Response
Debate on articles in Contemporary Nurse
Susan Tregoning
School of Nursing and Midwifery, University of South Australia, SA
PP: 053 - 055
Article Text
The first section of Kingsland, Smith and McKinley's paper: Introduction of managed care plans in a cardiac surgery unit, Volume 3(4), provides a good overview of why clinical management plans (CMPs) should be used in a case-mix based funding environment. The second part of their paper details how this was introduced in a specific clinical environment in a teaching hospital. The paper identified that 'such tools (CMPs) provide an explicit statement of the type and standard of care these patients have a right to expect from each care giver' (p.192). The availability of such tools would also permit patient participation in decision making where there is more than one treatment or care option. Indeed it is highly desirable to also use these tools to inform and prepare patients regarding what to expect during their hospital stay. This is another form of quality assurance and may result in improved outcomes as a result of improved psychological preparation. It allows the patient to have some control over daily events.
The authors identified the need for improved and integrated documentation. They also mentioned their desire to continue to be able to use everyday language. This was achieved through the use of exception based charting and computerisation. Whilst I have no argument with the authors regarding this solution, I would like to point out that to maximise the benefits of electronic clinical data there is an urgent need to develop and adopt a national thesaurus of clinical data elements used by all health disciplines. Such a thesaurus permits the use of local language but maps it automatically to an agreed standard language. Only then can one aggregate data across hospitals. Larger databases are desirable to improve statistical reliability when measuring outcomes relative to the use of different treatment options. They also provide a useful basis for developing national clinical practice guidelines.
The organisation based CMPs are in fact clinical practice guidelines. Australia is lagging behind the United States of America and Europe in this regard. The US Agency for Health Care Policy and Research has and continues to develop national clinical practice guidelines. Indeed, in the US, clinicians are expected to explain any variation from nationally developed clinical practice guidelines as these are now driving resource allocation. Work towards a clinical terms thesaurus is under way at the National Library of Medicine, Washington DC, and the UK NHS Centre for Coding and Classification. The US Computer-based Patient Record Institute is conducting work to facilitate the automation of every aspect of patient records. It is time for Australia to make its contribution.
Of course what this will ultimately lead to is the ability to track patients through the health care system irrespective of where they are being treated. This in turn will improve the capacity to measure outcomes. Such information may then be used to ensure that both patients and providers are better informed about treatment options together with probabilities of complication rates, adverse outcomes and desired outcomes. Indeed, this provides the basis for knowledge based systems to be used with a decision support system which allows the patient to consult with the provider and together they can make a decision regarding the best option for that patient. In conclusion the authors are commended for their initiative to develop CMPs, automate clinical data and adopt exception based charting. This is but a small beginning. Some national initiatives are needed now so as to maximise the benefits of such efforts.
Evelyn JS Hovenga, University of Central Queensland, Rockhampton
I applaud the perspicacity of Andrew Crowther's comments in his note on Nursing's new cultural revolution in Soapbox, Volume 3(4). Crowther attests to the ever widening chasm between the few proponents who value and see the contribution the pursuit of pure knowledge can offer the discipline of nursing, and those who consider practical knowledge should be regarded as the only path to nirvana. The following remarks reveal that the counter revolution has begun. The push to promote, foster and prescribe practical skills-based foundations for nursing as the only source of knowledge is antithetical to intellectual freedom and it denies the immeasurable opportunities the tertiary setting offers. As Crowther so rightly points out, the 'pathway to practice only' approach is most likely 'to bring the progress of nursing within a university context to a shuddering halt'. However, there is a beacon on the horizon and this is demonstrated by a growing element in nursing which does not consider the notion of practice quite as literally as others. This element is particularly well represented by the historians. An examination of the history of nursing provides several crucially relevant perspectives to the debates about the theory-practice divide, the clinician versus the academic nurse and the stormy issues central to the search for a knowledge base in nursing. For instance, as early as 1975, the American historian of nursing Teresa Christy, voiced concern about the fact nurses do not value their past and consequently, do not investigate the texts because too much emphasis is given to clinical issues and besides, texts are not so important to nurses. Further, and as recently as 1991, the scholars Packard and Polifroni targeted both the proclivity in nursing for the pursuit of only clinical knowledge and the absence of valuing what pure knowledge has to offer as areas which need to be seriously re-considered.
The future development of nursing is not predicated only on the clinical/practice dimension. Indeed, the historians Hezel and Linebach, offer pertinent comment that a study of nursing's past will provide knowledge and understanding about the ideas and debates of today and this, in turn, will augment nursing's options for the future.
Finally, the challenge for today's nursing, in its dual search for a knowledge base and an understanding of its past, is that it must give time to the body of literature it has already amassed and time to reconsider its interpretation of what research means. Nursing, in the tertiary context, now has the opportunity to consider itself as a body of knowledge distinct from the concept of applied science. The question is: can nursing emancipate itself from its present preoccupation with the notion of 'practice only', and while still pursing interests in the applied area, also devote energy to theoretical achievements?
Angela Cushing, Queensland University of Technology
I am compelled to refute and dispute almost everything Andrew Crowther has said, Soapbox Nursing's new cultural revolution, Volume 3(4). I cannot believe that just 10 years (maximum) after we moved from the clinical setting to the tertiary sector, nurse academics are keen to pull up the drawbridge behind them. I do not sense a reactionary movement designed to widen the theory practice chasm; and if I did feel paranoiac I would not interpret moves that encourage practice fluency and competence as likely to widen it. In my institution, the perennial lament is the lack of time, opportunity, clinical flexibility or clinical access for academics to get back to the 'fountains of hands on nursing'. My faculty has an established arrangement with several hospitals to allow staff to 'swap' for various periods to enhance cross fertilisation of ideas and allow skills maintenance. It was initiated at the academic's request. I simply cannot conceive that the personal contact or the updating of knowledge that an academic gains this way could do anything but narrow any perceived chasm. As for 'periodic ritual humiliation' that is a completely personal matter.
Where both the academics and the clinicians agree on the goals of the enterprise, humiliation is not an issue. At no stage would either be attempting to establish ascendancy. In pursuing clinical experience myself, I have long since abandoned expectations that I will be particularly competent (skilled) in my specialty area (ICU) but I do keep up with nursing and medical trends. No one has ever come close to humiliating me.
The analogy of the Chinese Cultural Revolution and trends toward nursing academic's clinical updating is over the top. There is no suggestion in this country that we have lost the plot and that moves are at hand to cut us down to size. The vital role of 'clinical' currency is long established in various faculties via joint appointments, clinical lectureships, industry consultancies and rights to private practice. None of this has brought other groups of academics to a 'shuddering halt'; rather I think it has prevented the development of isolationism and irrelevance in the education of both staff and students. I must say that my overwhelming response to Andrew Crowther's missive was to make a note to put aside a few weeks this year for (self indulgent) clinical time in my mid semester break before I get too busy with the bureaucracy of academia. It makes my teaching much easier.
Dorothy Kamaker, University of Sydney
eContent Home
