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Editorial. JNM editorial for May 2005 - Managing nursing in an increasingly complex environment of care

2005; Wiley; Volume: 13; Issue: 3 Linguagem: Inglês

10.1111/j.1365-2834.2005.00561.x

1365-2834

Melanie Jasper,

Complex Systems and Decision Making

Clancy and Delaney, in the first paper to be presented in this issue, identify the underlying causes for the growth in health care system complexity. They suggest ‘high task uncertainty in health care systems coupled with improved information access has created a self-reinforcing feedback loop that has spawned exponential growth in complexity’. Much of this arises from the increased demands for information, and the resultant increased technology required to support its capture, monitoring and report. Much of the resultant workload for maintaining these systems falls to nurses, resulting in documentation overload. Although writing from the USA, Clancy and Delaney voice the very same thoughts that are echoed throughout the pages of this Journal on a regular basis. We seem to be caught up in ever-increasing spiral of designing ‘systems’ to cope with the ‘systems’ we have just designed. I am old enough to remember the introduction of the nursing process in England in the 1970s. Back then the first cry from nursing staff was ‘we don't have the time to do the paperwork properly.’ And what has changed - very little apart from the relentless onward movement of the creation of yet more systems it seems. Clancy and Delaney's argument is for nurse administrators to use computational modelling and simulation as a refinement of traditional decision-making strategies, with the caveat that the tools used represent the real world of health care complexity. Maybe so. However, these kinds of tools are not in everyday use within most health care systems, and this issue of the Journal has deliberately used a wider definition of the notion of a ‘system’ to present a range of papers indicating strategies for organizing and managing nursing care. One such system may be the use of a model of nursing used to drive care. Kärkkäinen and Eriksson present the findings of a study evaluating the implementation of Eriksson's caring science theory. The focus of this report is the documentation of care using the model's central concepts to ensure care recorded reflected not only the care given by nurses, but also the views of patients and significant others. The evaluation concludes that nurses pay more attention to patients’ and others’ views when documenting care in this way, but that strong support is needed from managers if changes are to be successful when implementing a theoretical basis for the documentation of care. The notion of the need for managerial support for any sort of change is fundamental, and to some extent obvious. It is also a significant shift in culture from traditional health care management systems where it was the manager that initiated or led the change process. In many health care systems today though, we are witnessing a flattening out of the traditional hierarchies and power structures, where every practitioner, and particularly those at senior clinical levels, such as ward managers, are tasked with leadership for change and practice development themselves. One ‘system’ claimed to be able to support this individual and personal development is clinical supervision. Three papers present different perspectives relating to clinical supervision. First, Hyrkäs et al. present the results of a long-term study evaluating the impact of regular supervision in supporting and developing leadership in health care. They conclude that sustained supervision in the long-term has positive future-directed influences on nurse leaders’ work, relating, in particular, to their leadership and communication skills, their desire for self-development and their self-knowledge and coping strategies. Moreover, they suggest that this sort of support enables nurse leaders to develop strategies to respond to change and facilitate others through similar programmes of clinical supervision. Clinical supervision has been heralded as beneficial for nursing for many years now, but not for long enough for there to be a wealth of research knowledge relating to its impact. This study contributes to this knowledge base, effectively demonstrating the impact of supervision on first-line managers. Another study to present evidence of the efficacy of clinical supervision, in a rather more guarded way, is the study by Bégat et al. exploring nurses’ satisfaction with their work environment and the outcomes of clinical supervision on experiences of well-being. This comparative study concludes that clinical supervision may have a positive effect on nurses’ perceptions of well-being, as evidenced in fewer physical symptoms, reduced anxiety and fewer feelings of not being in control. This supports other authors’ work suggesting that an effect of clinical supervision is empowerment. Finally, Arvidsson and Fridlund present 25 experienced supervisors’ perceptions of their competence within group supervision, divided into two main categories. Supervisors considered it their ‘professional’ responsibility to create a secure learning environment within supervision that facilitated education and reflection. This included structuring material and creating an awareness of fundamental nursing values. From a ‘personal stance’ the supervisors experienced uncertainty and lack of self-assurance, but, conversely, they expressed security regarding their own performance as a supervisor. The study concludes that it is beneficial for the supervisors to have access themselves to others who are experienced supervisors for support. It is interesting that all three of these papers originate from Scandinavian countries, and are particularly concerned with evaluating and demonstrating the efficacy of clinical supervision. It appears that there is a commitment to not only the implementation of clinical supervision, but also to ensuring that it is of some benefit to nurses and nursing (and ultimately patient care). As with any system, the proof of its worth is whether it works or not. Unfortunately, in nursing, we often see systems introduced without rigorous evaluation and monitoring. Part of the problem lies in the lack of sufficient funding for nursing research in terms of supporting evaluation of new initiatives in many countries. This does not appear to be the case in Scandinavia. Our next two papers consider the use of language in nursing from very different perspectives. Mrayyan debates the use of standardized languages seen to be increasing in use in automated information systems. She suggests that many perceive this as decreasing nursing autonomy, resulting in a reduction of job satisfaction. She argues, however, that the use of standardized languages can actually remove barriers to care and facilitate communication resulting in increased nursing autonomy. This, she sees, as attributable to the development of tools enabling them to be autonomous and visible; to the ability to demonstrate nurses’ contributions, influence practice and facilitate critical thinking; and the recognition of their knowledge and skills to evaluate their practice. She concludes, therefore, that standardized languages are a valuable resource to the majority of nurses in multiple clinical settings. This is an example of a facilitative and empowering use of language. The next paper presents a more sinister view of the power of language in circumstances where it is used aggressively in nursing to bully others. Rane and Sherlock present the results of a study involving 214 nurses, identifying sources of verbal abuse at work. Nurses’ abuse to other nurses was identified as the most frequent abuse experienced. Whilst the majority of respondents identified adaptive or positive coping strategies to deal with this, such as clarifying the misunderstanding or dealing directly with the nurse about the aggression, a significant minority reported negative response patterns. These included silence and passivity, negative coping skills and going sick, with a resultant deleterious effect on job satisfaction and sense of well-being. The authors conclude that managers need to ensure that effective policies to deal with abuse are in place and to encourage the reporting of abusive incidents. In short, policies of zero tolerance need to be used, with educational programmes for all nurses instigated, and mandatory counselling implemented for those who abuse. Both these papers demonstrate the power of language in terms of job satisfaction and morale in nursing cultures. The next paper considers the impact of the changing Governmental agenda in the UK towards a focus on public health within a specific group of nurses who have traditionally worked in the community encompassing a public health role - the health visitor. Carr presents the views of health visitors and managers about their role within the public health agenda, and represents the confusion relating to this role and the ambivalence and uncertainty that the Government's direction has caused. She concludes that facilitating clarity of the role and its purpose must be a management priority, because Health Visitors provide the frontline service to many families within the community and are in the best place to develop and adapt their role to suit the current agenda. Another system that can be seen as crucial to efficient and effective health care is that of continuity between hospital and community settings, and the selection of the best place for patients to receive cost-effective services. Our final two papers present ways of achieving this. Satzinger et al. present an initiative aimed at improving communication for patients moving between health care systems in Germany. Despite the support from the agencies involved, structural and organizational factors appear to be impeding the implementation of a data information system which would improve continuity of care for patients. They conclude that the design of the system needs to be supplemented by binding agreements between the managers of the institutions involved, and the formation of local working groups that include representatives from all interested parties, if the system is to be successful. The final paper compares the cost of prophylactic treatment of neutropenia with filgrastim across three treatment venues inpatient hospital, outpatient and home care. Annemans et al. present the costs in terms of money, time and resources. They also consider quality of life issues within the paper, and other extraneous variables which impact on treatment and venue decisions. Whilst this issue has focused on ‘nursing systems’, the term has been interpreted very widely to enable a range of papers to be presented. These systems range from the high-tech models of computerized database systems, to those that are people-based and individualistic. It does not seem to matter what we call them, they are all indicative and illustrative of the explosion, as identified by Clancy and Delaney, of the complexity in health care systems today. What is not so clear however, is whether the plethora of systems developmentally contributes in a meaningful way to the quality of patient care, or whether they simply provide more information about that health care. It also appears that the system itself is one small part of the story - it is the managerial and political support systems, the financial implications, and the infrastructure involved in implementing and facilitating their use that also needs to be taken into account.