A Summary of the October 2009 Forum on the Future of Nursing: Acute Care

chow focused on five core concepts, described below, for imagining

the future of nursing in acute care.

core concept 1: leverage the power of the electronic health record

the ehr could be the connective tissue of the health care system.

an ehr not bound to one site or caregiver could enable improved care

coordination and transitions, provide complete information connectivity,

and transform the manner in which care is delivered and received, chow

said.

kaiser permanente has learned many lessons from the electronic system

it has developed and implemented. last year the system had 6 million

electronic visits—“imagine the personal time savings for the patient,

having an e-visit, versus coming into a clinic or an emergency department,”

chow said. the ehr has enabled the invention of new patientcentered

roles for nurses. for example, a pilot program in a southern

california kaiser permanente emergency department called the “virtual

charge nurse” tracks patients from the time they arrive at a hospital until

a decision is made to discharge or admit them. the ehr shows what has

or has not happened to a patient, allowing tests and procedures to be

moved online and providing patients with a “virtual advocate.” in another

program, ehrs have been used to standardize the documentation

and management of pressure ulcers. in kaiser’s experience, the

implementation of ehrs has reduced documentation loads and increased

nurses’ time in patient rooms. “the ehr is a tool that will raise the bar

for care delivery across all settings, including acute care,” said chow. “it

must be seamlessly integrated with other technologies and devices so that

nurses are not the human interface for technology that does not work together.”

core concept 2: achieve a balance among technologies, disruptive

business models, and human needs

incredible technological developments are on the horizon. for example,

chow highlighted miniaturization and wireless technologies that are

being used to create body sensor networks that will monitor everything

from heartbeats to brainwaves to temperature to blood glucose levels

from anywhere in the hospital or even remotely from home.

the convergence of molecular biology, computer, and medical science

with electrical, mechanical, genetic, and biomedical engineering

could have profound effects on practice models. in a revolutionized future,

technologies could assist nurses with much of their work and help

consumers in diagnosing and treating themselves with self-help tools and

personalized designer drugs. an example is the website developed by

microsoft and emory university (h1n1 flu (swine flu) response center -

microsoft) that allows users to determine if they likely have the flu, whether or not to be seen by a health care provider, and what their overall risk is as a flu patient. “imagine smart systems to guide patients and clinicians through available health information,” chow said. such technologies produce what she called a “wow factor.”

so-called disruptive innovations and business models,1 such as retail

health care clinics, nurse navigators, health coaches, and patient advocates, could be another prominent feature of a future health care system.

these disruptive business models could have a major impact on nursing

practice. furthermore, these innovations can be combined with or en-

abled by technology. in the future, technology will come to people rather

than people going to the technology. “remember when you had to send

your printing requests to a central duplication center?” chow asked.

“now you can print at your own desk.” in 2002, for example, general

electric sold a conventional ultrasound machine for $100,000 and up to

sophisticated hospital imaging centers. in 2007, ge sold a portable

ultrasound machine for emerging markets in developing countries at a price

of $15,000, giving remote areas access to high technology.

disruptive innovations aimed directly at human needs have been far

less plentiful. “what would we [need to] do to actually be human centered?

what are the core human needs? is it that i hate to travel to the

doctor’s office or the emergency department, but that i still want someone

to look me in the eye, to listen to me, to touch my hand, and to advocate

for me? how might we design for human needs and more efficiency,

while using innovative business-to-business and technology tools?” the

goal is to find a balance among technology, disruptive innovations, and

human needs

core concepts 3 and 4: implement rapid translation teams and

interdisciplinary teams of designers

nurses cannot design a patient-centered system by themselves.

technologies are arriving faster than they can be integrated into the

health care system, and people are not able to make sense of much of the

information already available. chow suggested that one possible solution

to this deluge of new technology and information is the creation of rapid

translation teams. they would assist in the implementation of patient

centered systems that were developed by interdisciplinary teams of designers.

these rapid translation teams could scan, understand, and integrate

the technological environment and make connections among technology,

research, science, and acute care. teams could include nurses and other

experts such as engineers, geneticists, academic researchers, architects,

ethnographers, designers, technologists, change specialists, and frontline

clinicians. rapid translation teams could in turn interact with

interdisciplinary teams of designers, including behavioral scientists,

marketers, engineers, clinicians, and patients. the result would be a

system for designing the future of acute care, with human needs consciously

incorporated into the design process. “change in acute care

will happen,” chow said. “it is a question of how we design it.”

core concept 5: create an infrastructure for rapid network exchange

of successful system design innovations

a system to design successful innovations will need to be agile.

technological changes occur too quickly to plan, prototype, and test

innovations over the course of several years. “we need to create a simple,

easy venue for the quick exchange of what’s working and not working,”

chow explained.

successful system design innovations also demand leadership and

coordination. for example, a national institute for human-centered,

empathy-based care with regional nodes could help spread the work of

the rapid translation teams and interdisciplinary design teams. such an

institute might focus on economic measures of the value of nursing. it

could emphasize an approach to nursing comparable to how one would

care for a parent or sibling. “we nurses want to help patients and family

members the way we do as the nurses for our families,” said chow.

health innovation design forums could also help disseminate the work of

rapid translation and interdisciplinary teams. nurses could help prototype

and pilot new processes, systems, and multidisciplinary practice models.

several institutions have demonstrated the value of these approaches.

for example, the university of pittsburgh medical center has piloted

equipment in 22 rooms designed to improve patient safety, increase

customer satisfaction, and help nurses and other health care professionals

to deliver the right care at the right time, every time. ascension health is

planning to have three innovation units, and kaiser permanente has

established a 37,000-square-foot facility to explore the intersection

of technology, space, and workflow.

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:

1. staffing methodologies, including workload and outcome indicators,

need to be embedded in ehrs.

2. funded and mandated registered nurse residencies are very important

to consider.

3. to advance the understanding of nursing and nursing contributions,

a standardized and structured language is needed that is embedded

in the documentation system.

joyce sensmeier,

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.