SNEAK PREVIEW Q&A with Safety and Quality Conference Keynote Speaker:
Dr Sean Clarke
Associate Director, Center for Health Outcomes and Policy Research
Assistant Professor of Nursing 
University of Pennsylvania, School of Nursing
About Sean:
As the Associate Director of Penn’s widely regarded Center for Health Outcomes and Policy Research and Senior Fellow of the Leonard Davis Institute of Health Economics, Dr Clarke is particularly interested in the impact of nurse staffing and organisational climate in hospitals on mortality and other adverse events.
How important is multidisciplinary team working to patient safety?
Extremely important. The complexity and intensity of services provided to patients across the continuum of care requires not only that each of the specialised disciplines involved in care exercise expert judgment and skill, but that they coordinate their efforts. Even though each of the healthcare disciplines may take a leading role in providing care for particular patients at certain points in their illness trajectories, very little healthcare is provided by one discipline alone. Research confirms what people have observed for years: both that communication (often across disciplines) is a major source of patient safety problems, and also that the best patient outcomes are found in environments where the members of the team are strong as individuals and come together in well-managed work environments.
What have been the greatest changes to the nursing profession in the last ten years and what are you expecting in the next ten years?
I think the most striking change in the profession is a renewed outward-looking focus--I think that while nurses remain committed to their clients and their facilities in their local communities and are concerned about their own working lives, nurses are more and more interested in national and international contexts of health care and are becoming more and more sophisticated in the way they respond to forces in the health care systems where they work. I think nurses have been full partners in the quality and safety movement in their home institutions and at least on the national level. I think we're seeing more nursing leaders trying to shape these trends through political action and activities within professional organisations and societies rather than merely reacting to them.
The biggest challenge for the profession is to continue evolving with the health care systems it serves while not abandoning the core values that are its reason for being--the service of the public. In pretty much every country in the world right now, there are serious questions about whether there will be enough professional nurses and skilled nursing workers with the right skill sets to meet societal needs in the next decades. In the next decade, we're going to need to offer well thought-through proposals to make sure we don't fall short on our obligations. We also have some work to do on career paths within our profession, especially in figuring out how to renew our leadership of the profession at all levels when so many will be retiring over the next years and there are relatively few who are prepared to replace them.
How difficult has it been to initiate long term change and improvement in the politicised (ie: tactical) environment of health care?
Getting agreement on principles is surprisingly easy--getting down to details is much tougher. We're not even 10 years into the current wave of patient safety and quality work that has revolutionised the way the public, politicians, clinicians, and managers think about health care--and the distance that has been travelled is remarkable. The 'tipping point' has been reached ... quality and safety are firmly on the health care agenda--for good, I believe.
The tougher part is getting to the point of changing health care in a practical, direct sense--the quality of care on the front lines, or on the sharp end. That we aren't doing as well as we could or should, is clear ... but where to start and what to prioritise is much trickier. I think the many excellent, highly-motivated people doing front-line quality and safety work in care delivery settings are doing a great job in very complicated (sometimes needlessly complicated) systems, trying to overcome with information and change overload as well as a surprising amount of inertia. Equally tricky is using state and national policy or health care payor initiatives to drive change on the front lines of care, when it's all too easy for regulatory guidelines or pay for performance initiatives to fall short of their intended targets or even produce unintended consequences.
How important do you think accreditation is to improving patient safety and the quality of care?
I think it's essential. Accreditation standards set meaningful baselines for healthcare providers and agencies; when revised and upgraded on a regular basis, they provide some of the best tools for raising the bar across an entire system or jurisdiction over time. The trick in designing accreditation processes is to make sure care processes and patient outcomes are the focus of activity, rather than the documentation and inspection components of accreditation, and to make sure everyone involved in quality management on the ground realises that quality and safety work need to go beyond meeting prescriptive dictates in accreditation alone.
The US, especially, and also the UK seem more willing to adopt nurse practitioner roles (or expanded scope of practice for senior nurses) than Australia. Why do you think this is and what are the consequences (or not) of not developing the role of nurses?
Well, first of all, I think that it's important to understand that even within the US, where there's what we might call a very 'entrepreneurial' attitude towards expanded scope of practice for specially-trained nurses in advanced practice roles, there are tremendous region-to-region variations in what comparably trained nurses are and aren't allowed to do on behalf of patients. To a great extent, this is due to the way local, state and national politics come into play in determining what kinds of restructuring of roles take place (or don't take place). Nurse practitioners in Pennsylvania have only had prescriptive privileges within the last five years, for instance. What 'privileges' are allowed and how credentialling takes place, and so forth, has a great deal to do with the politics of the medical profession and the costs and benefits politicians perceive are involved in loosening strictures that constrain advanced practice nursing. Patient needs and a lack of physicians willing/able to provide certain services in specific geographical areas often will trump even vigorous objections from physicians. Interestingly, it doesn't really have much to do with patient safety in the end (despite the very emotional outbursts to the contrary), at least in any evidence-based sense (a lot of research speaks to feasibility, safety and acceptability to patients of having nurses in these roles).
I think there's a danger of alienating experienced, talented nurses who are eager to provide certain kinds of services if advanced practice roles are not developed; I think the healthcare systems that fail to fully develop these roles (and I would include the US and the UK) are depriving their patients of a source of expertly-provided, cost-effective health care. But the political will needed to move some of these issues forward is staggering--in many quarters, organised medicine is prepared to fight over every inch of territory. We must be thoughtful about how much time, energy and good will we're willing to spend on this in nursing, when there are other professional and quality of worklife issues to be dealt with--ones that affect far more working nurses and patients.
Any particular aspects of your trip to Australia that you’re looking forward to?
I'm looking forward to hearing different perspectives on health care issues that we tend to take a very parochial view on in North America (superiority or inferiority of certain approaches, certain ways of framing issues and defining terms)--there's a lot less calcified thought and bandwagonism in Australia and a lot more willingness to critically examine issues, especially in nursing and health systems research. I am well aware it's not good to stereotype, but I also find the directness, lack of pretention and terrific sense of humor of Australians really refreshing and delightful.
Conference registration available now:
http://www.sapmea.asn.au/conventions/sqhc2007/index.html
