The Future of Nursing

Lillian Wald’s public health nurse uniform

The future of nursing should begin with people and community/population health. And to do that we need to disrupt our tired, outdated approach to nurse education. Not by tweaking here and there. Not by investing tons of money in yet more high tech simulation labs and “dummies.” Not by asking ourselves and our students, “What would Florence do?” (as in the Florence Nightingale, important as she is). Rather, we should begin by asking, “What would Dorothea do?” (as in Dorothea Dix, US and international mental health reformer) and “What would Lillian do? (as in Lillian Wald, the “mother of public health nursing” and founder of the Henry Street Settlement House in New York City).

“Begin with people, not body parts,” is what one of our nursing students told us recently when she heard that we are disrupting our pre-licensure nursing program at the University of Washington. Starting this coming academic year (begins in September), we will begin with people—with community, public health nursing instead of the longstanding “traditional” acute care medical-surgical nursing. I am excited to be teaching this “new” community/public health nursing course. It will begin at the true beginning with the social determinants of health equity. Not just with the social determinants of health (SDH)—those factors that affect our health from where we live, work and play. The social determinants of health equity extends past the SDH to acknowledge and address the inequities inherent in our society that affect health, including structural racism, and all the other “isms” of longstanding discrimination against women, persons of color, LGBTQ people, disabled folks, and the aged. Dr. Camara Jones and her “Cliff of Good Health” is the best illustration of this.

The Future of Medicine 2030 Seattle Town Hall was held at the University of Washington this morning. This builds on and extends the work of the Institute of Medicine’s Future of Nursing report back in 2010. The theme of today’s town hall meeting was “High Tech, High Touch.” I was dismayed (okay, I was irritated) that the lead speaker at today’s event was a physician, Molly Coye, who is an executive-in residence with AVIA, a network of US health systems “solving problems with digital technologies.” It is the “The Future of Nursing” after all and not “The Future of Our Insanely Expensive and Ineffective US Healthcare System.” And it should be led by nurses!

The one truly inspirational speaker at today’s event was a nurse—Dean Kenya Beard from Nassau Community College in New York. She spoke of some of the drawbacks of health technology and how they can amplify health inequities and how most of the proprietary algorithms for high tech “solutions” lack transparency. She called out the pressing need for nurse educators to “rise above any level of discomfort” and address structural racism and interventions that work. As to structural racism in our country she stated, “humans created it and only humans can destroy it.” She ended her talk with, “We need daring ingenuity.”

My question/comment which I posted online during the town hall was this:

“Why aren’t we using the much more useful term “social determinants of health equity” versus the rather status quo term “social determinants of health”? Why aren’t we killing forever the outdated and unhelpful message to our nursing students that they “have to have at least two years of inpatient med-surg” work before they go on (yes, go on) to community, public/population health nursing? Why aren’t we stopping the practice of educating nursing students to be “agents of social control” and instead to be “agents of social change?” Also, thanks for the refreshingly honest and necessary presentation and perspective from Kenya—Brava!

A Cheeky American Nurse

P1020873Immersion experiences in another country, another culture, can bring out the best—and the worst—in people. While living abroad you cannot help but make moment-by-moment comparisons between where you find yourself and where you call home. Seemingly little things: if they drive on the left instead of the right as they do at home, which side of the sidewalk should you walk on? (Answer, at least here in the UK: there are no sidewalk etiquette rules. Expect complete chaos.) To deeper comparisons such as “Why are all British nurses forced into one of four possible specialties (Adult, Pediatrics, Mental Health, and Learning Disabilities) from the very beginning of their education?”  Is this Florence Nightingale’s legacy?

As a cheeky American nurse (and nurse educator) living and working in the UK, this British approach to nurse education is something I sincerely hope that American nursing never tries to adopt. There is much to admire about the UK healthcare system, with the prime example being the existence of the NHS—although imperfect, as are all healthcare systems, it is much loved and functions so much better than the US healthcare ‘system.’ It occurs to me as ironic that while the US healthcare system is more fractured than the British NHS, British nurse education is more fractured than is ours in the US. Or at least that is how it appears to me.

This British nursing forced specialization practice is a holdover from the days (not so long ago here) of hospital-based apprenticeship, diploma-level nursing. Of course, in the US, we have also had this form of nurse “training” that is fast being phased out. In the UK, there continue to be debates about the value of a higher education degree for nurses, with some people arguing that university degrees are responsible for the apparent diminishment of empathy among British nurses. Empathy cannot be taught, but it certainly can be encouraged and modeled. I do wonder: how well can that happen in any nurse education model based primarily on traditional lectures with a class size of upwards of 700 (or more) students and multiple cohort intakes and graduations each year? That is the current reality of nurse education in the UK. Mass marketing of (or attempts to teach) empathy not only do not work—they have the opposite effect.

Notes:

  • The photograph included with this blog post is one I took in London last month at the excellent Wellcome Collection Museum. Even if you cannot visit this museum in person, check out their website for amazing online resources, including their six-part series, “The History of the NHS.” 
  • Although I am currently situated at a UK School of Nursing, I first learned about the strange (to me) structure of British nursing from two non-fiction/memoir books: 1) The Language of Kindness: A Nurse’s Story, by Christie Watson (London: Chatto and Windus, 2018 and 2) One Pair of Feet, by Monica Dickens (yes, related to ‘that’ Dickens), (Middlesex: Penguin, 1946). Monica Dickens’ book is based on her brief stint as a hospital nurse apprentice during WWII. Christie Watson’s book is based on her twenty years’ work as a pediatric nurse in London hospitals. I highly recommend Watson’s book, but not the one by Dickens unless you are a WWII buff of some sort.

Where have all the nursing professors gone?

Portrait of Florence Nightingale.
Image via Wikipedia

“The Future of Nursing: Leading Change, Advancing Health,” is a weighty tome published/released by the Institute of Medicine and the Robert Wood Johnson Foundation on October 5, 2010, and is written about by Pauline Chen, MD in her NYT article “Nurses’ Role in the Future of Health Care” (Nov 18, 2010). Dr. Chen’s article has been one of the most e-mailed NYT articles since it appeared last week, and at last count it had a total of 91 reader’s comments. It got people’s attention. I find it interesting that in her article, Dr. Chen links to the IOM report ($51 and you can read it), but doesn’t mention that the exact same report is available for free on the RWJ website (also has its own Facebook page). There is a 600 plus page version and a 4 page “Brief Summary” version, both free.

In the 600 page version, Chapter 4 is devoted to nursing education, and among other things, they address “the aging cadre of nursing researchers and educators.” We are dropping like mosquitoes around one of those electrified zapping machines. And there’s no one to replace us. The IOM/RWJ report states there are 5,000-5,500 unfilled nurse educator positions around the US. In my own school of nursing, within three years something close to 70% of our faculty will be 65 or older (disclosure: I’m not even close to being one of those…). Of course, that doesn’t mean they will retire, but that’s another story. That statistic is public information already, as is the fact that many other faculty in major schools of nursing across the country are ‘getting out’ of nursing education–burnt out, put out, or lured out by better opportunities in health care industry of one sort or another. Many of those are people I consider to be the best, brightest, most creative nursing educators we had. The IOM/RWJ report has many excellent recommendations about improving nursing education, but I wonder how they will get done with what’s left of our nursing professor workforce.