The Future of Nursing

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The Future of Nursing as Derived from the Past

A s the American Nephrology Nurses Association (ANNA) celebrates its 50th anniversary, it seems fitting to review a series of articles in The Online Journal of Issues in Nursing that examines the past,

present, and future of nursing. Past actions and principles are interwoven into aspects of action in which nurses can engage now and in the future. An article published earlier this year in the Nephrology Nursing Journal explored the evo- lution of nephrology nursing through a review of early nursing literature about the care of patients with kidney disease (Robbins, 2019). This recent series of articles looks at nursing and offers a vision into ways to build upon the past in current and future initiatives as we approach the bicentennial celebration of Florence Nightingale in 2020.

Reviewed: Shaffer, F.A. (2019). Overview and summary: Past, pres-

ent, and future: Nurses address the time of our lives. OJIN: The Online Journal of Issues in Nursing, 24(2). doi:10.3912/OJIN.Vol24No02ManOS

In this introduction to the five-article series of the past,

present, and future of nursing, Shaffer (2019) identifies the need for adaptation by learning from experiences and mis- takes for nurses to evolve to the needs of the future, and cites the origins of nurses to adapt, as did Florence Nightingale, who was both a trainer and nurse manager during the Crimean War. Nurses’ innovations today adapt to changes resulting from the climate, increasing epi- demics, mass migration, and advancements in information and technology. Failure to adapt can lead to disruption of nursing and health care systems throughout the world.

Facing this uncertainty, Shaffer (2019) offers three rec- ommendations to nurses: “1) become more entrepreneur- ial, 2) embrace technological advancement, and 3) global- ize your mindset and practices” (p. 1). Nurses must become more entrepreneurial and go beyond the bedside role by becoming educators, scientists, researchers, and policy makers, requiring adaptability, risk taking, and hard work. Nurses must continue to embrace advances in technology and assume leadership roles because it is a fact of life, and it is and will become an increasing presence in all aspects of everyone’s lives. The progression of globalization is accompanied by migration that includes workforces that are responding to shortages of nurses and health care

workers. Rather than fear this reality, it is important to rec- ognize the benefits it provides for those in need.

This series of articles is intended to shed light on nurses’ adaptation around the globe, even in these uncertain times, including future realities of climate change, aging popula- tions, increased globalization, and current examples of how nurses are addressing these trials. These articles are currently available to ANA members and will be available to all after September 30, 2019.

Reviewed: Rosa, W.E., Upvall, M.J., Beck, D.M., & Dossey, B.M.

(2019). Nursing and sustainable development: Furthering the global agenda in uncertain times. OJIN: The Online Journal of Issues in Nursing, 24(2), Manuscript 1. doi:10.3912/OJIN.Vol24No02Man01

Rosa, Upvall, Beck, and Dossey (2019) explore global

health in the context of the United Nations (2016) document on the 2030 Agenda for 17 Sustainable Development Goals (SDGs). The United Nations (2018) SDG report estimates that 783 million people or roughly 11% of the world’s pop- ulation live in extreme poverty, 815 million people are undernourished, minimum reading and mathematics profi- ciency standards are unmet by 58% of children and early adolescents, safe drinking water is unavailable to 29% of the population, and safe sanitation is not available to 61% of the population. These figures suggest the planet’s ability to sus- tain the global population is at great risk with dwindling nat- ural resources, including air, water, and the integrity of land (United Nations, 2018). The clear implications for nurses and how to intervene are the subject of this manuscript with the offer of hope because of nurses’ holistic understanding of humanity. Florence Nightingale’s commitment to facilitate healing and health for all people is personified in how nurses can lead in this global initiative.

Copyright 2019 American Nephrology Nurses Association

Robbins, K.C. (2019). The future of nursing as derived from the past. Nephrology Nursing Journal, 46(5), 551-555, 563.

Karen C. Robbins, MS, RN, CNNe, is the Associate Editor of the Nephrology Nursing Journal, a Past-President of ANNA, and a member of ANNA’s Desert Vista Chapter.

The NNJ Journal Club Department provides information on publications and resources of value to nephrology nurses. Please submit ideas for Journal Club topics and recommendations for articles that might be included in future Journal Club departments to [email protected].

Karen C. Robbins, Department Editor

NNJ Journal Club: Read It, Share It NNJ Journal Club: Read It, Share It

Karen C. Robbins

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NNJ Journal Club: Read It, Share It

The 17 SDGs contain 169 targets, addressing social, eco- nomic, and environmental health elements in the 2030 Agenda. The SDGs contain five categories: people, planet, partnership, prosperity, and peace. The agenda is not legally binding; countries prioritize the areas on which they choose to focus. Good health and partnerships are the corner stones of the Agenda’s strong care for social justice and inclusion.

‘Leave no one behind’ is a major focus of the SDGs. The United Nations Development Programme (2019) pro- vides the elements necessary to accomplish this: discrimi- nation, geography, governance, socioeconomic status, shocks, and fragility.

The Nightingale Legacy and the United Nations 2030 Agenda

“The 2030 Agenda is historically and distinctly a nurs- ing agenda” (Rosa et al., 2019, p. 6). The authors suggest Nightingale anticipated the SDGs for recovering and maintaining health. “End poverty in all its forms every- where” is SDG 1 (United Nations, 2016) and embodies her work to reform the Liverpool Workhouse Infirmary where 1,200 people were hungry and crowded into space that was unsanitary and unsafe. Nightingale urged the reform of the entire British workhouse system that changed the condi- tions for the first time by adding salaried nurses. Nurses today can likewise mount initiatives for positive changes.

How to Achieve SDGs Actions to implement the SDGs will vary by the

income level of the respective countries, which are consid- ered as low, middle- or high-income countries. The United States, a high-income country, may present a challenge for nurses to focus on how SDGs become meaningful on a global scale. Health is not defined in the same way in dif- ferent cultures. “To profoundly understand how the SDGs are interrelated, nurses must enter a shared experience with each other and diverse disciplines to promote growth, healing, and an experience of well-being” (Rosa et al., 2019, p. 8).

The United Nations 2030 Agenda for Sustainable Development: A Prescription for the Future

The agenda provides a roadmap to change the world to one without poverty and inequality in a place where the planet and the people endure. The rate of change varies widely; the United States ranks only 35 of 156, with respect to implementation outcomes (SDG USA & Sustainable Development Solutions Network, 2018).

The Code of Ethics with Interpretive Statements (American Nurses Association [ANA], 2015) provides an ethical frame- work through the identification of nine divisions and has implications in SDG implementation. Nurses working in a global context must embrace these provisions in striving to attain the 17 SDGs that encompass human needs, as well as the animal and planetary domains. Provision 2 states: “The nurse’s primary commitment is to the patient, whether an

individual, family, group, community, or population” (ANA, 2015, p. 5). To attain global safety and preserve nature’s resources, nurses must advocate for appropriate policy changes, and provide best practice and ongoing edu- cation inter-professionally through scholarly publications.

Provision 9 addresses the role of professional organiza- tions. “The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate prin- ciples of social justice into nursing and health policy” (ANA, 2015, p. 35). Referring again to Nightingale’s vision- ary beliefs, there is a global effort by nursing organizations to encourage action in keeping with the SDGs. The International Council of Nurses (ICN) and more than 130 national nursing associations that represent more than 20 million nurses are leading nurses to influence health policy within the nursing profession including noncommunicable diseases and mental health challenges and their impact on mortality, disability and quality of life (ICN & Nursing Now, 2018). Another focal area is to empower and invest in women and girls, promoting gender equality and improving their access to education, economic opportuni- ties, and health care.

Reviewed: Cleveland, K.A., Motter, T., & Smith, Y. (2019).

Affordable care: Harnessing the power of nurses. OJIN: The Online Journal of Issues in Nursing, 24(2), Manuscript 2. doi:10.3912/OJIN.Vol24No02Man0

Since the inception of Medicare in 1965, the cost of

health care has escalated as services expanded. “The groundbreaking Patient Protection and Affordable Care Act (ACA) compels nurses to continue innovation, trans- formational leadership, and care coordination as major stakeholders in provision of the next generation of cost containment, quality advances, and patient access improvements” (Cleveland, Motter, & Smith, 2019, p. 1). This article discusses the nurse’s role in containing costs, various models for reimbursement, quality and access to care, and opportunities as change agents.

Nurses Role in Reducing Health Care Costs A discussion of a number of models and systems of

health care is presented with specifics of the nurse’s role and the impact on costs. Examples of models and systems discussed include Medicare and Medicaid programs from inception to expansion, diagnosis-related groups (DRGs), and programs associated with the ACA. Some of those programs include Hospitals Readmission Reduction Program and the nurse-led Community-Based Care Transitions Program. Value-based purchasing represents a novel way to provide reimbursement based upon patient outcomes. There are several hospital-acquired conditions programs for which there are penalties for poor patient outcomes (e.g., central line-associated bloodstream infec- tions [CLABSI]). Conversely, pay-for-performance initia-

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tives reward providers with incentive payments when pre- determined quality and patient satisfaction parameters are met. The constant theme throughout these initiatives is the central role of the nurse’s level of participation in the care to enhance patient outcomes and decrease the cost of care. The cost of additional systems and nurses has been offset by the cost savings with improved outcomes, enhanced safety, and quality issues unanticipated by policy makers or insurance payers.

Nurses Opportunities to Influence Costs and Quality of Healthcare

The Robert Wood Johnson Foundation (RWJF) (2012) and the Institute of Medicine (IOM) (2010) collaborated to create The Future of Nursing: Leading Change, Advancing Health as a roadmap for nurses’ role in addressing changes resulting from the ACA. The report identified four key principles: nurses should achieve higher levels of educa- tion, practice to the full extent of one’s level of education, establish full partnership with physicians and other health professionals, and create effective workforce planning and policymaking (IOM, 2010). The principles have resulted in nurses becoming leaders in changing health care.

The Campaign for Action was established by the RWJF and the American Association of Retired Persons (AARP) to form Active Coalitions to address the IOM report rec- ommendations and advocate for healthier communities (RWJF & AARP, 2019). Coalitions were established in all 50 states and Washington, D.C., and are composed of vol- unteer nurses who partnered with organizations and busi- nesses to facilitate the implementation of the report’s ele- ments. The state coalitions campaign for policy changes within each state to influence nursing practice, access to health care, and quality care. Grants and awards for research and training are available (RWJF & AARP, 2019). A table is provided that describes the states’ successes.

To increase levels of education, some states have imple- mented regulations that give RNs without baccalaureate degrees 10 years after becoming licensed to earn it. There are an increased number of nurses acquiring more advanced degrees at the doctoral level, and all of these efforts to advance educational preparation address the ACA requirement to improve quality of care.

Full partnerships have evolved between advanced practice registered nurses (APRNs) and other health care professionals in many states as barriers to APRNs practic- ing to the full capacity of their education and licensure have been removed. Performance-based nursing care pro- vides price transparency for nursing care, as opposed to DRG lump sum charges that bury the cost of nursing care. The integral role of nurses is reflected in this performance- based care. Another element from the IOM (2010) report is developing effective workforce planning and policy making. Doctoral-prepared nurses facilitate and collabo- rate in scientific study of clinical and theoretical questions, and are tested in practice with translational research, and practice and outcomes data to inform policy development.

Quality Initiatives The ACA links reimbursement to outcomes and

adverse outcomes (e.g., CLABSIs can decrease reimburse- ment). While it is costly to treat CLABSIs, limited reim- bursement has not yielded a decrease in its incidence (Lee et al., 2012). Nurses are full partners with other disciplines to continue to explore approaches to improve patient care and outcomes.

The ACA fostered a shift from disease-specific, patient- centered focus to an emphasis on primary and preventive care via a health management approach (Ariosto et al., 2018). Enhanced communication across disciplines and care environments is crucial to de-escalate and stabilize health care spending, and demonstrates the critical role the nurse has on the business aspect of care delivery.

Access to Health Care “The impact of nurses providing access to care across

all populations is profound and long standing, with nurses leading initiatives to care for those in vulnerable and underserved populations” (Cleveland et al., 2019, p. 10). Yet gaps remain in coverage, and access to specialty care is difficult. The number of people who gained access to health care via the ACA included people who were sicker, had more comorbid conditions, and had less health litera- cy, not having previous access to care (Omolola, Preston, & Gonzalez, 2015). This emphasized the need for nurses to practice to the full extent of their licenses and led more states to allow APRNs to practice with full authority.

Nurses Leading Change Nurse participation in creating change throughout the

health care system has led to efforts for nurses to serve on governing boards. “All boards benefit from the unique per- spective of nurses to achieve the goals of improved health and efficient and effective health care systems at the local, state and national levels” (Nurses on Boards Coalition, 2019, p. 1). When serving on boards, nurses have an opportunity and obligation to affect the cost, quality, and access to health care.

“The time is ripe for nurses to harness the power of a unique disciplinary perspective and enduring patient trust to advocate for the advancement of policy and continua- tion of quality research, evidence-based initiatives, and patient centered innovation” (Cleveland et al., 2019, p. 13).

Reviewed: Fleishman, J., Kamsky, H., & Sundborg, S. (2019).

Trauma-informed nursing practice. OJIN: The Online Journal of Issues in Nursing, 24(2). Manuscript 3. doi:10.3912/OJIN.Vol24No02Man03

“Trauma-informed care (TIC) is a patient-centered

approach to health care that calls on health professionals to provide care in a way that prevents re-traumatization of patients and staff” (Fleishman, Kamsky, & Sundoborg, 2019, p. 1). This is applied to all interactions, even absent

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NNJ Journal Club: Read It, Share It

disclosure of a trauma experience. The setting should be safe and welcoming for patients and staff members, and policy and practice should reflect this.

Temporary stress may be manageable (McEwan, 2007), but prolonged stress may become maladaptive and lead to illness and disease (Hackney, 2006; Peters, McEwan, & Friston, 2017). Stress and adversity are linked to poor social, physical, and emotional outcomes at a later time (Felitti et al., 1998). Some of these risks are linked to child- hood trauma or harsh conditions, and include diabetes, increased risk for heart disease, autoimmune disorders, and even early death (Brown et al., 2009). How people engage with health care services may be affected with prior trauma, and the interaction could potentially re-traumatize them (Dubay, Burton, & Epstein, 2018). People experienc- ing trauma as children may be more likely to seek more care but fail to follow through with the prescribed regimen (Sansone, Bohinc, & Wiederman 2014).

Fight, flight, or freeze may be survival responses when threatened rather than the more rational parts of brain- associated memory, planning, regulation, and decision- making (McEwan, 2007). These responses may influence a patient’s ability to engage appropriately with the health care system and possible adherence to treatment plans (Sansone et al., 2014).

Trauma Informed Care The Substance Abuse and Mental Health Services

Administration (SAMSHA) (2014) identified specific prin- ciples for a trauma-informed approach: • “Safety (personal and emotional). • Trustworthiness; empowerment, voice, choice. • Empowerment, voice, choice. • Use of peer support. • Cultural, historical, and gender responsiveness”

(Fleishman et al., 2019, pp. 2-3). Note: the original document cited identifies a sixth

principle of “collaboration and mutuality” (SAMSHA, 2014, p. 10).

“Understanding how trauma has affected patients’ lives and their interactions with and perceptions of the health care system is fundamental to structuring a health care sys- tem that responds to these patients’ needs and promotes better physical and mental health outcomes” (Dubay et al., 2018, p. 2).

Healthcare and TIC Engagement in health care utilization may be increased

among traumatized patients (Sansone et al., 2024) and for emergency care in particular (Walker et al., 1999). Another study found that trauma victims had lower usage of screen- ing and preventive care (Yanos, Czaja, & Widom, 2010). Patients are not the only trauma survivors; health care providers may have also been traumatized. Turnover and absenteeism may be manifestations for health care workers

who were trauma victims. Administration must ensure sup- port systems are in place when staff members experience workplace trauma. “If nurses do not care for themselves, they will not be able to properly care for patients” (Fleischman et al., 2019, p.8).

Trauma-Informed Nursing Practice TIC for nursing practice requires fostering nurses who

are aware, sensitive, and responsive to patients’ situations. The authors suggest three basic questions to determine if TIC is being practiced: • “Safety: Does this cultivate a sense of safety? • Respect: Am I, and others, showing respect? • Trust: Does this build trust?” (Fleischman et al., 2019,

p. 4) The authors offer suggestions for caregivers (e.g., intro-

duce yourself and role with every interaction); this can empower patients to be involved in their care and avoid confusion or misunderstanding. Use body positioning that is not threatening to avoid the fight, flight, or freeze reac- tion. Explain any procedure with clear language, ask before touching, and explain universal precautions.

Reviewed: Anthony, M., Turner, J.A., & Novell, M. (2019). Fiction

versus reality: Nursing image as portrayed by nurs- ing career novels. OJIN: The Online Journal of Issues in Nursing, 24(2). Manuscript 4. doi:10.3912/OJIN. Vol24No02Man04

Novels published in the 1930s through the 1960s

depicted girls who were nurse role models and encouraged young women to pursue nursing careers. “These young adult novels provided girls with role models who sought personal achievement through careers as nurses despite societal limitations, love interests, and competing family obligations” (Anthony, Turner, & Novell, 2019, p. 1). Their premise is that these novels reflected the public image of nurses; positive images encouraged young women to go into nursing and unfavorable images deterred that path- way. In their review, nurses varied from seeking financial freedom and a degree of professional status, inherently self- less, and patriotic, to a naughty nurse, handmaiden to the physician, “battle axe,” and unhappy spinster nurse who wanted to make life miserable for all around her. They identified themes throughout, and their findings are sum- marized here.

Motivation to Become a Nurse In only one book did the young woman become a

nurse for the sole purpose of marrying a doctor. Others wanted a profession, to avoid being perceived as useless, had a desire to ease suffering, or help others, and sought a career that could be sustained even if married. Negative perceptions to overcome included scouring floors.

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Nursing Image Most of the main characters were white, and all were

female and young, with the exception of one who was in her 30s and “old.” Uniforms were an integral part of the image, with white uniforms and blue capes. The homo- geneity of their white uniforms provided a sense of com- mon purpose. The nursing cap was the “ultimate symbol” of their dreams, suggesting dignity and respect, and distin- guished them from other hospital staff members.

Personality and Stereotypes “Nurses in many of these novels were independent,

willing to act autonomously, and assertive when it comes to patients’ welfare” (Anthony et al., 2019, p. 5). It is note- worthy that many of these books were written in times of war, so nurses rose to the occasion in caring for the wound- ed, were “angels of mercy,” and were more independent and assertive. Their training was considered rigorous and became more so once receiving their caps that signified the end of their probationary period.

Discussion “Nurses and student nurses were depicted as a stabiliz-

ing force in tumultuous times, both unruffled and coura- geous” (Anthony et al., 2019, p. 9). Nursing presented an opportunity for travel, to leave home, or join war efforts, although the “angel of mercy” image detracted from the education and skills a nurse needed.

The caps have been shed, and not all nursing programs have pins denoting the school or college. The public, while respecting nurses, has a poor understanding of the com- plexity and sophistication of the collaborative efforts of what nurses actually do. “The world that these midcentury nurse novels describe is no longer the world that nurses of today enter, but for one constant – the profession continues to offer challenging, fulfilling opportunities for men and women who seek purposeful work in a challenging, uncer- tain world” (Anthony et al., 2019, p. 12).

Reviewed: Benton, D.C., Beasley, C.J., & Ferguson, S.L. (2019).

Nursing now! Learning from the past, positioning for the future. OJIN: The Online Journal of Issues in Nursing, 24(2). Manuscript 5. doi:10.3912/OJIN.Vol24No02 Man05

“The Nursing Now! Campaign, a program of the Burdett

Trust for Nursing, is being undertaken in collaboration with the World Health Organization and the International Council of Nurses (ICN) to create a social movement to improve health globally by raising the profile and status of nurses worldwide” (Benton, Beasley, & Ferguson, 2019, p. 1). The goal is to elevate the global status of nurses in pursuit of universal health care. The five goals are: 1. “Greater investment in improving education, profes-

sional development, standards, regulation, and employ- ment conditions for nurses.

2. Increased and improved dissemination of effective and innovative practice in nursing.

3. Greater influence for nurses and midwives on global and national health policy, as part of broader efforts to ensure health workforces are more involved in decision making.

4. More nurses in leadership positions and more opportu- nities for development at all levels.

5. More evidence for policy and decision makers about: where nursing can have the greatest impact, what is stop- ping nurses from reaching their full potential and how to address these obstacles” (Benton et al., 2019, p. 2). The emphasis of this article is on how universal health

care can be achieved. The contributions of the medical profession’s published research toward achieving universal health care are far more extensive than that of nursing that needs to be more robust. Policy change requires the sup- port of reliable and valid research rather than opinion. As an example, Nightingale was innovative in her use of visu- alization of data to provide evidence for change in the causes of death in the Crimean War that were from pre- ventable conditions. The authors offer a number of biblio- metrics and other data strategies to connect nurses working in similar areas of research to create networks for possible synergy, collaboration, and co-authorship. This analysis identified six domains in which nurses currently overlap in their scholarly initiatives.

Much of nurses’ work is undocumented in the clinical arena. There are innovative interventions that are not cap- tured because they are viewed as part of routine costs of care. “If the profession of nursing can harness the full potential of its enormous global workforce through ener- gizing staff at all levels in policy processes, then the possi- bilities for change are limitless” (Benton et al., 2019, p. 26).

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