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Thursday, April 22, 2010

Voice and agency

Janna, my Dalmatian, is a talker. She has always grumbled, moaned, sighed, barked, yodeled, and done this weird, uncanny half-whine, half chant when she is very excited about something amazing like finding my sock on the laundry room floor. Her sister, Maggie, is much quieter and very much the slightly-sneaky observer who notices everything. Most of the time, all that talking gets Janna what she is after—the lion’s share of attention. From her, much more than all that nursing literature out there, I’ve learned the deep connection between voice and agency. We are able to act as our own agents when our voice is heard; when we are marginalized, our voice is dismissed, or ignored, or simply drowned out by louder voices, and our ability to act as our own agent is negatively impacted. Our ‘vote’ is not counted. That toddler, sitting on his mom’s lap for an immunization, was clearly registering his vote. Thankfully, for his greater health, we shifted that vote with our distraction technique of bubble-blowing, otherwise his voice would have given rise to the agency of running out of the room!

As nurses we take this connection between voice and agency, between vulnerability and marginalization very seriously. On a daily, an hourly, basis we care for people who are made vulnerable by situation and have a voice, and people who are made vulnerable by society and have little-to-no voice. We see their disparate outcomes in recovery. For nurses, social justice is an integral component of practice: health and wellness outcomes are connected to voice and agency, vulnerability and marginalization.

Traditionally, nurses have always stood shoulder-to-shoulder with their patients, identifying with an equal plane of social power, acting as translators of ‘orders’ and advocates seeking to catch the ear of the white-coated medical elites. I cannot count the times that I have sat beside patients helping them think through and jot down questions they will take on their next doctor’s visit, seeking to give voice to their personal concerns and to have agency into their care. We act to empower these patients by coaching them to use their voice to gain ground in that short eight minutes they have the ear of their physician.

The dynamics of nursing have changed with time. We are now all-too-often fiscally restrained by time and outcomes not of our choosing; we are also moving up the ladder professionally and are beginning to sense the power distance growing between patients and ourselves. Along with the health care system, we are becoming ‘bigger’ and patients are becoming smaller. It is difficult to have your voice heard in the vast system that is the business of healthcare.

We cannot lose this innate call within nursing to identify voice, agency, vulnerability, marginalization in our care. To do so, would change the core of nursing. The pressure of practice today, however, is to move toward programs of interventions and guidelines of practice based on outcomes. There is everything right in this move, except that the decision to keep or axe a program or produce a guideline of practice is only as good as the evidence supporting it. Much of the evidence of which we are basing these fiscally-imposed decisions is from data that has failed to adequately capture the impact of nursing care interventions on patient outcomes.

For example, nurses’ care is often reduced to ‘tick sheet’ documentation that speeds up our world and is much easier to digitally record, however fails to record most of the actual care encounters that make up our shift. Narrative charting does not translate well to a digital world. The narrative portion of the chart (Nursing Notes) is helpful for communication between providers during an episode, but is disregarded after discharge. There is a huge component of nursing that has increasingly become invisible to decision makers, policy writers, and program evaluators. Two things happen with invisible voices: marginalization and lack of agency. We also forget who we are—a loss of identity because the new generation of nurses lose the connection of the ‘way things were.’

Doom and gloom for our profession? Of course not. We do need to acknowledge that change is the only constant in healthcare :-) … and we will continue to change with the needs of patients and populations. That is nursing and that is good. However, I do believe that to keep our strong core of advocacy and this commitment to social justice that informs our direct care and practice, we do need to strongly advocate for nursing sensitive indicators to be included in EHR systems so that we can document our care in a more complete, meaningfully manner. We need to raise our voices about what our direct and indirect care has contributed to outcomes of individual and groups of patients, of our communities and patient populations, or we will lose our ability to do what we do best. We need to learn to clearly articulate our needs as a profession and as individual professionals in our unique contexts of care, because if we cannot give voice to our needs this directly impact our ability to act, to be, nurses. Our agency is on the line.

God speaks as a still small voice. He also gets our attention by speaking in diverse ways (not necessarily louder). He speaks so that we can become bold in the knowledge of his great love for us and our neighbors. There is no exclusivity about such love. There is no circle of immunity to marginalization. We are called as nurses and as people of God to hear and to care. Let us support one another in continuing—and increasing—our ability to do so.

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