Challenges for Nursing in the 21st Century

Sister Rosemary Donley


Nurs Econ. 2005;23(6):312-318. 

In This Article

Increasing Complexity

The changing patterns of health care delivery have increased complexity in all practice environments. Evidenced-based practice models have intensified rather than simplified nursing care delivery because they have been inserted into traditional practice patterns. Nursing lacks systems to plot its patterns of care delivery (Pyzdek, 2004). Consequently, except in limited circumstances, nurses are unable to predict what activities make a difference in the outcomes and satisfaction levels of their patients. The inability to identify and control the processes, protocols, patterns, rituals, and tasks related to safe, compassionate care delivery and better health outcomes does not assure professional practice.

The field of engineering uses a statistical technique, principle component analysis, to determine what is important to control in systems (Pyzdek, 2004). Recently several clinical indicators of patient well-being have been related to nursing intervention. If nurses are to work smarter in complex environments, where a shortage of nurses is a constant factor, work redesign schemes must include process control features. As teachers cannot teach all possible content in nursing, practicing nurses cannot add more methodologies, expectations, and tasks. Future-oriented practice puts aside biases about rituals, tasks, and the traditional subject matter of nursing. It lets go of patterns, even those painfully acquired through education and experience, and uses data and the wisdom gained from experience to assess health care, nursing care delivery, and nursing education from the 64th floor (Heifitz & Laurie, 1997). This orientation lets nurses see that they cannot replace the Baby Boomer nurses in the profession, or practice nursing as they did in the '80s and '90s. A view from the top helps educators accept that the curricula can not encompass the extant nursing knowledge. It shows practicing nurses the folly of building practice models solely on economic principles.

Complexity calls for new modes of thinking, what some authors call thinking "out of the box." Working "out of the box" is working with X, an unknown variable. It is working outside traditional boundaries, or coloring outside the lines (The University of Texas, 2004). Nurses approach ambiguity and complexity differently. Intrinsically, the practice of nursing lacks surety because the objects of nurses' work are human beings with energy, intelligence, and free will. Yet, some nurses think "in the box" because they have invested years in their discipline; they believe that the current flux in health care is a storm, not a sea change; they worry about licensing boards and accrediting agencies; and they want to offer their students and patients a recognized epistemology that has borne the test of time. Their specialties and their curricula are their road maps. Other nurses are ready to think "out of the box" because they no longer find meaning in the patterns that they see before them; they view the changes in nursing education and health care as a watershed from which there is no going back; and they are intrigued by the possible futures of nursing.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as: