Guest Editorial: Care quality and safety: Same old?

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Healthcare’s increasing focus on quality and safety seem like a “natural” for nursing. The profession has prided itself in being the patient’s advocate and the keeper of quality and safety. While nursing has clearly provided consistent and committed leadership in these arenas, it is also possible that exclusive professional ownership of quality and safety may actually work against the best interest of both nursing and patients. This editorial challenges nursing to reconsider its role in and approach to quality and safety improvement. Building on the important perspectives presented in this issue of Nursing Outlook, the author identifies the need for nursing to advance its own professional contributions through building on the shared values and commitments common to health professions. Establishing common ground and extending the concept of care teams to incorporate others beyond direct-care providers are explored as a fundamental component of nursing’s work in quality and safety improvement.

This issue of Nursing Outlook is important, timely, educational, and old-fashioned. The first 3 of these descriptors are well-explicated in the editorial that follows—it is the last, old-fashioned, that I’ll spend most of my editorial license addressing.

“Old-fashioned” conveys many different meanings. Among these are “outdated, outmoded, unfashionable, non-contemporaneous,” to name a few. But there is also a meaning that runs in a different direction than these terms. It suggests that old-fashioned is grounded in nostalgia, or fondly looking back at better times. There is a sort of beckoning that comes with the idea of being old-fashioned—a call to simpler days when people were more connected.

The articles that appear in this issue are very much connected to notions of better times. This collection reflects the bedrock values of advocacy for patients and their families, care quality and safety, and health professionals working together. There is also a certain irony throughout this volume: what we aspire to achieve now is very difficult largely because of the “modern” ways in which our professions and healthcare have evolved.

Clearly, I’m suggesting that there may be some important things about the past that we ought to bring forward as we consider how we make care better for the people we serve. As we review the compelling evidence and ideas presented in this issue, I am suggesting that we frame our considerations through 3 very important, old-fashioned concepts: advocacy, care quality, and care safety. Further, I am proposing that these concepts represent the timeworn bedrock of nursing and medicine upon which a better future of caring must be built. And, to take it one step further, I believe that health administrators should be joined with nurses and physicians as the prime movers and partners in our quest to improve care.

So, let’s start with advocacy. We in nursing use this phrase to describe ourselves in fairly generous ways. We are the patient’s advocate. By adopting this stance, we claim a certain privileged place in the terrain of healthcare. Two key questions come to mind, however. The first is: “If we really are the patient’s advocate, why do we need this issue of Outlook at all?” I ask this question in all seriousness. There is a fundamental disconnect between nursing’s state of knowledge and practice of quality and safety, and our possibly self-congratulatory stance of being the patient’s advocate. As I mentioned earlier, I see advocacy as a bedrock value for nursing (so I’m with us at least part of the way on this). However, nursing’s identity as advocate does give rise to the second question: “How can we be the patient’s advocate if we are claiming this for nursing alone?” Yes, I’m raising the challenge here of whether our possible exclusivity runs counter to some of the very important lessons in the articles that follow. Improvements in care quality and safety will simply not happen with nurses working by themselves. To take it a step beyond what may seem obvious, it can’t happen just by adding physicians to the equation. It’s going to take the partnered engagement of other clinicians, health administrators and, ultimately, the public.

Another important message that emerges throughout this volume is that the improvement of care quality and safety require competencies beyond those commonly found in today’s curricula. As the profession considers how to incorporate these competencies into education and practice, there is a potential pitfall that we need to avoid—again in the name of true patient advocacy. I fear that we will make the mistake of specializing quality and safety (ah yes, the quality and safety officer movement) in the same ways that we have specialized infection control and other key functions. Specialization in and of itself is not bad—however, when we give full responsibility over to someone else, we fundamentally relegate our ability to be real advocates. Consider, for example, the ubiquitous problems of poor hand-washing practices and patient infections. While I have come to agree that blame does not belong in our quality and safety improvement processes, I have not abandoned the view that health professionals have responsibilities that link directly to our commitment to look out for the patient’s best interests. We can’t pose as advocates if we depend on others to fulfill our most basic responsibilities.

So we’ve talked about advocacy and its relationship to quality and safety—but, I suggest, never enough. Again, the lessons contained in this volume point to a real need for us to change the ways in which health professionals learn and work together—in the name of the wellbeing of those we serve. So what’s the stretch? This sounds like its right up our alley, right?

Let’s be honest and recognize that we’ve got some major stretching to do. If you felt a little uncomfortable about patient advocacy not belonging to nursing, then I think it may be an even greater source of discomfort to imagine that we need to abandon some of our most time-honored practices. Here’s a few to start with: (1) we need to stop talking to ourselves and start listening to others; (2) we need to abandon consensus and cheap agreement; (3) we need to actually learn and work with others in ways that we can explain, and support them and their contributions.

I must say, I have grown tired of us saying that we are making major strides in collaboration and partnership with others beyond nursing. I worry that we in nursing have fought so hard for our professional identity and autonomy that we see being separate from others as a condition for future success. I see our separateness (or “silo”) as antithetical to our most basic professional values. How can we reconcile our commitment to providing the best possible care when we still grapple with the place that nursing assistants, technicians and others have in relation to our work? What do they think and need—do we make them welcome members of the care team? We are missing an important opportunity here; nursing is in the perfect position to provide leadership in this regard.

Okay, since I’m on this roll, let’s talk about our physician colleagues. What real progress has been made in the dialogue between physicians and nurses? Have we heard in real terms the struggles that they face as medicine makes sea changes in every aspect of its practice? Do we understand the challenges that we face together? Have we listened to our colleagues in medicine and do we know what they have to say about us?

Please bear with me as I suggest another possible chink in our professional armor. When was the last time we really listened to what health administrators have to say about nursing and care? It seems ironic to me that we are often least connected to these colleagues at a time when nursing’s most fundamental concerns come up square against the administrative, organizational, and fiscal realities of care. We have a real opportunity to advance quality and safety by collaborating with health administrators. A starting point for us might well be having the views of health administrators integrated into our own concepts of how nursing can best contribute to improving care.

Lest my commentary appear to indict nursing, please rest assured that virtually every health profession lives in a well-protected enclave. (I successfully avoided the term silo here, having grown up on a farm and recognized the valuable function of this particular structure.) The quality and safety movement is shaking all of us at our foundations. Or, at least, it’s making us rethink what we see as foundational to our education and practice.

A major part of this process of professional reconsideration or recalibration is focusing on how we all work together, both within and beyond our professional boundaries. A key component of this is how we enable care team members to express dissent or concern. One would think that the whole concept of team is based on the notion of bringing together different perspectives. However, the notion of different views runs counter to what I’ve come to refer to as “cheap consensus”—or the idea that uniform agreement is somehow good for us or the patients we serve. This kind of consensus does nothing but reach a fragile lowest common denominator and isn’t good for anyone, particularly our patients. When we devalue differences, we lose the opportunity of multiple perspectives. We in nursing can play a central leadership role to advancing health care if we can trade-in the notion of consensus for the goal of building the common ground of health care quality and safety. This construct encourages us to openly entertain different views and challenge others, seeing both as key dynamics to improving care.

While creating common ground is crucial, it isn’t at all easy. It requires, again, moving beyond comfort zones for all of us. It does mean we take seriously all team members, that we do cultivate communication and actually listen, that we get to know and appreciate others in daily learning ways so that they are no longer “others” in our professional lives. It also means being able to articulate and measure the progress that is made in honoring the ground that truly is common to all. And, fundamentally, developing common ground means returning to the old-fashioned bedrock values that we share within and beyond nursing: advocacy, care quality, and care safety.

There are two other old-fashioned values that are required to truly advance care: hard work—and “walking the talk.” This volume of Nursing Outlook provides us with clarity about the directions we can take in moving care forward—this is the “talk” that needs to be walked if we are to move beyond the present. We have many miles to travel to effect change and a great deal of hard work ahead. But, let’s be clear—nursing does know a lot about what it is to work hard and to be true to its values. Who better than nursing to move into the forefront of improving care? While quality and safety are not “ours” alone, they provide us with the platform for being our professional best. This is the time for us to build on who we’ve been because it serves as such a strong foundation for the future.