Abstract

Summary:
Most nurses inherently value the concept of partnership, of complementary expertise, of collaboration. This stems from our service orientation and our holistic view of situations and solutions. As nurses, we also value the recognition that we bring unique skills and characteristics, what I term the nursing lens: an ability to view patients holistically in the context of their environment and daily experiences; to establish therapeutic relationships with a wide variety of individuals; to think in terms of systems and the big picture; to have a scientific basis for practice and a pragmatic view of what works.

Keywords: Participatory medicine, nursing.
Citation: Disch J. Participatory health care: perspective from a nurse leader. J Participat Med. 2009(Oct):1(1):e4.
Published: October 21, 2009.
Competing Interests: The author has declared that no competing interests exist.

As a novice nurse in the late 1960s, I entered the nursing profession passionately committed to “taking good care of my patients.” I studied hard, passed my boards, selected my first patient care unit, and anticipated becoming the all-knowing independent resource and advocate for my patients undergoing cardiovascular surgery and their families.

Fortunately, I had selected a work setting that was fundamentally based on collaborative relationships between nurses and physicians and with patients and their families. I did not need, nor would it have been advisable, to think I would be the sole resource and advocate.

What I witnessed instead was the exquisite collaboration between the head nurse and chief surgeon as they modeled collaborative decision making; jointly creating an extraordinary program that saved the lives of thousands of patients and families and shaped the professional careers of hundreds of nurses and physicians. As an example of lasting impact, in September 2008, 45 nurses and physicians returned to the medical center for a reunion to celebrate those days.

What I also learned was how to work with patients and their families and how to help them to be full partners in their care. For example, 40 years ago, we were teaching patients and their families how to monitor the patient’s prothrombin times and anticipate what the physician would do, given a certain result. Rocky Schmitz, our head nurse, would remind us: “Who has more at stake than the patient for understanding what’s going on and preventing a mistake?” That lesson of including patients fully as partners in all aspects of their care was ingrained in me early in my career.

In short, I learned that information is power, but relationships are the key. My approach to describing a nurse’s perspective about participatory medicine is to elaborate on mutual participation between nurse and physician as two key components of the health care team, and then to describe nurses partnering directly with patients.

Partnerships with Physicians

Those early years in critical care were challenging, often difficult, but there was a spirited relationship among nurses and physicians. Fairman and Lynaugh,[1] prominent nurse historians, recalled:

“To gain expertise about the care of complex patients, nurses learned through experience and from physicians. Although many physicians were equally unskilled in the care of physically unstable patients, physicians provided much of nurses‘ postgraduate education through formal lectures and informal conversations. Nurses learned through slow periods in the intensive care area. During these times, residents (usually) and nurses in the intensive care unit discussed patients in detail, each learning from the other. When cardiac monitors were introduced at one hospital, a nurse remembered, nurses and physicians grouped informally around the monitor screen in ‘pick-up‘ sessions…Unusually close camaraderie developed between nurses and physicians in the units because of the small areas, shared sense of adventure in the new setting, and the selection of the ‘expert nurses,‘ usually young and ‘energetic,‘ to staff the unit. ‘We (nurses and physicians) were all in this together,‘ one nurse noted. ‘We all learned from each other‘.

In 1999, Tom Gilmore wrote a small piece about productive pairs, or individuals who come together and develop a partnership to accomplish a shared goal.[2] Characteristics of these partnerships include:

• Separate bodies of knowledge, networks and other categories, even different ways of looking at the world;
• A shared passion for a common goal or vision;
• Understanding and valuing each other’s area of expertise and perspective; a belief that both areas need to be integrated in the service of the superordinate mission;
• Enough time or history together to explore the interdependencies;
• Trust of one another that enables direct talk and push back, even when the topic is centered in the other’s world;
• Minimal use of “triangling in” another party as a way of exporting difficulties in the pair to an absent third party; and
• Resistance to being divided by the manipulations of their respective colleagues.

Most nurses inherently value the concept of partnership, of complementary expertise, of collaboration. This stems from our service orientation and our holistic view of situations and solutions. As nurses, we also value the recognition that we bring unique skills and characteristics, what I term the nursing lens: an ability to view patients holistically in the context of their environment and daily experiences; to establish therapeutic relationships with a wide variety of individuals; to think in terms of systems and the big picture; to have a scientific basis for practice and a pragmatic view of what works.

Decades of research have shown us that collaboration yields more than nurse/physician satisfaction. Morbidity and mortality, length of stay, and other very quantifiable outcomes can also be affected by how effectively nurses and physicians work together.[3][4][5][6][7][8] In a partnership relationship between colleagues, nurses and physicians have the opportunity to advance their best ideas, to create new solutions, and to grow professionally. They can be a productive pair accomplishing shared goals. Physicians and nurses working successfully in partnership form a terrific foundation for effective participatory relationships with patients and families.

Partnerships with Patients and Families

According to Virginia Henderson, a nursing leader from the last century revered by some as much as Florence Nightingale, “The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge.[9]” This requires that the nurse work within another partnership relationship—with each individual, sick or well—to determine each patient’s strengths, will, and knowledge, and to develop personalized approaches to augment them as indicated. This is patient-centered care.

Over the years, however, the definition of patient-centered care has become muddy, ranging from the patient as decision maker and/or full partner in care decisions, to what one physician described as ” patient-centered care…I take care of patients.” Fortunately, this is changing. In 2001, the Institute of Medicine (IOM) urged patient-centered care, ie, “Providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.[10]” In 2003, the IOM proclaimed that, “All health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics.[11]” The nursing competency in this area, as outlined in the Quality and Safety Education for Nurses (QSEN) project funded by the Robert Wood Johnson Foundation, is to “…recognize the patient or designee as the source of control and full partner (italics added) in providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs.[12]”

Achieving Participatory Health Care

With the launch of this journal, a new vehicle has emerged for enriching partnerships among health care providers and with individuals, their families, communities, and populations, to improve health. The goal is appropriate and timely: “A cooperative model of health care that encourages, supports, and expects active involvement by all parties (health care professionals, patients, caregivers) in the prevention, management, and treatment of disease and disability and the promotion of health.[13]” The approach is essential: building an “interdisciplinary field of inquiry and practice.[14]” This is a goal and approach that everyone providing care or receiving it can support.

How will we evaluate success? What will be in place or what will we see if participatory health care between care providers and with individuals and their families becomes a reality? Here are some indicators that would reflect success among health care providers:

• Clear identification of membership on interdisciplinary teams
• Collaborative development of patient goals, as well as ongoing assessment of progress and evaluation of outcomes
• Known times and locations for team meetings so that members can attend and participate
• Inclusion of a diverse array of health care providers as members of the team, each making contributions based on patient needs and their expertise
• Sharing of the leadership of the team based on who has the best knowledge of the patient’s  problem or aspect of care at the time
• Formal and informal consultation between all members of the team, dependent on their particular areas of expertise
• Open communication and respectful expression of disagreements.

Participatory health care does not require everyone meeting together to jointly do all of the work. Rather, it takes advantage of differential areas of expertise and capitalizes on a shared commitment to achieving jointly determined goals.

For success in partnering with patients and families, the following indicators from the QSEN project could be assessed:

• Patient values, preferences, and needs are elicited and incorporated into the plan of care
• The patient, family, or designated surrogate is actively included in the care process according to their preferences
• Care is provided in a culturally sensitive manner, and communication targeted at an appropriate comprehension level
• Pain in all of its dimensions is managed
• Barriers to the presence of families and other designated surrogates are removed according to patient preferences.

The current environment within health care has been described as VUCA — volatile, uncertain, chaotic, and ambiguous. Gone are the days when patients stayed in the hospital for weeks for simple procedures such as coronary artery bypass, or when nurses gave patients bags of supplies to take home with them so they wouldn’t have to worry about paying for them. But the benefits of being part of a collaborative team—which includes patients and their families—that works together, values each other’s knowledge and contributions, and can make a profound difference in people’s lives, both their patients’ and their own.

References

1. Fairman J, Lynaugh J. Critical Care Nursing: A History. Philadelphia: University of Pennsylvania Press; 1998:85. ↩

2. Gilmore T. Briefing notes: productive pairs. Philadelphia: Center for Applied Research, University of Pennsylvania; 1999. Available at: http://www.cfar.com/Documents/prodpairs.pdf.  Accessed October 19, 2009. [Google Scholar] ↩

3. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. An evaluation of outcome from intensive care in major medical centers. Ann Intern Med. 1986;104:410-418. (Medline) [Google Scholar] ↩

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9. Tomey AM, Alligood MR. Nursing Theorists and Their Work. St. Louis: Mosby; 1998:102. ↩

10. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington DC: The National Academies Press; 2001:40. Available at: http://www.nap.edu/html/quality_chasm/reportbrief.pdf. Accessed October 19, 2009. ↩

11. Institute of Medicine. Health Professions Education: A Bridge to Quality. Washington DC: The National Academies Press; 2003:45. Available at: http://books.nap.edu/openbook.php?record_id=10681.  Accessed October 19, 2009. ↩

12. Cronenwett L, Sherwood G, Barnsteiner J, et al. Quality and safety education for nurses. Nurs Outlook. 2007;55:122-131. (Medline) [Google Scholar] ↩

13. e-Patient Dave. Why the Journal of Participatory Medicine? e-patients.net. October 12, 2009. Available at: http://e-patients.net/archives/2009/10/why-the-journal-of-participatory-medicine.html. Accessed October 19, 2009. ↩

14. Goethals GR, Sorenson GJ, Burns JM, eds. Encyclopedia of Leadership, Vol. 4. Great Barrington, MA: Berkshire: 2004:xxxv. ↩

Open Questions

1. In what ways are the contributions of nursing to participatory medicine different from those of physicians and other health providers?
2. Why are successful nurse/physician relationships important for participatory medicine?  Are these alliances any more or less important than those between other professional groups?
3. How do shorter hospital stays impact the importance and relevance of participatory medicine?

Copyright: © 2009 Joanne Disch. Published here under license by The Journal of Participatory Medicine. Copyright for this article is retained by the author(s), with first publication rights granted to the Journal of Participatory Medicine. All journal content, except where otherwise noted, is licensed under a Creative Commons Attribution 3.0 License. By virtue of their appearance in this open-access journal, articles are free to use, with proper attribution, in educational and other non-commercial settings.