A Summary of the October 2009 Forum on the Future of Nursing

ACUTE CARE

Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

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Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine

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THE NATIONAL ACADEMIES PRESS • 500 Fifth Street, N.W. • Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. Support for this project was provided by the Robert Wood Johnson Foundation (Contract No. 65815). Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the views of the organizations or agencies that provided support for the project. International Standard Book Number-13: 978-0-309-15021-7 International Standard Book Number-10: 0-309-15021-3 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2010 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Cover credit: Select photos reprinted with permission from Lisa Hollis of Cedars-Sinai Medical Center. Suggested citation: IOM (Institute of Medicine). 2010. A summary of the October 2009 forum on the future of nursing: Acute care. Washington, DC: The National Academies Press.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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COMMITTEE ON THE ROBERT WOOD JOHNSON FOUNDATION INITIATIVE ON THE FUTURE OF NURSING, AT THE INSTITUTE OF MEDICINE DONNA E. SHALALA (Chair), University of Miami, Coral Gables, FL LINDA BURNES BOLTON (Vice Chair), Cedars-Sinai Health System and Research Institute, Los Angeles, CA MICHAEL BLEICH, Oregon Health & Science University School of Nursing, Portland TROYEN A. BRENNAN, CVS Caremark, Woonsocket, RI ROBERT E. CAMPBELL, Johnson & Johnson (retired), New Brunswick, NJ LEAH DEVLIN, University of North Carolina at Chapel Hill, School of Public Health CATHERINE DOWER, University of California–San Francisco ROSA GONZALEZ-GUARDA, University of Miami, Coral Gables, FL DAVID C. GOODMAN, Dartmouth Medical School, Hanover, NH JENNIE CHIN HANSEN, AARP, Washington, DC C. MARTIN HARRIS, Cleveland Clinic, Cleveland, OH ANJLI AURORA HINMAN, Intown Midwifery, Atlanta, GA WILLIAM D. NOVELLI, Georgetown University, Washington, DC LIANA ORSOLINI-HAIN, City College of San Francisco, CA YOLANDA PARTIDA, University of California–San Francisco, Fresno ROBERT D. REISCHAUER, Urban Institute, Washington, DC JOHN W. ROWE, Columbia University, New York BRUCE C. VLADECK, Nexera Consulting, New York Study Staff JUDITH A. SALERNO, Executive Officer SUSAN HASSMILLER, Director, Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine ADRIENNE STITH BUTLER, Senior Program Officer ANDREA M. SCHULTZ, Associate Program Officer KATHARINE BOTHNER, Research Associate THELMA L. COX, Administrative Assistant TONIA E. DICKERSON, Senior Program Assistant GINA IVEY, Communications Director, Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine v

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LORI MELICHAR, Research Director, Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine JULIE FAIRMAN, Nurse Scholar-in-Residence Consultants PAUL LIGHT, New York University STEVE OLSON, Technical Writer JOSEF REUM, The George Washington University, Washington, DC vi

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Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its pub- lished report as sound as possible and to ensure that the report meets in- stitutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confi- dential to protect the integrity of the process. We wish to thank the fol- lowing individuals for their review of this report: Suzanne M. Boyle, New York Presbyterian Weill Cornell Hospital Larry A. Green, University of Colorado at Denver Angela Barron McBride, Indiana University School of Nursing Alan H. Rosenstein, Physician Wellness Services Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the final draft of the report before its release. The review of this report was overseen by Ada Sue Hinshaw, Graduate School of Nursing, Uniformed Services University of the Health Sciences. Appointed by the National Research Council and the Institute of Medicine, she was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authors and the institution. vii

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Preface On October 19, 2009, the Cedars-Sinai Medical Center hosted the first of three public forums of the Initiative on the Future of Nursing, a collaborative effort between the Robert Wood Johnson Foundation (RWJF) and the Institute of Medicine (IOM). In the morning, several members of the IOM committee toured a number of the Center’s acute care units to experience firsthand the innovations in nursing pioneered at Cedars-Sinai. In the afternoon, more than 300 people attended the fo- rum—and hundreds more from across the United States watched on a live webcast—to hear approximately 30 speakers explore new ap- proaches that involve nurses providing safe, efficient, and effective care in acute care settings and across the health continuum. In the evening, about 30 RWJF scholars and fellows, who also attended the forum and the morning’s site visits, dug more deeply into the issues to develop their recommendations for the future of nursing in acute care settings. The day was intense, exhilarating, and extremely productive. Many unknowns about health care remain as the country pushes ahead with health care reform. But one thing is certain: The United States cannot adequately address the challenges facing its health care system without also addressing the challenges facing the nursing profes- sion. Nurses are the largest segment of the health care workforce and are essential to providing quality care. Yet projected shortages of nurses, a lack of opportunities for educational advancement, limited resources, and the fragmented environment in which nurses provide care pose formida- ble barriers to fulfilling the promise of health care reform. The goal of the Initiative is to help transform nursing as part of far-reaching reforms in the health care system. ix

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x PREFACE The forum was an information-gathering session that the committee used to hear perspectives and ideas, which it will examine in depth and discuss as it shapes its findings, conclusions, and recommendations. This summary of the forum presents the main points made by invited speak- ers, panelists, and forum participants who offered testimony at its con- clusion. The summary should not be seen as representing the positions of committee members in attendance, the IOM, RWJF, or the Cedars-Sinai Medical Center. Committee members typically ask probing questions in information-gathering sessions such as forums, and these questions may not be indicative of their personal views. In addition, under the skilled direction of the forum’s moderator, Dr. Josef Reum, interim dean of the School of Public Health and Health Services at the George Washington University, committee members, speakers, and participants at the forum explored a broad array of issues and perspectives on the many challenges that face nursing. The forum focused on three topics within the context of acute care: safety, technology, and interdisciplinary collaboration. A number of im- portant points emerged at the forum, but the ones that resonated with our experiences include the following: • The knowledge of frontline nurses that they gather from their in- teractions with patients is critical to reducing medical errors and improving patient outcomes. • Involving nurses at a variety of levels across the acute care set- ting in decision making and leadership benefits the patient, im- proves the organizations in which nurses practice, and strengthens the health care system in general. • Increasing the time that nurses can spend at the bedside is an es- sential component of achieving the goal of patient-centered care. • High-quality acute care settings require integrated systems that use technology effectively while increasing the efficiency of nurses and affording them increased time to spend with patients. • Multidisciplinary care teams characterized by extensive and re- spectful collaboration among team members improve the quality, safety, and effectiveness of care. • Many of the innovations that need to be implemented in the health care system already exist somewhere in the United States, but barriers to their dissemination keep them from being adopted more widely. As Dr. Marilyn Chow observed, “the future is here, it just isn’t everywhere.”

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xi PREFACE The current system of health care in the United States is unsustain- able. Now is our chance to get the system on a sustainable and produc- tive path by looking to the mistakes of the past and alternative remedies for the future. The IOM committee, which is chaired by University of Miami President Dr. Donna Shalala, is developing a set of bold recom- mendations and a clear agenda for action. It is considering changes in public and institutional policies at the federal, state, and local levels as it seeks to provide guidance on the future of nursing. Nurses have the benefit of experience in identifying problems and the capability to implement solutions that work for patients. To achieve the promise of health care reform, we need to keep the better parts of our current health care system and eliminate the less effective parts that are not adding value. The Initiative on the Future of Nursing is an important step toward making that goal a reality. Linda Burnes Bolton Committee Vice Chair and Forum Host Robert D. Reischauer Committee Member and Forum Planning Group Chair

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Acknowledgments The Robert Wood Johnson Foundation (RWJF) Initiative on the Fu- ture of Nursing, at the Institute of Medicine (IOM), wishes to thank the many individuals and organizations that contributed to the Forum on the Future of Nursing: Acute Care. The forum was graciously hosted by Linda Burnes Bolton and Tom Priselac at Cedars-Sinai Medical Center. Their staff, particularly Barbara Fields, Lynette Huff, and Jane Swanson, ensured seamless arrangements for the day, including several site visits to various units of the Medical Center. The Initiative would also like to thank the speakers, panelists, and all who provided testimony throughout the plenary sessions; the insight and experience that was shared with the committee contributed greatly to its deliberations. The sessions were facilitated by Josef Reum, broadcast online by ON24, and transcribed by Joy Biletz. The Initiative is grateful to Steve Olson for his editorial and writing assistance, to Laura Penny for copyediting the summary, and to Dan Banks for designing the cover. The forum would not have been a success without the willingness of the committee planning group to lend their time and expertise. The planning group was chaired by Robert Reischauer, and included Linda Burnes Bolton, Catherine Dower, Rosa Gonzalez-Guarda, David Goodman, Martin Harris, Anjli Aurora Hinman, Liana Orsolini-Hain, and Yolanda Partida. Following the forum, a group of alumni from various RWJF fellow and scholar programs gathered to reflect on the day’s discussions. They proposed several thoughtful and innovative ideas for the future of nurs- ing in the acute care setting to the committee. For their diligent and creative work throughout the course of the forum, we would like to recognize the Initiative staff members, led by xiii

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xiv ACKNOWLEDGMENTS Susan Hassmiller and Adrienne Stith Butler, with guidance and oversight from Judith Salerno. The following individuals were involved in plan- ning the forum, day-of support, and the production of this summary: Katharine Bothner, Thelma Cox, Julie Dashiell, Tonia Dickerson, Gina Ivey, Lori Melichar, Abbey Meltzer, and Andrea Schultz. We would also like to recognize the contributions of the following staff and consultants to this activity: Clyde Behney, Julie Fairman, Christine Gorman, Jillian Grady, Amy Levey, Paul Light, Sharon Reis, Autumn Rose, Christine Stencel, Vilija Teel, Lauren Tobias, Jackie Turner, Gary Walker, and Jordan Wyndelts. Finally, the Initiative would like to express its appreciation to RWJF, whose generous financial support, and mission to improve the health and health care of all Americans, made the forum possible.

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Contents 1 INTRODUCTION 1 Site Visits, 2 Forum Welcome, 3 2 THE CURRENT AND FUTURE STATE OF ACUTE CARE 7 Core Concepts for Imagining the Future of Nursing, 9 Institutional and Policy Changes, 12 Conclusions, 13 3 QUALITY AND SAFETY 15 Improving Care Through Nurse Empowerment, 15 Value, Reliability, and Collaboration in Nursing, 19 Reactions from Responder Panel, 21 Committee Question-and-Answer Session, 22 4 TECHNOLOGY 25 Technology-Enabled Innovation, 25 Technology-Enabled Nursing, 28 Reactions and Questions, 31 5 INTERDISCIPLINARY COLLABORATION 35 Fostering Collaboration Among Health Care Professionals, 35 Disruptive Behavior, Nursing Care, and Patient Safety, 38 Reactions and Questions, 41 6 SUMMARIES OF TESTIMONY 43 xv

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xvi CONTENTS APPENDIXES A References 55 B Agenda 59 C Speaker Biosketches 61