Future of Nursing Blog

[#1]

This blog post is from Donna E. Shalala, Ph.D., former secretary, U.S. Department of Health and Human Services; president, University of Miami; chair, Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine and is the inaugural post for the Initiative on the Future of Nursing.

We’re now in my second week as chair of the study committee for The Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine. When we launched this initiative on July 14th in the presence of so many groups with a stake in what happens with nursing, it became even clearer to me the importance of our work.

Over the next 10 months, this committee will tackle some of the most pressing and systemic problems facing the nursing field. The end goal of this process is to do nothing short of helping to determine how to transform the way Americans receive health care services. And very few efforts will have as direct an effect on the American patient as determining the most effective ways to apply the skills of nurses. 

Nursing is absolutely fundamental to preserving the quality and reducing the cost of patient care in this country, and any efforts to address the challenges facing our health care system must take into account the expertise of the nursing community to succeed.  The recent words of the first lady are encouraging: “One of the most important things I learned while working in the hospital is nurses are critical to the health-care system in the United States.” Washington Post, July 8, 2009 [http://www.washingtonpost.com/wp-dyn/content/article/2009/07/07/AR2009070702071.html] 

Along with the full range of professionals on the health care team, nurses are working now to solve problems and find efficiencies in hospitals, long-term care facilities and minute clinics across the country. But they are unique.  As a function of their jobs and by the very nature of nursing, these women and men are the front-line of patient care; they spend the most time with patients and their families and that knowledge prevents costly medical errors, unneeded tests, and expensive hospital stays. As the largest group of health professionals, the experience of nurses is key to the effective design and implementation of health system change.  This is why it is critical to examine the specific function of nurses within a reformed system.

So given what the nursing profession can do, one of the tasks of the Initiative on the Future of Nursing is to determine how to ensure this critical part of the workforce is adequately staffed and prepared to meet the changing needs of our society. A significant hurdle is the continuing shortage of nurses across the country. If nothing changes, the U.S. faces a shortage of 500,000 nurses by the year 2025, and this number is only expected to rise as our population ages and faces the enormous challenges of managing chronic disease.

The charge for The Initiative on the Future of Nursing is daunting, but some of the best minds out there are also hard at work mapping out ways to help Americans live healthier lives and to make our system of health care solvent and sensible.  The American public and its elected officials are hungry for answers.  The committee for the Initiative on the Future of Nursing is committed to shining a light on the solutions that already exist within the nursing profession and to finding new ones. Stay tuned.

[#2]

Dr Shalala,  Please remember Nurse Practitioners ,such as myself, have done primary care since  1972. I  am part of the solution. There are 125,000 of us nationwide.We are rarely mentioned in the health care reform talks regarding nursing.This week in two days ,I have served over 70 women ,such as a mother of 2 who is age 15 and seeks family planning services. We are happy to help her in her new choices. We need your help to recognize Nurse Practitioner's role in helping achieve a great health care reform package.Thank you.I volunteer to help in any way.

JoAnn Woodward WHNP-BC  www.joannwoodward.com

[#3]

Dr. Shalala,

Thank you for giving us this opportunity to be heard.  Earlier this year I had a wonderful opportunity to meet 14 of my peers from across the country who are nursing managers in Federally Qualified Community Health Centers.  We are all very close to the front lines of nursing care in community health care and as a group have over 120 years of nursing experience. We will be watching this blog and are eager to participate in sharing our knowledge and experience, strength and hope for the future of nursing and health care reform.

Luann P. Sweeney, RN

Director of Nursing

Geiger-Gibson Community Health Center

Dorchester, MA.

If you aren't at the table, you may be on the menu!

---

[#4]

Dr Shalala,

Please remember the LPN who in times past WAS the go to person between doctor and patient.  We are still there, at the bedside,  and for some of us, have never left.  I would like to see the recognition for us as well. We are under represented in all healthcare talks and led out to pasture to make room for the RN.  I feel if EVERY nurse was put in the lime light for their level of ability,  it opens more choices for the person seeking a career in nursing as well as help the nursing shortage.  Utilize your LPN's.  Make us feel valued in this reform for all of our hard work. I am willing to help in any way to represent my colleagues.

[#5]

Dear Dr. Shalala:

Thank you for your leadership of this critical task force. I am nursing faculty at a university in the Midwest and teach undergraduate seniors leadership theory (clinical leadership, conflict management, change etc) to prepare them for their future roles as staff nurses on the frontline. While nursing has done a good job in articulating and researching the role of staff nurses in terms of participation on micro and meso system task forces and committees, knowledge of and strategies to enhance the clinical leadership role of the staff nurse while engaged in the provision of direct care is sorely lacking.

The ongoing development of staff nurses as clinical leaders on the frontline is critical for patient safety and quality. The new AACN Essentials for Baccalaureate Nursing does an excellent job in articulating curricular leadership requirements. However, I would say that ongoing development and facilitation of nurses as clinical leaders once they are in practice is neglected. Also, there are many organizational barriers that prevent frontline nurses from bringing this leadership to the forefront in the solution of numerous ethical patient care issues.

As your Task Force advances its agenda, I sincerely hope that these issues are addressed. The frustration and the experience of moral distress experienced by our frontline staff nurse clinical leaders has been shown to increase turnover plus the loss of nurses from the profession.

Sincerely,

Jean Barry, PhD, RN

Associate Professor of Nursing

Grand Valley State University

Kirkhof College of Nursing

[#6]

Dear Dr. Shalala:

Thank you for your leadership of this critical task force. I am nursing faculty at a university in the Midwest and teach undergraduate seniors leadership theory (clinical leadership, conflict management, change etc) to prepare them for their future roles as staff nurses on the frontline. While nursing has done a good job in articulating and researching the role of staff nurses in terms of participation on micro and meso system task forces and committees, knowledge of and strategies to enhance the clinical leadership role of the staff nurse while engaged in the provision of direct care is sorely lacking.

The ongoing development of staff nurses as clinical leaders on the frontline is critical for patient safety and quality. The new AACN Essentials for Baccalaureate Nursing does an excellent job in articulating curricular leadership requirements. However, I would say that ongoing development and facilitation of nurses as clinical leaders once they are in practice is neglected. Also, there are many organizational barriers that prevent frontline nurses from bringing this leadership to the forefront in the solution of numerous ethical patient care issues.

As your Task Force advances its agenda, I sincerely hope that these issues are addressed. The frustration and the experience of moral distress experienced by our frontline staff nurse clinical leaders has been shown to increase turnover plus the loss of nurses from the profession.

Sincerely,

Jean Barry, PhD, RN

Associate Professor of Nursing

Grand Valley State University

Kirkhof College of Nursing

[#7]

Dr. Shalala,  Thank you for your initial blog regarding the challenge for nurses in this health care reform era.  I am the Director  of the Online Masters in Nursing Program at a small private health care college in Nebraska (Nebraska Methodist College).  Currently there are two tracks available online;  nurse educator and   nurse executive.  We (the faculty)  believe that both of these tracks are very important and essential to decreasing the looming nursing shortage which includes the faculty nursing shortage.   In addition, the faculty  have set up the program so that nurse educator and nurse executive students are collaborating together  in courses and beginning to  realize the importance of such partnership for improved patient outcomes.  In the capstone courses that the the students take, groups of nurse educator and nurse executive students  work together to develop an evidence-based project that  provides best practices for  advancing the profession of nursing.  We are also beginning to think about adding a third  track in the area Gerontological CNS or Public Health MSN.    I believe that either track will continue to add to the nursing shortage with the needed advanced education our nurses will need to care for the aging population.  I have been receiving the NFLP (nurse faculty loan program) from HRSA since 2004 which has greatly enhanced the number of nurse educators applying for our program.  This year, we also received addition monies from the American Recovery and Reinvestment Act which will help many more  nurses who want to be nurse educators.  I am asking that your taskforce also look at  ways that monies can be available to help support  nurses returning for their MSN degree  no matter what the track.   Nurses with advanced education will continue to be in demand.   

[#8]

Dr Shalala, 

        It seems to me that in fact we do not have a nursing shortage. We have a shortage of nurses who are willing to practice their profession in the current health care climate. As an educator who continues to practice, I must confess that after 30 years, I have to search long and hard to find the rewards at the bedside that sustained me previously. While I embrace the assets that technology brings to the table, the electronic record constrains my ability to give care to my patient. Many a day I feel I have served the computer not my patient. When I add to ever -expanding amount of time spent on coordination of medical care, again I feel I have limitted time to care for my patient. Perhaps this is the new primary role of the RN - patient care coordination. If so, the very people we want and need to keep will be leaving in ever expanding numbers.

    As you investigate this problem and possible solutions, please, please, please, spend a great deal of time talking to long-term sucessful bedside practioners.  They have a lot to say and would love to be heard.

    Thank you!

Marilyn Vanderpol Wells BSN MS RN

Professor of Nursing

Seminole State College of Florida

[#9]

As a registered nurse working in emergency services for almost 10 years, I  humbly appreciative of the remarks made by First Lady, Michelle Obama, regarding nurses. I have for years discussed with colleagues the communities view of nursing and how we can change our image. I am proud to be a registered nurse for almost 10 years working In emergency services. I have taken such great pride in my field and most certainly been an advocate for our field encouraging and supporting other nurses, training and embracing new grads and speaking to those interested in becoming nurses about the role and the tremendous power it holds.  

Knowing that nurses spend the predominance of time with patients and their families, working in collaboration with the health care team in an effort to delivery quality care that is cost effective as well as comprehensive, health care reform most certainly should be on agenda for nurses as a group. Our role as advocate dictates that we assist with implementation of changes that will assure all of our patients are avail the same services.

Theresa Ducksworth-Sanchez, R.N.

[#10]

Thanks for seeing into the struggles and efforts of nurses. One of your goals is seeing that adequate staffing is reached. I hope this problem is handled by ensuring that hospitals/healthcare facilities employe enough healthcare personnels, equal to the job they are assigned. We all talk about shortages; why then are many students turned down by colleges/nursing institutions? I understand all these problems want to be solved but I'm affraid that those who are involved in the decision making processes/ most influential may be the cause of these problems. It's alright for healthcare facilities to make profit; but the desire to make money has surpassed the desire to" take care" and "heal the sick", thereby driving the owners of these corporations/hospitals( who are also very influential in decision making processes about our healthcare system) to hire less nurses( overwhelming those employed with more patients) in order to save money/make more profits.

          Mavis Njokom

[#11]

Dr Shalala:

First Thank you for allowing us to comment.

I have been a Registered Nurse for 25 years and have worked in many areas of healthcare (including management). I am currently a psychiatric staff nurse in a Crisis Unit in an Emergency Department.

I feel our biggest challenge is the dfsconnect between Hopital Administration and the frontline workforce. I have many examples of dangerous situations I and other staff have been put in because of inadequate staffing. We work with a potentilly violent population and are aware of that but are left with a Nurse and a Social Worker or tech to care for as many as 5 patients.

Hospital are spending millions of dollars hiring consultants to address various issues such as how front line staff treat our "customers"  I do not think this is a big problem staff seem very helpful and kind to patients in general the only time this is may not true is when we become overwhelmed by too much to do and our patients suffer the results by long waiting times, and overstressed/worked staff that are being watched via computer software on how fast turnover times are regardless of acuity.

I love working Crisis in the ED however I would take another opportunity out of direct care only because of staffing. Whatever you can do to help frontline Nurses (and other staff) in having adequate staff to care for patients would be appreciated. As Nurses if we had sufficient time to do what we are trained to do we would stay in staff Nursing (at least that is true for me) The new initiative to have staffing ratios made public is a great idea!

[#12]

I agree with your statement maviskeng, "It's alright for healthcare facilities to make profit; but the desire to make money has surpassed the desire to" take care" and "heal the sick", thereby driving the owners of these corporations/hospitals (who are also very influential in decision making processes about our healthcare system) to hire less nurses (overwhelming those employed with more patients) in order to save money/make more profits. Adding to this the fact that many overwhelmed and under financed health care institutions are being forced to close has added additional complications to an already stressed system. The safety of the patient and delivery of quality care being the end result signifies that the reform of our health care system as it currently stands is that much more important. 

[#13]

Dr Shalala,

Thank you for your great work and for speaking out on our behave. I am a 4 Years Registered Nurse working in a critical care unit. Relating to the shortage of nurses and poor public awareness of what our profession is all about, I lost 3 year of my life to escape having to be a male nurse because of my poor knowledge of what nurses do. I did not know the great opportunity that the profession offers. Four years of been in this profession is the best year of my life having to do what I am passionate about. I am very thankful that now some media programs, such as "Hawthorne and Nurse Jackie" are now out there relating to the public what nursing profession is about. This and more media out lets like these would have saved me 3 years and hopefully it will safe many more people these nursing opportunities.

 For the safety of clients and the dignity of the profession, I am concern on how we are handling the hundreds and thousands of students on waiting to get into the nursing school. I learned how Business companies are now getting into the nursing school for profit and how would we ensure that they are truthful to the profession rather than their pockets especially with length of nursing school getting shorter. How I hoping they maintain the dignity of this profession for many years.

[#14]

I often wonder why we don't utilize our LVN's in our hospitals and for basic aftercare of patients discharges. I feel that LVN's can perform so many tasks that most RN's do on a daily bases. Even though we do see LVN's at some hospitals, not all use them. In the Emergency room, we see hundreds of patients each day. I can say that 80% of those patients are level 4 and 5's(very low acuity), and can be taken care by LVN's. I think that if we use our LVN's the hospital settings, perhaps money can be saved overall. Moreover, we do not encourage students to become LVN's much less respect their roles in healthcare.

Christine Garrison R.N.

[#15]

Dr Shalala,

Thank you for your excellent presentation. I have been an RN for 1 year, so every day I am learning more from different nurses that I work with and patients. I like your statement that nursing is fundamental to preserving the quality and reducing the costs of patient care but for some people, nursing is a way to make money; in 1 year, I met nurses that they go to work because they need money; course, all of us need money, but the real nurse will advocate for a patient; it will not complaint and neglect care of a patient because they need to chat with coworkers, but I wonder if the guilty part are the expensive nursing schools that they are easy to get into, but a nurse comes with a big debt, and the other part, it will be the economy because some people are force into nursing; they can not find a job in their original career.

[#16]

I do believe the role of the Registered nurse will change drastically with in the next five years.  Now more that ever, nursing is at the forefront of the media.  Seeing members of the CNA standing on the same stage as President Obama, was a very proud moment for me.  The nation will get the message soon than later.  The President and first Lady are acknowledging our profession, they have both made public acknowledgement of how important our role is to patient safety and care.

Not only is technology changing, but the task of the nurse is changing as well.   Gone are the days where the nurse is responsible for giving the bed bath or changing the bed linen.   Hospitals are now hiring technicians to replace duties the nurse once held.   The changes in time have indeed thrust more advance practice on Registered Nurses.   Registered nurses can now insert a centrally located Catheter in the Jugular vein, weather it’s a line for central venous pressure monitoring of a tunneled dialysis catheter in the jugular vein.  Yes, we have come a long way.  I am one of those nurses who are at the forefront of advanced practice.  As a PICC nurse at my facility, I am in the process of taking over a role that was once reserved for the medical Doctor.

As nurses let's embrace the future as our role changes, let us not forget our primary role of patient advocate.

[#17]

Dr. Shalala,

I applaud the work of this committee. I have been a nurse for seven years and I remain passionate for the field. I recently have become a clinical instructor for a local community college for fourth semester graduating students in an ADN nursing program. I work hard to encourage and support these upcoming nursing professionals. The majority of my students are adults entering a second career. They are mature, caring, and have much life experience to bring to this field. Financially these students were not able to enter an expensive four year program for the BSN degree, nor would they qualify for aid for them. The plan seems to be that they will begin work as a nurse with an ADN degree and obtain a BSN while working. With the recent increases in Cal State tuitions, there are concerns that financially this will be unattainable. I hope to see this taskforce help provide more financial awards for these individuals to continue their education while gaining experience in the field.  

Ann V.   RN

[#18]

Dear Future of Nursing Committee & RWJF,

I applaud the interest in deciphering the future of nursing. Why is a nurse not chairing this committee? How many more of these efforts do we, nurses, allow to be driven by others? In my opinion, this is the number one problem with nursing: Nurses historically have not taken the lead in defining their profession. The reasons for this are numerous and well known by any nurse who has not been able to participate in such activities. I have been a nurse for 23 years; 15 of those years in a large university hospital's CCU. My sister who has a high school diploma and no certifications, works for a community hospital group in NJ as a Billing & Budgeting Analyst (she writes & runs computer programs for the CFO because he does not want to pay the hospital group's consulting firm extra) and she makes $120,000/year. When I make comments about the disparities in pay scales in hospitals, she shares comments she & her co-workers have made...."why do nurses complain about their hourly wages and schedules, when that is the job they chose to do?" So, in 2000, I chose not to work as a nurse anymore. Now my need for caring for others is satiated as a volunteer for adults with intellectual disabilities.  My need for a paycheck is accomplished by working as a healthcare consultant.  My graduate nursing education, alone, cost me close to $200,000....100% out of my pocket. Do I expect to become rich being a nurse? No. I do, however, expect to make enough money to repay my school debts and to provide for myself and my son who is profoundly affected with autism. I also expect to be respected among others working in the healthcare industry  and the public as a knowledgeable, competent, and caring nurse who brings exceptional value to healthcare services. Let me know when I can expect these and maybe, I'll return to nursing.

My suggestions for this committee: 1) Chair the effort with a doctorally prepared nurse.  2) Address the need for improving working conditions for nurses. 3) Insist that state & federal governments & licensing & billing authorities allow nurse practitioners and all other advanced practice nurses to practice independently. 4) Inform the healthcare reform debate going on by explaining the difference between healthcare and medical care and propose system changes to reflect the differences.

Thank you,

Sheri Morgan, MSN, PhD (c), RN