Loretta ‘Lee’ Ford: Still trying to change the world (Part One)

By RNL Editors | 01/01/2014

Beth Houser talks with Ford in sixth installment of The
RNL Interviews.

Loretta Ford Beth Houser top image

It’s the first sentence of the first chapter of the first volume of
Pivotal Moments in Nursing:Loretta Ford, RN, EdD, PNP, FAAN, FAANP, is a nurse leader who transformed the nursing profession by initiating a movement that changed the delivery of healthcare, so much so that the words 'nurse practitioner'are nearly synonymous with the name Loretta Ford.” Recently, Beth P. Houser, DNSc, RN, FNP, NEA-BC, co-author of Pivotal Moments and vice president/chief nursing officer at Baylor Regional Medical Center, Grapevine, Texas, USA, spoke with Ford about universal health care, innovation, and transformational leadership.

Beth Houser: You are a great source of vision and continued innovation, not only in nursing but in health care overall. So, thank you for taking the time to do this.
You’ve always lived by the motto that crisis invites opportunity. Certainly, we’re in a place and space right now that, perhaps unlike any time since Medicare was put in place, is creating current crises as well as future crises. From the “30,000-foot perspective,” what do you think these changes are going to mean—first, for health care, and second, for nursing.
Loretta “Lee” Ford: You know, Beth, universal health care proposals have been around for more than a century. You can go back in history and find that the Public Health Association—I think in the early 1920s—was recommending it, and almost every president we’ve had since then has had some kind of position on universal health care. As far as I’m concerned, we are now at the tipping point. We either have to go for it or not.
There’s a great deal of difference in vision between people who think about health care as a privilege and those who think of it as a right. I tend to be on the side of those who see it as a basic human right, because, to me, it’s like education.
I think people who are against universal health care think of it as a kind of gift, a give-away. I think the idea of “right” also includes responsibility and, regarded that way, it changes the equation. The right to health care brings with it a commitment, a responsibility on the part of the individual to maintain health. So it isn’t always the government that is providing the right.
Individuals with a “right” to health care choose to make a difference in their own lives, in their communities, and the nation. I also look at universal health care as a huge national resource. I grew up thinking about public health as public wealth. When you look at it from that viewpoint, a healthy population is a productive, economically viable population and, in that sense, health care is an investment, just as education is. These, for me, go together.
Houser: Eric Topol, MD [editor-in-chief of Medscape and author of The Creative Destruction of Medicine], has written about how the digital revolution will create better health care by shifting responsibility back to the individual. I’m wondering how it’s going to make that shift—number one—and how long it’s going to take for us to really shift responsibility back to the individual. What do you think?
People do not like change, and they do not like deviations from what they believe has been the tried and true historical approach to whatever they are doing.

Ford: I think it’s going to shift sooner rather than later. You know why? Because the technology that Topol cares about in terms of individual responsibility—sensors, for example, that contribute to individualization of health care by helping people understand their own genomic codes—is already available. You know, as I perceive it, you’ll have one of these sensors inserted in the back of your neck—like your dog—when you’re born, and it’s going to give you your genomic code. You are going to know your risks and consequences, and you’ll be able to monitor your EKG. You will also be able to monitor your macular degeneration, glaucoma, blood pressure, and blood sugar, of course. I see a power shift where health care consumers have the information—this mysterious information—and the role of the professional is going to be for interpretation, teaching, counseling, and coaching.
You know, we spend a lot of time doing clinical teaching, and that’s going to shift. I see a big paradigm shift coming. People say, “Oh, well, that’s going to be way in the future.” But just look at the iPads—all sorts of things—and it’s clear that this advancement of technology is going to make a tremendous amount of difference.
I see it changing the power relationship that currently exists between the professionals and the patient. This whole argument we have about territoriality is going to go away, because patients will decide those boundaries—where they get information from. Half of them are seeking second opinions on the computer; they aren’t even using the professionals.
At present, this whole business of saying “See you doctor” or “Ask your doctor” makes us laugh, because you don’t even get to talk with the MD. But that’s going to go away, because patients are going to be having opportunities like they’ve never had before. Even though patients have had access to information, they haven’t had a way to determine its meaning, so I think we’re going to see a tremendous paradigm shift in that power relationship.
Houser: I think you’re right about technology being a driver or potential driver. I wonder how we’re going to transfer that ownership. We hear a lot of talk now about population management. Yet, when you listen to Topol et al., he’s talking about individual accountability management, through more laser-like distribution of information. How long is that going to take? How long can we afford to let this sit on the tarmac before we get it on the runway?
Ford: Topol says it’s the medical group that’s reluctant to take advantage of available technology, but I think the reason medicine is reluctant to move into this new technology is because they don’t want to give up power, control, and money. There are some things they do now that are very lucrative and some things they do that we don’t need to do, but I see them worrying.
They worry that patients will have too much information and not know what to do with it. I think this will occur somewhat, but I think we underestimate people and their ability to not only access but to absorb and understand data they are going to get. And they will do it very quickly, I think, once they get on to it. After all, the new generations coming up are very used to all this technology. This is not going to be news to them.
Houser: You said that health care is a right rather than a privilege. Take a moment, if you would, and discuss affordability—the socioeconomic burden, as you see it—and how it relates to this paradigm shift.
Ford: In the beginning, I think there is going to be a relatively long period of adjustment to achieve the more, I would say, futuristic look of the Affordable Care Act, the ACA. It will be like the community health services some years ago, where people had not had any health services at all, and we moved into communities with community health centers. The first thing that happened, we had a flood of people coming in with conditions—both acute and chronic—that had not been addressed for a long time. Trying to use those community health centers for just preventive care and promotion of health was not possible.
So, I think we’re going to have to go through a period of dealing with that, but after reorienting the system, we’ll be able, through education and support, to help people understand that, although they have choices and rights, they also have responsibility. The population will become more educated, more computer savvy, and more independent. I don’t think they’re as unsophisticated as we think they are.
Houser: Looking back, a good portion of how we practiced nursing was based on “because we’ve always done it that way,” as opposed to evidence-based. We are now in the evidence-based era and looking for research solutions. However, as we look at the economic side of health care, most providers, most participants, are flying blind. They have no idea of the cost, and there are so many barriers in the way of publishing the cost. We’re really in the infant stages when it comes to relating cost to health care. How do we overcome that?
Ford: Economics isn’t among the strong points in many of our curricula. Most people are not aware; look at the mess they got into with their credit cards! When it comes to medications, people are beginning to recognize that, whether they have insurance coverage or not, they need to ask some serious questions about generics. Given the incentive, people can learn and learn fairly quickly.

Houser: Eighty percent of our dollars are spent on 20 percent of our population, so it really is a very focused group. Yet, we don’t seem to manage end-of-life quite the way we should. When you talk about end of life, it really is the palliative-care portion that our culture is so uncomfortable with.
Ford: Part of it is that we don’t discuss it very openly, so we don’t really know what people want. You know, recognition by those of us who are older that they’re spending this huge distribution of funds isn’t talked about much in terms of individual care. It’s an ethical and moral problem, when you think about it. Ethically, I think it should be in the hands of the patient, in terms of recognizing, for example, how much good a test is going to do. There are a number of very interesting articles now on that topic. I’m asking my doctor right now, what difference does it make if I get a mammogram? Even if you find something, I’m not going to do anything about it. So, why bother? Give it to somebody who really needs it and would benefit from it.

Houser: What you’re saying is, it’s the individual’s right to ration his or her care, relative to age and quality of life, right?
Ford: Right.

Houser: How do we socialize that in a culture that thinks we’re immortal?
Ford: I think nurses have a big role to play in that. They can help patients and their families by providing information about choices and the impact that certain treatments are going to have—or could have—on them, and if they want to choose. It’s up to them to choose.
See, we haven’t given patients a lot of choice, when it comes right down to it. I think we really need to reorient ourselves. We’re talking about patient-centered care, but I don’t think we’ve even begun to think about what that involves. What it involves is us giving up some power, and we don’t like to do that, no matter what our profession is. We think we know better! Well, we do know better, generally.
Houser: An example of nursing not being able to give up control is something as simple as bedside reporting and how uncomfortable we are in exchanging information about the patient in front of the patient. For two years, I’ve been trying to get nurses to do bedside reports, and it has been a slow, uphill climb. It breaks all the rules of behind-the-door communication. If we’re not putting the patient in the center of that conversation, we’ve taken away their opportunity to learn, know, and contribute to their own health care.
Ford: It isn’t usually on the agenda in a lot of clinical services. For ages, we’ve run into the problem of the physician being very controlling of information—not willing to have nurses give reports to patients or not willing to have nurses tell patients things they don’t want the patient to know. They want to keep the information to themselves. Knowledge is power, so sharing that knowledge is a sharing of power. I don’t know that nurses have that much of a problem with information sharing, but I think physicians do.
Houser: Lee, you have stated, “To take a leadership role, nurses will need to innovate, imagine, and inquire.” How do nurses innovate, imagine, and inquire in our most effective way? To get in front of all those i-words, how would you recommend that nursing shortcut traditional barriers?
Ford: If you read the Harvard Business Review faculty’s studies on innovation, you’ll find out that difficulty in innovation is not peculiar to health care or nursing but that it’s a way of life in terms of everything you can think of—business and more. They’ve done some interesting studies, and they found that innovation in big companies—any major innovation—is almost impossible. So what happens is, people go outside the system and develop small companies.
Look at technology. A lot of today’s technology wasn’t developed by big companies; it was developed by small companies. These people have gone into entrepreneurship and have done it themselves, building their own structures and their own organizational concepts. That’s probably also true in health care. I believe that innovation is possible on units, and then from unit to unit, but that’s a very slow process because, as they say, “It’s sort of a way of life here.”
People do not like change, and they do not like deviations from what they believe has been the tried and true historical approach to whatever they are doing. All you have to do is look at nursing. It took us a long while to change, but some of the things I learned in nursing years ago are really ancient history. (I’m old, so I can remember those things.) It was a waste of time to teach me all that, because it was soon gone. (It wasn’t gone as soon as it should have been!)
We eventually began to ask, is this procedure necessary? Is it therapeutic? What difference does it make? It’s easy to say, “Well, innovate! Whatever you can do, do it! It’s easy; you can change a whole hospital system.” My approach is to take a unit at a time and make the other units so jealous they want to go into it. But it involves almost a generational shift in mentality, I think.
Houser: So, what should we be innovating? What should we be doing?
Ford: Because we already have a start in technology, I would see nurses leading this—also, developing technology themselves and moving it over into entrepreneurship. See, I don’t think we have the entrepreneurial spirit. I spoke with a nurse the other day—a researcher—who has developed a system for monitoring patients with dementia at night—worked with bioengineers to do it. The problem, she told me, is marketing it. I said, “First of all, get yourself a business partner.” She said, “But I don’t want to make any money on it. I just feel this is something for the patients’ good.” And I said, “Wait a minute!” She’s ready to give away the whole store! The whole thing!
I said, “No, no, no, no. No way! If you want to give money away, get it first, and then give it away.” This researcher has worked for years on this thing—has a beautiful system of monitoring but doesn’t have a clue about marketing it, to make it available, and then make it profitable. I mean, you can’t have things that are not profitable. So, there has to be some kind of business mentality, combined with the spirit and courage to do it. It takes a lot of guts to be different! It’s not easy. 
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