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

CARE IN THE COMMUNITY

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

INSTITUTE OF THE 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. 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: 978-0-309-15279-2 International Standard Book Number-10: 0-309-15279-8 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: Top photo © 2010 Gregory Benson. Bottom photos reprinted with permission from USeventPhotos.com. Suggested citation: IOM (Institute of Medicine). 2010. A summary of the December 2009 forum on the future of nursing: Care in the community. 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 (TROY) 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, 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: Patricia Gerrity, Eleventh Street Family Health Services of Drexel University Tine Hansen-Turton, National Nursing Centers Consortium and Public Health Management Corporation Charlene A. Harrington, University of California, San Francisco Mel Worth, Emeritus Scholar, Institute of Medicine Although the reviewers listed above have provided many construc- tive comments and suggestions, they were not asked to endorse the final draft of the report before its release. The review of this report was over- seen 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 car- ried 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 In 2009 the Initiative on the Future of Nursing, a collaborative effort between the Robert Wood Johnson Foundation (RWJF) and the Institute of Medicine (IOM), undertook a major study on the future of nursing during a critical period in the history of the U.S. health care system. The health care reform debate in Congress and throughout the nation revealed many questions and unknowns. Yet one theme to emerge was the neces- sary re-examination and re-imagination of the role of nurses to take on challenges facing the profession and to help fulfill the promise of a re- formed health care system—improving health. The charge of the RWJF Initiative on the Future of Nursing, at the IOM, is to recommend changes in public and institutional policies at the federal, state, and local levels in order to provide a blueprint for action for the future of nursing. On December 3, 2009, the initiative held its second public forum at the Community College of Philadelphia. The forums were designed to inform the committee about the critical and varied roles of nurses across settings. With opening remarks by Governor Edward Rendell on health care reform efforts in Pennsylvania, this forum examined the future of nursing in the community, focusing on community health, public health, primary care, and long-term care. This forum was especially important to the committee since care is increasingly being provided in non-acute set- tings and is more focused on disease prevention, health promotion, and chronic illness management. While well over half of all nurses practice in acute care settings, nurses in community settings are vital to ensuring access to quality care. More than 200 forum attendees—and an even larger audience watch- ing the live webcast—heard a series of presentations from leaders in the field, including testimony from 15 individuals representing a variety of ix

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x PREFACE organizations and personal views. Prior to the forum, several members of the IOM committee visited a number of community-based health centers across Philadelphia. Concluding the day’s events, 30 RWJF fellows and scholars reviewed their observations at the forum and site visits to de- velop a set of relevant recommendations for the committee’s considera- tion. It was an informative and often eye-opening day for the committee members and RWJF fellows and scholars who attended the events. The forum presenters described a segment of best practices in the community that shed light on what is currently available and what will be required to meet the changing health needs of the diverse populations of this country. As a result of this forum, the committee was given an op- portunity to consider how changing health needs in the community will affect the future of the nursing profession in terms of the way care is de- livered, the setting in which care is provided, and the education require- ments for the necessary skills and competencies to provide quality care. Many important messages emerged from the forum, including: • Budgets for public health and community health programs are being cut at a time when these programs are needed most to care for aging populations and when greater emphasis is being placed on prevention, wellness, chronic disease management, and mov- ing care into the community. • Nursing in the community occurs through partnerships with many other individuals and organizations, and nurses need to take a leadership role in establishing these vital partnerships. Fostering this type of collaboration could improve the continuum of care between acute and community care settings. • Technology has the potential to transform the lives of nurses providing care in the community, as well as their patients, just as it is transforming commerce, education, communications, and entertainment for the public. • Varying scopes of practice across states have, in some cases, prevented nurses from providing care to the fullest extent possi- ble at the community level. • Nurse-managed health clinics offer opportunities to expand ac- cess; provide quality, evidence-based care; and improve out- comes for individuals who may not otherwise receive needed care. These clinics also provide the necessary support to engage individuals in wellness and prevention activities.

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xi PREFACE • Nursing students need to have greater exposure to principles of community care, leadership, and care provision through changes in nursing school curricula and increased opportunities to gain experience in community care settings. • The delivery of quality nursing care has the potential to provide value across community settings and can be achieved though ef- fective leadership, policy, and accountability. At one point during the forum, the moderator, Dr. Joseph Reum, in- terim dean of the School of Public Health and Health Services at the George Washington University, asked members of the audience to con- sider how nursing would be different if all of the barriers to change sud- denly disappeared. The responses were fascinating. One respondent said that she would have access to a nurse whenever she needed one. Nurses would be members of interdisciplinary teams that would care for indi- viduals from birth to death, said another attendee. Nurses would provide care in all settings, was a third response, from hospitals to home and eve- rywhere in between—schools, churches, community centers, health de- partments, long-term care facilities. Nurses would have instant access to electronic medical records, said a fourth person, so that they always have the information they need to provide the best possible care. The committee is developing a set of recommendations that will lead to bold changes in nursing and will help ensure the health of Americans. The forum in Philadelphia gave us not only ideas but also hope that such change is possible. As Mary Selecky, the secretary of the Washington State Department of Health, said in her keynote address, “It is time to seize the moment, to step up to the challenge, and to create the future that should be.” Donna E. Shalala Committee Chair Jennie Chin Hansen 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 numerous individuals and organizations that contributed to the success of the Forum on the Future of Nursing: Care in the Community. The forum was graciously hosted by the Community College of Philadelphia; its staff, particularly Elaine Tagliareni, Monique Westcott, and Joe McFad- den, provided invaluable support throughout the planning and execution of the forum. The initiative would like to thank Josef Reum for his facilitation skills, as well as the speakers, panelists, and all who provided testimony throughout the forum; the insight and experience that was shared throughout the day greatly contributed to the deliberations of the com- mittee. The initiative would also like to recognize the alumni from vari- ous RWJF fellow and scholar programs who participated in the forum. These individuals gathered to reflect on the day’s discussions and offered the committee several thoughtful and innovative ideas to consider for the future of nursing in community care settings. While in Philadelphia, the initiative visited several community health centers and would like to express gratitude to the following individuals for warmly welcoming us into their facilities and providing us with on- the-ground perspectives of nursing care across community settings: Joan Bland at the Philadelphia Department of Health, Community Health Cen- ter #3; Kent Bream at the Sayre School-Based Health Clinic; Patricia Gerrity at the 11th Street Family Health Services of Drexel University; Eileen Sullivan Marx at the LIFE Program; Nancy Rothman at the Health Connection; and Donna Torisi and Lorraine Thomas at the Health Annex. xiii

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xiv ACKNOWLEDGMENTS The forum could not have happened without the expertise and lead- ership of the committee planning group. The planning group was chaired by Jennie Chin Hansen and included Michael Bleich, Troy Brennan, Leah Devlin, Anjli Aurora Hinman, Yolanda Partida, John Rowe, and Donna E. Shalala. For their steadfast and creative work throughout the course of the fo- rum, we would like to recognize the Initiative staff members, led by 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. The forum was webcast by ON24 and transcribed by Joy Biletz. The Initiative is grateful to Steve Olson for his editorial and writing assistance, to Florence Poil- lon for copyediting the summary, and to Dan Banks for designing the cover. We would also like to recognize the contributions of the following staff and consultants to this activity: Clyde Behney, Christie Bell, Julie Fairman, Christine Gorman, Amy Levey, Paul Light, Tamara Parr, Sharon Reis, Christine Stencel, Vilija Teel, Lauren Tobias, Jackie Turner, Gary Walker, and Jordan Wyndelts. Finally, the Initiative would like to express its appreciation to the 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: A Laboratory for Health Care Reform, 3 2 PUBLIC POLICY AND PUBLIC HEALTH NURSING 7 Challenges Facing Public Health Nurses, 8 Public Policy Implications, 10 Responses to Questions, 12 3 COMMUNITY AND PUBLIC HEALTH 15 Nursing in the Community, 15 The Future of Nurses in Community Care, 19 Responses to Questions, 22 4 PRIMARY CARE 25 Nurse Practitioners as Leaders in Primary Care, 25 The Indian Health Service: A Rural Health Care Service, 29 Responses to Questions, 33 5 CHRONIC AND LONG-TERM SERVICES AND SUPPORTS 35 Nurses’ Roles in Meeting Long-Term Health Care Needs, 35 Evercare Models of Nursing, 37 Responses to Questions, 39 6 TESTIMONY 41 xv

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xvi CONTENTS APPENDIXES A References 59 B Agenda 63 C Speaker Biosketches 65