By Debra Wood, RN, contributor
Jan. 15, 2010 - What are and will be the critical issues facing nurses this year and in the coming decade? NurseZone spoke with several of the country's top nursing leaders--including association executives, distinguished educators, chief nursing officers and consultants--to get their opinions on the most important issues of the day. Their insights reveal a number of trends and hot topics that nurses will want to watch in the months ahead.
Health reform and revamped roles for nurses
Cheryl Peterson, RN, MSN, reports that health care reform has energized nurses and hopes their interest in governmental processes continues.
Health care reform and how it may affect nursing remains the big unknown as the profession enters 2010, yet regardless of the outcome, the debate has elevated the topic to the forefront of issues facing the country and galvanized many nurses to speak up.
"The health care reform debate has really energized nurses," said Cheryl Peterson, MSN, RN, director of the American Nurses Association's department of nursing practice and policy. "They are contacting their members of Congress, have been engaged in that debate and attended the town hall meetings at the local level."
Peterson hopes the profession can retain that enthusiasm as the legislation moves into a regulatory phase, where the details are worked out.
"We should have health care reform on our radar," added Beverly Malone, Ph.D., RN, FAAN, chief executive officer of the National League for Nursing. "Nurses need to be prepared to deal with the complex, comprehensive patient in the home and in the community. That is a huge issue we will be dealing with. The nation is gearing up for that, and nurses need to be leaders in that."
Malone expects preparing nurses to the level they need to provide that complex care will become a "hot issue."
Fay Raines, RN, PhD, said the nursing profession should anticipate an increased demand for nurses and nurse practitioners due to health care reform.
American Association of Colleges of Nursing President Fay Raines agreed, saying that the profession must ensure it educates sufficient entry-level and advanced practice nurses. Raines and most nursing leaders expect health reform will create opportunities for nurses, as millions of formerly uninsured people obtain coverage and seek care.
"Nurses are going to have an expanded role," said Rosemary E. Mortimer, MSEd, RN, CCBE, instructor at Johns Hopkins School of Nursing in Baltimore and immediate past president of the Maryland Nurses Association. She expects registered nurses will find new positions as hospitals expand, home care embraces telehealth, and prevention and lifestyle change come to the forefront, while nurse practitioners will see greater demand for them to become front-line providers.
"We don't have the primary care providers to care for those people, so I think the demand for nurse practitioners will grow astronomically," said Karen Haller, RN, PhD, FAAN, vice president of nursing at Johns Hopkins Hospital.
"This will be as a real opportunity for advanced practice nurses, as primary-care providers and leaders of medical homes, and with enhanced reimbursement opportunities," said Judith Haber, Ph.D., APRN-BC, FAAN, the Ursula Springer Leadership Professor in Nursing and associate dean of graduate programs at New York University College of Nursing.
What nurses have seen in the past year is that what happens in Washington can and will affect their lives. Many also have found that they can influence those decisions.
"We are going to have to get nursing educators and nurses involved in the Congress of this United States and get the nurse at the bedside up to snuff on terms of what it means to be political while you are a clinician and taking care of patients," said Malone, suggesting it can be as easy as email, Twitter and Facebook. "There are so many ways to touch Congress and decision makers. It's about getting the passion for politics into nursing. 2010 will be the beginning of a new decade for that."
Malone added that nurses must realize that elected officials are interested in funding programs that make a difference for the citizens of the country, not because they are good for the nursing profession, so nurses must tailor the message accordingly.
"That's the real learning for 2010," Malone said.
Many nurse leaders expect the trend toward nurses' greater involvement in shaping the health care debate to continue this year and in the years ahead.
"We will see more interest in legislation," Mortimer said. "Health care reform has gotten people interested in legislation and lobbying."
Nursing organizations are starting to speak with one voice to law- and policymakers about broad issues affecting nursing.
"Nursing has finally come together," said Brenda Nevidjon, MSN, RN, FAAN, president of the Oncology Nursing Society and a clinical professor and specialty director of nursing and healthcare leadership at Duke University School of Nursing in Durham, N.C. "We have figured out a way to come together and not be fractured, and that is making a difference on The Hill. I hope and expect that trend will continue."
Workplace and workforce issues
"The biggest challenges we're going to face, from a nursing standpoint, are preparing for the staffing challenges," said Eileen Gillespie, RN, ND, vice president and chief nurse executive at Advocate South Suburban Hospital in Hazel Crest, Ill. "As we go through 2010 and the economy recovers, more nurses will exit the job market."
Recent data supports that concern. The U.S. Bureau of Labor Statistics announced in November its expectation that registered nurses will experience greater job growth than any other occupation by 2018, with 581,500 jobs or a 22.2 percent increase.
Not only will the country need more nurses, "the intensity of the work is not going to diminish," Nevidjon added.
Holy Cross Hospital Executive Director of Nursing Services Taren Ruggiero, MSN, RN, also expects high acuity of inpatients will continue.
"We will need to find nurses who have critical thinking and are getting away from being task oriented," Ruggiero said. "We are over-hiring to prepare for retirements and such."
Holy Cross has a nurse residency program, which has helped with retention of new hires. Increasingly, hospitals are turning to such programs when bringing in recent graduates.
Many leaders believe the economy is improving and will affect nurses' employment opportunities and decisions.
"New graduates will have an easier time getting jobs, and we may see some experienced nurses who came back into the workforce go back home, which would be too bad," said Julie Stanik-Hutt, Ph.D., ACNP, CCNS, FAAN, director of the mater's program at the Johns Hopkins University School of Nursing.
Haller reported steady staffing at Hopkins, with almost no vacancies, which she expects will continue as long as the economy remains level.
"New graduates will have to start looking earlier and broaden their search geographically and clinically," Haller said. "Eventually, we will see what I call a silver tsunami of retirement, because boomers cannot hang on forever. But right now they are deferring retirement."
If, as many expect, the nursing shortage returns, "the light will shine again on nurse retention," said Kristin Baird, RN, president of Baird Consulting of Fort Atkinson, Wis. "We'll have to pay close attention to nurse engagement, so they stay longer."
Beth Hammer, RN, MSN, APN-BC, anticipates improving the work environment will be important in 2010, and the American Association of Critical-Care Nurses offers tools to help nurses achieve that goal.
Beth Hammer, RN, MSN, APN-BC, president of the American Association of Critical-Care Nurses, predicts improving the work environment, including resolving staffing, leadership and communication concerns, will become even more important in 2010 as the need for nurses increases.
"This is coming to the forefront with retention and where new nurses want to work," Hammer said.
Lillee Gelinas, RN, MSN, vice president and chief nursing officer of VHA Inc., a network of not-for-profit hospitals, encourages hospitals to look at capital spending before cutting personnel, which will destroy trust and fuel the fire of unionization.
"Employees are our most important asset," Gelinas says. "Yet that's where we go first for cost reduction. Nonlabor expense reduction is the priority for 2010, and we need to make sure we have creative solutions everywhere."
Provider perspectives and initiatives
Lillee Gelinas, RN, MSN, encourages hospitals to look for innovative ways to become more efficient without cutting staff.
"The nursing care model today is FRED--frantically running every day, that we cannot decide between one task and another," Gelinas says. "To be an effective leader in 2010, we need a clear picture, we need to maintain perspective, focus on the right things and rise above the distractions. For nurses, that means our core skills of assessment, intervention and evaluation have to take precedence, and we need to stay focused on delivering outstanding nursing care, no matter the odds."
That will require creativity on the part of nurses, she said, and for hospital executives to provide them with a greater understanding of the big picture. Nurses also will need to remain more vigilant in protecting patient privacy, Gelinas indicated, and not give in to the temptation to share confidential information on social media Web sites.
Haller reported a shortage of applicants for nursing leadership positions--nurse managers, clinical nurse specialists and educators.
"This is a good time to be in school," said Haller, who reported the creation of patient safety officer positions at Hopkins, filled by master's-prepared nurses. "Quality and safety improvements are by and large led by nurses."
Quality and safety will remain top concerns. Leaders are paying attention to nurse-sensitive indicators and communication lapses and taking action where they see a need for improvement, said Anne Jadwin, RN, MSN, AOCN, NE-BC, assistant vice president of nursing services at Fox Chase Cancer Center in Philadelphia.
"It's become a blueprint for how we conduct day-to-day business, and that movement has been driven by consumers and insurance companies," added Jadwin, who expects hospitals will also continue to focus on improved productivity, throughput and cost containment.
"We will try to maintain quality but do so under more constrained resources," Jadwin said. "With all of the stresses the environment is under, this is often a time when you will see the most innovation and creativity, when people are forced to start thinking about how we can do things differently and better."
The federal government has allocated funds to support implementation of health information technology.
"There's a push to use information technology to enable clinical practice, to make us more efficient and more effective, so there is a demand for nurses to work in informatics and redesign workflow," Haller said.
Gillespie added that patient-safety goals require acute-care nurses also prepare patients for taking care of themselves at home.
Home-health nurses also will ensure patients and families have the knowledge and skills they need to manage safely at home, added Meg Doherty, MSN, ANP, MBA, executive director of the Norwell Visiting Nurses Association and Hospice in Boston. She expects a growth in home-health nursing.
"I see more nurses transitioning out of acute care hospitals to work in community settings and in particular what is now acute and sub-acute care at home," said Doherty, who predicted that will include specialty nurses and nurses with degrees in management and education.
Nevidjon expected more technology will be placed in patients' home, enabling nurses to monitor, educate and manage care from afar.
While some in academia have seen greater interest in nursing, including Haber at NYU and Mortimer at Hopkins, Patrick R. Coonan, EdD, RN, NEA-BC, dean and professor of the Adelphi University School of Nursing, in Garden City, N.Y., anticipated a drop off as candidates watch fewer new graduates able to secure jobs.
"We're seeing some decline in applications," Coonan said. Only half of Adelphi's new graduates secured jobs this year compared to 100 percent three years ago.
On the other hand, Mortimer reported that all of Hopkins 2009 graduates who wanted a job found one.
"We were used to hiring 300 or 400 people a year, but now it's much reduced, but compared to other fields, it's still a good field to be in," Haller said.
The American Association of Colleges of Nursing will introduce a central application service this year, making it easier for potential students to apply to multiple nursing programs.
If as most experts and data suggest the country needs more nurses, nursing leaders from the provider side and academia agree that the profession needs more faculty.
"We're going to have to look at issues of how nurse educators are recruited and retained, and compensation is going to be a part of that issue," Malone said.
Gillespie added nurse employers will need to continue working with educators to ensure they have enough faculty.
"From a nurse executive perspective, the challenge continues to be strengthening partnerships between academia and practice, so we can help support the ongoing education and development of our future nursing staff," Gillespie said.
Haber reports significant investments are being made in simulators to aid in training nurses and advanced practice nurses to provide measurable, standardized clinical experiences and ensure they possess needed competencies. At NYU, students spend half of their clinical time in the simulation lab and half with real patients. Preparation also includes the use of actors to allow nurses to hone history-taking and communication skills.
Educators also anticipate the growth of specialties, such as forensic nursing, reported by Vida Lock, PhD, RN-BC, director of the school of nursing at Cleveland State University in Ohio, and genetics, according to Nevidjon.
Overall, the nursing profession remains strong but with some uncertainty that mirrors the nation and the health care industry as a whole.
"We're looking at a time with lots of challenges and also opportunities," Raines said. "If the number of people who have access to care is expanded with health care reform, the need for nurses will increase to provide care to these people. … We need to make sure we are preparing sufficient numbers of nurses and nurse practitioners to meet the demand."
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