the nurse, agency or institution. Nurses must first record information about their patients and then set standards (Table 1). Nightingale, too, was certain that nurses would systematically contribute to the information base that would be tabulated by patient type. She wrote: “. . . to the experienced eye of a careful observing nurse, the daily, I had almost said hourly, changes which take place in patients, and which changes rarely come under the cognizance of the periodical medical visitor, afford a still more important class of data, from which to judge of the general adaptation of a hospital for the reception and treatment of sick.” The time to heed Nightingale's message is long overdue. In our era of computers and electronic communication, nurses must now place themselves in a position to summarize, store and retrieve this important class of data from the careful observing nurse. While Nightingale did not specify which data, Virginia Henderson and ICN Nursing Services Committee were very specific – nurses are to summarize, store, and retrieve information about their patients' fourteen human needs, circumstances always affecting them, and pathological states that may affect need. Two reasons for making the recommendation that nurses summarize and store human need information for later retrieval and review are to, first, improve patient care and, second, to develop professional skills. If nurses were to simply count and record how many of the fourteen human needs the nurse and patient agreed were problematic each day, and ask and record the same question day after day, they would see the patterns of both patient dependence and progress towards independence. Subsequent observations and recordings about the patient will help gauge how effective interventions were. The choice of interventions to meet any need are numerous; Henderson reviewed these methods, as well as the research and expert-opinion literature that went into reports about methods, and then wrote several chapters of her textbook on each need. The essential link that underlies recommendations to summarize and record for retrieval information about human needs, is the centrality of the professional literature to these problems in patients. Were we unsuccessful in managing needs in patients, we should be reassured that consulting our literature will offer us a variety of methods to help the patient. Nurses, too, should reflect on the problems seen in practice so the literature can be consulted to aid in increasing competence and knowledge. New methods and techniques are regularly reported, and these reports are now stored for retrieval in computerized databases. A few clicks of the mouse will afford the nurse the latest clinical and research information about effective and demonstrated methods. Even using older citations from her textbook and entering them into the National Library of Medicine/National Institutes of Health computer database called PubMed, the ‘Related Articles’hypertext function can be used to access updated journal articles. Hundreds of citations can be narrowed into a relevant few by coupling the organization of Basic Principles of Nursing Care and Principles and Practice of Nursing, 6th edition, to guide a PubMed computer search. Patients and their nurses benefit from the application of knowledge from these two great women, Nightingale and Henderson. It may seem quaint to some to look back 30–150 years to find relevant direction for the contemporary nurse, but their trailblazing work is still key to our understanding of the profession. Statistics were as new to Nightingale as computers are to many of us. Henderson's manual compilation of a profession's literature and synthesis into a textbook will never be done again, yet we can rely on her organization to help us systemize knowledge. It is our task to complete the unfinished business of these two heroic women. Compile statistics about your patients and store them for retrieval and review. Use ICN's universal human needs to categorize patient information and use the categories to access the literature in order to further develop professional skills for patient well-being. The process outlined here treats every nurse as researcher – a vital concept for the future of patient care (Evans 1980). The WHO has taken action on two fronts related to data requirements and access to patients. The first occurred when the WHO published a 2001 manual for classifying functioning, disability and health, or ICF (WHO 2001). The ICF is a complex version of what ICN commissioned Henderson to write. A checklist from ICN's Basic Principles of Nursing Care, used repeatedly, is an earlier, more complete version of the WHO ICF instrument which few now use. The ICN version comes with the content available in 31 languages and with an army of potential users – nurses. Were nurses to share that serial information as a component of a digital record, policy makers could better judge the effectiveness of practices designed to improve function, reduce pain, and help individuals experience peace at life's end. Perhaps the WHO should abandon the ICF and enlist ICN to encourage nurses' use of the human-needs checklist during each encounter to record patient information. The second WHO initiative concerns access to care. It has been 31 years since the 134 member states of the WHO adopted primary care as the key strategy for achieving ‘health for all’ by the year 2000 at Alma Ata. The WHO revisited the topic of health for all in 2008 when it published ‘Primary Health Care – Now More Than Ever’ (WHO 2008). The challenges revealed in the new document are those that face nurses; hospital centrism, fragmentation of care, and unregulated commercialism in health care. Women must exert greater influence on health care through WHO, and nurses must lead women. Nurses should see patients before doctors and provide primary care. None of the innovations recommended here can be done without nurses and patients working together. I would describe what we would do for patients if we had direct access to them in primary care, using the two sentences Virginia Henderson wrote: Nurses help people, sick or well, in the performance of those activities contributing to health, its recovery (or to a peaceful death), that they would perform unaided if they had the necessary strength, will or knowledge. Nurses help people gain independence as rapidly as possible. I would also show patients Henderson's 2119-page textbook and tell them this is what we learn in nursing school. People today need direct access to nurses for the same reasons as in the past and for the reason Nightingale founded our profession – dominant medicine does not provide, nor should physicians prescribe, all that patients need. Nightingale's prevention and relief pertains as much to the communicable diseases of our era as hers, and to the chronic conditions of those growing old (Thorpe 2005). We have evidence that nursing works. Nurses need direct access to patients and ICN should engage the WHO to develop strategies to ensure primary health care from nurses becomes the norm.