Nursing Outlook
Volume 49, Issue 4 , Pages 182-186, July 2001

Profound change: 21st century nursing

Tim Porter-O'Grady is senior partner, Tim Porter-O'Grady Associates, and associate professor, Emory University, Atlanta, Georgia. He is an international health care consultant specializing in health systems conflict, crisis, and innovation. He is a registered mediator and arbitrator and a clinical nurse specialist in gerontology. He lectures internationally on preferred futuring and its implications for nursing and health care. He can be contacted at drtpog@aol.com

Article Outline

Abstract 

Nurs Outlook 2001;49:182-6.

 

There are two kinds of truths. There are superficial truths, the opposite of which are obviously wrong. But there are also profound truths, whose opposites are equally right.

—Neils Bohr

Wisdom and insight are hard to come by these days. The pace of change is untenable in health care as it is in all arenas of the social and business enterprise today.1 Increasingly it is harder to fathom just how to lead others into a world that moves faster and with different rules than any time in our human experience.2 It is impossible to initiate change without the inevitable fear that it will never see completion. Harder still is any sense of ownership of work process simply because whatever approach is in place will inevitably be transformed by circumstances beyond the control of any one person.3

Now that we are all on the other side of the millennium, it becomes clear that the world really is different and the rules that govern it are not discernible by means any of us have who spent our decades within the parameters of the 20th century. The mental models necessary to even conceive the characteristics of the present time are so foreign to the understanding of persons who have spent most of life in the 20th century that it is frightening to imagine our leading organizations into this “new world.”4 What is even more disconcerting is to open any of the myriad of business magazines and see the pages replete with the success stories of wealthy contemporary leaders, many of whom are not yet older than the age of 30 years. Much of the executive leadership in health care today would not have even considered the notion of having attained success at any time before the age of 40 years.

With all this challenge to current models of life and leadership, is there anything the executive today can do to meet and embrace the challenges of leading in an age characterized by such an unfamiliar landscape? Are there really different matters at issue in the unfolding organizations and systems of the postmillennial age? Of course, the answer to both these questions is yes; and therein lies the challenge. Because there are affirmative answers and they demand fundamentally different responses than the experience of most leaders, much profound and personal transformation must be undertaken if good leadership is to continue and effective results are to be obtained.

Back to Article Outline

An altered mental model for the age 

The age of the organization as institution is dead. Whereas this notion may appear a mite dramatic at first reading, it is necessary to say it out loud. In fact, the major effort in hospitals and health systems to make the institutional model work is perhaps the greatest threat to their continued existence. The architecture of “in place” work and bricks and mortar workplaces is giving way to the infrastructure of information and technology.5 Fixed work models are being challenged by more fluid and mobile models of work. Permanence and loyalty are replaced by transition and outsourcing as the framework for work distribution. Partnership is replacing disciplinary excellence as a measure of sustainability. Time-bound activities are disappearing under the pressure of short-term, low-intensity, high-turnover clinical processes that no longer require extensive time to achieve desirable results. Service relationships are more accurately defined by their context rather than their content.

The real work of leadership in health care today is the active and committed deconstruction of much of the infrastructure of health care as currently configured, and doing it quickly.6 Technology is currently moving at such a pace that by 2007 much of what once was done within the walls of our health care institutions will be done in doctor's office or in clinics. The increasing portability of technology is mobilizing all health care at a pace and in way presumed to be a far more distant reality than it is turning out to be. Nursing practice in its current configurations and forms is dying as the demands of the health system are changing both substance and service.

It is that ending that most nurses are confronting in their various workplaces today. Hospital work is increasingly impossible to do as a schizophrenic census reels from full to empty in an untenable pattern that is impossible to manage. Nurses continually attempt to do 5 days worth of work in a day or less. They take on more of the new tasks and activities in a mobile and fast-paced service setting. They do all this while maintaining their commitment to do all that they have ever done for patients from a time when patients stayed around long enough to get it. Nurses burn out at an accelerating rate as they become overwhelmed with the workload in a workplace that can no longer afford what nurses do yet still claim there are not enough nurses to do it.

The role of the clinical executive is to end the practice of nursing as we have known it. It is only in the demise of the industrial models of nursing work where space will be made for the emerging requirements of a new practice arena. The times indicate that our experience is not much different today from the time at the end of the 18th century when the trade guilds of Europe were becoming extinct because what they did no longer had a place in a world that was changing in a way that could no longer support them. This scenario is not distinctly different for nurses in the current time. Holding onto old notions and practices that no longer characterize the demands of the time will do nothing but exacerbate the conditions which facilitate the demise of nurses and nursing work. The struggle for the profession is discerning what nurses should bring with them into this new age and what should be left behind.

Back to Article Outline

From 20th century nursing into the 21st century 

In the 20th century much of the activity of nursing was related to “doing for” others. Eighty percent of the time, nurses work was with the sick or disadvantaged. Much of the activity of caring was “late stage” caring. Here, persons were already sick or disadvantaged and needed to move through their experience, get well, or accommodate their limitation. There was a much stronger dependency relationship between nurse and patient because, 9 times out of 10, of the condition and the needs of those nurses served. Much of the frame of reference and content of education of the basic practitioners was around those alterations from the norm and the clinical focus was on re-establishing the normative or “fixing” the problem so persons could get back to the business of their lives. This is no longer the foundation for the future of nursing practice or of health service.

In the 21st century the whole foundations of health care are being shaken. Technology is taking service to new heights of portability: less invasive, short-term, and with greater impact on both the length and quality of life. Along with portability is the immediately emerging impact of genomics/proteinomics with all that implies for how life processes will be dealt with, when they will be addressed, and the techniques and technologies that will be used to treat persons. Now the question is: what will genomic nursing look like in the 21st century?

We are, in short, moving inexorably to “early engagement health services” that have a different foundation and construct for service. Instead of event-based, after-the-fact response, we will be able to anticipate potential for alteration and address treatment while it is still a potentiality rather than an actuality. Through genomic typing we soon will be able to anticipate the anomalies that lead to illness and catch them in their earliest stages rather than when they later present symptoms. Each of us will soon have our own chip with our genetic map imbedded within; it will serve as the vehicle for service, treatment, and care contained in a radically altered health record. As is already evident, persons will simply not need to stay around long enough to either need or receive the kind of care nurses were once so well known for giving.

Time-based nursing care with the activities of bathing, treating, changing, feeding, intervening, drugging, and discharging are quickly becoming historic references to an age of practice that no longer exists. Now the challenge for nursing practice skills relates more to taking on the activities of accessing, informing, guiding, teaching, counseling, typing, and linking. The mental models and skill-sets for this kind of nursing practice require a different learning and practice focus than most nurses currently have. Across the land in the variety of settings where nurses practice, one often hears about what nurses no longer have the time to do or the growing time demands and reducing numbers they are experiencing. Related issues are written about and discussed with great articulation. Less often do you see or read the growing awareness that what we once were and were able to do may increasingly be in its terminal stages. Nurses now are at the outset of a new paradigm for practice, yet many are not yet able to move from mourning the loss of what they were to engaging what they might become.

It is increasingly apparent to the purveyor of history that nursing may be at the same critical juncture in time as those trade guilds of the 17th and 18th centuries. Much of what nurses once were and did is now subject to contest. Newer models of application of practice in a different context for service has become the great demand of the time. Leaders are now faced with the work of transforming their contextual framework for the future of nursing practice and to form new foundations for 21st century practice.

Back to Article Outline

New realities for nursing education 

The hospital as we know it is no longer the future of health service. This does not mean that there will be no more hospitals. The hospital as we have defined it and used it for the major part of the 20th century is dying, as well it should. The hospital is in the chaos of becoming something different and is having a difficult time making the journey. There are a lot of stakeholders who are affected and have a vested interest in its remaining viable in its current form. Physicians and surgeons still want to use its equipment and services in a way that has the hospital bearing most of the financial burden for it. Nurses still want to care generously for patients who they would like to stay long enough to get all they have to offer, and patients want it as a place that will accept the responsibility to care for an illness that 80% of the time, either by omission or commission, they played a role in causing. Administrators still want to make money in this kind of place. Technology, the times, and economics are conspiring to make these circumstances no longer the prevailing reality.7

Back to Article Outline

New implications for learning 

Educators preparing the next batch of professional nurses for the health system need to know that the hospital no longer remains the foundation for the learning experience. Caring for the dependent person in disadvantageous circumstances is no longer the predominant activity of nurses. The pathophysiologic basis for nursing practice is inadequate to the emerging demands of the time. The foundations for this kind of nursing practice are now severely threatened.

Furthermore, the design for the future of education creates real stress for the existing models of nursing education. The classroom-patient's room dyad for basic nursing education is an inadequate framework for learning in the new age. The foundation for health care is inexorably being moved into an early-engagement, mobile, and noninstitutional model for clinical service. Moreover, the locus of control is shifting from providers to consumers. Service-friendly and flexible design constructs for clinical intervention are the cornerstone of future clinical activity. The days of long-term nursing care activities synonymous with longer lengths of stay and patient residence are just this side of extinct. How many nursing programs still use resident, bed-based patient care fundamentals as the foundation for basic nursing education? Just as the bed-bound nurse is feeling the compression of a job that is in the chaos of its latter days, so too is the educator threatened at seeing the elemental fundamentals for teaching nursing as he or she knows it becoming quickly extinct. This circumstance now lays questions at the feet of current faculty as to just what they teach today's students.

Back to Article Outline

New technology 

The new technology of learning bodes well for the new substance of nursing education. Highly decentralized, Internet-moderated, satellite-facilitated, portable digital-assisted, and distance-based learning models, while in their infancy, are clearly a part of the emerging models for education in the 21st century. In less than 10 years the computer-based Internet and Web-based hardware will make it possible for learning to be located anywhere and for the person to be in direct verbal and visual communication with fellow students and professors in a wide variety of settings. The array of approaches to gaining knowledge and evidencing competence will allow the learner a wide variety of options to obtain what they need to grow and advance. Educational facilities will have 2 key functions in this decentralized environment—content provision and certification of learning. The medium and means of learning will be the responsibility of the student. A primary role of faculty will be in helping the learner choose the best form of access to learning that will best fit with the learner's skill-sets, personal needs, and learning style. Following this, it remains for the faculty to be able to evidence that competence is present in the learner sufficient to move the learner to another stage in the developmental continuum.8

For faculty, the greatest threat to present models of nursing education is that learning means are becoming fluid. The classroom, teacher-driven learning model no longer predominates, and the accountability for ensuring learning occurs is shifting to the student. It is now the obligation of the learner to give evidence that learning has occurred and that it results in sustainable action. Many teachers and students are not yet ready for this shift in accountability and ownership for learning. There remains then the need for a real goodness-of-fit between the design of education and the utility of the graduate.

Back to Article Outline

New learning foundations 

The conceptual foundation for practice finds its grounding now more in principles of facilitating access to knowledge and resources than to simply providing care. The focus of health service reflects a more mobile, fluid, fast-paced service script, and technology makes it possible for patients to get what they need in hours rather than days. As a result, nurses residential-based practices driven by the length of stay are terminating. This indicates that the means of learning and the process of education changes. Combined with the possibilities of technology, implied shifts in both content and process occurs. The question is no longer when will the educational framework for nursing learning change but how fast? This raises some serious issues for educational leadership:

1.The role of the faculty changes from provider of learning to facilitator of the learning process. There are only 2 questions that are critical to the faculty role: (1) Does the student have access to the right learning content, and (2) Can the student give evidence of a satisfactory level of competence?

2.The tools of learning are now more in the hands of the student than they are in the faculty. The faculty now facilitates access to the means of learning rather than simply delivering content themselves. There now must be a goodness-of-fit between the means of learning and the ability of the student to make use of them. The major role of the faculty is imbedded in moderation of the means to the content of learning and the ability of the student to make use of them.

3.The faculty now play a stronger role in teaching the learner to learn and to use the mechanisms of learning that are essentially self-driven by the learner. The maturity, investment, self-direction, and learning skills of the student are now the critical variable in professional education.

4.There is a greater component of the curriculum development process that is devoted toward a wide variety of clinical experiences for the student that reflect the future of health care delivery. This means more opportunities in employer-based, community-driven, clinic-based, and ambulatory settings for nursing service delivery. Emphasis on mobile rather than fixed skill-sets will be important to the nurse's sustainability in a growing non-late stage health service system.

5.Greater integration of learning between the disciplines is increasingly more important. Besides the obvious cost-efficiencies of such an approach, there is a strong reaffirmation of the essential interdependence of the work of the disciplines in relationship to each other and those they serve. Sharing expectations and collectively articulating the common basis for practice (physiology, pathology, assessment, systems, critical clinical processes, etc) is an opportunity both to negotiate roles and to define the expectations each discipline has of the other and collectively acknowledge the contribution each makes to the other(s) and to the patient.

6.For graduate education there is a need for a more integrated curriculum that links several academic arenas and pathways to a nursing core. As the profession inserts itself into a vast array of new clinical opportunities in a wider field of application, a more flexible student-designed curriculum will be required. From criminology to health systems design, nurses will want a much more fluid and specific curriculum that easily incorporates other learning into a nursing core requiring a flexible boundaryless process between programs and schools that allows a greater variability in the design and application of graduate education.

It is clear that nursing education is about to see the greatest challenge to both the form and process of preparing future nurses. Beside either the content or context of learning is the burgeoning hardware of education technology that is in the process of forever changing how and what students will learn in preparation for their nursing work. This, along with the changing character and content of nursing practice, promises educators a challenging experience in the reformatting of nursing education over the next decade.

Back to Article Outline

Challenges for nursing research 

A couple of comments about nursing research is in order here since it is often tied to the academic processes in nursing. In the past, nursing scholars were often honored for the amount of research activities or dollars they are able to garner in their careers. Unfortunately the amount of research dollars and projects a researcher is able to accumulate in her or his career is no longer a viable measure of success.

Increasingly the funders of research are interested in value for the exchange of dollars for research activity. The question is no longer about what research is being done but instead it is what difference does the research make and what is its value added for the research activities undertaken? Indeed, the issue is increasingly imbedded in the value exchange: dollars for outcomes. Evidence of a focused contribution is now a more significant measure of both research rigor and financial stewardship than is simply the amount of research activity undertaken. The focus of good research process is now disciplined by the value to which it contributes. The researcher is now called on to give evidence of the viability and value of the work in the broader arena of advancing the circumstances of health. This requisite raises ethical issues and increases the intensity of the process. The challenge for the nurse researcher is to transfer the precision attached to good process into the value it advances and ensure that value is obtained.9

Back to Article Outline

New parameters for practice 

What is critical for nursing practice is the recognition that it is now different from whatever it has been throughout the 20th century. Care of the sick and patient-focused notions of service are no longer the basic constituents of good practice. Technology has made it possible to change the character and content of the work altering forever what the nurse does and the places where she or he does it. Much of the 20th century nursing has been directed to increasingly intense sickness services grounded in institutions. The history of nursing is strewn with the institutional challenges and processes that defined its predominantly working in hospitals for much of the 20th century.10

In the 21st century health system the vagaries of technology change the relationship of the nurse to those she or he serves and their relationship to the service system. Nursing now has the obligation to change the following elements of nursing service within a more contemporary model of clinical care.

•Portability of medical hardware guarantees cheaper, short-term, ambulatory delivery of service for the majority of consumers, eliminating forever the need for care activities that depend on tenure and residency.

•The Human Genome Project due to be completed by the end of 2001 replaces the germ-theory basis of 20th century western medicine to a genomic foundation for medical practice, changing forever the activities and functions of health care. The corollary nursing care changes are as dramatic and definitive.

•The aging of the largest cohort of the American population (mostly baby boomers) alters the focus of health service and forces the system to accommodate a more independent, controlling, and affluent user who is increasingly intolerant of provider-controlled and institutional approaches to care and service.

•Chemo-, bio-, and pharmaco-therapeutics replace invasive mechanical procedures as the primary clinical modality in this century altering the service framework for health care from primarily provider intervention to more access facilitating and the support and informing of consumer decision making.

•Health care information will not be rendered by the provider as the first medium of choice for the consumer. Web-based information infrastructure and generation will serve as the primary clinical information base for the user. The role of the provider will be to facilitate access and provide support for information and choice translation and validation.

•Organized health services will now center around population configurations rather than allopathic (disease) diagnostic categories of care. The closer the health systems represent the characteristics of the populations they are positioned to serve, the better the service and the more sustainable the health of the population cohort. Social, health, and intervention standards will be community-based and will form the foundation of evaluating the effectiveness and viability of health care service systems (through use of integrated, clinical-economic data systems).

•Alternative and complimentary therapies will become better and more seamlessly integrated into existing clinical options. The impact of whole life health services is just beginning to exhibit clinical value. As more of these approaches show clinical value (sorted from those that do not evidence any clinical value), they will become a part of an increasingly diverse array of medical and health services from which the consumer can make meaningful and appropriate choices.1

Back to Article Outline

The 21st century nurse 

Whereas there are a host of related activities associated with the aforementioned dramatic shifts in health service, most of them will be corollary to the aforementioned changes. The role of the nurse in reflection of these shifts will point toward an entirely different matrix of activities than in the past. Most nursing activity will be in facilitating access, interpreting information, advising and guiding consumers in sorting through increasing complex health therapeutic choices, educating the consumer for the use and application of new therapies, and partnering with the consumer and his other significant support persons in making choices that fit lifestyle and therapeutic options as well as all the activities related to genomic options and choices.

As a result of the changes in the framework for health services and the mobility of the consumer, it is the nurse who will need to exhibit mobile skill-sets. Providers will now have to mobilize and provide services in a manner that fits the population characteristics of those cohorts being serviced. Since health care systems will need to be organized around populations rather than diagnostic categories, there will need to be a true goodness-of-fit between the designs of these organizations and the culture and demographics of the populations being served.

What is significant about these challenges and changes to existing nursing practice is the dramatic shift that will occur with the positioning and use of nursing resources. In the past 20 to 30 years, upward of 70% of nurses were working in hospital settings. That percentage is inching closer to 50% as we move deeper into the 21st century and the options above become more of the prevailing reality for health practice throughout the United States. Whereas issues of payment, choice, therapeutic efficacy, and value are worked out, the inexorable movement of new technologies and therapies will push the walls of existing models of service and the context of health service delivery.

Back to Article Outline

Conclusion 

Many persons would suggest that these changes and challenges are far enough away that there is time to consider their impact on nursing practice and the future foundation for nursing in the 21st century. However, it should be said that the innovations we are accommodating today are the science fiction we were all reading 10 and 20 years ago. Most nurses never anticipated that they would live through the chip-based technologic innovations that are now commonplace in today's health service environment. The conflict in many nursing services is evidenced in the radically different perspectives of nurses from different demographic eras.11 Much of today's challenge to the nursing profession is its ability to accommodate the loss of what we all once understood as nursing activity at a time when much of it will disappear.

It is not the patient who is mourning the loss of the past age of health care—they actually have access to better therapies than at any time in human history. It is the nurse who is mourning the loss. Without engaging and embracing the issues around a new emerging foundation for nursing practice in the 21st century, it is quite possible that nurses will fail to find a meaningful place in 21st century health service. Persons need only to be reminded again of the passing of the trade guilds of Europe in the 17th and 18th centuries to note that work groups do not have a guaranteed hold on the future. A strong and noble past is no assurance of a viable future. It is only when the activities of the present respond with a goodness-of-fit with the emerging demand for them that a viable future can be anticipated. Nursing is at that crossroads. Will those of us who lead it be able to see its future from the perspective of its journey with insights from the future we are becoming? To do so is the test of nursing's credibility and sustainability in a rapidly changing context for health care at the beginning of the 21st century.

Back to Article Outline

References 

  1. Beckham D. Hearing the tidal wave. Healthcare Forum J. 1996;39(2):68–78
  2. Anderson T. Transforming leadership. Boca Raton (FL): St Lucie Press; 1997;
  3. Drucker P. The organization of the future. San Francisco: Jossey-Bass Publishers; 1997;
  4. Harman W. Global mind change. San Francisco: Jossey-Ball Publishers; 1998;
  5. Evans P, Wurster T. Blown to bits: how the new economics of information transforms strategy. Boston: Harvard Business School Press; 1999;
  6. Gryskiewicz S. Positive turbulence. San Francisco: Jossey-Bass Publishers; 1999;
  7. In: Editors  editors. Healthweek Outlook. 7:1999;
  8. Jones G. Cyberschools: an education renaissance. New York: Digital Century; 1997;
  9. Fagin C. Nursings value proves itself. Am J Nurs. 1990;10:17–30
  10. Ashley JA. Hospitals, paternalism, and the role of the nurse. New York: Teachers College Press; 1976;
  11. Zemke R, Raines C, Filipczak B. Generations at work: managing the clash of veterans, boomers, xers, and nexters in your workplace. Chicago: AMACOM; 2000;

PII: S0029-6554(01)57254-1

doi:10.1067/mno.2001.112789

Nursing Outlook
Volume 49, Issue 4 , Pages 182-186, July 2001

Article Tools