Innovating Nurses

In “Innovating ‘In the Here and Now’” (Issues, Winter 2021), Lisa De Bode shares several accounts of nurses in the United States who leveraged their own innovative behaviors to problem solve for the benefit of their patients’ health status during the COVID-19 pandemic. Nurses developed innovative workarounds at scale as a result of significant unmet needs due to a lack of sufficient and available resources for their hospitalized patients and themselves.

While workarounds are not new to nurses, as Debra Brandon, Jacqueline M. McGrath, and I reported in a 2018 article in Advances in Neonatal Care, the circumstances of the pandemic are new to us all. We have not seen a health crisis of this caliber in over 100 years. The COVID-19 pandemic revealed the many systemic weaknesses in the nation’s health care delivery system. De Bode shares a few aspects of how those systemic weaknesses revealed unmet needs affecting nurses’ ability to provide quality care. In response to these pervasive unmet needs, nurses were left to their own devices. Nurses amplified their own innovative behaviors to create workarounds at scale.

I am delighted to see nurses’ innovative behaviors highlighted and shared with the world. I am also grateful for how De Bode so eloquently integrates the historic role of nurses in the 1918 Spanish flu pandemic: “nursing care might have been the single most effective treatment to improve a patient’s chances of survival.” This year, 103 years later, nurses were voted the most trusted profession for the 19th year in a row. Thus, the value of nurses on the health of the public has sustained over a century. Yet we continue to expect nurses to work around system-level limitations within health care organizations instead of recognizing how these workarounds are placing nurses, patients, and their families at risk for suboptimal care and the potential for medical errors.

To innovate is to address unmet needs for a population of people that brings positive change through new products, processes, and services. De Bode’s article reveals a population of people, the nursing workforce, who have sustained significant unmet needs for an enduring period with no visible end in sight. As a profession, an industry, and society, we cannot ignore that nurses are human beings, too, also in need of care and resources.

If nurses do not have what they need to provide quality care for patients, then time is unnecessarily spent working to first solve for the unmet need, in order to then care for the patient. Researchers have found that time spent on workarounds can be upward of 10% of each nurse’s shift, a factor likely contributing to symptoms of burnout. Months before the pandemic, the National Academy of Medicine reported in Taking Action Against Clinician Burnout that 34% to 54% of nurses were experiencing symptoms of burnout.

This empirical data combined with the enduring COVID-19 pandemic should be more than enough for our profession and the health care industry to recognize the need to reevaluate how we invest in our nurses and the environment in which they deliver care. We may be able to work around a lack of equipment and supplies, but we cannot risk working around a lack of nurses in the workforce.

Tiffany Kelley

Nursing has long been a poorly respected, poorly paid, but high-risk profession. Historically in Europe and North America, nurses were volunteers from religious denominations; in other societies, nurses typically were family or community caregivers. Even as nursing professionalized and added requirements for classroom education and clinical training, it remained lower status than other medical disciplines. Numerous studies have tracked detrimental impacts of this dynamic on patient outcomes; in extreme but strikingly frequent cases, intimidation by surgeons has prevented nurses from speaking out to prevent avoidable medical errors.

As Lisa De Bode describes, nurses nevertheless have played a central role as innovators throughout history. She cites Florence Nightingale’s new guidelines on patient care and the efficacy of nursing during the 1918 flu pandemic before noting that nursing generally is considered a field of “soft” care that enables physicians and surgeons to invent “hard” tools, therapeutics, and other biomedical machinery. Yet as Jose Gomez-Marquez, Anna Young, and others in the Maker Nurse and broader nurse innovation communities have identified in recent years, nurses have been “stealth innovators” throughout history. Interestingly, this work was recognized within the profession at times. From 1900 to 1947 the American Journal of Nursing ran an “improvising” column of nurse innovations that met criteria of efficacy, practicality, and not creating new risks to patients or attendants. After 1947, the journal ran a regular series to share innovations, “The Trading Post,” which included sketches, lists of materials, and recipes. Ironically, as nursing professionalized, recognition of the tinkering mindset and peer-to-peer sharing of ideas declined.

De Bode’s article provides diverse examples of rapid response, nurse-originated innovations during the ongoing COVID pandemic. She also observes and subtly pushes against definitions of innovation that are based solely on “things,” such as pharmaceuticals and medical devices. Innovations—and inventions—that originate from nurses typically fall into vaguely classified categories of “services” and “care.” They aren’t patentable, reducible to products that can be licensed to other clinics, or the basis for making a pitch deck to present to venture capitalists. Like the invention of hip-hop, the creation of new clothing styles by individuals in the Black community, and the work of thousands of inventors who are Black, Indigenous, or people of color in low-status professions, these advances are not treated as property of the inventor and often are not archived and celebrated as breakthroughs.

Just as 80% of the mass of the universe is made up of unobserved dark matter, we ignore the majority of the innovations that ensure that hospitals function or that myriad other aspects of our daily lives actually improve year on year. Ironically, even as the United States celebrates itself as an innovation-based economy and advocates for stronger intellectual property systems worldwide, it ignores the majority of its domestic innovations. A reset in how we define “inventor” and which innovators we resource with funding and recognition is overdue.

Arthur Daemmrich

Lisa De Bode has cast a critical spotlight on the role of innovation undertaken by nurses, particularly within the crisis of the COVID pandemic. Many nurses would not consider themselves as inventors or entrepreneurs, nor do many others in the health system—but in fact often they are. Nurses are often commonly considered as the doers, executing the plans of others and for the most part this is true. As De Bode explains, nurses often engage in “workarounds,” tailoring approaches designed for them, not designed with them or by them.

But the fact is that many nurses devise innovative approaches and designs. As innovators, nurses can drive changes in systems and processes that impact care delivery and patient outcomes and improve the working life of nurses and other health professionals. Increasing collaborations with patients, their families, health providers, and members of other disciplines, such as engineers, demonstrate significant promise. De Bode has created a window into the working lives of nurses. Listening to their views and opinions and leveraging their expertise is vital to solving the complex problems of our health systems.

For decades nurses have been voted the most trusted profession. Clearly, our patients value us. So it is important that those who design and fund our institutions and models of care to listen to the voices of nurses and their advocacy for patients. The impacts are potentially transformational.

Patricia Davidson