Summaries of Testimony
Prior to the forum in Los Angeles, a variety of stakeholders and the public were invited to submit written testimony to the committee in three areas of relevance to acute care: quality and safety, technology, and interdisciplinary collaboration. Those submitting written testimony were asked to describe innovative models in these three areas; barriers that nurses face in implementing these models; and how nurses could be further engaged or effectively used to advance quality and safety, technology, and interdisciplinary collaboration in acute care settings.
Nineteen people at the forum provided oral testimony for the Initiative on the Future of Nursing; in most cases, these individuals or the organizations they represented also presented written testimony. Many important ideas and suggestions for the initiative emerged from this testimony and are summarized below in the order in which the comments were made. This testimony should not be interpreted as positions or recommendations of the committee, the Robert Wood Johnson Foundation, or the Institute of Medicine.
Donna Herrin-Griffith, President
American Organization of Nurse Executives (AONE)
AONE has been working in a number of areas, said Herrin-Griffith, including identifying solutions for the shortage of nurses and faculty; addressing concerns about quality and safety; highlighting the importance of the environment in which care is provided; and emphasizing the need to transform care delivery to achieve the goals of safe, effective, patient-centered, timely, efficient, and equitable health care.
AONE has defined the key responsibilities for nurses in its Guiding Principles for the Role of the Nurse in Future Patient Care Delivery. The six elements of that model are the following:
The core of nursing is knowledge and caring.
Care is user based.
Knowledge for nursing is access based.
Knowledge for nursing is synthesized.
Care is provided through relationships, either in person or virtually.
The journey of care is managed through partnerships between patients and nurses.
Herrin-Griffith said these concepts embody a model of future care for the health care industry to develop and implement.
Nancy Donaldson, Co-Principal Investigator
Collaborative Alliance for Nursing Outcomes
A gap exists in efforts to engage hospitals in building capacity to reliably and strategically use measures to inform priorities and improve performance, said Donaldson. The Collaborative Alliance for Nursing Outcomes, which is the nation’s oldest nursing quality database and a joint venture between the Association of California Nurse Leaders and the American Nurses Association/California, advocated the following priorities:
Systematically build the capacity of clinicians and clinical administrator leaders to be accountable for and to use nursing quality data to guide decisions and performance.
Strengthen clinician access to and capacity to use web-based information.
Institutionalize ergonomic assessment of the potential impacts of patient care quality and safety initiatives on the nurse workload prior to implementation.
Invest in new metrics that add value for clinical administrative leaders and public policy stakeholders.
Operationalize the expectation that nurses systematically evaluate their practice.
Institutionalize and align measures in research, education, and practice.
Phyllis Gallagher, Nurse Attorney
(presenting on behalf of Teri Mills, National Nursing Network Organization)
Gallagher said that the U.S. Congress should enact legislation to create an Office of the National Nurse. The National Nursing Network Organization believes that creating this position could improve health literacy, heighten the visibility of nursing on a national basis, promote the use of patients as caregivers to lower costs, and be a voice for national learning. The office could mobilize volunteers for projects such as adopting a school and school readiness programs.
Nearly 80 groups have already endorsed this proposal. “I would urge you to exercise your rights as citizens and try to promote this,” said Gallagher.
Suzanne Boyle, Vice President for Patient Care Services
New York-Presbyterian Hospital/Weill Cornell
Boyle said the call for nurses to be transformational leaders is absolutely clear. As a result, an infrastructure is needed to identify best practices quickly and disseminate them, thus inspiring innovation. Also, Boyle indicated that examination of the roles of nurses must emphasize quality, safety, transitional models of care, and cross-disciplinary work.
Kathy Dawson, President
Association of California Nurse Leaders (ACNL)
To ensure that nurses provide competent, safe, and quality patient care in a complex health care environment, the current workforce must be retooled to elevate the standard of practice and to prepare the future workforce to meet the challenges of an ever-changing world, said Dawson. Knowledge is exploding in all facets of health care, and technology is changing the way nurses practice every day. To keep pace, the art and science of nursing must evolve.
Expecting that newly graduated registered nurses can perform immediately at the proficient level is inconsistent with the evidence of what is possible in the novice-to-expert model of practice development, Dawson said. The ACNL, in conjunction with other professional organizations in California, is developing transitional competencies based on the Quality and Safety Education for Nurses model as a framework for novice nurses in their first year of practice. These transitional competencies are meant to reinforce patient care practices that are safe and of high quality. In addition to the theoretical and didactic learning that takes place in nursing schools, the competencies learned from immersion in the role of the professional nurse are essential to gaining the experience nurses need. In particular, mandatory residencies are critical to prepare the registered nurse of the future, Dawson said.
Margaret Talley, Clinical Nurse Specialist
Palomar Pomerado Health (presenting on behalf of Christine Filipovich, National Association of Clinical Nurse Specialists)
The clinical nurse specialist (CNS) plays an essential role in acute care and in the future of nursing, said Talley. CNSs are leaders of interdisciplinary teams that improve the safety and quality of acute care by translating clinical expertise and integrating scientific knowledge and methods to design evidence-based solutions. They address the big picture in three key spheres of influence in acute care: the patients, nursing and the nursing staff, and the health care system as a whole.
CNSs’ research and design solutions to the various problems and complications that arise in vulnerable patient populations, such as geriatric, pediatric oncology, neurology, psychology, rehabilitation, and emergency room populations. Programs developed by CNSs and implemented by interdisciplinary health care teams prevent avoidable complications, including patient falls, medication errors, hospital-acquired pressure ulcers, and infections. CNSs also act as faculty and mentors for new nurses and nurses pursuing advanced practice education.
The CNS is the ideal academic liaison for nursing schools to ensure a safe and comprehensive acute care learning experience, Talley said. Few other providers are prepared or in a position to design and implement the safety and quality solutions offer by CNSs.
DeAnn McEwen, Staff Nurse
Intensive Care Unit, Long Beach Memorial Medical Center (presenting on behalf of Gerard Brogan, California Nurses Association)
The most critical barrier to the health, welfare, and safety of patients in acute care settings is the lack of unified, mandated safe staffing standards, including the lack of the right to advocate in most states in the exclusive interests of the patient without fear of retaliation, McEwen said.
Staffing standards are essential for the provision of competent, safe, and effective care. McEwen indicated that clearly defined, legally protected, and enforceable duties and rights for direct care registered nurses to advocate exclusively for the interest of patients are also needed, as well as whistleblower protections that encourage patients, registered nurses, and other health care personnel to notify government and private accreditation entities of suspected unsafe patient conditions.
According to McEwen, numerous studies done by the nation’s most respected scientific and medical researchers affirm the significance to patient safety of direct care registered nurses-to-patient ratios. Improved staffing ratios have been associated with reductions in hospital-related mortality, in failures to rescue, and in lengths of stay, she said.
Hospitals are required to demonstrate they have mechanisms in place to collect and analyze patient outcome data with input from the nursing staff while incorporating clinical decision-making technologies. McEwen said human cognition is superior to machine intelligence, so there must be a strong commitment to preserve effective interdisciplinary collaborations.
The greatest barrier to interdisciplinary collaboration in acute care settings is access to entries made by other disciplines on the patient electronic record, McEwen said. Registered nurses have a unique patient advocacy role in the health care delivery system, and technology should be used to augment that role. In analyzing the safety, therapeutic value, and effectiveness of any technology, registered nurses must be able to explore the potential of technology to replace human interaction and to supplant critical thinking and independent clinical judgment with rigid clinical pathways. Health care providers must seek to control technology, not allow it to control health care.
Joyce Sensmeier, Cochair Alliance for Nursing Informatics
Nurses play an important role in leveraging health information technology to improve patient safety, quality, and the efficiency of care delivery, Sensmeier said. They are also integral to achieving a vision to adopt and implement electronic health record (EHR) systems in a meaningful way. Sensmeier said that meaningful use of health information technology, when combined with best practice and evidence-based care, will improve health care for all Americans. The future of nursing relies on this transformation as well as on the important role of nurses in achieving a digital revolution.
Sensmeier indicated that nurses must be supported in a health care environment that adequately enables their knowledge-based work in a variety of roles. These roles include being leaders in the effective design and use of EHRs; integrators of information; full partners in decision making; care coordinators across disciplines; experts in improving quality, safety, and efficiency and in reducing health disparities; advocates for engaging patients and families; contributors to standardized EHR infrastructure; researchers on safe patient care; and educators for preparing the workforce.
Michelle Troseth, Chief Professional Practice Officer
Clinical Practice Model Resource Center/Elsevier
The CPM Consortium provides an infrastructure in which nurses and interdisciplinary partners can come together and create best places to give and receive care. Clinicians can focus on the fundamental elements that enable integration of quality care, technology, and interdisciplinary collaboration and make the combination come alive.
Troseth noted that the consortium has developed innovative, technology-leading, intentionally designed automation (IDA) at the point of care in partnership with multiple health information technology vendors. This system enables capture of the patient’s story, development of an individualized evidence-based plan of care using clinical practice guidelines, assessments and interventions within the context of the patient’s diagnosis and situation, and evaluation of progress toward goals.
The consortium has more than 125 acute care settings that have nurses and interdisciplinary teams using IDA within the CPM Framework. Outcome measures include reduced patient falls, reduced pressure ulcers, exceeding national and regional benchmarks by 85 to 95 percent, and increased nurse satisfaction, Troseth said. CPM Consortium sites also have been national exemplars for the TIGER (Technology and Informatics Guiding Education Reform) initiative, Sigma Theta Tau International, and American Nurses Credentialing Center Magnet-Designated Hospitals.
Dianne Moore, Vice President of Nursing Academics
West Coast University (presenting on behalf of Tina Johnson, American College of Nurse Midwives)
Childbirth is the leading reason for admission to U.S. hospitals, and hospitalization is the most costly component of U.S. health care. Combined hospital charges for childbirth and care for newborns in 2004 were $75 billion, said Moore. This amount far exceeded that for any other condition, yet pregnancy is a normal, natural physiologic event.
Moore noted that various forces have led to a style of care that is ill suited to the great majority of mothers and babies who are healthy and have reason to expect an uncomplicated birth. For example, Childbirth Connection’s national Listening to Mothers II survey found that professionals tried to induce labor 41 percent of the time; 32 percent of deliveries were cesarean-section deliveries; and 25 percent of births involved episiotomies. Due to the considerable overuse of these and other common interventions, many women experience risk without benefit, Moore said. Conversely, many beneficial practices with excellent safety profiles are underused.
Using the appropriate mix of providers and limiting the overuse of technology can provide desirable benefits, Moore indicated. For example, the Centering Health Care Institute, a nonprofit organization with offices in Cheshire, Connecticut, is seeking to change the paradigm of health services to a group care model to improve the overall health of mothers, babies, and new families across the life cycle. The Institute was incorporated in 2001, and there are now more than 300 sites led by nurse midwives across the United States that employ this group care model. Moore also cited research conducted by Yale University of more than 1,000 women in public clinics in New Haven, Connecticut, and Atlanta
that demonstrated a 33 percent overall reduction in preterm births for women receiving this type of group care and a 40 percent reduction for the African American women in the same study group (Ickovics et al., 2007). In addition, Moore suggested that midwives should have their own independent admissions privileges.
Barbara Nichols, Chief Executive Officer
CGFNS (Commission on Graduates of Foreign Nursing Schools) International
The mobility and migration of nurses worldwide and their impact on the global delivery of health services and nursing shortages have become topics of international debate. Although the recruitment of foreign-educated nurses traditionally has been perceived as an immediate and temporary solution to U.S. nursing shortages, foreign-educated nurses are already vital, essential, and permanent members of the U.S. nursing workforce, said Nichols. The majority of these nurses enter on occupational, spousal, or family visas that are permanent. Their skill mix and productivity are critical factors in the outcomes of health care delivery.
Accordingly, employers and institutions should make long-term investment in advanced education for faculty and leadership roles, Nichols indicated. CGFNS data suggest that the majority of foreign-educated nurses work in acute care settings, are an average of 15 years younger than their American counterparts, hold Baccalaureate degrees, bring 1 to 5 years of nursing experience to their positions, and are viewed as safe and competent practitioners. Yet these factors often are not considered in making short-term initial placement or long-term leadership decisions, she noted.
Foreign-educated nurses have been and will continue to be a vital part of the U.S. nursing workforce. Foreign-educated nurses represent an underused and valuable resource both within and outside of acute care settings, Nichols said.
Dana Alexander, Chief Nursing Officer
TIGER is a national collaborative of nurses from various sectors, including administration, practice, education, informatics, technology,
organizations, government agencies, vendors, and more than 100 specialty nursing organizations. This collaboration is bridging the quality chasm with health information technology, enabling nurses to use informatics in practice and education to provide safer and higher quality care, Alexander said.
Alexander described three priorities from the TIGER collaborative:
Develop a nursing workforce that is capable of using EHRs to improve the delivery of health care.
Engage more nurses in leading both the development of a national health care information technology infrastructure and health care reform.
Accelerate adoption of smart, standards-based, interoperable technology that will make health care delivery safer, more efficient, timely, accessible, and patient centered while also reducing the burden on nurses.
Linda Arkava, Swedish Medical Center/First Hill (Seattle)
(presenting on behalf of Valerie Tate, Nurse Alliance of SEIU [Service Employees International Union] Healthcare)
The SEIU Healthcare Nurse Alliance advocates for quality improvement from the point of care by frontline nurses and other members of the health care team in partnership with hospital employers. Arkava said a true collaboration recognizes nurses’ capacity to use their expert knowledge to solve problems and provides them with an equal role in defining and implementing a quality agenda. This requires committed leadership and equal accountability for shared goals from hospital executives, union leaders, organizations representing the nursing profession, and practicing nurses. Arkava indicated that frontline nurses should be engaged in the design, development, implementation, and evaluation of nursing innovations and solutions, whether for models of care or new technologies.
Frontline nurses also should be involved in the decisions and implementation of evidence-based policies, practices, and work environments for improved patient outcomes, increased nurse professional satisfaction, and increased safety for all, Arkava said. For example, Swedish Medical Center is using a collaborative model through unit-based staffing committees—which include nurses, ancillary staff, and managers—that are
developing evidence-based staffing plans submitted with the units’ yearly budget requests. Staffing effectiveness data will be collected to build adequate staffing and cultures of safety.
Improvements in patient outcomes, financial outcomes, and professional satisfaction exist where partnerships between SEIU nurses and employers have been built on shared priorities and responsibilities for quality, Arkava said. The most important and consistent feedback received from practicing nurses is that to provide quality and safe patient care, there needs to be not only standards for adequate staffing, but real oversight for compliance, Arkava noted.
Cathy Rick, Chief Nursing Officer
Department of Veterans Affairs
Acute care has become a fast-paced, episodic set of intensive events that requires system redesign to support the work of nursing. This system design needs not only to transform care at the bedside, but across the continuum of care, Rick said. Acute care nursing requires a cadre of nurses who are well prepared to provide focused attention to clinical surveillance and targeted, proven interventions that are coordinated with interdisciplinary care partners. She noted elements in moving toward not just a patient-centered, but also a patient-driven, model of care that includes the role of the clinical nurse leader (CNL), data-driven staffing methodologies, registered nurse residencies, and structured language for nursing documentation.
The CNL is an essential component of the patient care delivery model of the future, Rick said. CNLs are master clinicians who advance nursing practice at the point of care through application and dissemination of evidence-based nursing practice and system redesign. The CNL is prepared at a master’s degree level as a generalist who is an expert in managing care challenges from a clinical perspective. Rick indicated that the Veterans Administration has fully endorsed this new nursing role and has a comprehensive plan to implement the role across all settings by the year 2016. Early findings demonstrate a positive impact on financial indicators, quality of care, and patient satisfaction.
Rick highlighted three areas to consider about the future of nursing:
Staffing methodologies, including workload and outcome indicators, need to be embedded in EHRs.
Funded and mandated registered nurse residencies are very important to consider.
To advance the understanding of nursing and nursing contributions, a standardized and structured language is needed that is embedded in the documentation system.
Penny Overgaard, Adult Cystic Fibrosis Program Coordinator
Phoenix Children’s Hospital
Patient education is a critical element in the future of nursing. Patients are being discharged from acute care facilities sicker and earlier than ever before, and this trend will continue. As a result, patients and their families spend more time in self-care than they do in the care of a nurse, Overgaard said. Even something as simple as knowing who to call after discharge may be left undone in patient education. Much education is done in a hurry, is not completed, or is not understood when it is done, she explained.
Nurses are uniquely qualified to use their professional expertise to provide individualized education to patients. Nursing education at the college level and continuing education must emphasize how to assess learning readiness, ability, and literacy and provide an understanding of the impact of social disparities on patient education, said Overgaard. Overgaard indicated that nursing research should explore the connection between patient education and positive outcomes so that people know there is value in having nurses teach. Finally, she said that future care models must value patient education, allow nurses time to teach in acute settings, and design novel ways to extend patient education into communities.
Elissa Brown, President
American Nurses Association of California
The involvement of nurses in new health care models and in designing and using technology needs to be supported, Brown said. In addition, mental health care, long-term care, hospice care, and palliative care have good models for interdisciplinary collaboration that need to be examined. She suggested using the term “health care home models” instead of
“medical home models.” Finally, Brown indicated that nurses need to be members of committees involved in decisions that affect patient care.
American Association of Critical-Care Nurses
The American Association of Critical-Care Nurses considers acute and critical care to be on a continuum. Acutely ill patients are everywhere—from the intensive care unit to the home. Matching nurse competencies to patient needs is important, said Hartigan.
Beverly Malone, Chief Executive Officer
National League for Nursing
Health care teams need to include allied health colleagues such as licensed practical nurses and other care providers, particularly as medicine moves toward telemedicine and out of the hospital care, Malone said.
Kathy Harren, Chief Nurse Executive
Providence Little Company of Mary
The initiatives launched by the Institute for Healthcare Improvement have provided important lessons in the reform of care delivery, and the implementation of these models needs to be accelerated, Harren said. In addition, economic incentives will lead the transformation of the health care system and reveal the important and varied roles of nurses, both in the hospital and in other care delivery settings.