1. Bleich, Michael R. PhD, RN, FAAN

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* A health system in the Pacific Northwest used a facilitator to engage physicians in a yearlong dialogue that increased nurse-physician valuing of each discipline's contribution to patient care, improved communications, and led to Advanced Practice Registered Nurses gaining admitting privileges at the hospital.

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* A hospital system in the East is modeling an online residency program connecting nurses in rural settings to a larger peer group to support their transition to practice.


* An academic health center in the Midwest now has nurse-physician coleaders on all major services. Clinical care protocols and mutual problem solving have ignited an esprit de corps that is palpable to staff, patients, and families.


* A health system in the Southwest has reconfigured staff development programs to give support to mid- and senior-level careerists, critical players who have been under-resourced.


* Major nursing organizations are aligning to reestablish care and practice standards, with some designed to reflect key functional areas maximizing the range of nursing's influence on the healthcare system, not captured in traditional nursing process language.



Each of these examples is real, not contrived, and each is in response to nurse leaders who have taken the findings of the Committee on the Robert Wood Johnson Foundation (RWJF) Initiative on the Future of Nursing1 at the Institute of Medicine (IOM) to heart. The report's key messages and recommendations have provided-arguably for the 1st time in nursing's history-a unifying blueprint focusing energy that postures nursing to meet the dynamic changes in healthcare delivery. Nurse leaders who act on this report are achieving institutional-level change to reinvigorate nursing and make our contribution to the health and well-being of countless people across the care continuum explicitly visible.


As a committee member, I admired the leadership of the initiative throughout the process of studying nursing's future role and in the writing and shaping of the report. Furthermore, it is a study in change dynamics to laud the credible follow-up that is unfolding through the RWJF's implementation strategies, ongoing communication strategies, and efforts to keep the report's messages fresh and vital. But it is at the level of each nurse and the readers of JONA that the recommendations take on life and rich meaning. Nurse leaders realize the immediacy of this action opportunity and are vested in the deeper reality of sustained efforts offering hope for increased public recognition and valuing of nurses and the discipline. The examples above are testimony to engaged leadership. If you have not yet used or accessed the report, it is not too late, but the time is now to become involved, for much is at stake.


Future Challenges Are Upon Us

First, too few nurses are at the table as models of accountable care are conceptualized, and this is serious. The new structures-for there is no single model-will influence the scope of practice, the location of care delivery, and the volumes and types of access to myriad citizens who have not had access to care. The IOM report stretches the public and other providers to recognize the untapped scope of nursing practice. Nurses must then step up to the plate and demonstrate ongoing competency development. These clinical recommendations are linked to evidence that nurses can lead and impact health systems design. History should inform us that if a nursing lens is not built into the systems now while under construction, nurses will be left to react to models that may stymie our capacity to influence health until the next iteration of health reform.


Second, although the public acknowledges high trust levels for nurses, the frequent mental model is that of us in an assistive-only role, primarily to physicians and also to other disciplines absent in off-shifts and on weekends. Nurse leaders must influence all nurses to give voice to and act on our unique role as the singular health discipline who addresses care both holistically and contextually. This lens of holistic care is not uniform in the education of other health disciplines, nor does discipline-specific education ensure a comprehensive knowledge of the patient in the context of family and community. A recent nurse leader told me that other nonnurse colleagues tell her that she "thinks differently"; I pointed out that she links her decisions through a nursing lens. To her, decisions are not just economic, disease-oriented, or political compromises but rather encompass a much broader set of outcomes. We must publicly give voice to the value of this perspective and use hardwiring as a team asset, whether providing direct care or in other roles.


Finally, nursing has a long history of becoming distracted by siloed self-interests or becoming derailed by the agenda of other health disciplines. The IOM report offers a framework for unifying nursing for the public's good, as unprecedented demographic shifts occur in an era of rampant chronic care issues, influenced with life-sustaining technologies. The IOM report (1) outlines that we must embrace and lead the science tied to care management and clinical knowledge integration. This is our heritage; it needs voice, and it means ongoing professional development and role expansion for nursing.


To some, the Future of Nursing report may contain what seemed obviously apparent. Leaders should assist others in interpreting that the report was written for ease of public interpretation, that it is evidence-based, and that it endured the scientific scrutiny of IOM review teams for validity and reliability. Further, it was written from the vantage point of the public's vision and need for nursing, not from our self interests. Each recommendation is rich with opportunity and requires change agent expertise for implementation. For instance, at the institutional level, getting the scope of practice for nurses expanded is influenced by human resource and risk management personnel, and politics aligned with professional turf, all which could undermine the capacity of expert nurses to bring their full set of abilities to the forefront.


The Challenge

To each reader of JONA; You are leaders with the capacity for creating work environments, adding to empirical research, improving quality and safety, and shaping care models to recast nursing in light of current demands and future needs. Use the IOM report (1) as a strategic and operational guide for change in your realm and beyond. By doing so, we will span boundaries and give voice to human needs.




1. Robert Woods Johnson Foundation/Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press; 2010. Available at Accessed January 23, 2012. [Context Link]