Nursing is in the midst of revolutionary changes. How are these changes affecting the profession today—and how are they likely to affect it in the future? For the premier issue of American Nurse Today, we decided to examine current trends in nursing and healthcare, and predict future developments that could influence nursing in years to come.
For help with our analysis and predictions, we turned to several nursing experts and leaders, as well as pharmacy and future studies experts. We also tuned into the “buzz” in the nursing profession and explored several innovative national programs.
We found that nursing remains a vibrant profession. Yes—we have controversy and divisiveness. But we also see a wealth of positive energy that’s driving change and improving the lives of nurses and patients.
Many forces are driving changes in nursing and healthcare. Healthcare associations continue to issue new guidelines that influence nursing practice. Let’s look at a few other driving forces.
Portability and mobility
Talk to Tim Porter-O’Grady, RN, EdD, for any length of time and you’re likely to hear the words mobility and portability again and again. He sees these features as the basis for any healthcare delivery model. “Portability and mobility are the cornerstones of technotherapeutic interventions,” he states. The growth in freestanding clinics, ambulatory care centers, and other nonhospital settings supports his view.
Technology will extend patients’ lives—and Porter-O’Grady reminds us that we’re not aging the same way previous generations did. Many Americans are “aging in place,” with communities finding ways to support older people in their homes. Futurist Andy Hines, MS, says, “Baby boomers are going to want to avoid institutions for themselves and their parents.”
These forces mean that much of the patient’s healing takes place where nurses don’t typically deliver round-the-clock care—the home. Unfortunately, most nurses have been educated in a hospital-based model, which doesn’t mesh with today’s trends. Porter-O’Grady urges us to remember that patients don’t necessarily benefit from a hospital stay. “There is a direct line from length of stay to increased morbidity and mortality.”
At the same time, Hines remarks, “There’s a shift away from institutional care toward individual responsibility, and a move from hospitals and nursing homes to retail, kiosks, and home.” He adds that consumers want more personal control over their healthcare, so we can expect more self-diagnostic tests and innovative ways to deliver care.
Porter-O’Grady knows it isn’t easy for seasoned nurses to accept these changes. “Some nurses are mourning the loss of all they used to do for patients, but that loss isn’t a bad thing.” He advises hospital-based nurses to focus on helping patients make the transition to where they’ll be healing—at home.
You can’t turn around in nursing without encountering the term evidence-based practice (EBP). It’s on the lips of everyone from staff nurses in ambulatory care centers to heads of government agencies.
EBP is one reason facilities designated as Magnet hospitals by the Magnet Recognition Program have been so successful: They’ve set up systems that foster evidence-based care, bringing improved patient care and nurse satisfaction. EBP also serves as the foundation for the disease management work done by nurse practitioners (NPs) and many other nurses.
EBP is more than a buzz term, says Porter-O’Grady. “It’s about getting a handle on what we do that is valuable—what difference it makes. Can we do it again, and can we do it even better the next time?”
Emphasis on safety and quality
Patient safety and quality of care are two trends that have benefited nursing. Rebecca M. Patton, , RN, CNOR, cites the National Quality Indicator Database as an example of a program that’s tracking nurses’ impact on patient care outcomes. This database of nurse-sensitive indicators, with data from almost 1,000 hospitals, is one of several that show nurses’ importance in the delivery of safe, high-quality care in every setting.
Because of the quality push, healthcare workforce leaders may see more pay for performance—payment by third-party or government payors based on the quality of care delivered by the facility. Linda Aiken, RN, PhD, believes nurses must be involved in establishing payment criteria.
High times for high-tech
The explosion of medical technology has led to myriad lifesaving and life-enhancing inventions, including spare body parts ranging from knees to thumbs and dramatically improved sensors and diagnostics. Hines says medical devices are “getting more precise, user friendly, and cost effective.” Here’s a rundown of a few areas where technology is making a big impact.
Genes and stem cells
Researchers are linking more and more diseases to genes, with tremendous implications for educating patients about their conditions—and tremendous potential for ethical dilemmas regarding genetic testing. As for stem cell research, Hines cautions that while such research is yielding exciting knowledge gains, these gains are clouded by the ethical controversy that surrounds this issue.
Robots in the OR
Computer-assisted surgery has moved to the next level. Robots have elbowed their way onto the operating-room bed and into the perioperative team. Although too expensive to use for every surgery, robots have proven their mettle in complex procedures and those that require manipulation in a tight area.
We’ve even seen primitive robots that can help nurses, although their abilities are limited. uses a robotlike automated guided system to deliver supplies, says Linda Burnes Bolton, RN, PhD.
Of course, robots won’t replace surgeons or nurses, but they can enhance their abilities. Robots also can free up nurses to spend more time with patients. And, given our aging population and the extension of lives through medicine and technology, nurses will need every means of support possible.
As recently as 2004, a national survey found that 82% of nurses thought there was still a nursing shortage. That’s consistent with others’ perceptions: Earlier that same year, 81% of physicians perceived a nursing shortage where they admitted patients. In 2005, 74% of hospital chief nursing officers and 68% of chief executive officers also perceived a shortage.
For insight into the current state of the nursing workforce, we turned to Peter Buerhaus, RN, PhD. “Clearly the nursing shortage isn’t as intense as in 2001 and 2002, but it has by no means gone away.” But Buerhaus thinks we’re experiencing the calm before the storm. In April 2006, the American Hospital Association reported a vacancy rate of 8.5% in nursing job openings. In his experience, vacancy rates of 9% usually indicate a shortage. He points out that the demand for nurses is rising, with only slow increases in supply, and that nurses’ earnings flattened in 2004 and 2005.
When the nursing shortage grows more critical again, some will say it’s because nurses aren’t satisfied with their jobs. But a study Buerhaus headed in 2004 found that 83% of nurses were satisfied with their jobs. This rate is similar to that of other professionals—about 80% for lawyers, business executives, and primary care specialists. On the other hand, teachers’ job satisfaction is only at 61%.
Patton sees opportunities in the nursing shortage. “As difficult as it will be for us, it will help us as a profession to redefine the role of every member of the healthcare team. We’ll see better utilization of nursing skills, and we could also see better access” to the nurse.
Whether or not they’re satisfied with their jobs, nurses will continue to spot grey hairs in the mirror as they age. The physical workplace environment will need to be adapted to keep older nurses in the workforce. “We need their experience,” says Burnes Bolton, “but we need to take the burden out of care.” Technology can help accomplish this. She cites the example of using gurneys as patient beds so nurses can avoid back-straining patient transfers.
As the core of the nursing workforce nears retirement, younger nurses are entering the profession, creating intergenerational teams. Nurses of different age-groups need to understand and accept each other’s perspective and appreciate what everyone brings to the team.
Let’s look at a few other factors affecting the nursing workforce.
Physician shortages. A shortage of physicians will increase the demand for NPs. “The sense is that the physician shortages are severe,” says Buerhaus, and these shortages aren’t likely to end any time soon. As the demand for healthcare keeps growing, “we’re going to need NPs in huge numbers, and they could take over much of what medicine does today in our lifetime.”
Foreign nurses. Buerhaus foresees more foreign nurses working in the —double or triple today’s number. He speculates that by 2020, as much as 25% of our nursing workforce may have received their nursing education outside the United States.
Hines agrees that foreign nurses are here to stay. He also raises an issue nurses have long faced: How do the standards of one country apply to another? Common standards are needed for the emerging global workforce. At the same time, Patton cautions that using foreign-educated RNs must not detract from the need to offer all nurses a better work environment.
Staffing ratios. Will legislated ratios play a role in the upcoming demand for nurses? Aiken and Buerhaus say no. Aiken believes legislated ratios “will never dominate because most of the institutions in this country are in the private sector; few are government owned.” However, she does think legislation on public reporting will become more common—and these reports may include ratios. She predicts hospitals will increasingly move to better staffing as a result of the evidence.
Buerhaus warns, “If ratios catch on and become federally mandated, it would lead to the demise of the nursing profession. The public would lose trust because they won’t really see better outcomes; the science isn’t there to show it.”
Healing spaces, empowered nurses
Our panelists concur that although nurses’ work environments are improving, more needs to be done. Hospitals already are working on reconfiguring rooms so nurses don’t have to walk so far and supplies are easily accessible. Some have gone a step further, creating healing spaces—quiet areas with calm colors, meditation rooms, and gardens.
Some hospitals are working to make the environment more personally satisfying by offering mindfulness retreats and posting affirmation messages that nurses can read while on duty. Still others have adopted caring models that refocus nursing delivery on caring.
Seeking a balance
Hines predicts the power will shift from the healthcare institution to the individual nurse as nurses seek to balance work and personal life work. “The schedule and quality of life for many nurses is dreadful,” he says. “You have these long, tiring shifts of 12 hours on your feet, and lots of on-call and overtime. This runs counter to the social trend toward a greater work-life balance. Right now, the institutions have power over the nurses, but that could shift as nurses realize the opportunities outside the institutional setting.”
Can technology help get nurses back to the bedside?
“Nurses spend less than 40% of their time on direct patient care,” says Burnes Bolton. “We’ve designed a system that doesn’t allow them to be with the patient.”
Technology can help turn that around. Burnes Bolton points out that some devices already in use are aimed at “reducing the time nurses spend hunting and gathering and communicating multiple times in getting or giving information to team members.” These products include tools nurses wear to improve communication and monitor patients remotely, and tools that help nurses and other team members get the information they need to make decisions. Many of these devices have “forcing functions,” such as built-in safety checks used on “smart” infusion pumps.
“Smart” technology is used in many other ways as well. Some beds detect blood flow in the patient’s legs and alert the nurse to possible deep vein thrombosis. Special patient vests collect physiologic data and transmit it to a healthcare worker’s personal digital assistant. “Smart” technology also is being used to promote medication safety.
These communicating and data-gathering devices allow nurses to interpret information and spend more time with patients. Cedars-Sinai nurses told Burnes Bolton they want access to a continuous flow of patient information in the patient’s room so they can spend time observing, educating, and coordinating care instead of collecting data.
But all of this technology has a downside: Many of these products don’t “talk” to each other.
Burnes Bolton also is working on efforts to partner with industries to include nurses in developing new technologies for practice. In her view, we need more biometric systems based on individual patients—for instance, a system that automatically knows the patient’s weight and calculates weight-based drug dosages. She encourages nurses to borrow ideas from other fields and industries as well.
Another use of technology is to ensure that patients are informed of surgical risks. Burnes Bolton says Cedars-Sinai uses an interactive product to help patients “really understand what the risks are and what we are going to do to reduce them.”
Who is a nurse?
Students making career choices will increasingly turn to nursing, if they heed official career predictions. The government website Career Voyages (www.careervoyages.com) lists registered nursing as fifth on its list of “hot careers that don’t require a four-year degree.”
But this list’s title reflects one of the biggest controversies in nursing: What entry-level education should be required for nurses? Many of our panelists called for consistency in the basic education of nurses.
This is more than a theoretical point. Aiken points out that her 2003 study found that hospitals in which a higher proportion of direct-care RNs held BSNs had lower mortality rates, and notes that further research in this area is needed. In her view, “we are falling behind” because many other countries require a baccalaureate degree for entry-level nurses.
“Nurses must be knowledge workers who have the ability to analyze and synthesize data,” says Burnes Bolton. “We need to have an education system capable of producing that type of nurse.”
Jeanette Lancaster, RN, PhD, believes we need a more highly educated workforce because of the complexity of patient care, advances in technology, and patients with chronic illnesses who are living longer and need more specialized and sophisticated care. “There is a need for highly skilled nurses in clinical practice,” she says.
Facing the faculty shortage
Lancaster believes that in the next 5 to 10 years, nursing schools will face a worsening crisis, with enrollment increasing as more faculty members retire. Faced with this situation, schools are looking for options. “More and more advanced practice nurses in hospitals are participating in the education of students,” says . This partnership benefits both the students and the clinicians, who believe it keeps them on top of their game.
Some schools are developing certificate programs to help nurses prepare to be faculty members. These nurses have a shared teaching/clinical position or alternate periods between practitioner and teacher. “Schools will continue to rely on practice partners for help in educating students,” Lancaster says.
Educational delivery and teaching methods
Content delivery and teaching methods are changing, too.
Delivery. Distance learning has become a popular way to get a nursing degree. Although few people advocate online learning for basic nursing preparation, it has become an increasingly common option for nurses seeking to enhance their education. Schools also are experimenting with the order in which courses are taught. Some are giving all the classroom work up front, then following that with the clinical work—similar to the model used in business schools.
Teaching methods. Patient simulators can help students prepare for complex situations before they ever lay a hand on a patient. These are not the same simulators you may have used as a student. Today, a patient simulator can take a student through a complex scenario without the instructor needing to make multiple setting changes along the way. Such complexity comes with a price—thousands of dollars per simulator. To offset the cost, look to schools, hospitals, and even businesses to partner to create regional patient simulation centers.
Is the nursing process a sacred cow?
Is the nursing process a tool for the future—or a problem-solving process that has outlived its usefulness? “The nursing process is an iterative, industry-based, predigital model,” asserts Porter-O’Grady. “It’s an impediment. We need to suspend attachment to data and think in a multilateral, multifocal, and integrative way.”
Not so fast, caution other panelists. Patton believes the nursing process “helps to distinguish nursing. It teaches us how to think, plan, act, and evaluate. We use it in our entire life.”
Lancaster believes that no matter what terminology is used in the future, “the bottom line is critical thinking. The nursing process is the foundation of the problem-solving process and has been around for many years. It fits with evidence-based practice.”
Surviving in the new world
We asked our panel what it will take to survive in the nursing world of the future. Being open to change topped the list. “Our work isn’t changing. Change is our work,” Porter-O’Grady says he tells nurses. “If you looked at change like that, it wouldn’t be an enemy.” Like other panelists, Porter-O’Grady emphasizes the need for continual learning, but that doesn’t mean nurses need to know everything. “I need to have a mental model in which I have access to the most current data and information possible.” Patton advises, “See opportunities instead of challenges. There are opportunities for significant reforms in our healthcare system.” Patton adds that nurses need to learn political skills so they can influence others, and should try to understand the business side of healthcare.
Advice for nursing leaders
Several panelists pointed out that some nursing leaders are uncomfortable with change and struggle with transforming the system instead of serving as role models. They fear these leaders may be abdicating their leadership roles. “Unfortunately, you can hear a sucking sound as leaders are pulled out of leadership roles into operations,” Porter-O’Grady says.
What advice does our panel have for nursing leaders? Porter-O’Grady encourages them to make it safe to discuss what nurses can stop doing and make sure they’re letting go of the right things. He urges them to model change and to discourage their staff from saying “I want to do the most I can for my patients,” because there’s no relationship between volume and value.
He believes leaders have to be comfortable with change and with being vulnerable; they have to be comfortable admitting, “I don’t know, but I can find out….I’m not sure how we’ll get there but I’ll be with you. I won’t desert you.”
Burnes Bolton advises nursing leaders to work together during this crucial time. “We have the attention of the federal government and organizations like the Institute of Healthcare Improvement and the Robert Wood Johnson Foundation.” Our panelists express concern about a leadership gap and wonder where the next leaders will come from. While new leaders are emerging, the panelists emphasized they have the responsibility to mentor future nurse leaders. “They know that the more impact they have on their profession and their colleagues, the more service they can provide to patients. It’s a different way to serve,” Porter-O’Grady says.
Moving forward together
As we move forward, nursing will continue to evolve. But some of the basics won’t change—basics such as advocating for patients, seeing how all the pieces fit together for the patient and, most importantly, caring for the patient as a human being. As important new developments continue to affect nursing and healthcare, American Nurse Today will help you understand these challenges and master the skills you need to cope with them. We hope you’ll join us as we explore every facet of the challenging, frustrating—and richly rewarding—profession of nursing.
Cynthia L. Saver, RN, MS, is President of CLS Development, Inc. in Columbia, Maryland.