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Do Androids Dream of Being Nurses?

September 11, 2006 -- A fairly good piece by Nikki Cobb in today's San Bernadino County Sun highlights the reaction of California nurses to their hospitals' growing reliance on monitoring technology. "Nurses seeking final say: Contracts limit equipment's input" reports that nurses are starting to place provisions in their contracts stating that the nurses' judgment will prevail in any conflict with such technology. The piece relies on quotes from management and union nurses. It makes the point that such technology can be useful, but excessive reliance on it can threaten patient care. The piece might have provided more specifics about the nurse-machine conflicts and the contract provisions that address them. It might also have explored the extent to which technology could constrain nursing practice in the future, and whether it might be used to justify reductions in nurse staffing.

The article reports that some nurses say their professional judgment can be undercut in situations where a nurse "observes clear signs of distress in a patient," but monitoring technology says the patient is fine. As a result, some nurses have started to insist on contract provisions ensuring that they will have the "final word on the condition of the patient." The piece notes that nurses at Northern California Catholic Healthcare West last year approved contract language "guaranteeing that their expertise will never be superseded by technology," and that nurses at St. Mary Medical Center in Apple Valley did the same. (The exact nature of these provisions is not explained.) Liz Jacobs and Diane Hirsch-Garcia of the California Nurses Association are both quoted saying that such provisions are becoming increasingly common, as nurses seek to make sure fast-moving technology does not override their clinical judgment. Jacobs says another type of clause nurses are starting to consider requires hospitals to allow a panel of nurses to review all potential new technology purchases. St. Mary nurse Lois Sanders notes that one area of concern is hospitals' increasing use of monitoring technology that would transmit patient information to an off-site location to be analyzed, but apparently not to the patient's nurse: "If something happens, you need to know right away...You don't want to wait for somebody to call you with information on your patient."

Quotes from two administrators at Arrowhead Regional Medical Center in Colton suggest that they share the unions nurses' concerns about excessive reliance on technology. One of these is chief nursing officer Judy McCurdy. (McCurdy is described here only as "associated hospital administrator for patient-care services," the type of description that, by itself, obscures the fact that nursing is a distinct clinical science requiring high-level nurse managers). McCurdy stresses that a common situation is when patient has a serious problem but an electronic monitoring device gives no warning. In such a case, she says, the technology is an "adjunct" but not a "substitute" for the nurse's judgment.

The piece makes some good general points about technology and nursing. This may be an especially difficult issue because the common reverence for technology is often matched with an insufficient appreciation for nursing expertise--which as the piece says is the result of "years of training and practice." It is hardly unthinkable that many people would choose a machine's judgment over a nurse's, and this could present real threats to nursing practice and autonomy. The piece also does a good job of highlighting nurses' general concern that excessive reliance on technology can harm patients.

In fact, the piece includes so many quotes with that basic warning that it might have used some of the space to go into greater detail on certain issues. For instance, how exactly does current hospital practice result in technology overriding nurses' judgment? Does someone prevent a nurse from acting to save his patient if a monitor fails to show a problem? Will other caregivers not respond to the nurse's concerns unless a machine agrees? What do the new contract provisions do to prevent technology from overriding nursing judgments? And what are some specific types of technology that present issues? Do the monitoring systems that transmit information to a central location really bypass the nurse, and encourage nurses to rely on someone off-site rather than their own observations? This could be a genuine issue for short-staffed nurses who may not have time to monitor patients as closely as they would like--as well as an argument that nurse staffing can be minimal, since off-site monitoring seems to be helping with nurses' work. Do those at the off-site locations tend to call on-site nurses with non-issues based on faulty or incomplete information, thus impeding nursing care?

The piece might also have explored broader implications that reliance on technology could have for nursing practice. Some may feel that futuristic technology can actually replace nurses. At least one surgical robot was marketed in this way for a time. Others may only suggest that technology can reduce the need for bedside nurses, an idea that monitoring products with names like "electronic nurse" do nothing to discourage. Of course, new technology can be very useful, as the nurses quoted in this piece stress. It may lead to efficiencies in nursing practice and improved patient care. But the danger is in excessive reliance, a risk that is heightened when decision-makers do not fully understand what nurses know and do for patients. If you don't know that nurses do more than hand surgeons instruments or take occasional vitals--and you might be surprised to learn of the health professionals who don't know that--then it is far easier to imagine that nurses can be partially or fully replaced by machines, or that nurses' judgment should be secondary to that of machines. Some may also see in the nurse vs. technology tension a reflection of more long-standing issues that go to the core of nursing practice. Does nursing consist more in the exercise of critical thinking and independent judgment, or more in the diligent, efficient following of established protocols?

We thank Nikki Cobb and the San Bernadino County Sun for this helpful piece.

See "Nurses seeking final say: Contracts limit equipment's input" in the September 11, 2006, edition of the San Bernadino County Sun.

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