Response
Debate on articles in Contemporary Nurse
Susan Tregoning
School of Nursing and Midwifery, University of South Australia, SA
PP: 141 - 143
Article Text
Evelyn JS Hovegena's article How will nurses make the transition to the information era? Vol 5(2) sets nursing knowledge and work in the context of an exploding information technological era and raises important issues for both nursing and health care professionals more generally. She notes that technologies are now available to document all aspects of care, to provide timely data for decision-making and for information retrieval. Digitised information enables pictures such as radiographic images or photographs of wounds to be displayed on screen. She advocates that nurses must become involved with moving these technologies forward and that the absence of a formally recognised discipline of nursing informatics will somehow hold the process back. Large numbers of South Australian nurses have been involved with developing nursing informatics technologies in an organised way since 1989 with the implementation of the Nursing Automated Systems Project managed by the South Australian Health Commission. Nurses 'cut their teeth' on products like Excelcare and Proact, clinical and management products which were further developed and enhanced through nurses' use. We learnt to use the information we generated for decision-making. For example, at Flinders Medical Centre staffing acuity data is generated through calculating staffing requirements based on the patient care plan and exported to a rostering product- Proact. Nurse managers can view this acuity data side by side with the rostered staff. Clinicians track clinical indicators such as pressure ulcers and IV site infections. This data is exported in file format and imported to a database product-Access where it is manipulated and presented as a data point for comparison to previous month's and previous year's results. Trending of this information results in the identification of opportunities for practice enhancement. We saw the possibilities of using technologies to improve nursing practice, management, research and education. South Australian nurses involved in the NAS project developed skills through networking and sharing information. Collaboration across health units and disciplines assisted everyone involved. We learnt where our respective computing departments were and developed lasting relationships with programmers and operations technologists.
On a broader front, Info 2000 the information technology department of the South Australian Health Commission, is currently implementing a variety of projects aimed at moving information technologies forward in South Australian public hospitals. Nurses are closely involved in many of these projects and the skills which we developed over the last seven or so years has given us skills and the confidence to take active roles in current developments.
Hovenga raises the concern that if nurses cannot name what we do then difficulties may arise with electronically representing nursing work. She believes that if we don't have a common nomenclature or an international clinical nursing language then we will not have data which will be amenable to national statistical data collection. She uses the example of AN-DRG's saying that this classification has enabled hospitals to clearly define, describe and cost their products. While I agree with this as a general point, it does not adequately recognise the negative side of classification systems including that they do not adequately describe the human side of health care; and this is so much of what nursing is about. It is my view that much of the nurse-patient relationship and the documentation of those interactions will be a rich and vibrant free text. The challenge is not how can we make nursing fit into a classifications system amenable to electronic capture but how can information systems truly and accurately represent nursing in all its richness. If the codification process reduces nursing into something we cannot recognise, then perhaps it is not worth pursuing? Anyway, I agree that much more work needs to be undertaken to answer this question.
At Flinders Medical Centre, nursing, in partnership with other health care team members, Information Technology Department and Administration are evaluating technologies and working together to move ahead. I don't believe that nursing can implement technologies without close collaboration with all members of the health care team. Collaboration with other disciplines has the spinoff in that they learn more about what nursing is and in turn nursing gains a greater understanding of other roles in the health care team. Such relationships can only benefit patient care. I support Hovenga's view that there is an urgent need for formal informatics education for nurses. I believe that this could be delivered within the concept of a formal health care informatics education, and do not understand the irony to which Hovenga alludes. Nurses studying in such a multidisciplinary environment, I believe would benefit from networking and interdisciplinary study. The bottom line is still that nurses must value nursing and within the broad scope of Health Care Informatics develop, nurture and sustain nursing's integral place therein.
Virginia McMillan
Clinical Manger Nursing
Information Systems-Quality Management
Flinders Medical Centre
In her article, Environmental ways forward in a postmodern (nursing) world Vol 5(2) Carol Emden puts forward a case for nurses to engage in practices which promote a 'sound environment'. While such a request may be received favourably by the majority of nurses, the question which needs to be asked is 'Why?'; specifically, how are nurses' responses to the call to be understood? The postmodern framework within which Emden frames her discussion of 'human wellbeing and the environment' constitutes a powerful strategy for addressing this question. Indeed, I would suggest that a deconstructive reading of the article itself would enhance understanding of the issues implied in such a task. This response offers a brief insight into that process while impressing upon the reader the imperative of placing her subjectivity under similar scrutiny.
As Emden argues, postmodernism- whether viewed as a specific historical era or as an intellectual tradition, or both-is marked by a rejection of the ideals of humanism, of scientific rationality and evolutionary development. Essentialist and universalist notions are hence abandoned in favour of diversity and a celebration of the productive power of the local site. As she puts it,'... postmodernism accepts ephemerality and fragmentation and does not try to transcend either...' (Emden 1096: 81).
However, while espousing this stance, Emden's argument suggests an acceptance of some 'truths' such as 'nature', the 'natural environment' and 'natural world', and their endorsement as 'good'. My concern with this practice transcends the issue of the nihilistic impotence of postmodern inquiry or the need for each of us to work with some 'truths' in order to make sense our experience. Rather, I believe there is danger in failing to illuminate their discursive grounding. The notion, for example, that nurses may wish to 'preserve or improve the natural world in which they live and work' (Emden 1996: 83) begs the question of which world-for example, the material world in which they are located or the human system of which they form a part? How do these constitute 'natural' contexts? Indeed, Emden challenges the sense of separateness suggested by this portrayal of the nurse and her environment by urging nurses to adopt practices which contest its negative qualities. However, I would argue that this challenge cannot be taken up until the particular discourse of environment' which informs the nurse, is made explicit and its implications understood.
For while Emden argues for a shift in thinking among nurses, which heralds a postmodern sensibility, the shift may be somewhat illusory. It may signify a modernist 'revolt', in which new 'environmentally sound' practices are premised on the perceived need to enhance the effectiveness and/or efficiency of care. As such, the change will serve to 'shore up', not oppose, the prevailing discursive context. But the categorisation of any challenge, be it the replacement of concrete 'garden' areas with grass and flower beds in community centres or 'greening' of nursing curricula, should not be presumed. Rather, the forces which shape it require critical scrutiny; preferable at the planning stage of its generation.
With these cautions in mind, Emden's call to rework and develop nursing practices which accord with our ideal of an environment which sustains and promotes wellbeing, is applauded. Understood as a postmodern enterprise, this journey will be marked by a myriad of different goals and strategies; its 'end' indeterminate with the continual reinvention of its agendas. A sense of cautious optimism should perhaps accompany these endeavours for oppositional change is rarely welcome or easy to initiate and sustain. In this sense, the 'environmentally' driven efforts of the nurse parallel those which contest other contemporary barriers to equity and justice in the field of health care.
Dr Nina Bruni PhD M Ed Stds Dip Ed BA (Hons) RN
It is with interest that I read Vivian Yong's article Doing clinical: The lived experience of nursing students Vol 5(2). The title intrigued me, but as I read on I became impatient with some of the content and in particular the section related to 'the ideal' versus the real.
How long has nursing been in the tertiary sector? At least eight years in New South Wales. So why are we still investigating the experiences of student nurses 'doing clinical'? After all, the author did mention a few studies which have already reported that clinical experience is stressful, anxiety provoking and of great concern to student nurses. The studies were reported in 1987,1988, 1989 and 1990. The findings from this study were not news to me.
Why are we still teaching students 'the ideal' when we know this is disparate from the 'the real'. In fact, it is the major source of role conflict for young students. I felt like shouting 'Get real!'-challenge the dogma and teach what's relevant. Start examining what is real and if the patient is not suffering and their safety assured then teach what is more reflective of everyday practice. Let down the walls, don't work in isolation, work with the health services to identify a more realistic approach. Don't develop programs to help students deal with the conflict, remove its source instead.
Is the conflict between university- and hospital-based training still going on? After all this time, have we not accepted that college- and university-based training is a reality, and have we not integrated it into our lives? On the other hand, has the author interpreted the participants' comments incorrectly? If neither is true and the conflict still remains then we have another reason for working more closely together.
I'm not sure that I agree with the author's conclusion that we need to study 'doing clinical' any further. Our own common sense, the results of this and previous studies are enough. Let's now seriously embrace some initiatives to challenge the old and develop new and innovative ways to treat the patient. The values and practices we espouse have to be congruent across the system and shouldn't just belong to the school; what's the sense in the belonging if they don't serve the purpose for which they were intended? They should be developed to meet the service needs and in collaboration with the service providers. It is only then that some of the strategies developed to assist nursing students cope with the unfamiliar, probably hostile and often unpredictable environment of a health service will be effective.
Kathy Daffurn RN SCMICU & CCU Certs BHA MAppSc(Nursing)
Manager Anaesthetics
Liverpool Hospital, NSW
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