healing community pp, 3.1.13

PAULETTE C. COMPTON, RN, MSN, MCPROGRAM DIRECTOR

BANNER BOSWELL MCC

HEALING COMMUNITY ANNUAL SPRING MEETING

MARCH 1 , 2013

2010 IOM Future of Nursing Report & Health Care Reform:

Impact on Nursing Practice & Nursing Education

Paulette C Compton, RN, MSN, MC

2

How is ‘nursing practice’ connected to ‘health care reform’?

“Many unknowns about health care remain as the country pushes forward with health care reform. But one thing is certain. The US cannot adequately address the challenges facing its health care system without addressing the challenges facing the nursing profession. Nurses are the largest segment of the heath care workforce and are essential to providing quality care…….The goal of this initiative is to help transform nursing as part of far-reaching reforms in the health care system.”

SOURCE: Preface to Summary of IOM October 2009 Forum on the Future of Nursing: Acute Care

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3

Inter-Dependent Influences

Health Care = Reality of current health care now and future

Health Care Reform** = Needed changes in health carenow and future

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**ANA website link: http://www.nursingworld.org

http://www.nursingworld.org/




4

Where is the history & evidence US Health Care needs reform?

Jeopardy Answer….’What is’ the IOM?

“The Institute of Medicine asks and answers the nation’s most pressing questions about health and health care.”

“The mission of the IOM is to advise the nation on matters of health and medicine.”

SOURCE: www.iom.edu/About-IOM.aspx

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http://www.iom.edu/About-IOM.aspx


5

What does the IOM do?

“The IOM applies a distinct research process to provide objective and straightforward answers to difficult questions of national importance.”

“These leading national and international scientists [who conduct the studies], all of whom serve as volunteers, are asked to set aside preconceptions and to rely on evidence in their pursuit of knowledge and truth.”

SOURCE: www.iom.edu/About-IOM.aspx

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6

What is the IOM?

Institute of Medicine

Private, non-governmental, nonprofit organization providing unbiased and authoritative advice to decision makers and the public.

Established in 1970, the IOM is the health arm of

the National Academy of Sciences, chartered under President Abraham Lincoln in 1863.

www.iom.eduSOURCE: www.iom.edu/About-IOM.aspx

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http://www.iom.edu/



7

What is the relationship between education & practice?

Past-Present-Future

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Nursing Practice-Nursing Education Relationship

PAST (History): Very close relationship with diploma programs

in hospitals

PRESENT: Disconnected; education silo & practice silo

NOW & FUTURE: Need to collaborate on preparing nurse of

future

AZ Action Coalition Education-Practice Collaborative Task Force

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9

Why are IOM Reports Essential to Nursing Education?

The IOM Reports:1) provide evidence how to improve our

healthcare system2) provide evidence how to improve the health

of Americans & improve patient outcomes in our nursing practice

3) IOM focus is also on healthcare professions education with goal of a consistent framework with all healthcare professions education emphasizing interdisciplinary care

SOURCE: Finkelman A & Kenner, C (2009) Teaching IOM: Implications of the IOM Reports for Nursing Education. ANA: Silver Spring, MD

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What is the evidence to support need to improve nursing education & nursing practice?

1999 IOM To Err is HumanIOM Quality Chasm series2003 IOM Health Professions Education2004 QSEN2009 Patricia Benner’s book, Educating

Nurses: A Call for Radical Transformation2010 IOM Nurse of the Future, Leading

Change, Advancing Health

3.1.2013

2010 IOM Future of Nursing Report Recommendations:

Leading Change, Advancing Health Report

1) Nurses should practice to the full extent of their

education and training.

2) Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.

3) Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States.

4) Effective workforce planning and policy making require better data collection and an improved information infrastructure.


12

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13

Relationship/Structure of AZ Education-Practice Collaborative Task Force

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IOM & Nursing Education

“The IOM reports are at the center of the current restructuring of healthcare systems and the movement toward inter-professional work, and they influence funding from research, education, and health policy agencies and professional organizations. They ( IOM reports) should therefore be at the core of all nursing education programs.” Finkelman & Kenner, (2009) Teaching IOM, P.xvii.

“Educators often feel they know what needs to be taught though they have long been out of practice or only practice intermittently. This is a dangerous stand to take and may have poorly served students or employers who hire new graduates. This is also not serving our consumers, patients and their families.” Finkelman & Kenner, (2009)Teaching IOM, pp.xviii-xix.

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1999 IOM Report: To Err is Human

The report identified remarkably high incidence of errors in health care. At least 44,000 to 98,000 people die in hospitals each year in the US as a result of medical errors that could have been prevented, based on estimates from two major studies.

Definition of ‘medical error’-the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.

The highest incidence of medical errors with serious consequences occurs more frequently in ICUs, ORs, and EDs.

Recommendation of need to change to blame-free environment which does not focus on punishing individuals for errors but changes to a root cause analysis to determine individual practice and system problems which result in errors.

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2001 IOM Report: Crossing the Quality Chasm 2001

The report found our health care system is fragmented, inefficient, and poorly organized.

IOM 1990 definition of ‘quality’-“the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”

The report identified ‘quality’ as a system property with six important improvement aims.

Health care ‘quality’ should be: Safe Effective Patient-centered Timely Efficient Equitable

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2003 IOM Report: Patient Safety: Achieving a New Standard of Care

The report identified the need for a much broader approach to patient safety than was first stated in To Err is Human.

Definition of ‘patient safety’-The prevention of harm to patients, where harm can occur through errors of commission and omission.

The report describes the need for commitment from all stakeholders to a culture of safety and improved information system, which us clinical data at point of care to prevent, recognize, and recover from adverse events.

Recommended need HHS assume lead role for establishing a standards-based nation health information infrastructure to support comprehensive patient safety programs to detect and analyze adverse events and near misses.

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Paulette C Compton, RN, MSN, MC 18

Note: * Estimate. Expenditures shown in $US PPP (purchasing power parity).Source: Calculated by The Commonwealth Fund based on 2007 International Health Policy Survey; 2008 International Health Policy Survey of Sicker Adults; 2009 International Health Policy Survey of Primary Care Physicians; Commonwealth Fund Commission on a High Performance Health System National Scorecard; and Organization for Economic Cooperation and Development, OECD Health Data, 2009 (Paris: OECD, Nov. 2009).

AUS CAN GER NETH NZ UK US

OVERALL RANKING (2010) 3 6 4 1 5 2 7

Quality Care 4 7 5 2 1 3 6

Effective Care 2 7 6 3 5 1 4

Safe Care 6 5 3 1 4 2 7

Coordinated Care 4 5 7 2 1 3 6

Patient-Centered Care 2 5 3 6 1 7 4

Access 6.5 5 3 1 4 2 6.5

Cost-Related Problem 6 3.5 3.5 2 5 1 7

Timeliness of Care 6 7 2 1 3 4 5

Efficiency 2 6 5 3 4 1 7

Equity 4 5 3 1 6 2 7

Long, Healthy, Productive Lives 1 2 3 4 5 6 7

Health Expenditures/Capita, 2007 $3,357 $3,895 $3,588 $3,837* $2,454 $2,992 $7,290

Country Rankings

1.00–2.33

2.34–4.66

4.67–7.00

Overall Ranking

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19

IOM 2003 Report on 5 Essential Core Competenciesfor all Health Professionals Education

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2003 IOM Health Professions Education Report5 Core Competencies

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QSEN : Quality and Safety in Nursing Education(2004) 6 Core Competencies

SafetyQSEN

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What is QSEN?

Quality and Safety Education in Nursing

QSEN is a comprehensive website for quality and safety education for nurses, funded by Robert Wood Johnson Foundation

QSEN is a faculty resource to learn and share ideas about teaching-learning strategies, which promote quality and safety competency development in nursing

QSEN includes video presentations and annotated bibliographies for faculty and nursing students to learn about quality and safety in nursing

www.QSEN.orgSOURCE: www.QSEN.org

3.1.2013

http://www.QSEN.org/

http://www.QSEN.org/


23

QSEN: Quality & Safety Education in Nursing

QSEN initial goal to describe competencies which would apply to ALL nurses & define a competent and qualified nurse.

QSEN utilized IOM recommended 5 competencies for all health professions AND created 2 competencies for IOM Quality Improvement competency: Quality Improvement & Safety

QSEN identified KSAs (Knowledge, Skills, & Attitudes) for each competency

QSEN competencies to serve as guide for Curricular development for academic programs Transition to practice Continuing education programs.

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Massachusetts Nurse of the Future 10 Core Competency Model

Source: http://www.mass.edu/currentinit/NiNofCompetencies.asp

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http://www.mass.edu/currentinit/NiNofCompetencies.asp

http://www.mass.edu/currentinit/NiNofCompetencies.asp

Paulette C Compton, RN, MSN, MC 25 3.1.2013

Paulette C Compton, RN, MSN, MC 26

Ten Core Nursing CompetenciesIn 2010 publication

Nursing Knowledge as foundation Communication Quality improvement Safety Evidence-based practice Patient centered care Leadership Teamwork and Collaboration Professionalism Informatics Systems Based Practice

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27

Relationship/Structure of AZ Education-Practice Collaborative Task Force

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Survey Monkey Results: #3

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Survey Monkey Results: #5

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What is the major impact of health care reform on nursing education?

1) Evidence indicates the need for more educated nurses due to the increasingly complex health care system and improved patient outcomes, including decreased mortality and decrease failure to rescue, with increased percentages of BSN RNs.

IMPACT ON NURSING EDUCATION:1) Increase pre-licensure BSN pipeline2) Increase seamless educational progression programs from ADN RN to BSN and/or MSN RN3) Increase concurrent enrollment pipeline of ADN/BSN programs

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Nurses are the ‘least educated’ healthcare profession!

Healthcare Occupations: Minimum Education Degree for Entry to Practice

Associate Registered Nurse Respiratory Therapist Tech Pharmacy Tech Occupational Therapy Assistants Physical Therapy Assistants

Baccalaureate Respiratory Therapist

Masters Occupational Therapist Social Worker Speech Therapist Counselor

Doctoral Physician Pharmacist Physical Therapist

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What is the Tri-Council for Nursing?

“The Tri-Council for Nursing is an alliance of four autonomous nursing organizations each focused on leadership for education, practice and research. …... These organizations represent nurses in practice, nurse executives and nursing educators….” Tri-Council Member Organizations:1) American Nurses Association

2) National League for Nursing

3) American Association of Colleges of Nursing

4) American Organization of Nurse Executives

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2010 Policy Statement from Tri-Council for Nursing

Educational Advancement of Registered Nurses:

A Consensus Position (cont)

Quote from 2010 Policy Statement:

“A more highly educated nursing profession is no longer a preferred future; it is a necessary future in order to meet the nursing needs of the nation and to deliver effective and safe care.”

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‘New’ Arizona Tri-Council for Nursing

Robin Schaefer, Executive Director, AZNA:Arizona is in the process of forming a tri-council. It will be called Arizona Tri-Council for Nursing, based on the national Tri-Council for Nursing model with 4 organizations. The first meeting was on January 25th. The group is in the process of writing the mission and identifying areas for collaboration.

The involved groups are:Arizona Nurses Association (AzNA)Arizona Organization of Nurse Executives (AzONE)Arizona League for Nursing (AzLN)Arizona State Board of Nursing (AZBN)

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2) Evidence indicates health care reform needs to focus on nurses (and all health professions) educational preparation in all of the 10 Mass. Nurse of the Future Core Competencies.

IMPACT ON NURSING EDUCATION:1) Need to educate nurses all of the 10 Mass NOF core

competencies2) Need to incorporate all Mass NOF core

competencies knowledge, skills, and attitudes content in all levels of nursing education, including RN-to-BSN

3) Proposed rule change in AZ Nurse Practice Act will require all nursing programs to include the 6 IOM/QSEN core competencies in the curriculum.

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2) Evidence indicates health care reform needs to focus on nurses (and all health professions) educational preparation in all of the 10 Mass. Nurse of the Future Core Competencies. (continued)

IMPACT ON NURSING EDUCATION:4) AZ Education-Practice Collaborative Task

Force (AZEPCTF) officially affirmed the adoption of the Mass Nurse of Future Core Competency Model and changed the name.

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AZ EPCTF Meeting, Feb 22, 2013

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AZ EPC Task Force Model & Purpose

On January 28, 2013 the AZ EPC Task Force affirmed and adopted the Massachusetts Nurse of the Future Core Competency Model and Purpose:

Establish a formal coalition (AZ AC

Education-Practice Collaborative Task Force: AZ EPCTF) to create a seamless progression through all levels of nursing that is based on the evidence-based consensus competencies of the Massachusetts Nurse of the Future Core Competency Model, which includes transitioning nurses into their practice settings.


38

AZ EPC Task Force Purpose Consistent with AZ Issues/Concerns

1. Seamless progression through all levels of nursing education (AZ- New Grad Practice Readiness)

2. Consensus on competencies to serve as a framework for educational curriculum (AZ acceptance of AZ Evidence-Based Massachusetts Nurse of the Future Core Competency Model)

3. Nurse internship/preceptor program (AZ-New Grad Practice Readiness & Nurse Residency)


Arizona Nurse of Future Core Competency Model

1) DECISIONS: AZ (EPCTF) Education-Practice Collaborative Task Force adopted the Massachusetts Nurse of Future Core Competency Model on 1.28.13 and changed the name on 2.22.13

2) REVISED NAME: Arizona Nurse of Future Core Competency Model (AZ EPCTF adopted and changed the name of the Massachusetts Nurse of Future Core Competency Model)


40

Arizona Assumptions (Adopted from Massachusetts Assumptions, 2.22.13)

1) Education and Practice partnerships are key to developing an effective model.

– Nursing education and practice setting should facilitate individuals to move more effectively move through the educational system.

– An integrated practice/education competency model will positively impact patient safety and improve patient care.

– Nursing practice should be differentiated according to the registered nurse’s educational preparation and the level of practice and further defined by the role of the nurse and the work setting

– Practice environments that support and enhance professional competence are essential.


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2) It is imperative that leaders in nursing education and practice develop collaborative curriculum models to facilitate the achievement of a minimum of a baccalaureate degree in nursing (BSN) by all nurses.

– Advancing the education of all nurses is increasingly being recognized as essential to the future of nursing practice.

– Evidence has demonstrated that nurses with higher education levels have a positive impact on patient care.

*Please note this assumption does NOT state ‘BSN minimal entry into practice’ but means the goal is for all RNs, including Diploma & Associate RNs, to achieve BSN through collaborative curriculum models.


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3) There is a need to develop a more effective educational system that is capable of incorporating the shifting demographics in order to prepare the nursing workforce to respond to current and future health care needs and population health issues.

– The competencies are designed to be applicable across all care settings and to encompass all patient populations across the lifespan.

– In this global society, essential to the care of diverse populations is the need for evidence-based knowledge and sensitivity to variables such as age, gender, culture, health disparities, socioeconomic status, race, and spirituality.


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4) The nurse of the future will be proficient at a core set of competencies.

– There is a differentiation in competencies among practicing nurses at various levels.

– Competence is developed over a continuum and can be measured

5) Nurse educators in both education and practice settings will need to use a different set of knowledge and teaching strategies to effectively integrate the Nurse of the Future competencies into curriculum.


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Additional Arizona AssumptionApproved

6) As nurses and patient advocates, the AZ EPC Task Force supports the need for increased education for all nurses because with increasingly complex health care, the patient requires a more educated nurse in order to deliver effective and safe care.

The Massachusetts NOF assumptions and the above additional assumption were adopted by the AZ EPCTF on Feb 22, 2013.

AZ Nurse of the Future: Core Nursing Competencies

These competencies are the expectations for all professional nurses of the future.

The Knowledge, Attitude and Skills (KAS) grids are the minimal expectations for initial nursing practice following completion of any pre-licensure professional nursing educational program.

What were the professional standards used for the framework of Nurse of the Future Core

Competencies

ACGMEAHRQAACNANAAONEBologna AccordCCNE

COPAIOMICNNCSBNNLNNLNACQSEN

See page 42, NOF Core Competencies

Knowledge Attitudes/behaviors Skills

Describes the nursing context for improving care

Recognizes that quality improvement is an important part of being a nurse.

Actively seeks information about quality improvement from relevant institutional, regulatory and local/national sources.

Understands that the nurse and care delivered is part of a broader health care system.

Recognizes that interdependent relationships and a professional work process are important to quality improvement.

Participates in the use of quality improvement tools (such as flow charts, cause & effect diagrams) to make processes of care interdependent and explicit

Explains the importance of variation and measurement in providing quality nursing care.

Appreciates how unwanted variation affects care and how standardization can support quality patient care.

Participates in the use of quality measures (such as control and run charts) to assess performance and identify gaps between local and best practices.

Describes approaches for changing processes of care in which the learner is involved.

Recognizes the value of what individuals and teams can do to improve care.

Participates in the use of measures to evaluate the effect of changes in the delivery of care.

Quality Improvement The Nurse of the Future will use data to monitor outcomes and care processes, and use improvement methods to design and test changes to continuously improve the quality and safety of healthcare.

Core Competency ComparisonsSource: Maureen Sroczynski

IOM ACGME QSEN NOFApply

QualityImprovemen

t

Practice based Learning & ImprovementSystems Based Practice

Quality Improve-mentSafety

Quality ImprovementSafetySystems based practice

Provide Patient-Centered

Care

Patient CareInterpersonal & Communication Skills

Patient CenteredCare

Patient Centered CareCommunicationLeadership

Work in Inter-DisciplinaryTeams

Professionalism Teamwork and

Collaboration

Teamwork and CollaborationProfessionalism

Employ Evidenced-Based Practice

Medical Knowledge

Evidencebased practice

Evidence based practice

Utilize Informatics

Informatics

Informatics

NOF

Professionalism

Evidence-based practice

Nursing knowledge

Informatics

AACN. (2008). Essentials of Baccalaureate Education for Professional Nursing Practice (adopted by AACN 10/28/08)

Professionalism & Professional Values

Scholarship for evidence-based practice

Liberal Education & Discipline of Nursing

Information Literacy & Information Management and Patient Care Technology


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3) Evidence indicates health care reform needs to focus on promotion of wellness in the community and decreased hospital admissions.

IMPACT ON NURSING EDUCATION:1) Need to educate nurses on the role of ‘the nurse

coach,’ which will be a new important role in health care

2) Need to educate nurses on ‘motivational counseling/interviewing.’

3) Need to have increased clinical experiences in ‘the community with health promotion’ rather than treatment focus in acute care

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4) Evidence indicates health care reform needs to focus on management of multiple chronic illnesses.

IMPACT ON NURSING EDUCATION:1) Need to educate nurses on the role of

management of multiple chronic illnesses.2) Need to educate nurses on ‘motivational

counseling/interviewing.’3) Need to have increased clinical experiences

in ‘the community’ with focus on management of multiple chronic illnesses

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5) Evidence indicates health care reform needs to focus on safety and quality improvement

IMPACT ON NURSING EDUCATION:1) Need to educate nurses about quality improvement

processes, including root cause analysis, near misses, system-based practice to prevent avoidable medical errors

2) Evidence indicates new RN grads have not been taught about quality improvement

3) Evidence indicates harm rates continue to be about same level as 1999 IOM To Err is Human data.

4) New role ‘Nurse patient safety officer’

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Evidence New Grad Knowledge Gaps in Quality Improvement Education

Kovner, C.T., et al. (2010) New Nurses’ Views of Quality Improvement Education. The Joint Commission Journal on Quality and Patient Safety. 36(1), 29-35.

STUDY RESULTS: N=436 (38.6%) newly licensed RNs thought they were “poorly” or “very poorly” prepared about or had “never heard of QI.” BSN grads reported significantly higher levels of preparation in EBP, evidenced-based practice; assessing gaps in practice, teamwork, collaboration; and many research skills.

STUDY CONCLUSIONS: RN educational programs need to improve education about and application of QI concepts and to consider focusing QI content into a separate course to assure it is taught.

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6) Evidence indicates health care reform needs to focus on evidence-based practice

IMPACT ON NURSING EDUCATION:1) Need to educate nurses about evidence-base

practice2) Need to increase EBP curriculum content in

all levels of nursing education3) Evidence indicates new RN grads have not

been adequately taught about evidence-base practice

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Evidence New Grad Knowledge Gaps in EBP & Quality Improvement Education

Sullivan, D. T., et al. (2009). Assessing quality and safety competencies of graduating prelicensure nursing students. Nursing Outlook. 57, 323-331.

STUDY RESULTS: N= 565. Only 49% newly licensed RNs reported curriculum included reliable resources for locating evidence-based reports and clinical guidelines. Students believed they were most prepared to perform skills in core competencies patient-centered care & informatics. Students felt least prepared for skills in evidenced-based practice & quality improvement tools and evaluating the effects of practice changes.

STUDY CONCLUSIONS:Due to gaps between theoretical presentation of quality and safety information and demonstrated application in practice, need to focus on redesign of curriculum content to include quality and safety education/practices. Special attention is needed to develop student competency in quality improvement.

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7) Evidence indicates health care reform needs to focus on improving health literacy.

IMPACT ON NURSING EDUCATION:1) Need to educate nurses about health literacy2) Need to increase health literacy curriculum

content in all levels of nursing education3) Evidence indicates new RN grads need health

literacy evidence-based practice interventions to improve health literacy and decrease avoidable medical errors resulting from poor health literacy.

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8) Evidence indicates health care reform needs to focus on high incidence with high mortality/morbidity management of chronic illnesses.

IMPACT ON NURSING EDUCATION:Need to educate nurses on evidence-base treatment for 20 priority areas for curricular content (2003 IOM Report-Priority Areas for National Action: Transforming Health Care)

Based on: A) Impact or extent of burdenB) Improvability or gap between

current practice and evidence-based practiceC) Inclusiveness or relevance of an

area to broad range of individuals3.1.2013


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IMPACT ON NURSING EDUCATION:Need to educate nurses on evidence-based treatment

for 20 priority areas for curricular content (2003 IOM Report-Priority Areas for National Action: Transforming Health Care)

Areas in most need of improvement in nursing curriculums in red font

1) Care coordination2) Self-Management & health literacy3) Asthma4) Cancer screening evidence-based, focus

on colorectal and cervical

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IMPACT ON NURSING EDUCATION:5) Children with special health care

needs6) Diabetes7) End of life care with advanced

system failure8) Frailty associated with old age9) Hypertension10) Immunizations11) Ischemic heart disease12) Major depression screening and

treatment

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IMPACT ON NURSING EDUCATION:

13) Medical management: Preventing medication errors and overuse of antibiotics

14) Nosocomial infections15) Pain control16) Pregnancy and childbirth17) Severe and persistent mental

illness18) Stroke19) Tobacco dependence20) Obesity

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9) Need for nurse clinicians who are also experts in how to implement technology to improve patient care quality

IMPACT ON NURSING EDUCATION:1) Need to educate nurses to assume roles of

A) Chief nursing informatics officerB) Chief nursing clinical informatics officer

2) Advanced practice degree in informatics and certification in clinical informatics

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10) Need for nurse clinicians who are also experts in how to coordinate care

IMPACT ON NURSING EDUCATION:1) Need to educate nurses to assume roles of

A) Care coordinatorB) Nurse Navigator

2) VA ‘Nurse navigator role’ uses VA Nurse-Patient Shared Decision Support Tool

(Source: Holtz,B. et al (2013) A Nurse-Patient Shared Decision Support Tool. AJN(113)1.

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SUMMARY: 10 Selected Major Impacts of Health Care Reform on Nursing Education

10 selected impacts identified; not comprehensiveCheck out ANA resources on Health Care Reform: http://nursingworld.org/MainMenuCategories/Policy-Advocacy/HealthSystemReform

Significant need for advanced practice primary care nurse practitioners not included in presentation

Collaboration between nursing education and nursing practice essential to improve new grad practice readiness to meet the quality and safety needs of patients and families

If you are interested in volunteering to work on AZ Education-Practice Collaborative Task Force, email me: [email protected]

3.1.2013

http://nursingworld.org/MainMenuCategories/Policy-Advocacy/HealthSystemReform

http://nursingworld.org/MainMenuCategories/Policy-Advocacy/HealthSystemReform

mailto:[email protected]


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DropBox

DropBox ‘link’ to access AZ Education-Practice Collaborative Task Force docs:

https://www.dropbox.com/sh/79qvd8u71awjjd4/yebFUkJjlh

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Questions/Comments

3.1.2013

healing community pp, 3.1.13

Health & Medicine

iom nursing education

education practice

health care system

future health care reform

redesigning health care

health care professionals

paulette c compton

health report