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American Association of Colleges of Nursing   Geraldine Polly Bednash, PhD, RN, FAAN Chief Executive Officer/Executive Director



Represent baccalaureate and graduate degree granting universities Represent the entire academic unit, including deans, faculty, staff Leadership networks:  Business Officers  Associate deans  Graduate recruiters

- Development Officers - Curriculum directors - Research directors

 Practice leadership

The Future or Nursing: Leading Change, Advancing Health

Transformation: •

Transform: Change or alter in form appearance, or substance • Alteration • Change • Conversion • Revolution • Renovation

The Future or Nursing: Leading Change, Advancing Health Assumption that nursing can play a fundamentally important role in meeting the demands for quality, safe, and effective health care. Awareness that a static approach to nursing education, practice and research will not create the answers to current and future health care challenges

This report is published at a time of great opportunity in health care.  How does the system accommodate the increased demand while improving quality of health care services  What roles will nurses assume to meet this emerging demand?  Nursing brings a steadfast commitment to patient care, safety, quality, and better outcomes. 

Leading Change: Advancing Health Focus on transforming health care and an understanding that all health professionals must rethink how their roles are played out in delivering care  Understanding by the members of the IOM Commission that nursing is essential to creating change in health care and to delivering high quality, accessible care. 

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Examining the context: Changing demographics and care needs    

Growing diversity – under the age of 1 – 54% minority. Our present and our future. Dramatic aging of the population Increasing chronicity in pediatric and adult populations Geographic expansion of issues to be addressed

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Lusting for the Purple Pill  Highly

involved patients with DTC marketing and the internet

Creating demand – Direct to Consumer marketing  Billions in advertising  TV – Newspapers – Magazines 

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Patient Driven Decision Making: The Engaged Consumer On an average day, 8 million Americans seek health information via the Internet.  More than half of all those who have used the Internet report that it has improved their ability to obtain needed health information, and 70% report that the information they found affected a personal health care decision. 

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Examining the context: What framed these recommendations?

What is patient centeredness? Understanding that the consumer of health care is the owner/driver of the decision process.  Growing sense of distrust of the corporate and social entities that deliver care.  Seeking answers in nontraditional ways and in order to control unsure outcomes  How do we know we are patient centered? 

The knowledge explosion is creating a mandate for a markedly different notion of what practice should look like - not just for nursing The revolution in health care delivery will mandate a reconceptualized practice for all health professionals Consumers of health care will have a stronger role and will change the dynamics of care delivery

Converging Realities – Nursing and the Quality Dilemma

Examining the context: The knowledge explosion Knowledge explosion means we can never own the full set of information to be a good professional  Wikipedia – 40,000 clinical trials in process at any one time  Our responsibility is to seek knowledge, be knowledge workers not instrumentalists 



Keeping Patients Safe – Transforming the Work Environment of Nurses: “Research is now beginning to document what physicians, patients, other health care providers, and nurses themselves have long known: how well we are cared for by nurses … can be a matter of life and death.”

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Informatics and Knowledge Explosion Attempt to manage the data and knowledge in a way that will create access and utility to the explosion of information and the intersections of these  Challenge: will it increase quality, decrease costs and medical errors, improve the ability of patients to drive and select their care options  Data are not clear but the mandate is clear 

Practice Evolution and Revolution The organizational frameworks for care delivery are undergoing dramatic reformation and change and these changes will occur with or without the ACA  Transformation of care frameworks, organizations, providers, and care demands  Medical (health) homes, accountable care organizations, health care innovation zone,  Innovation and experimentation  Care teams and interprofessional practice 

Informatics and Meaningful Use 

“What information consumes is rather obvious: it consumes the attention of its recipients. Hence a wealth of information creates a poverty of attention, and a need to allocate that attention efficiently among the overabundance of information sources that might consume it.” Harvey Simon

Managing Risk and Anticipating Change    

Moving from reactive models of care to anticipatory exchanges Understanding that risk must be anticipated and managed Creating an understanding of the system’s role in change and outcomes More importantly, making visible the central role that nursing care plays in assuring quality, effectiveness and safety

What are the challenges to this opportunity? 

Leading will require an engagement in policy, collaboration across and within professions

Why do this? 

It takes a team!

Can we lead and follow?  Creating policies that shape our future depends on collaboration and across the professions work to find a common place. 

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Vermont Advanced Primary Care Teams – Why teams are better Having community health teams work with primary care providers to assess patients’ needs, coordinate community-based support services, and provide multidisciplinary care for a general population.  A recent analysis of the first pilot program found significant year-over-year decreases in hospital admissions and emergency department visits, and their related per person per month costs. Health Affairs, 30, no.3 (2011):383-386

Team Members = Wholistic Care 



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Each community health team is led by a registered nurse, who performs clinical duties and supervises the team. Providers felt they could respond to a range of patient needs—nonclinical as well as clinical—with the team’s support. Physician Dana Kraus: “Having access to the community health team removes the fear of asking a patient the simple open ended question, ‘So, how are things?’ If the patient breaks into tears or admits that things at home are chaotic, I do not feel that I need to solve all of their social woes then and there by myself. I have a whole team to help.

Examining the Context: How is Health Care Changing?

Team Based Care Innovation Center for Medicare and Medicaid Innovation Innovation challenge grants to improve care, lower costs, and improve quality.  106 awards with $1 billion funding over three years  Team based approaches to improved care  Nursing is a significant player in the largest portion of these awards  Driving change for new approaches to care 



Interprofessional Education and Practice  Understanding that teams are the core of best

practice  Creating a new mandate for learning with others to

share the care delivery process and to understand the complex mix of assets available in the team  Understanding that teamness is no longer an elective but is a mandate  Being a member of a team does not mean we are being directed or that we are not leading.

Examining the context: a focus on consumer expectations •

•

The Triple Aim - overarching theme of a newly conceptualized patient centered care focused on assuring quality New care designs must be created to accomplish three critical objectives • Improve the health of the population • Enhance the patient experience including quality,

access, and reliability • Reduce or at least control costs of care

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Converging Realities – Nursing and the Quality Dilemma

Ten years – Little Change IOM’s Quality Chasm Series IOM’

Leading Change: Advancing Health 

Recommendations:



Keeping Patients Safe – Transforming the Work Environment of Nurses: “Research is now beginning to document what physicians, patients, other health care providers, and nurses themselves have long known: how well we are cared for by nurses … can be a matter of life and death.”

Leading Change: Advancing Health

 Scope of practice – beyond advanced practice  Advancing educational preparation – baccalaureate

to graduate degrees  Developing leaders and creating the opportunity to lead  Supporting transition to practice  Creating the data resources to drive change and understand the profession

Transforming Education

Where do these lead us in our work to assure that these recommendations are implemented? What are the challenges these opportunities bring us?

Education of the RN Workforce

A redesigned health system will demand a better educated nursing workforce  Better is not the only issue – different is  Professional nurses are knowledge workers not instrumentalists doing tasks  To assume full accountability and authority for practice as a professional requires a fundamentally different professional education 

Source: Findings from the 2008 National Sample Survey of Registered Nurses, September 2010. Health Resources and Services Administration.

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Leading Change: Advancing Health 



 

What are the challenges to this opportunity?

A more highly educated nursing workforce will require transformation of the educational content and process Building a future and the leaders for that future will require stronger academic and practice partnerships Leading requires not only a different education but more education Moving to the DNP and the CNL

 Must

focus on mentoring and nurturing our future leaders through a newly conceptualized career model  Will we encourage our new colleagues in the profession to reach for the stars and do it quickly?

Leading Change, Advancing Health  Scope

of Practice

 The most contentious part of the report  Markedly negative response from physicians – are we

surprised?  Anticompetitive behavior of state laws is under the

microscope from many policy makers

Advancing APRN Practice 

IOM Report: “What nurse practitioners are able to do once they graduate varies widely for reasons that are not related to their ability, education or training, or safety concerns, but to the political decisions of the state in which they work.”

UNITED STATES OF AMERICAN FEDERAL TRADE COMMISSION “The FTC is charged with enforcing the FTC Act, which prohibits unfair methods of competition and unfair or deceptive acts or practices in or affecting commerce. Effective competition is at the core of America’s economy; vigorous competition among sellers in an open marketplace gives consumers the benefits of lower prices, higher quality products and services, more choices, and greater innovation.”

UNITED STATES OF AMERICAN FEDERAL TRADE COMMISSION 

Available evidence suggests that APRNs generally are safe providers of health care services when they provide services consistent with their training. More broadly, the available empirical evidence indicates that APRN-delivered care “across settings, is at least equivalent to that of physician-delivered care as regards safety and quality, and that increased APRN care may even be associated with improved outcomes for particular disease…

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UNITED STATES OF AMERICAN FEDERAL TRADE COMMISSION 

UNITED STATES OF AMERICAN FEDERAL TRADE COMMISSION

Requiring physician supervision of APRNs imposes costs on Texas health care consumers. Both S.B. 1260 and S.B. 1339 would reduce those costs, and the Bills likely would improve access and increase choices for Texas health care consumers as well. Absent evidence that the current statutory restrictions are required to address patient harms, FTC staff urge the Texas legislature to enact either S.B. 1260 or S.B. 1339 to remove those restrictions.

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Transformation and Change

Based on current evidence, H.B. 4103 appears to represent a procompetitive improvement in the law, one that is likely to benefit Florida health care consumers. As Florida’s Department of Health notes in its own analysis of H.B. 4103, reducing current supervision requirements “would allow more access to healthcare.” We therefore urge the legislature to consider carefully the impact of the 2006 requirements and to avoid maintaining provisions that would limit ARNP provision of health care services more strictly than patient protection requires.

Harvard Business Review

This is a story about change and the tremendous opportunity we have to lead and serve  Why are we being given this opportunity?  What leadership will we assume?  What are the challenges to assuming our leadership opportunity?  Why are we here now? 

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“A Survival Guide for Leaders”   

Harvard Business Review (2002) Heifetz and Linsky “Let’s face it, to lead is to live dangerously. While leadership is often depicted as an exciting and glamorous endeavor, one in which you inspire others, such a portrayal ignores leadership’s dark side as others attempt to take you out of the game!”

PHYSICIAN SUPPLY and DEMAND PROJECTIONS to 2025 400

Physicians per 100,000 of population .

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350

300

GDP  1.0%  Health spending  ~1.5%  Health workforce  ~1.2%  Physician workforce  ~ 0.75%

Deficit= ~200,000 physicians (~20%)

Supply

250

200 1980

Demand

1990

2000 Year

2010

2020

Effective Supply

Source: Richard Cooper, MD

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Cracks in the Opposition

Redefining Reality “I’m convinced that joining forces with APRNs to develop innovative models of team care will lead to the best health outcomes. In a world of accountable health care organizations, health innovation zones, and medical “neighborhoods,” we gain far more from collaboration than from competition. As we ring in the new year, let’s stop clinging to the past— and redirect our energies toward envisioning the future of health care.”

“Since the supply of physicians will not be adequate to care for the increasing population of patients with chronic disease, academic medicine’s leadership must place the needs of the patients in the forefront and work with the leadership of nursing to determine how best to provide the care those patients will need. It is simply unacceptable to have the needs of those patients go unmet.”

Jeff Susman, MD, Editor-in-Chief, Journal of Family Practice, 12/2010

Michael E. Whitcomb, MD, Academic Medicine, 2006

Concurring Voices 

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“A non-physician (such as a nurse) may serve as a trusted advisor and medical home to coordinate services effectively and efficiently. (2008 - Association of American Medical Colleges) Current state nurse practice acts and accompanying rules should be interpreted and/or amended where necessary to allow APRNs to fully and independently practice as defined by their education and certification, March 2010 AARP

Future of APRN Practice In October 2010, the National Committee on Quality Assurance (NCQA) began recognizing nurse-led primary care practices as PatientCentered Medical Homes in states that permit APRNs to lead practices.  APRNs are well-prepared to lead Medical Homes since they are educated to provide a broad range of primary, preventative, and transitional care services. 

Leading Change: Advancing Health The report is a challenge to us – how will we lead change and advance health?  Not a report on nursing rights but rather a report on the many challenges in health care to which we must respond  Provides strong advocacy for nursing’s authoritative role in the issues  But 

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Limits to APRN Practice 

What does it mean for us?

Only 14 states plus DC permit NPs to see primary care patients without physician supervision.

If we want to lead, we need to lead. Will require a commitment to collaborating with the full community of nurses and with other health professionals of like mind.  Tell our story and bring others to the understanding that nursing holds the answer to many of our nation’s health care concerns  

Leading not following – creating our destiny

Golden Age or Age of Opportunity

We have been give golden opportunities but also need to own the accountability this creates.  We have the potential to address the contextual issues that have created these opportunities.  What are the challenges to the nursing profession and to those of you working to prepare the next generation of nursing professionals and leaders? 

Nursing is receiving tremendous exposure, support and scrutiny at a time of significant change and opportunity  IOM Report is a doorway to that opportunity  The environment of change will create huge challenges for us as a discipline and we must use these to forge a preferred future  Creating our destiny is within our power 

Leading Change, Advancing Health

Nurses Leading Change Marilyn Tavenner, Ellen Marie Whelan, PhD NP, RN – Senior Advisory, CMS Innovation Center  Mary Wakefield, PhD, RN – Administrator, Health Resources and Services Administration, HHS  Jan Heinrich, DrPH, RN, - Director, Bureau of Health Professions

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The array of recommendations in this important report come at a time of tremendous opportunity and change in health care But we will be challenged to reconsider old views of our profession, the process for educating professionals, the way we deliver and monitor care, and the way we interact with other professionals and the consumer of health care.

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AWHONN: Leading for Change 

Clearly addressing the dominant issues in nursing and health care:  Informatics - Perinatal Nursing Informatics

Guide for Clinical Health Information Technology  Implementation Science and Translation of Research  Cultural Competence: Nursing in a Diverse Society

Of Course it’s hard – if it wasn’t hard, anyone could do it! Coach in A League of “Their Own 5/10/2013

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The world of nursing will continue to evolve & it will be different.

Boston April 2008

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Creating the Future 

We have a responsibility to create the future for our patients, for our profession, and for the health of the public.

Eric Hume

Andy Warhol

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