AJN, American Journal of Nursing:
Changing our language to fit the ecology of care.
Kathleen M. Thies is a senior clinical researcher in the Department of Nursing Education, Practice, and Research at Elliot Health System, Manchester, NH, an adjunct associate professor at the University of Massachusetts Graduate School of Nursing, Worcester campus, and a developmental psychologist. Contact author: email@example.com. The author has disclosed no potential conflicts of interest, financial or otherwise.
How often have you heard the term frontline staff used to refer to direct care nurses and others working at a patient's bedside? It conjures images of the great world wars, of soldiers marching across battlefields to fight the enemy. The infantry are invariably young, dispensable, interchangeable. Commands are issued by generals and passed down through the ranks. No questions are asked.
Front line, when used in regard to the provision of health care, implies conflict—most clearly with disease, but also, perhaps, with our patients, each other, or those in other disciplines. The military metaphors that have prevailed since the 19th century will not serve us well as we respond to calls for health care reform in the 21st century. Indeed, the heroic imagery of battle is already yielding to idioms that more accurately reflect the complex challenges we face. For example, "fighting disease" has become "managing illness."
I propose that we refer to core nursing staff instead of frontline staff. When the patient is at the center of care, core clinical staff—nurses, physicians, and others—practice together at this central position, where colleagues are valued and collaboration is built over time. This center will not hold amid the current tensions and challenges that pervade our practice unless we learn to value this metaphor of the nurse's role and cultivate it.
The word core better characterizes nurses' current and prospective role. In patient-centered care, patients (and their families) are at the core of our reason for existence as professionals and health care organizations. We might conjure an image in which a circle represents the patient and family. Four concentric circles ring this center circle, with the first of these representing direct patient care. The next ring encompasses the services and departments needed to support direct patient care, such as pharmacy. The third ring represents administrative functions, and the fourth the legal and financial complexities of health care policy.
In patient-centered care, the patient and family are embedded within systems that make up the ecology of patient care. Changes to any one of these will affect the others. For example, a population of older adults with multiple comorbidities will place great demands on core staff, support services, and the staffing budget. A decrease in reimbursement from third-party payers will affect the staffing budget, which in turn will place additional demands on core staff and may affect patient care.
Patient-centered care focuses first on the patient and then moves outward to related systems and functions before returning to the patient. This approach acknowledges the complexity of health care systems, in which multiple factors are simultaneously at work in multiple systems, as described by Plsek and Greenhalgh in 2001 in BMJ. A systems model of care calls for flexibility and mutual influence, in contrast to unilateral command.
Aside from suggesting images of centrality, core is a better word choice because it means "basic" or "fundamental." Core nursing staff are neither dispensable nor interchangeable. As providers of direct patient care, they are often the most knowledgeable about it. Deming noted in his 1986 book, Out of the Crisis, that those who do the work must participate in efforts to improve its quality. For example, core nursing staff would regularly review outcomes data and propose evidence-based strategies to improve upon them. The organization as a whole is only as good as the care they provide.
Clinicians and professional organizations must change their language in order to alter how we think about our place in health care. Language, culture, and thinking are inseparable, and to alter one is to affect the others. Core staff offers a robust image: clinicians clustered around a patient who's at the center of care.