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The Future of Nursing: Leading Change, Advancing Health C Highlights from the Forums on the Future of Nursing Throughout course of the Robert Wood Johnson Initiative on the Future of Nursing, at the Institute of Medicine (IOM), the Initiative hosted three public forums on the future of nursing. These forums were designed to inform the committee about the critical and varied roles that nurses play across settings and were part of a much broader information-gathering effort by the IOM committee and staff, which is discussed in greater detail in Appendix A. The forums provided an opportunity for members of the committee to hear from a range of experts, stakeholders, and members of the public and to see, first-hand, the challenges and innovations in settings where nurses provide care and are educated. The three forums were held in Los Angeles, Philadelphia, and Houston and focused on acute care, care in the community, and education, respectively. Prior to the forums a variety of stakeholders and the public were invited to submit written testimony to the committee in areas relevant to the forums. Those submitting written testimony were asked to share their insight and describe innovative models in these areas; barriers that nurses face in delivering care or advancing the profession; how nurses could be further involved in advancing these areas; and their vision for the future of nursing. Each of the forums was webcasted live to a much larger national audience. Additionally, participants at the forum were encouraged to share their thoughts and reactions to the discussion through open microphone sessions, as well as social media tools such Facebook and Twitter. Each of the three forums was planned with the guidance of a subgroup of the committee, which was led by a planning-group chair; Robert Reischauer chaired the planning group for the acute care forum in Los Angeles, Jennie Chin Hansen led the planning group for the care in the community forum in Philadelphia, and
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The Future of Nursing: Leading Change, Advancing Health Michael Bleich served as chair for the planning group for the education forum in Houston. The half-day forums were not meant to be an exhaustive examination of all settings in which 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 to highlight some of the key challenges, barriers, opportunities, and innovations that nurses are confronted with while working in an evolving health care system. Many of the critical challenges, barriers, opportunities, and innovations discussed at the forums overlap across settings and throughout the nursing profession and also are applicable to other health providers and individuals who work with nurses. The following sections of this appendix offer brief summaries and highlights from each of the three forums on the future of nursing: acute care, care in the community, and education. Appendix A of this report includes the agendas for the forums, and the full text of the forum summaries are available at www.iom.edu/nursing and are also included on the CD-ROM in the back cover of this report. ACUTE CARE The Initiative on the Future of Nursing held its first forum on October 19, 2009, at Cedars-Sinai Medical Center in Los Angeles. This forum was designed to explore the challenges and opportunities for nurses in acute care settings and the changes needed to improve the quality, efficiency, and effectiveness of patient care. The forum focused on three topics within the context of acute care: quality and safety, technology, and interdisciplinary collaboration. Acute care settings were particularly important for the committee to examine, because well over half of all nurses work in acute care settings, where they are patients’ primary, professional caregivers and the individuals most likely to intercept medical errors. However, because hospital systems and acute care settings are often complex and chaotic, many nurses spend unnecessary time hunting for supplies, filling out paperwork, and coordinating staff time and patient care, reducing the time they are able to spend with patients and delivering care. Nearly 300 people attended the acute care forum and heard presentations and discussions with 30 experts, including welcoming remarks from 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, and a keynote presentation from Dr. Marilyn Chow, vice president of National Patient Care Services at Kaiser Permanente in Oakland, California. During the forum, 19 individuals offered testimony for the committee’s consideration. These individuals provided organizational and personal perspectives on the future of nursing in acute care settings.
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The Future of Nursing: Leading Change, Advancing Health Key Themes The presentations offered the committee with insight into the important role that frontline nurses play across acute care settings, as well as the challenges and barriers that these frontline nurses face in their daily work. It was apparent from the presentations that there are a number of successful and promising innovative models being used in acute care settings across the country. However, these models are infrequently transferred widely. The discussion at the forum provided the committee with an opportunity to consider how rapidly advancing technology, interdisciplinary relationships, and changes in the way acute care is delivered will affect the nursing profession and how nurses will need to be educated to be adequately prepared for their varying roles and responsibilities. A number of important points emerged at the forum: The knowledge of frontline nurses that they gather from their interactions with patients is critical to reducing medical errors and improving patient outcomes. Involving nurses at a variety of levels across the acute care setting in decision making and leadership benefits the patient, improves 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 essential 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 respectful 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.” Site Visits and Solutions Session In the morning before the forum began, individual committee members 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 providers, and administrators about the challenges nurses encounter in their work in acute care settings. The units that were visited within the Medical Center ranged from critical care, emergency department, and surgical units to child and maternal health and obstetrics units. Following the site visits and the forum, a group of Robert Wood
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The Future of Nursing: Leading Change, Advancing Health Johnson Foundation (RWJF) scholars and fellows,1 who had attended the forum and participated in the site visits, met to consider solutions and the most promising future roles for nurses in acute care settings with respect to the subthemes of quality and safety, technology, and interdisciplinary collaboration. A summary of this session was provided to the committee for its review and consideration at the committee’s subsequent meeting in November 2009. CARE IN THE COMMUNITY On December 3, 2009, the Initiative on the Future of Nursing held its second forum at the Community College of Philadelphia. This forum examined the challenges facing the nursing profession with regard to care in the community, including aspects of community health, public health, primary care, and long-term care. Members of the committee planning group for this forum believed that these topics were especially important to the committee’s work overall; as the health care system evolves, the provision of care is increasingly occurring in nonacute settings and is increasingly focused on disease prevention, health promotion, and management of chronic illnesses. Nurses who practice in community settings are vital to ensuring access to quality care. More than 200 forum attendees heard a series of presentations from leaders in the field, including opening remarks from Pennsylvania Governor Edward Rendell and a keynote from Mary C. Selecky, Secretary of Washington State’s Department of Health (an agenda for this forum can be found in Appendix A). During the forum, committee members also heard testimony from 15 individuals representing a wide variety of organizations and personal viewpoints, as well as remarks made by a number of forum participants as part of an open-microphone session. Key Themes 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 opportunity to consider how changing health needs in the community will affect the future of the nursing profession in terms of the way care is delivered, the settings in which care is provided, 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 17 of its scholar, fellow, and leader programs to participate in the Forum on the Future of Nursing. The alumni came from a variety of backgrounds and disciplines, including academia, service delivery, research, policy, and health plan administration. Many of the participants 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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The Future of Nursing: Leading Change, Advancing Health the education requirements for the necessary skills and competencies to provide quality care. Many important messages emerged from the presentations, discussions, and site visits, including the following: 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 moving 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 possible at the community level. Nurse-managed health clinics offer opportunities to expand access; provide quality, evidence-based care; and improve outcomes for individuals who may not otherwise receive needed care. These clinics also provide the necessary support to engage individuals in wellness and prevention activities. 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 effective leadership, policy, and accountability. Site Visits and Solutions Session Prior to the forum, several members of the IOM committee visited a number of community-based health centers across Philadelphia. The six Philadelphia sites visited by committee members and the RWJF fellows and scholars were the Living Independently for Elders (LIFE) program at the University of Pennsylvania School of Nursing, the Sayre High School School-Based Health Clinic, Community Health Center #3 of the Philadelphia Department of Health, Health
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The Future of Nursing: Leading Change, Advancing Health Annex, Health Connections, and the 11th Street Family Health Services of Drexel University. Concluding the day’s events, RWJF fellows and scholars reviewed what they had heard at the forum and seen during the site visits to develop a set of recommendations for the committee’s consideration that were relevant to the delivery of nursing care in the community; highlights from the solutions session were provided to the committee at its January 2010 meeting. EDUCATION On February 22, 2010, the Initiative held its final forum on the future of nursing at the University of Texas M.D. Anderson Cancer Center in Houston. This forum was designed to examine challenges and opportunities associated with nursing education. The nursing education system consists of multifaceted educational pathways with a mixture of starting points and opportunities for advancement to higher levels. This complex system is responsible for educating and training future generations of nursed that are prepared and able to meet the needs of diverse populations across the lifespan in a health care system that is constantly evolving. This forum on the future of nursing featured welcoming remarks from Dr. John Lumpkin of RWJF and Dr. John Mendelsohn of the University of Texas M.D. Anderson Cancer Center and included three armchair discussions that were each led by a moderator from the committee. The armchair discussions focused on three broad, overlapping subjects: what to teach, how to teach, and where to teach (an agenda for this forum can be found in Appendix A). More than 300 people assembled in Houston to listen to the discussion and participate in the forum, and an additional 330 registered for the forum’s live webcast. During the forum 12 participants presented formal testimony to the committee, while several more participants offered ad hoc remarks and insight during an open-microphone session that concluded the discussion at the forum. Key Themes The armchair discussions clearly illustrated the challenges of educating and developing a nursing workforce that can achieve the delicate balance among advancing science, translating and applying research, caring for individuals and families across all settings, and providing leadership. The committee heard about the shortcomings of the educational pipeline and infrastructure that have resulted in a deficiency in the number of nurses completing advanced degrees and moving into faculty positions, which in turn contributes to the limited the capacity of the system. Armchair discussants offered a glimpse of the future of nursing education as they described strategies, innovative models, and technologies that are being implemented across the country to expand the capacity of the education system and to better prepare nursing graduates with the competencies and
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The Future of Nursing: Leading Change, Advancing Health skills required to confront the challenges they will encounter in practice settings throughout their careers. Several important points emerged from the forum: Collaboration, communication, and systems thinking should be the new basics in nursing education. Nurses, particularly nurse educators, need to keep up with a rapidly changing knowledge base and new technologies throughout their careers to ensure a well-educated workforce. Care for older adults, increasingly occurring outside of acute care settings, will be a large and growing component of nursing in the future, and the nursing education system needs to prepare educators and practitioners for that reality. The nation will face serious consequences if there are inadequate numbers of nursing educators to develop a nursing workforce adequate in both number and competencies to meet the needs of diverse populations. Technology—such as that used in high-fidelity simulations—that fosters problem-solving and critical thinking skills in nurses will be essential for nursing education to produce sufficient numbers of competent, well-trained nurses. Nursing education needs to make use of resources and partnerships available in the community to prepare nurses who can serve their communities. Articulation agreements and education consortiums among different kinds of institutions can provide multiple entry points and continued opportunities for progression through an educational and career ladder. In addition to necessary skill sets, nursing education needs to provide students with the ability to mature as professionals and to continue learning throughout their careers. Site Visits and Solutions Session Following the forum, committee members participated in visits to one of three sites in Houston: the University of Texas Health Science Center at Houston School of Nursing, the Texas Woman’s University, or the National Aeronautics and Space Administration (NASA). During the site visits, committee members had the opportunity to converse with nursing students, educators, administrators, and experts in training for quality, safety, and collaboration about some of the innovative strategies that are being used to better educate nurses. Some of the models described included use of: distance learning and accelerated doctoral programs; advanced technology in educational settings and interdisciplinary education programs; and training for quality and safety, collaboration in a team environment, and continuing education. The site visits also offered a number
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The Future of Nursing: Leading Change, Advancing Health of demonstrations such as a physical assessment lab using retired physicians as educators, students working in high-fidelity simulation labs, and a nurse-managed clinic. After the completion of the forum and the site visits, a group of RWJF scholars and fellows, who had attended both activities, met to discuss possible solutions and the most promising directions for the future nursing education with respect to what should be taught, how it should be taught, and where it should be taught. A summary of this session and the solutions suggested was provided to the committee for its review and consideration at the committee’s subsequent meeting in April 2010.