Linda Heitman, Ph.D., APRN-CNS,BC

Current Issues and Trendsin Practice

“Illness is the night-side of life, a more onerous citizenship. Everyone who is born holds dual citizenship, in the kingdom of the sick. Although we all prefer to use only the good passport, sooner or later each of us is obligated, at least for a spell, to identify ourselves as citizens of that other place.” Susan Sontag Illness as Metaphor, 1978, p.3

4% of hospitalized patients are harmed by care supposed to help

Deaths per Year•Medical Errors-98,000•Motor Vehicle Accidents-43,458•Breast Cancer-43,297•AIDS-16,000•Post-operative infections and other preventable complications-32,000•8% of hospitalized patients experience preventable outcomes from errors

Health Care Is Not As Safe As It Could Be

•Medications•Surgery>wrong site•Diagnostic inaccuracy>wrong treatment•Transfusion error>blood type, wrong patient•Laboratory>incorrect labeling•System failure>no double check•Environment>failure to clean up spills•Security>child abduction

Examples of Errors

The Lewis Blackman Story

video

American Association of Colleges of Nursing

QSENQuality and Safety Education for Nurses

qsen.org

To prepare future nurses with:

•Knowledge•Skills•Attitudes

necessary to continuously deliver quality and safe patient care

GOAL

1. Patient Centered Care2. Teamwork & Collaboration3. Evidenced-Based Practice4. Quality Improvement5. Informatics6. Safety

Phase ICompetencies

Chronic Conditions (all ages)

Acute , hospital-based care is a “slice of life”

Use as a starting point to “change trajectory of an illness” (Strauss, 1970; Naylor, 2009)

Person and family-centered care

Focus on patients across settings >care will be paid for across settings in bundled payments

or episodes of care

Health Care Delivery in this Millennium

Number of beneficiaries with 5 +chronic conditions increased from

30 % in 1997

to more than 50% in 2002

Thorpe & Howard,2008

The Burden on Medicare

•Nearly 20% care recipients and 25% caregivers said transitions not well coordinated•15 % care recipients and 32% caregivers reported readmissions within 30 days of discharge•24% received conflicting information from 2 or more providers•23% reported medical errors, 61% which were major•16% endured unnecessary tests and 13% unnecessary hospitalizations•Quality and safety problems were more likely among caregivers who felt less capable

AARP,2008

AARP Pubic Policy Instituteon Chronic Care

Care should be based on continuous health relationships

Care should be customized based on patient’s needs and preferences

Patients should be the source of control; andKnowledge should be shared and information

should flow freely.

IOM, 2001

IOM: Four areas where health care should be redesigned

Self-management supportCommunity resourcesOrganization of health care Interdisciplinary teamsDecision supportClinical Information Systems AARP,

2008

Important Elements of Quality Chronic Care Wagner’s Chronic Care Model

Home to Hospital>providers operate in a vacuum

Hospital to Home>research identifies problems

>Pennsylvania found 40% of readmits related to medications: 6 out of 10 preventable

Hospital to Nursing Home> critical information missing.

Nursing Home to Hospital>Up to half of patients were lacking medical history, care plans and treatment wishes resulting in duplicated tests

Transitional Care

Loss of mobility and/or independenceUncertain expectations for recovery

and/or prognosisPainAnxietyNot remembering their clinicians

instructionsFeeling abandonedMany patients and caregivers felt the “ball

was dropped” after discharge

Patient Reported Problems with Transitions

Medical (Health) HomesHome Health Care with House CallsTransitional Care ServicesAccountable Care OrganizationsBundling Payments for Care Pay for PerformanceNurse-Managed Clinics

Promising Models

Alerts about abandoned test results or other findings that need to come to the attention of a provider

Clinical decision support tools such as linkage to protocols related to patient problems

A centralized mechanism for access from different locations and institutions

Efficient use of storage space for patient dataInstantaneous retrieval of information by

several people at the same time Aggregation of data to assess quality

measures

Integrated EHR Systems

•Target Populations•Cost•Implementation•Comparative Effectiveness Research•Patient and Caregiver Research•Health Care Policy

Suggested Research

10-20 years to get scientific findings incorporated into practice

Efforts by federal government and professional organizations

>Synthesis of evidence, including research

evidence >Formulation of guidelines >Dissemination of guidelines

Use in Practice: What we know from Science

Nothing but our BEST will do.

Professional Accountability.

Brenda P. Johnson, PhD, RN

Current Issues and Trendsin Education

Aging/ Chronicity/Acuity of Illness

Outcome Driven Reimbursement /Quality and Safety ….several of he CMS hospital-acquired conditions are highly “nurse-sensitive’ (Stage III & IV pressure ulcers, nosocomial infections, and falls)

85% of new BSN graduates are employed in acute care

Increasing the number of BSN graduates in acute care decreases patient mortality rate and improves quality of care (Aiken, 2003)

Population Shifts & Complexity of Care

Occupational Therapist required to have a master’s degree for professional licensure O.T. assistant required to have an Associate

DegreePhysical Therapist required to have a

master’s or doctorate for professional licensure (>90% of 210 accredited programs offer the DPT degree; 75% of 2008 graduates had the DPT)P.T. assistant required to have an Associate

Degree Growing international trend for BSN

as minimum degree required for licensure as a professional nurse (e.g. Canada, Portugal, Iceland, The Phillipines)

Interprofessional & International Trends

2/3 of nursing workforce to hold BSN or graduate degrees by 2010(currently 45%)

BSN identified as providing soundest foundation in the sciences and arts for addressing the complex health care needs in a system of higher acuity and older patients with co-morbid conditions as well as a base from which nurses move into graduate education and advanced nursing roles.National Advisory Council on Nurse Education & Practice

AACN Vision for entry into practice

Currently more than …

230 accelerated/2cnd degree BSN programs in U.S.

600 Rn-to-BSN programs

161 RN-to-MSN programs in U.S

Master’s programs to prepare “generalist” practitioner recognized by the credential “CNL” with role emphasis on improving patient safety

Evaluating patient outcomesCohort risksChanging plan of care Interprofessional teamwork

AACN Vision -master’s level generalist

Currently more than 88 master’s CNLprograms in

U.S

By 2015 ALL population specific specializations

CNS, NPs (FNP, GNP, ANP), midwives, and anesthetists will be at doctoral level and recognized by credential “DNP”

(AACN, 2004)

Expected roles are :Direct-care practitioners Executives and directors of clinical programs and quality

initiativesClinical faculty positions

AACN Vision for Advanced Practice

E

Currently more than 200 DNP programs in

U.S.

Enrollment in DNP/PhD Programs – Past 5 years

Projections for development of future DNP programs

APRN education programs will be transitioned by 2012 and State Boards of Nursing will have regulation that reflects the model by 2015

Certification exams will be revised by 2012-2013 to reflect new model.

All APRN (CNS and NP) education programs must prepare graduates for one of the four APRN roles and at least one of six populations (neonatal, gender specific, pediatrics, adult-gerontology, psych/mental health, or across the lifespan)Model can be accessed at http://www.aacn.nche.edu/education/pdf/APRNReport.pdf

AACN Consensus Model ( for APRN Education (January, 2010)

All current NP or CNS programs preparing individuals to provide care to the adult populations must provide full complement of competencies for the entire adult population (young adult, older adult, and frail elderly).

Adult Health CNS Acute and Critical Care CNS-AdultAdult NPGerontology NPAdult Acute Care NP

JAHF/AACN Initiative (2009, 2010)

Preparing for an Aging Population

“Given the complexity of care, growth of information and biomedical technology, an aging and increasingly diverse population, and worsening disparities in care, the need for a DNP program to prepare clinicians to fill the growing societal need for expert clinicians is timely and necessary. The DNP is the natural evolution and needed expansion of existing clinical degrees in nursing: the basic BS and the site-specific MS.”

Columbia University School of Nursing

“The DNP is an outgrowth of the increasingly complex role that advanced practice nurses must play today. They aren’t just taking care of individual patients or groups of patients, but working in a system that requires them to understand policy, economics, and quality and safety issues, all topics that warrant preparation at the doctoral level.”

Dr. Anne Belcher, Johns Hopkins School of Nursing

PhD and DNS/DNSc as required preparation for academic and research positions

Small percentage of those with DNP preparation may move into a full faculty role and will also need to complete a PhD program (much as would an MD moving into an academic/research role requiring a PhD).

AACN Vision for Academia & Research

Quality and Safety Education for Nurses (QSEN) adapted IOM’s 6 competencies (patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics) for nursing.

Knowledge, Skills, and Attitudes (KSAs) developed for pre-licensure nursing education.

Sample educational strategies at …

http:www.qsen.org

Transforming Nursing Education to Meet National Goals for Quality and Safety

Transforming nursing education to fit with the new roles and a team approach to care.

Educating students so that they can learn to adapt .

Teaching about the health care system and the political, social, financial context within which care is delivered.

Collaborating with clinical partners to teach students how systems report outcomes, analyze adverse events, and structure quality improvement programs.

Challenges and Opportunities

What knowledge, skills, and attributes do nurses and midwives require to take a central role in the design and delivery of services?

What would you like to see nurses and midwives doing more of and/or doing differently in the future – whether in people’s own homes, in the community, or in hospital?

What might be preventing nurses and midwives from doing this now? How can these barriers be overcome?

What is the potential for/benefits of nurses and midwives leading and managing their own services, and what frameworks and support are needed to achieve this?Prime Minister’s Commission on the Future of

Nursing and Midwifery in England, 2009-2010

“Nurses and midwives are responsible for so much of what we

have achieved over the last 10 years. They are experts who know best how

the service can meet the needs of patients and their local communities. We must be bold in putting nursing in control and at the heart of our plans

for a world-class NHS.”

Gordon Brown, Prime Minister of Great Britain, March 10, 2009

Then and Now….No man, not even a doctor,

ever gives any other definition of what a nurse should be than this – ‘devoted and obedient.’ This definition would do just as well for a porter. It might even do for a horse. It would not do for a policeman.”

“I think one’s feelings waste themselves in words; they ought all to be distilled into actions which bring results.”

Florence Nightingale1859