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Introduction

On October 19, 2009, the Initiative on the Future of Nursing, a collaborative effort between the Robert Wood Johnson Foundation (RWJF) and the Institute of Medicine (IOM), held a forum at Cedars-Sinai Medical Center in Los Angeles to examine the challenges facing the nursing profession and the changes needed in nursing to improve the quality, efficiency, and effectiveness of patient care. The forum was the first of three and focused on the future of nursing in acute care settings. The second forum, on December 3, 2009, in Philadelphia, looked at nursing care in the community, with emphasis on community health, public health, primary care, and long-term care. The third forum, on February 22, 2010, in Houston, examined the future of nursing education.

The three half-day forums were not meant to be an exhaustive examination of all settings where nurses practice nor an exhaustive examination of the complexity of the nursing profession as a whole. Given the limited amount of time for each of the three forums, a comprehensive review of all facets and all players of each of the main forum themes was not possible. Rather, the forums were meant to inform the committee on important topics within the nursing profession and highlight some of the key challenges, barriers, opportunities, and innovations that nurses face while working in an evolving health care system. Many key challenges, barriers, opportunities, and innovations discussed at the forums overlap across settings and throughout the nursing profession. They are also applicable to other providers and individuals who work with nurses.

The forums have been part of an intensive information-gathering effort by an IOM committee that is the cornerstone of the Initiative on the Future of Nursing. The committee will use the information collected at these forums, at its two technical workshops, from data provided by the



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1 Introduction On October 19, 2009, the Initiative on the Future of Nursing, a col- laborative effort between the Robert Wood Johnson Foundation (RWJF) and the Institute of Medicine (IOM), held a forum at Cedars-Sinai Medi- cal Center in Los Angeles to examine the challenges facing the nursing profession and the changes needed in nursing to improve the quality, ef- ficiency, and effectiveness of patient care. The forum was the first of three and focused on the future of nursing in acute care settings. The sec- ond forum, on December 3, 2009, in Philadelphia, looked at nursing care in the community, with emphasis on community health, public health, primary care, and long-term care. The third forum, on February 22, 2010, in Houston, examined the future of nursing education. The three half-day forums were not meant to be an exhaustive ex- amination of all settings where nurses practice nor an exhaustive exami- nation of the complexity of the nursing profession as a whole. Given the limited amount of time for each of the three forums, a comprehensive review of all facets and all players of each of the main forum themes was not possible. Rather, the forums were meant to inform the committee on important topics within the nursing profession and highlight some of the key challenges, barriers, opportunities, and innovations that nurses face while working in an evolving health care system. Many key challenges, barriers, opportunities, and innovations discussed at the forums overlap across settings and throughout the nursing profession. They are also ap- plicable to other providers and individuals who work with nurses. The forums have been part of an intensive information-gathering ef- fort by an IOM committee that is the cornerstone of the Initiative on the Future of Nursing. The committee will use the information collected at these forums, at its two technical workshops, from data provided by the 1

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2 FORUM ON THE FUTURE OF NURSING: ACUTE CARE RWJF Nursing Research Network, and from a number of commissioned papers to inform the development of findings, conclusions, and recom- mendations. The committee’s final recommendations will be presented in a report on the capacity of the nursing workforce to meet the demands of a reformed health care system. This summary of the forum describes the main points made by speakers and participants throughout the afternoon session in Los Ange- les. A complete agenda of the forum can be found in Appendix B and biosketches for the speakers can be found in Appendix C. The remaining sections of this chapter describe two activities that occurred in conjunc- tion with the forum and present the introduction to the forum by Thomas Priselac, president and chief executive officer of the Cedars-Sinai Health System and chair of the Board of Directors for the American Hospital Association. Chapter 2 provides an overview of the issues facing acute care nurses, as presented by Dr. Marilyn Chow, vice president of Na- tional Patient Care Services at Kaiser Permanente in Oakland, CA. Chap- ters 3 through 5 are organized by the three main topics discussed at the forum: the quality and safety of care, technology, and interdisciplinary collaboration. These chapters include the summaries of the presentations, reactions from the panelists, and the discussion that resulted from the committee’s questions and the answers provided by the speakers. Patient care in acute care settings involves a team that includes a spectrum of individuals from nurses to physicians to pharmacists to patients and their families. To hear the diverse, on-the-ground perspectives of some ex- perienced members of the care team, a panel was assembled that con- sisted of five individuals: an advanced practice nurse, a hospitalist, a pharmacist, a recent nursing student, and a patient. Chapter 6 summa- rizes the oral testimony presented by 19 forum attendees. Comments made at the forum should not be interpreted as positions of the committee, RWJF, or IOM. Committee members’ questions and comments do not necessarily reflect the conclusions that will be in the committee’s report. They were designed to elicit useful and relevant in- formation and perspectives. SITE VISITS In the morning before the forum began, individual committee mem- bers participated in a series of site visits to a variety of acute care units within Cedars-Sinai Medical Center. They spoke with nurses, other care

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3 INTRODUCTION providers, and administrators about the challenges nurses encounter in their work in acute care settings. Observations made during these site visits are not part of this summary of the forum, but the site visits in- formed at least some of the questions directed to speakers by committee members at the event. The units that were visited at the hospital ranged from critical care, emergency department, and surgical units to child and maternal health and obstetrics units. Robert Wood Johnson Foundation Solutions Session Following the forum, a select group of RWJF scholars and fellows 1 was hosted by RWJF to discuss what they saw on the site visits and heard at the forum in the context of their own expertise, knowledge, and judgment. This session was independent of the IOM committee and the Forum on the Future of Nursing. The goal of this session was to provide an opportunity for the fellows and scholars to consider solutions and the most promising future roles for nurses in the acute care setting with re- spect to the subthemes of quality and safety, technology, and interdisci- plinary collaboration. The solutions offered by the panels of fellows and scholars are not described in this summary of the forum. But summaries of their solutions were provided to the committee for its review and consideration at the committee’s subsequent meeting in November 2009. FORUM WELCOME Americans are asking fundamental questions about the future of their health care system, said Thomas Priselac, president and chief executive officer of the Cedars-Sinai Health System, in his opening remarks at the forum. These questions are complex because modern medicine and 1 RWJF works to build human capital by supporting individuals who seek to advance health and health care in America. RWJF invited alumni of seventeen of its scholar, fellow, and leader programs to participate in the Forum on the Future of Nursing. The alumni come from a variety of backgrounds and disciplines, including academia, service delivery, research, policy, and health plan administration. Many of the partici- pants were alumni of the RWJF Executive Nurse Fellows Program and the RWJF Nurse Faculty Scholars Program. Non-nurse participants included alumni of the Investigator Award Program, the RWJF Health Policy Fellows Program, and the RWJF Clinical Scholar Program.

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4 FORUM ON THE FUTURE OF NURSING: ACUTE CARE health care are complex. Yet at the core of the health care system is the professional who translates the complexity of modern health care into the unique forms of care focused on and provided to each health care recipi- ent. That person is usually a nurse. “They are, quite simply, the face of health care today,” Priselac said. The American Hospital Association (AHA), which Priselac currently chairs, is committed to improving health care by drawing on the exper- tise and experiences of nurses and others who provide care in hospitals. About a decade ago, the AHA released a collection of best practices based on programs that enrich and support America’s nurses (AHA, 2002). Today many of those practices are standard in hospitals nation- wide, he said. “Without effective, trained, satisfied, and engaged nursing, a high-quality care environment is impossible.” What nurses do in today’s health care environment must be evalu- ated regularly to better understand how to support the nurses of tomor- row. The nursing-sensitive performance indicators recently adopted by the Centers for Medicare & Medicaid Services provide an excellent ex- ample. These indicators delineate the connections between effective nursing practices and the prevention of avoidable harm, such as injuries from falls, central-line infections, pressure ulcers, and mortality after surgical procedures. Another example of a program that has contributed to understanding the importance of nurses’ roles is the Transforming Care at the Bedside (TCAB) initiative, which was supported by RWJF and began in 2003. This nurse-led initiative has demonstrated the many benefits of a strong partnership between nurses and health care execu- tives to improve patient safety and meet quality improvement goals at institutions. Cedars-Sinai Medical Center has been one of 10 innovative hospitals working to make TCAB a national standard, Priselac noted. Under the leadership of the American Organization of Nurse Execu- tives (AONE), and in collaboration with AHA, TCAB is rapidly becom- ing an essential part of more and more hospitals’ efforts to provide sustainable, reliable, high-quality care every day to everyone, every- where. In May 2009, AONE announced that TCAB would be at the heart of a new program designed to create the patient care delivery models of the future. Building on a $1.5 million dissemination project funded by RWJF, AONE is expanding the number of participating hospitals. By adding their own experiences to the TCAB initiative, these institutions will contribute to improving the care environment for patients and strengthening the connection between hospital leaders and nurses. The

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5 INTRODUCTION Institute for Healthcare Improvement, an original TCAB partner, is also disseminating the program. Nurses represent the largest group of health professionals in the country, Priselac said, and their expertise has a direct effect on the qual- ity, safety, and cost-effectiveness of health care. For example, according to research from the National Quality Forum, the deployment of ad- vanced practice nurses decreases hospital readmissions and improves transitions to nursing homes and community settings. Providing nurses with the knowledge and skills to deliver evidence-based care practices and empowering them to lead in the long-term improvement of health care delivery will be essential in creating a better health care system in the United States.

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