The obverse of Rob Fraser’s post — “Are Nurses Innovators?” — over at Nursing Ideas. When I commented on his post, I thought that innovation among nurses is hampered by institutional and cultural factors, indifferent leadership and the unfortunately prevalent equivocation of innovation with negative changes to nursing work life and patient care standards. When many nurses hear the word “innovation”, frankly, they run the other way. The suspicion of innovation is so ingrained among bedside nurses that even when change can be demonstrably shown to improve patient care, resistance is almost always fierce and very frequently successful.
My classic story about resistance to change and innovation involved some telemetry nurses at the hospital way up North where I was first employed. The manager of the telemetry unit decided that the nurses there ought to be able to read cardiac monitors: the telemetry packs were actually monitored in the ICU. The advantages should be obvious: faster response to potentially lethal cardiac arrhythmias, real time correlation of symptoms, and for the nurses, gaining skill and knowledge to enhance their practice and patient care — greater satisfaction for all and decreased mortality and morbidity. Win for everyone. And the hospital was going to pay for tuition and time so each RN could take Coronary Care I!
What could possibly go wrong?
My spies tell me that even after 12-odd years the nurses on Telemetry still can’t read monitors. There and in other places where I have worked, nurses invariably presented the same reaction to change: No, not on my life, over my dead body. “Can’t do it” is the default position. The reasons given are almost always unchanged: will increase workload and therefore compromise patient care, don’t have the time, not given enough support, has not been communicated well: no, absolutely not, won’t do it, can’t do it.
I’ve thought about this failure of innovation frequently since. I’m not persuaded that using sophisticated strategy, i.e. engaging informal leaders, building consensus, getting buy-in or any of that would have made much difference. In my mind, the reasons for resistance are complex. Many nursing leaders, managers and hospital administrators fail to appreciate how deeply scarring the last couple of decades have been on the nursing profession. Massive cuts to nursing staff in the 90s (and ongoing in some places), increasing patient acuity and workloads, ever-decreasing ancillary services all have left an atmosphere of malaise and mistrust. Hospital administrators treat nurses and nursing as a human resources problem to be managed and disciplined, only slightly above the kitchen staff in the institutional pecking order. In such circumstances — in the hierachical, authoritarian model of management which has be the ne plus ultra of nursing culture, lo these many years — there is bound to be pushback to any innovation. It’s reflexive. And sadly, I don’t think it’s an exaggeration to state bedside nurses have been mostly right. Examples of hospital administrators and managers pissing on nurses in the name of innovation are legion.
So if top-led innovation is difficult, what about innovation from the front lines? Even harder, in my judgement. In the first place, innovation and creativity are not highly sought-after characteristics for front line nurses — though they should be. Innovation is never found on job descriptions. (I suspect — and I would love to hear from nursing managers on this point — that nurses who think too deeply are probably viewed as undesirable and more likely to cause trouble. Though if I were a manager, I would probably take the opposite point of view.) Secondly, managers and administrators (and bedside nurses themselves) tend to view innovation as a management function. If you’re a front line nurse, and you have an idea or read a study that would improve practice in your unit, the sad fact is that you will get very little traction unless your idea is already on management’s radar. Your peers will be unlikely to view your ideas as positive and will often actively try to undermine you. Managers are usually unwilling to engage in a process of change that involves much more than moving a linen cart from A to B if it involves negotiations with other departments: they have to pick their battles too. At the end of it all, who needs the aggravation?
Which leads me to my third point: institutional inertia. Let me provide an example. Some years ago, at a previous employer, I was involved in an ad hoc committee to revise the nursing assessment forms for the emergency department. The old forms were frankly useless, and we were quite excited about being the opportunity to create positive change for ourselves and our colleagues. (The fact we were so excited, actually, speaks volumes.) We worked very hard, and came up with some very presentable forms. Then the “approval” process kicked in. First the forms had to clear both the Manager and the department Nurse Educator. Then the physicians group had to approve them, because, apparently, mere nurses were incompetent to create forms for their own use. Then the manager’s manager would have to have a go at them, and then would send them around to various other interested parties and committees for approval, including the Housekeeping Manager(!) and the quarterly meeting of the Pharmacy and Therapeutics Committee (because, apparently, lowly nurses know nothing about deciding how to document medication properly), and finally to the all-powerful Medical Advisory Committee for final approval, because doctors are so much more smarter than nurses, especially when it comes to charting. Interestingly, the physicians had final say over nursing documentation.
Almost needless to say, the process broke down somewhere between the Nurse Educator, who promised to take our lovely forms forward, and the initial physician approval. They simply fell off the plate. But apart the inevitable breakdown in process, the interesting thing to note about this tale of disillusionment is that apart from the initial burst of creativity, nurses had no real control over the innovation, instead relying on the (sometimes) dubious expertise of others for validation and approval. Again, this speaks to how seriously, or not, nursing innovation is made and developed in practice. The conclusion one comes to, if you are among the 80-odd per cent of us in front line practice, is not much, who cares, and why bother. I don’t doubt nurses are innovators, at all levels, and I don’t think nurses are inherently resistant to change. But creating a culture and providing the leadership where nursing innovation is valued and rewarded — it clearly isn’t now — will require a revolution in thinking and practice — from hospital administrators and managers to the bedside. It’s maybe time to think about how we as nurses can do this — because ultimately, it’s about the future of our profession.