Three Years After Release of 'The Future of Nursing' Report - What Progress Have We Made?

On December 11, the Institute of Medicine's (IOM) 2013 Richard & Hinda Rosenthal Lecture focused on progress made advancing the recommendations of the IOM report, The Future of Nursing: Leading Change, Advancing Health, released three years ago.

Donna Shalala, president of the University of Miami in Florida, former head of the U.S. Department of Health and Human Services, and chair of the Committee on the Robert Wood Johnson Foundation (RWJF) Initiative on the Future of Nursing, gave the keynote address, urging nurses and their allies to take this opportunity to transform nursing.

Among the victories cited by Shalala, RWJF President and CEO Risa Lavizzo-Mourey, and other speakers  were: the launch of the Future of Nursing: Campaign for Action; the removal of barriers to expanded scope of practice for advanced practice registered nurses in seven states; an increase in the number of streamlined nursing education programs that enable nurses to advance their education; and an increase in the appointment of nurses to decision-making boards.

Watch the webcast here.

Indiana Program Illustrates Potential of Nurse-Led Initiatives

A series of nurse-led initiatives in Indiana improved patient outcomes and is projected to save health care organizations in the state more than $5.2 million. These results demonstrate the importance of increasing nurses’ leadership opportunities, a key recommendation of the Institute of Medicine’s (IOM) landmark “Future of Nursing” report.

The American Association of Critical-Care Nurses (AACN) launched the Clinical Scene Investigator (CSI) Academy last year as a team-oriented and hands-on educational experience that placed nurses as clinician leaders. The nurses led initiatives and generated quantifiable improvements in the quality of patient care and hospital finances. Nurse-led initiatives studied in the program helped to:

• Improve patient satisfaction by as much as 20 percent;
• Reduce stays in the pediatric intensive care unit (ICU) by 0.5 days;
• Cut incidences of patient falls and hospital-acquired device-related nose and mouth pressure ulcers by more than 50 percent;
• Decrease overall pressure ulcers by more than 60 percent; and
• Drop mechanical ventilation days for ICU patients by 0.44 days.

Forty-two hospitals spanning six U.S. regions are participating in the preliminary national program rollout. The program continues to run at hospitals in Massachusetts, New York, North Carolina, Pennsylvania, and Texas. Ongoing projects include preventing ventilator-associated pneumonia, catheter-associated urinary tract infections, central line-associated bloodstream infections, pressure ulcers, falls, extubation, and improving communication and teamwork.

Media coverage of the AACN findings included Infection Control Today, Nurse.com and Advanced Healthcare Network for Nurses.

INQRI-funded research has focused on nurse-led initiatives in many of these areas,  including patient falls, central line-associated bloodstream infections and pressure ulcers.

A Look Ahead at the Future of Nursing - Catch the Webcast Today at 5pm Eastern

This year marks the third anniversary of the Institute of Medicine (IOM) report, The Future of Nursing: Leading Change, Advancing Health.  A live webcast this afternoon as part of the IOM's 2013 Richard and Hinda Rosenthal Lecture series, will discuss the impact of the report, progress in implementing the report's recommendations at the national and local levels, and what's on the horizon.

The discussion will be moderated by Harvey Fineberg, president of the IOM and Donna Shalala, president of the University of Miami and chair of the Committee on the RWJF Initiative on the Future of Nursing will deliver the keynote address.

Panelists will be:  

Carmen Alvarez, Julio Bellber Postdoctoral Fellow, Department of Health Policy, The George Washington University

Linda Burnes Bolton, vice president and chief nursing officer, Cedars-Sinai Medical Center; vice-chair, Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing

Susan Hassmiller, senior adviser for nursing, Robert Wood Johnson Foundation; study director, Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing

Darrell Kirch, president and chief executive officer, Association of American Medical Colleges

David Vlahov, dean and endowed professor of nursing education, School of Nursing, University of California, San Francisco


Watch the webcast at 5pm EST today.

INQRI In the News

New guidelines from the Joint Commission highlight the key role of nurses in preventing central line-associated bloodstream infections (CLABSIs), Infection Control Today reports. "Nurses are on the front lines and can take advantage of their constant contact with patients and other caregivers to explain infection control techniques and help health facilities develop and enforce standards of care that have been proven effective against CLABSI," said INQRI grantee Patricia Stone, PhD, MPH, RN.  She is also quoted in Long-Term Living,  Advanced Healthcare Network for Nurses, and Becker’s ASC Review.  

The health care system must ready itself for the influx of newly insured patients resulting from the Affordable Care Act, and advancing the role of nurses may be one way of addressing a potential physician shortage, according to an MSNBC.com article. The Institute of Medicine’s "Future of Nursing Report" is quoted in the article: “Now is the time to eliminate the outdated regulations and organizational and cultural barriers that limit the ability of nurses to practice to the full extent of their education, training, and competence.”

A Reuters Health article profiles the INQRI-funded study "Scope-Of-Practice Laws For Nurse Practitioners Limit Cost Savings That Can Be Achieved In Retail Clinics" and quotes co-lead investigator Joanne Spetz. "It appears there are cost savings when those nurse practitioners are allowed to operate autonomously in the retail clinic settings," Spetz told Reuters Health.

Promoting Rigorous Interdisciplinary Research and Building an Evidence Base to Inform Health Care Learning, Practice, and Policy

By Mary D. Naylor, PhD, RN, FAAN, Marian S. Ware Professor in Gerontology, director of the NewCourtland Center for Transitions and Health at the University of Pennsylvania School of Nursing, and co-director of INQRI. This commentary originally appeared on the Institute of Medicine website.

The Institute of Medicine (IOM) established the Roundtable on Value & Science-Driven Health Care to accelerate the advancement and application of science to achieve the best possible health and health care outcomes and value for Americans. The work of the roundtable is predicated on the notion that our health care system must continuously learn from rigorous evidence in order to innovate and improve. To that end, it acknowledges and promotes the importance of identifying best practices in health and health care, developing and testing innovations, and—most importantly— promoting collaborative efforts.

This vision for improving health and health care is shared by the Robert Wood Johnson Foundation, which funds an innovative and unique initiative to improve patient care by examining the role nurses play in improving care quality: the Interdisciplinary Nursing Quality Research Initiative (INQRI). Mark Pauly of the University of Pennsylvania and I have had the great privilege of serving as co-directors of this program since its inception in 2005.

More than 3.1 million strong, nurses represent the largest segment of the health care professional workforce in the United States and are the professionals who provide the most direct patient care. But, until the launch of the INQRI program, there was little rigorous research linking nursing’s contributions to patient outcomes. INQRI has served to advance the science of health care by investigating those linkages and providing evidence to inform policies and practices that improve patient care and outcomes, thereby improving our health care system overall.

Since INQRI’s launch, the program has encouraged researchers to develop new strategies to improve health care value and demonstrate nursing’s role in accomplishing that aim. To date, INQRI has supported 48 multidisciplinary teams of scholars whose studies have dramatically increased the evidence linking nursing to quality of care. These teams not only examine the nursing practices and processes that affect the patients’ experience with care and outcome, but also design and implement nurse-led interventions to improve patient outcomes. Equally important, findings from INQRI teams have helped to distinguish effective ideas from solutions that are often popular, yet ineffective.

A series of articles recently published in a special supplement of Medical Care revealed that, collectively, these studies have helped to improve the rigor of research methodology, built a solid base of evidence demonstrating linkages between nursing care and patient outcomes, and helped advance interdisciplinary research and practice. To a large extent, INQRI’s contributions to our knowledge are a function of the singular requirement that every INQRI research team include investigators from more than one discipline. As IOM’s Roundtable on Value & Science-Driven Health Care has drawn on the insights of a multidisciplinary community, so have INQRI teams. By requiring that researchers collaborate across disciplines, the program raises the bar for the level of rigor, ensuring that diverse perspectives contribute to the design of each study and are also brought to bear in the analysis of the findings.

The roundtable has sought to accelerate progress through six stakeholder Innovation Collaboratives: 1) Best Practices; 2) Clinical-Effectiveness Research; 3) Evidence Communication; 4) Digital Learning; 5) Systems Approaches for Health; and 6) Value Incentives. To make significant change, we must look at all aspects of the health care system. To that end, INQRI attempts to understand the nurses’ role in delivering high-quality care across a variety of patient populations and settings.

INQRI has funded several studies that examined nursing practices and tested interventions that can improve patient care and safety, including

• changes in nursing processes and the practice environment to facilitate nurses’ ability to intercept costly and dangerous medication errors;
• nurse-led innovations to reduce the incidence of facility-acquired
• pressure ulcers among residents in long-term care settings; and
• strategies to improve intensive care unit patients’ ability to communicate with nurses and other health team members regarding their care needs and preferences.

INQRI grantees have also applied rigorous research methods to examine a broad range of approaches to improving the value of health care—increasing quality while reducing health care costs associated with issues such as patient falls, hospital-acquired infections, and rehospitalizations. Studies aimed at reducing events that drive up health care costs have included

• an analysis of the factors that influence the quality of preparation of patients and family caregivers for the transition from hospitals to home and the impact of enhanced preparation on patients’ perceived readiness and rates of re-hospitalization;
• relationships between the level of professional nursing practice, adoption of evidence-based care strategies, and the number and kind of injuries from falls;
• effects on patients’ health of diabetes prevention information delivered by visiting nurses to residents in subsidized housing units; and
• linkages between nurse staffing levels in neonatal intensive care units and outcomes for very-low-birth-weight infants in those units.

In addition to contributing to continuous learning in our nation’s health care system, improving the rigor of research, and identifying the linkages between nursing and the quality of patient care, INQRI has helped to define what we mean by “quality” in the context of health care and to identify new metrics and measures that should be used in future health care research. As any research endeavor should, INQRI has proven to be greater than the sum of its parts.

Suggested citation: Naylor, M. Promoting rigorous interdisciplinary research and building an evidence base to inform health care learning, practice, and policy. Commentary, Institute of Medicine, Washington, DC. http://iom.edu/interdisciplinaryresearch

The Importance of Nursing in Achieving the "Best Care at Lower Cost"

by Richard C Lindrooth and Olga Yakusheva

The Institute of Medicine (IOM) released the findings of its Committee on the Learning Health Care System in America in a report entitled "Best Care at Lower Cost: The Path to Continuously Learning Health Care in America"[1] in early September, 2013.  The report recognized that the complexity of clinical decision-making is rapidly increasing and that clinicians need to continuously update their skills in order to keep up with:

(1) rapidly expanding diagnostic and treatment options; and
(2) the increasingly complex and chronic clinical condition of patients.

Given the growing external demands placed on nurses, the IOM reports that a critical determinant of the success of an organization in dealing with these demands is how "a learning health care organization harnesses its internal wisdom—staff expertise, patient feedback, financial data, and other knowledge—to improve its operations."   Nurses in particular are in an excellent position to play a central role in creating a virtuous feedback loop such that it is feasible to continuously adjust and incrementally improve systems in response to rapidly changing external demands.  The report, supported by the results of a growing and increasingly robust body of academic research, stresses the important role of leadership and management in fostering and maintaining an environment within which continuous learning could take hold.

The recommendations highlight the critical importance of continuing investments in the human capital necessary to enable clinicians' (nurses) to thrive in the dynamic health care market.  Bachelors of Science in Nursing (BSN) programs teach nurses the critical communication skills and analytical tools and that can be harnessed by a well-managed organization in creating an environment that fosters and rewards continuous learning. 

The good news is that employers will increasingly recognize the value of a BSN and reward staff for the additional cost and effort required for the degree.  The IOM Future of Nursing report documents the value of an advanced degree and knowledge of the value of a BSN is reflected in recent hiring trends.  Standard economic theory predicts that the value of a BSN - and human capital in general - depends upon the ability of an organization to put those skills to productive use.  Well-managed organizations will be apt to reward advanced training precisely because the organization can harness the human capital to increase productivity. 

The IOM report documents the experiences of many organizations that have successfully fostered the skills and experience if their staff to improve outcomes and productivity.  While the case studies are encouraging, there are even more organizations that still have not adopted the management practices necessary to facilitate continuous learning.  An organization's future success hinges on its ability to keep up with rapidly changing treatments and the increasingly complex needs of patients. Those organizations that are successful in doing so will thrive and grow market share at the expense of organizations that fail to keep up. 

______________________________________________________

[1] Smith, M; R. Saunders, L. Stuckhardt, and J.M. McGinnis, Editors. 2013. ""Best Care at Lower Cost: The Path to Continuously Learning Health Care in America." Available at: http://www.nap.edu/catalog.php?record_id=13444, accessed on September 20, 2013.

New Brief Makes the Case for Baccalaureate-Prepped Nurses

A new policy brief authored by Ann Kutney-Lee and Linda Aiken and distributed by the Leonard Davis Institute of Health Economics at the University of Pennsylvania makes the case for baccalaureate-prepared nurses.

Researchers found that increases in the percentage of nurses with baccalaureate degrees were associated with significant reductions in surgical mortality rates and failure-to-rescue rates.  They also found that a ten-point increase in a hospital’s percentage of baccalaureate-prepared nurses was associated with an average reduction of 2.12 deaths for every 1,000 patients. (The average reduction was 7.47 deaths per 1,000 patients in the subset of patients with complications.)

These results suggest that if all the hospitals in the study had increased their percentage of baccalaureate nurses by ten points, about 500 deaths might have been prevented.  This is an incredibly important finding, given the recommendation made in the Institute of Medicine report, The Future of Nursing: Leading Change, Advancing Health to increase the number of nurses holding a baccalaureate degree to 80% by the year 2020.

The brief also explains that in addition to improving patient outcomes, higher numbers of baccalaureate-prepared nurses could also lead to an increased number of graduate-level nurses prepared to either become nurse faculty or accept advanced-practice positions in primary care.  Aiken found that nurses with initial associate's degrees were less likely than those with an initial baccalaureate degree to earn a master's degree.

This brief is based on the following articles: 

1. A. Kutney-Lee, D.M. Sloane, L.H. Aiken. An increase in the number of nurses with baccalaureate degrees is linked to lower rates of post-surgery mortality, Health Affairs, March 2013, vol. 32, pp. 579-586;
2. L.H. Aiken. Nurses for the future. New England Journal of Medicine, January 20, 2011, vol. 364, pp. 196-198.

New Survey: Physicians, Nurse Practitioners Disagree on Nurses’ Role in Providing Primary Care

By Lori Melichar Gadkari, PhD, MA

Lori Melichar Gadkari, PhD, MA, is a senior program officer at the Robert Wood Johnson Foundation (RWJF), in the Research and Evaluation Unit and the program officer for INQRI.

Yesterday the New England Journal of Medicine published the results of a study co-funded by the Robert Wood Johnson Foundation, Johnson & Johnson, and the Gordon and Betty Moore Foundation. “Perspectives of Physicians and Nurse Practitioners on Primary Care Practice” finds that 96 percent of nurse practitioners and 76 percent of physicians agreed with the Institute of Medicine report recommendation that “nurse practitioners should be able to practice to the full extent of their education and training.” The new study is authored by Karen Donelan, ScD, EdM, Catherine M. DesRoches, DrPH, Robert S. Dittus, MD, MPH, and Peter Buerhaus, PhD, RN.

When asked how increasing the supply of nurse practitioners would potentially affect the United States health care system, the authors found that the majority of physicians (73%) said increasing the supply of primary care nurse practitioners (PCNPs) would lead to improvements in the timeliness of care. A much smaller majority of physicians (52%) said increasing the supply of PCNPs would lead to improvements in access to care for people in the country. 

However, the new survey found significant disagreement between primary care physicians and PCNPs about whether increasing the supply of PCNPs would improve patient safety and the effectiveness of care, and whether it would reduce costs. There was also a large professional divide about proposed changes to PCNPs’ scope of practice, putting PCNPs in leadership roles, and the quality of care that PCNPs provide.

The Case for Nurse Residency Programs

The Institute of Medicine Report, The Future of Nursing: Leading Change, Advancing Care, includes several recommendations for strengthening nursing education. Nurse residency programs are one avenue for doing that, while also boosting nurse staffing at hospitals and helping those hospitals retain new nurses.

An article in the Anchorage Daily News looks at one nursing residency program at Alaska Regional Hospital and how it's preparing nursing school graduates and increasing nurse staffing. In addition to classroom instruction, Alaska Regional's program includes nurse-to-nurse mentoring, daily debriefing and frequent testing and evaluation.

The Future of Nursing: Campaign for Action includes several Action Coalitions working to develop or expand nurse residency programs. Most recently, the Rhode Island Action Coalition launched a statewide clinical nurse residency and mentoring program with a State Implementation Program grant from the Robert Wood Johnson Foundation. The Rhode Island program will place nursing school graduates in a range of settings from nursing homes to community clinics, as well as hospitals.

Coordinated Care Still Needs Some Work

While coordinated care is widely considered the best way to keep costs down and provide better patient care and is a centerpiece of the Affordable Care Act, too often care coordination isn't really happening according to a story produced by Kaiser Health News in collaboration with the Washington Post.

Kaiser Health News quotes leading health policy analyst Lucian Leape: "nobody is responsible for coordinating care." According to the story, lack of coordination is resulting in an estimated 44,000 to 98,000 deaths from medical errors annually. This, despite health care's strong response to the landmark Institute of Medicine report, To Err Is Human, published in 1999. That study was the subject of an INQRI blog carnival in 2010, featuring posts from several INQRI-funded researchers.

There is good news, however -- an article HealthLeadersMedia, published earlier this week indicates that nurses have the skills and experience provide effective and successful coordinated care. According to sources in the article, nurses' experience at the bedside - caring for multiple patients and handling their varying needs - makes them uniquely suited to understand and provide coordinated care.

Several INQRI teams have investigated how nurses' contribute to improved care coordination, especially in times of transition from hospital to home.

INQRI Grantees' Article Supports Future of Nursing Recommendation

INQRI grantees Mary Blegen and Tom Vaughn and their team recently published a new article, "Baccalaureate education in nursing and patient outcomes" which examined the effects of registered nurse (RN) education by determining whether nurse-sensitive patient outcomes were better in hospitals with a higher proportion of RNs with baccalaureate degrees.

The Institute of Medicine's report, The Future of Nursing: Leading Change, Advancing Health recommends increasing the percentage of RNs with baccalaureate degrees from 50% to 80% by 2020. Research has linked RN education levels to hospital mortality rates but not with other nurse-sensitive outcomes.

This was a cross-sectional study that, with the use of data from 21 University HealthSystem Consortium hospitals, analyzed the association between RN education and patient outcomes (risk-adjusted patient safety and quality of care indicators), controlling for nurse staffing and hospital characteristics. Hospitals with a higher percentage of RNs with baccalaureate or higher degrees had lower congestive heart failure mortality, decubitus ulcers, failure to rescue, and postoperative deep vein thrombosis or pulmonary embolism and shorter length of stay.

The recommendation of the Future of Nursing report to increase RN education levels is supported by these findings.

Click here to access the article via PubMed.

INQRI Grantees to Serve on IOM Committee on Credentialing Research in Nursing

The Institute of Medicine (IOM) recently announced the membership of the Standing Committee on Credentialing Research in Nursing, chaired by Dr. Marilyn Chow.  Congratulations to INQRI grantees Robin Newhouse and Jack Needleman, who were named to the committee along with fellow scholars: Murielle Beene, Kaye Bender, Bobbie Berkowitz, Robert Dittus, Richard Hawkins, Ronda Hughes, Paul Mazmanian, Matthew McHugh, Wendy Rheault, Patrick Romano, and Joanne Spetz.

This committee will maintain surveillance of the field, discuss planning and program development, and serve as a focal point for discussions and potential ad hoc studies.

To learn more, please click here.

Promoting Nurses as Leaders: IOM Elects Two Nurses as New Members

This week, the Institute of Medicine (IOM) announced the names of 70 newly elected members, including two nurses. Election to the IOM recognizes individuals who have demonstrated outstanding commitment to service and made major contributions to the advancement of the medical sciences, health care, and public health. The two newly elected nurses are:

• Marilyn J. Rantz, Ph.D., R.N., F.A.A.N., Curators' Professor, University Hospitals and Clinics Professor of Nursing, and Helen E. Nahm Chair, Sinclair School of Nursing, University of Missouri, Columbia
  
• Diana J. Wilkie, R.N., Ph.D., F.A.A.N., professor and Harriet H. Werley Endowed Chair for Nursing Research, and director, Center for Excellence for End-of-Life Transition Research, department of biobehavioral health science, College of Nursing, University of Illinois, Chicago 

See the full list of new members here.

National Midwifery Week

As noted in the Institute of Medicine report, The Future of Nursing: Leading Change, Advancing Health, many states have not made changes to their scope-of-practice regulations to allow certified nurse midwives to see patients and prescribe medications without a physician's collaboration or supervision.

In honor of the IOM committee's recommendation to remove scope-of-practice barriers, we celebrate National Midwifery Week this week.

This event was created by the American College of Nurse-Midwives (ACNM) to celebrate and recognize its members. This year, ACNM is using a new public awareness initiative, Our Moment of Truth™: A New Understanding of Midwifery Care, to build the midwife brand across the country.

Click here for a list of actions you can take this week to commemorate the event. 

Massachusetts' Governor Signs Bill Banning Mandatory Overtime

Earlier this week, Governor Deval Patrick's signed new health care cost containment legislation that included a ban on mandatory overtime at acute care hospitals. Since the Institute of Medicine's focus on preventable deaths related to mandatory overtime on patient care in their 2004 report: "Keeping Patients Safe: Transforming the Work Environment of Nurses", many states have enacted similar legislation to ban the practice of mandatory overtime.

To read more about the passage of this integral piece of patient safety legislation, click here.

Report: Higher Payments Are No Cure For Doctor Shortage

Earlier this week, Jordan Rau, reporting for Kaiser Health News, detailed a recent report by the Institute of Medicine that recommended that Medicare should not raise reimbursements to lure practitioners to rural areas. The panel of experts suggested that instead of raising reimbursements, Medicare should provide payment for the use of telemedicine, in addition to supporting the expansion of scope of practice laws in restrictive states. By promoting the use of advanced practice nurses, the IOM believes it is possible to close the primary care physician gap using the existing workforce and network of resources currently available.

To read more about the report, click here.

Too Little Mental Health Care For Baby Boomers

A recent report released by the Institute of Medicine has found that one in every five seniors suffers from a mental health or substance abuse issue and with the health care workforce lacking adequate training in these fields, many issues may arise over the next decade for treating this vulnerable population. With the health care sector preparing for the physical needs of the aging baby boomer population, this report serves as a critical reminder about the importance of a holistic approach to treating patients.

You can access a synopsis of the report here.

To read the full report, click here.

The Future of Nursing Report is the IOM's Most Read Report In June 2012

Even though it was released almost two years ago, the Institute of Medicine (IOM) report, "The Future of Nursing: Leading Change, Advancing Health" continues to be one of the most read documents on the IOM's website. If you are not familiar with this document, you can read some of our previous blog coverage related to this landmark report. Since its initial release, the Future of Nursing Report has continued to expand its scope of impact with the expansion of Action Coalitions across the United States, while also acting as an important resource for nurses and nursing organizations in their efforts to improve the nursing workforce.

Did You Miss Monday's Webinar?

If so, you can catch it right here.  We were joined by INQRI grantees, Linda Flynn and Suzanne Gordon for the seventh session in our series on the Institute of Medicine report, "The Future of Nursing: Leading Change, Advancing Health."

This webinar focused on Recommendation 2: "Expand opportunities for nurses to lead and diffuse collaborative improvement efforts."

"Expanding Opportunities for Nurses to Lead: Impact of a Nurse Manager Development Program" - Presented by Linda Flynn, PhD, RN, FAAN & Suzanne Gordon, Journalist & Advocate.

IOM's Future of Nursing Report Highlighted in The Atlantic

Yesterday, Liz Seegert of The Atlantic, wrote a brief summary of the Institute of Medicine (IOM) report, Future of Nursing: Leading Change, Advancing Health. Ms. Seegert discussed the continued growth of the nursing workforce in the United States and how nurses will play a critical role in transforming the United States' healthcare system over the next few decades.

To read Ms. Seegert's full article as it appears in The Atlantic, click here.

To read additional blogposts relating to the Future of Nursing report, click here.