ENK October 2004.pdf - Sigma Repository

A Policy of Transformation

This issue of ENK arrives with Jean Scholz RN, MS, as guest editor. Scholz is at the center of FutureThink, a forward-looking program that's directing nursing and health care toward a preferred future. She's a regional leader in policy issues relating to the nursing workforce.

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Nurses Thinking Ahead

The future is a popular topic in nursing conversations these days. Nurses in Ohio have turned talk into action with an ambitious new agenda. It's called FutureThink and it begins with a preferred vision of the year 2013 then brings nurses together to make the vision real.

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To The Future

Jean Scholz sets a course for a better way to experience health care, both for nurses who are taking leadership and consumers who are taking responsibility.

A Health Care Model for the Year 2013>by Jean Scholz

The History of the Future: Creating FutureThink>by Jean Scholz and Scott Beckett

Empowering Nurses as Health Care Leaders>by Scott Beckett and Cathy Day

In Practice

As FutureThink moves from the white board to the clinical units, a series of pilot projects and relationship-building programs were launched. In this series of essays, learn about how a vision of better health care is becoming a day to day reality.

Developing Collaborative Competencies>by Deb McKee

ESP: Enhancing Strategic Partnerships>by Linda Miller and Darla Vale

Creating Healthier Consumers>by Cherie Spragg

Project BRIDGE: Keeping New Nurses>by Karen Gorby

The Question of Consultants>by Jean Scholz

In the Schools

Change begins where nurses start: schools of nursing. In this series of essays, read about how FutureThink is helping to create a framework for change in curriculum, faculty and long-term planning.

Developing a Core Curriculum with FutureThink>by Pam Falasco

Educators as FutureThinkers>by Patricia Martin

Building a Future Pipeline in Nursing>by Jean Scholz

FROM THE EDITOR

This was our goal: Create a forum where nurses could encounter nursing’s best ideas, tested by the challenge of real world nursing. You’re looking at the result. Every month, a new issue of ENK will be shaped by a guest editor whose work deserves a larger audience. These are nurses working in settings where nursing knowledge is directly applied -- where research and reality are engaged in a lively debate.

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Excellence in Nursing Knowledge (ENK) is a monthly online publication from Sigma Theta Tau International.

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Jean Scholz, RN, MSDirector of Health PolicyOhio Hospital [email protected]

Jean Scholz

A Health Care Model for the Year 2013

Complex problems tend to resist simple solutions. That doesn't mean the questions we ask in solving them have to be complex. In fact, the elemental, basic questions are essential first steps in getting past the limitations of short-term thinking. In this essay, ENK guest editor Jean Scholz presents the questions driving FutureThink. Questions like: What should health care look like a decade from now? What can nurses do now to get there? The answers are both goals and starting points in a long journey.

Creating the future is a popular topic in nursing these days. The theme for the 2004 annual meeting of the American Organization of Nurse Executives (AONE) was “Creating the Blueprint of the Future.” Through keynote and breakout sessions, participants were presented with ideas and innovative solutions designed to help nurses create a better way of meeting the needs of health care consumers by focusing energy on creating a preferred future. The Honor Society of Nursing, Sigma Theta Tau International supports this future thinking. Honor society President Dan Pesut, APRN, BC, PhD, FAAN, ushered in the honor society's 2003-05 biennial with his theme “Create the Future Through Renewal.” Through these and other similar initiatives, nurses today are poised to create the change needed to get our health care system to a better place.

As the feature articles in this month's ENK show, nurses in Ohio have not only started talking about creating the future, they have stepped up to the plate to develop and take action on a new agenda for the future of health care delivery. FutureThink, an initiative developed collaboratively by the Ohio Organization for Nurse Executives (OONE) and the Ohio Hospital Association (OHA), presents a preferred vision for the future of the delivery of clinical care for all Ohioans—a creative vision that could help nurses and health care organizations everywhere step out of the here-and-now and think about what the future of health care delivery could be like a decade from now.

2013: One Possible Model for Health Care DeliveryThe FutureThink vision developed by clinical leaders in Ohio provides a powerful and profound way to look at what health care delivery could be within a decade. The following model, set in the year 2013, was designed to help health care leaders consider what 2013 might look like if the strategic objectives of the FutureThink vision are realized. The following model, visualized in the “present” of 2013, and background information will help the FutureThink vision come alive and help readers further understand the intent of the FutureThink strategic objectives.

The year is 2013. Ohioans now maintain physical, mental, and

A Health Care Model for the Year 2013 Page 1 of 5


spiritual well-being through timely prevention and illness services in collaboration with health care workers.Through a comprehensive strategy of putting consumers in charge of their health care and putting health care coaches in place alongside them, consumers have become successful in managing their whole person—mind, body, and spirit.

In 2004, as YMCAs and other community centers were being built across the state of Ohio, few envisioned that these structures would become the place to receive comprehensive health and wellness services. In 2013, however, community resources have been utilized in such a way as to ensure that all persons have access to health and wellness resources. Local disease entity groups such as heart and cancer associations, public health services, churches and other faith-based facilities, human service agencies, clinics, and hospitals have come together to support health and wellness facilities. Consumers have easy access to the comprehensive services offered in these centers, which makes taking charge of their own health very easy. Through partnerships with hospitals, the community centers are able to provide more extensive services through telemedicine services and other technology so individuals can access resources without actually going to the hospital emergency room or clinic. The new health and wellness structures are available in each community and offer a variety of educational opportunities and access to complementary therapies including massage, spiritual leadership, and preventative screenings.

When making a trip to the community center to exercise, the consumer can also get a flu shot or a massage, or consult with his or her health care coach. The health care coach works with the individual to develop a lifelong health care plan. Usually health care coaches are nurses — or what were called nurses earlier this century. Through individual assessment and interpretation of the client's health and personal history, the coach works with the individual to develop a plan that meets the individual's need for wellness or optimal levels of well-being. The community resource centers make it easy for the health care coaches to be accessible to the consumer. Health care coaches, or nurses, are well versed in adult learning principles and have been trained to help consumers manage their behavior to get to their desired healthy outcomes. The coach serves as researcher — accessing the latest scientific findings for the individual — and then as teacher or interpreter to put the information in context for the individual.

Using a personal wellness device, PWD for short, consumers maintain control of their own health care records. The PWD is a personal hand-held device that has become a powerful tool for the consumer. The consumer is in charge of his or her own health records and lab values, pertinent history, physician results, and other vital statistics that are maintained on the PWD. Only the consumer can access the device using a biometric sign-on. Some PWDs have a fingerprint reader for access while others have a retinal-scan device that allows the consumer to maintain the confidentiality of his or her records, releasing them only to those granted permission to access them.

Individuals with chronic illnesses have a much different outlook for the future than they did 10 years ago. In partnership with health care coaches, those who have chronic illnesses take full advantage of available opportunities for illness prevention. Most, therefore, have very few hospital admissions for acute exacerbations of their illnesses.


In 2013, health care teams provide an integrated plan of care using advanced interactive technology and information systems.The PWD is of huge benefit to those hospitals that provide services for the few patients who need acute care. In the year 2013, hospitals are still needed to care for those whose personal wellness plan is not completely successful. When a person does enter the hospital, the patient accesses his or her personal wellness record and transfers that data to the hospital system. Therefore, there is no need for creating a paper file for each patient that enters the hospital. All health information obtained during the diagnosis and treatment of conditions during the hospital stay is sent back to the patient's individual wellness record prior to discharge. Since the individual is responsible for his or her own records and payment of services, the hospital does not retain records.

When a person needs to receive acute-care services, the physician or other admitting professional checks individuals into the hospital using a Web-based system whereby the physician or other admitting professional assigns the appropriate type of hospital room based on the individual's needs. After the individual arrives in the patient room, one of the hospital-based health care coaches works with the patient to develop the plan for the acute care stay. The health care coaches use their ability to think critically, to supervise, and to make autonomous decisions as a full partner in the provision of hospital care. No longer does the patient or hospital staff wait for the physician to start acute-care treatment and services. This greatly benefits the patients served in the acute-care center.

Throughout the hospital stay, the health care team maximizes technology to provide superior care. But much of the care is still hands-on to address the specific needs of patients and tailor strategies to the needs of the conditions. The teamwork does not end when the patient no longer needs acute health care services and is ready to return to his or her home. By recording pertinent information for the patient in his or her PWD, the information is ready for consumers to share with their primary health care providers, including their health care coaches, upon discharge from the hospital. Through the joint efforts of the public health system, there are coaches immediately available to assist the consumer in reaching his optimal level of well-being. Therefore, when the person leaves the hospital, he or she doesn't leave the caring behind.

In 2013, health care organizations are recognized for creating an environment that attracts and retains bright, diverse, and talented individuals.Since care in all health and wellness centers revolves around the individual, there are no hierarchies of caregivers. Each member of the team is an equal partner in assuring that the person gets the health and wellness services he or she needs. It is an integrated care team.

Furthermore, health care coaches and other members of the care team in hospitals focus on holistic-based care for the patient, not task-based services. This makes working in a hospital highly rewarding and interesting. Each member of the team has valuable input into the decision-making, and consultations among coaches and other providers are encouraged.

Since individuals are so much healthier, much of the basic hands-on care is no longer needed. The few members of the team providing the task-oriented care are valuable, however. In addition to providing much of the hands-on care, these caregivers also continually input information into documentation systems for quality control, they evaluate the environment


of care, they evaluate the safety of staff, and they provide other assurances that hospital systems are functioning well. These caregivers take action and find the resources to solve problems and make the hospital function effectively.

In 2013, health professional education programs share a common core curriculum, building collaboration among professionals and integrating students into practice.Ohio's primary and secondary schools now begin education on personal health management early in a student's educational process, beginning with the basic concepts in kindergarten. The education on personal wellness increases throughout the coursework so that by the time high school students take science courses, there is a firm foundation for understanding the science behind personal health. Examples of blood chemistry, acid-base balance, and human movement are incorporated into the student's chemistry, biology, and physics courses. Therefore, when students exit high school, they are well underway to being able to personally manage their own health; they also have an adequate foundation for entering a career in health care.

Furthermore, when high school graduates begin the formal education process to become health and wellness experts, they start the programs with the same academic foundation of physics, anatomy, chemistry, physiology, language, communication, mathematics, and complementary therapies. The general education components foster collegiality among health and wellness experts, as well as respect and equality. Some of the courses are taken in traditional classrooms, but many of the fundamental courses can be taken via distance learning and other interactive telecommunication delivery mediums. After the fundamental courses are completed, health and wellness providers continue to expand learning through mentorships, advance didactic education, distance learning, and alternative learning pathways. The clinical preparation for health care coaches further reinforces the collaboration necessary to work as a health care professional.

Regardless of the next step in an individual's career as a health care practitioner, the collaborative education model preparing health care coaches provides a common, standardized level of education that a person can build upon to meet future demands of an ever-changing health care environment.

It's Happening NowHealth care systems will be very different in 2013 than they are in 2004. This health care model for the year 2013 may seem like science fiction or pie-in-the-sky thinking. Maybe it seems too simplistic? Interestingly, countries around the world including France, Germany, the United Kingdom, Taiwan, and Australia — and even some U.S. cities and states — are using smart card technology to track vital patient information, health care coverage information, and care and pharmaceutical histories, and to eliminate the costly and inefficient paper trail. PWDs are easy enough to imagine for anyone who has used a PDA or one of the new smart phones that do everything from text messaging to photography, and even function well as phones too ( http://www.silicon-trust.com/trends/tr_healthcare.asp ). The smart card technology and current PDAs easily align with the FutureThink health care model for 2013.

Furthermore, nurses have long been making a difference in health and wellness, and in many cases have served as informal health care coaches. In Ohio, nurses in Cincinnati have been credited with saving significant


http://www.silicon-trust.com/trends/tr_healthcare.asp

http://www.silicon-trust.com/trends/tr_healthcare.asp

health care dollars by coaching diabetic patients. Nurses in the Dayton area provide care management for people with asthma in order to keep those patients healthier and prevent expensive hospital care. Nurses naturally gravitate to these roles even now. In 2013, that care will be commonplace.

The Future…Health care continues to change and evolve. Frequently, individuals and groups allow history to map the future. With FutureThink, and other future-thinking projects, we have the opportunity to develop our own future — a preferred future. Although the future might look very different than the model presented here, this model will surely have an impact on what comes next and will continue to stimulate the thinking necessary for forward movement toward the vision for a preferred future.

Author BiographyJean Scholz is Director of Health Policy for the Ohio Hospital Association, where her focus is health policy issues with an emphasis on nursing and the health care workforce. She has been instrumental in establishing FutureThink, a statewide initiative to solve nursing and health care workforce shortages by creating a preferred future for the delivery of clinical care. In 2003, FutureThink was given the American Organization of Nurse Executive's Affiliated Local Group Award in recognition of the work done through the OHA/OONE partnership to advance nursing practice that can serve as a model for other states. Jean also spearheaded OHA's efforts to obtain a $1.2million workforce investment grant which will provide Ohio hospitals with funding to provide health care licensure education for incumbent workers. Jean serves on the Nursing Spectrum Midwest Advisory Board, Ohio 's Universal Newborn Hearing Screening Committee, the Columbus Chamber of Commerce Workforce Leadership Council, the American Hospital Association State Forum on Workforce, and the Arthritis Foundation Board of Directors. Jean has also been active with the Columbus Jaycees and is a founding member of two colleges' of nursing honor societies. In May of 2003, Jean was named as a Robert Wood Johnson Executive Nurse Fellow. Jean was one of 20 nurse executives in the country who were named to the 2003 fellowship program. Other awards Jean has received include the Dorothy Cornelius Congress Leadership Congress Award by the Ohio Nurses Association, Nurse Excellence Award from Riverside Methodist Hospital and Employee of the Quarter, Ohio Hospital Association. Jean earned her bachelor's degree from the Ohio Wesleyan University Riverside School of Nursing and her master's degree from the Ohio State University College of Nursing.




Scott BeckettThe Rosenberg GroupLaguna Beach, California [email protected]

Jean Scholz

History of the Future: Creating FutureThink

When nurses take ownership and express leadership, good things happen. We see it in short-term decision-making, and even when the goal is more ambitious. In this essay, ENK guest editor Jean Scholz and consultant Scott Beckett offer you one possible road map as you envision the long-term future of health care, and of nursing, in your region, state, or hospital.

Where We StartedIn 1998, the Ohio Hospital Association was at a crossroads. It had been quite successful in fulfilling the needs of its members through effective lobbying at the state and federal levels, but the board of directors and staff of the association knew that there was more change the organization needed to effect. With the support of The Rosenberg Group, a leading consulting firm in organizational transformation and corporate effectiveness, the OHA set about designing and implementing a future for Ohio's hospitals that was to be a future from the future, not an extension of the past.

Through the dedication and innovation of the 45 OHA staff members and the leaders of Ohio's 170 hospitals, OHA developed a vision for the future of health care delivery in the state of Ohio. The OHA's work on developing the vision and working on the strategic objectives took the organization and its members into completely new realms of effectiveness.

The OHA's work to date has produced some amazing results. Ohio's hospitals are being recognized for leading the way in the state and local cities and towns. Last year hospitals were spared funding cuts in the face of a $4 billion state budget shortfall that impacted every other state service. The OHA worked to impact tort reform by helping to get elected two state Supreme Court justices. Vacancy rates in Ohio's hospitals are far lower than the national average. Moreover, the OHA is bringing to the table groups, constituencies, and individuals in a way that has heretofore never been realized. These parties are engaging in meaningful dialogue and working together in whole new ways to cause the transformation of health care in Ohio. With the creation of a vision for a preferred future, OHA began to transform health care in the state of Ohio by innovative, unpredictable means. Rather than trying to strong-arm others to agree with OHA's positions and initiatives, the association

History of the Future: Creating FutureThink Page 1 of 6



Scott Beckett

began to engage the people of Ohio in an entirely new conversation about health care.

Creating FutureThinkOne of those conversations OHA developed was related to the creation of health care centers that had no workforce shortages. Made up of hospital representatives including CEOs, CNOs, staff nurse representatives, human resource executives, and a public affairs specialist, the OHA Workforce Work Group was charged with developing specific short-term goals for achieving the OHA's objective to attract and retain talent. While some Ohio hospitals relied on the typical short-term strategies for overcoming nursing shortages — paying sign-on bonuses, increasing wages, and consideration of the hiring of foreign nurses — the Workforce Work Group designed strategies to make Ohio hospitals attractive environments in which to work.

However, the OHA Workforce Work Group knew that if long-lasting change was the goal, then changes must be made to affect the way care is delivered. Furthermore, this group knew the potential that the convergence of the number of nurses retiring, the shortfall between the need for nurses and the actual number of student nurses, and the aging of the baby boomers would create a serious crisis for the health care delivery system in Ohio in about 2010. Therefore, changing the dynamics of the workforce shortage and attracting and retaining talent required the group to consider how to develop new models for delivery of care and to consider new ways of providing health care services that were less labor intensive than existing models. Based upon the successes, staff considered if a similar type of designed effort could bring about long-term solutions to the nursing and health care workforce shortages felt by hospitals and other health care providers in our state.

In leading its members toward success, the OHA staff realized that the group did not have the expertise within the OHA staff structure to design the hospital of the future; it was decided to consult those with clinical care expertise to explain how a health care delivery system of the future should be designed.

Partnering With NursesAlthough the Workforce Work Group had shown leadership in developing strategies to attract and retain talent, the membership was not representative of every part of the state. As many of the group members did not have clinical expertise, it became obvious that this expertise would need to be found outside the group in order to design a preferred future for the delivery of clinical care.

The most logical group to fill this need was clearly nurses. Nurses are by far the largest critical mass of health care providers in hospitals, and they are health generalists who provide care to patients around the clock. Furthermore, nurse leaders are the primary managers and administrators with oversight of most of the clinical care delivered in Ohio hospitals. Developing nurses as the


leaders of FutureThink was a natural fit and a key to the success of the FutureThink effort. The Ohio Organization for Nurse Executives (OONE), a personal membership group affiliated with OHA, became a natural partner to provide the structure, leadership, and contacts, as well as the backbone for developing focus groups and getting input into creating the preferred future.

The partnership with OONE allowed the work group to design focus groups all over the state of Ohio with leaders of the OONE chapters serving as hosts and organizers. More than 300 staff nurses, nurse executives, nurse educators, and hospital administrators participated in the 12 focus groups held around the state.

During the focus groups, participants were asked to describe what they thought would happen to health care by the year 2013 if changes were not made to alter the current course. The majority of the predictions were gloomy: decreased access for Ohioans to get appropriate health care, worsening shortages of nurses and other health care providers, dissatisfaction of patients, and other issues that did not describe an optimistic, innovative future for the delivery of clinical care.

Participants were then asked to describe how they would like to see health care in the year 2013: What would make them excited to go to work? What would make health care truly satisfying for their communities and the patients they served? How could the health care system deliver patient care that is far superior to current practices?

From within these answers, the group heard many stimulating ideas surrounding technology, partnerships between health care providers and consumers that would improve the health of each person, flexibility and collaboration among health care workers in how they are educated and practice, and making the patient care delivery system easier for nurses and staff to work in. The ideas that came from the focus groups were innovative, full of imagination, and enriched with the broad base of experiences the focus-group participants represented.

Designing the FutureThink VisionCreating a vision to direct us toward the preferred future for the delivery of clinical care was no easy task. Taking some 1,000 ideas from the focus groups and turning them into something innovative, stimulating, and challenging was the work of the design team. The design team maximized the talents of nurses and nurse executives and then added a physician, a hospital CEO, and the dean of a school of nursing in order to broaden the perspective to outside of nursing and nursing administration. Age groups were well represented, including two people under the age of 30.

The design team was a phenomenal success. It created a powerful, highly motivating vision statement for the future of health care delivery in Ohio:


The state of Ohio recognizes health is more than the absence of illness. All Ohioans have access to care, which assists them in achieving their optimal being. Ohioans are informed, motivated and personally accountable to actively participate in maintaining a healthy lifestyle, just as health care providers are accountable to Ohioans. The health care workforce is inspired and educated to be part of a care delivery model that promotes collaboration, respects the contributions of different caregivers, and utilizes integrative technology. This model attracts bright, diverse, and talented individuals to serve our population.

Along with this challenging vision statement, the design team developed five strategic objectives to serve as milestones in building the preferred future for the delivery of clinical care. Points on the road map included creating roles for health care workers to partner with consumers for healthier outcomes, maximizing technology to reduce the burden on the health care workforce, creating collaborative teams through a core educational curriculum for all health care workers and reducing the regulatory burden that takes people away from delivering care.

FutureThink Strategic Objectives:

● Ohioans maintain physical, mental, and spiritual well-being through timely prevention and illness services in collaboration with health care workers.

● Health care teams provide an integrated plan of care using advanced interactive technology and information systems.

● Health care organizations are recognized for creating an environment that attracts and retains bright, diverse, and talented individuals.

● Health professional education programs share a common core curriculum, building collaboration among professionals and integrating students into practice.

● Health care professionals and organizations demonstrate financial and clinical accountability directly to the citizens of Ohio.

Continued Nursing Leadership Using the FutureThink vision and strategic objectives, OONE chapter presidents were asked to lead the development of a regional pilot project that aligned with the FutureThink vision and addressed at least one of the strategic objectives. The purposes of the pilot projects were threefold: 1) to demonstrate successes with movement toward the preferred future, 2) to develop nurses as leaders with skills to carry on conversations about the preferred future, and 3) to strengthen and develop the OONE chapters.

Through leadership intensives led by Scott Beckett of The Rosenberg Group, the nurse executives learned a variety of concepts to help them lead their projects. Included in the


leadership intensives were topics such as:

● Ways of operating to create success ● Project formulation ● Enrollment of leaders in the pilot project ● Handling breakdowns ● Coaching others ● Conversation for leadership ● Recipe for accomplishment

What's Next?FutureThink has already delivered a return on the investment. First of all, FutureThink has provided a showcase for the role of nurses as leaders. Nurses are powerful thinkers and are poised to be essential partners in the creation of a preferred future for health care delivery in Ohio. Even though saddled with burdens in their own hospitals, nurses have shown their commitment to their communities, their profession, and the health care industry, and they have driven innovative and collaborative pilot efforts that are leading Ohio toward the FutureThink vision.

FutureThink has also showcased the power of bringing people together to discuss and create possibilities. The FutureThink pilot projects have designed collaborative curriculums for health care education and have addressed the needs of new nursing graduates as well as the health education of children in middle schools. Hospitals have come together to design an effort to reduce regulatory burdens for implementing new computerized order entry technology. Two years into the effort, FutureThink has achieved national recognition from the American Organization of Nurse Executives (AONE) and the Voluntary Hospital Association (VHA). In addition, Ohio hospitals have seen a decrease in vacancy rates and a leveling off of turnover. OHA and OONE are bringing to the table nurses, consumers, constituencies, and groups in a way that was not realized before FutureThink. These parties are altering and transforming their thinking and engaging in meaningful actions to transform health care in Ohio.

The FutureThink future depends on a myriad of people and organizations joining together to revolutionize the health care system. A significant next step toward creating the FutureThink future is the development of a FutureThink Institute that will formalize the agenda and continue to bring people together to create health care leaders. This institute will be designed to continue the progress toward the FutureThink vision for the year 2013 and will develop projects that align with the FutureThink strategic objectives. The institute will provide the structure to share best practices and new ideas about reaching the preferred future. With the end in mind, the institute will work backwards to design strategies for continued progress on creating a future where workforce woes are a thing of the past.


Scott BeckettPartnerThe Rosenberg GroupLaguna Beach, California [email protected]

Cathy Day, RNC, MSNDirector of Med/Surg/OB/OncologyCommunity Hospitals of Williams CountyBryan, [email protected]

Scott Beckett

Empowering Nurses as Health Care Leaders

FutureThink's leaders recognized immediately that nurse executives at hospitals across the state were essential drivers of change at the center of the initiative. Unfortunately, until recently, nurse executives were not well known for their leadership outside of their individual organizations. Read about how that reputation is changing for the better across the country and how Ohio leaders are continuing to take steps to improve nursing leadership in that state.

To lead FutureThink in a meaningful way, Ohio Hospital Association (OHA) leaders recognized that nurse executives needed to be trained and practiced in leadership in a completely new way. It was believed that giving these executives more courses in the traditional leadership development notions was not going to make much of a difference. FutureThink's leaders asked The Rosenberg Group to support the development of the nurse executives to move FutureThink forward in a meaningful way.

More than six months ago, The Rosenberg Group met with the participants for three highly interactive workshops. At the first workshop, The Rosenberg Group began by building a foundation from which the nurse executives could begin to transform their relationship to their roles and transform themselves into leaders committed to causing the unpredictable in their hospitals and across Ohio. Participants learned new models for leading in situations in which the focus was less upon what were the right things to do and more on creating the context for causing something beyond the predictable.

By the end of the first workshop, the participants had designed a FutureThink project. The project had a few unique characteristics. First, the project had to be something that the nurses could not accomplish on their own; it must involve others from the community and state. Second, it must be something that made a real difference. Lastly, the project was not to be about solving some sort of problem, like nurse staffing, rather, it was to begin the 10-year commitment of FutureThink—create a new model for clinical care and have it be practiced throughout Ohio. The request that the nurse executives develop a pilot project was based on the notion that leadership skills would be developed as the nurse executives worked on leading an effort. Furthermore, the pilot projects were designed to be completed in 12 to 18 months, and to create successes that would stimulate and inspire the next level of projects that would take the initiative to the vision for the year 2013.

Having been left in action at the completion of the first workshop, the participants returned five weeks later for the second workshop. Now with

Empowering Nurses as Health Care Leaders Page 1 of 3



Cathy Day

some real results under their belts and having had the opportunity to put into practice what had been learned at the first workshop, participants were educated in a language of leadership designed to produce new results; they were educated in a methodology for enrolling others in possibilities beyond the common, ordinary ways of working, with the goal of accomplishing those things previously written off as too difficult or even impossible. Participants were trained in a technology for formulating and building true teams of people to produce something beyond the ordinary.

Built upon the first two workshops as well as the experience of leading a pilot project for several months, the third workshop was held five months later. The focus of the third leadership intensive was to provide the nurse executives tools to design a FutureThink pilot project within each of their hospitals. In partnership with their chief executive officers, the nurse and hospital leaders learned to see the future of design. These partnerships supported the concept that the continued development of nurse leaders is contingent upon nurses considering how they can design their future and then develop the confidence to fulfill the future they've designed.

Using the techniques demonstrated in the final FutureThink leadership intensive, one participant from a small rural hospital was particularly successful. Learning strategies and techniques associated with creating a preferred future, rather than a predictable future, enabled her to take the technology taught in the workshops and lead an exercise that ultimately resulted in the development of a plan that will take her hospital down a path to technological innovations and the development of electronic health records. Even though the budget is tight and the resources and expertise are limited, the staff of the hospital created a challenging yet exciting vision for technological advances and is now implementing steps to get there.

Reports from participants of the leadership intensives indicate the significant impact the sessions had on the nurse leaders. Rather than focusing on maintaining day-to-day operations, nurses in the leadership intensives learned new communication techniques to handle those health care professionals who are frustrated with the current health care environment. After completing the leadership intensives, nurse executives were able to create dialogue using statements such as, “Let's discuss the possibilities, no matter how far-fetched some may seem.” Using these strategies for considering possibilities, others soon began to participate in the conversations and realize it is actually fun to think outside the box.

With so much of today's patient care directed by regulations and laws, nursing leaders may feel they have little or no influence on the process and outcomes of health care. Participating in those “possibility” conversations helps to plant the seed that puts nurses in control of their futures, if they so choose. When a leader feels a sense of control, she or he has the confidence within to make great things happen.

The leadership intensives gave nurse executives tools for empowering themselves and others in the face of the difficult and trying circumstances in which they often find themselves. By the end of the workshops, nurse leaders had the tools to successfully complete their FutureThink projects and cause results that, three months earlier, would not have seemed possible. In Ohio, nurses are recognized as leaders who have made the choice to “create our future” instead of letting our future control us. It is through the simple act of communication that this has been made to happen.


Author BiographiesCathy Day. Cathy Day is a nursing director for Community Hospitals and Wellness Centers, Bryan, Ohio. Cathy is a member of Sigma Theta Tau International; the Ohio Organization for Nurse Executives; the American Organization of Nurse Executives; the American Women's Health, Obstetrics, and Neonatal Nursing (AWHONN); and Northwest State Community College Nursing Advisory Board. Cathy has been an executive board member for the Ohio Organization of Nurse Executives since 2000. Cathy is certified in inpatient obstetrical nursing and serves as an instructor for neonatal resuscitation and the University of Virginia perinatal program. Cathy received her associate's degree in nursing from Owens Community College, Toledo, Ohio. She earned her bachelor's degree in nursing from Medical College of Ohio/Bowling Green State University, and her master's degree in nursing from The University of Phoenix.

Scott Beckett. Scott Beckett is a partner with The Rosenberg Group, a global management consulting firm specializing in organizational transformation and corporate effectiveness. Scott's practice is in getting teams and groups to be able to produce results beyond that which they can deliver on their own. His work in the health care industry has made a dramatic impact on the success, teamwork, and results of many hospitals, associations, and initiatives. Scott is based in The Rosenberg Group's Laguna Beach, California office.



Deb McKeeVice President, Patient ServicesJoint Township District Memorial HospitalSt. Marys, [email protected]

Deb McKee

Developing Collaborative Competencies

The road to a preferred future is built by collaboration, especially between nurses in education and service. That included arriving at a common way to talk about goals. Read about how this nurse executive used a FutureThink pilot project to enhance her own leadership skills.

Learning to Lead TogetherWork in West Central Ohio towards creating a preferred future for the delivery of patient care has been all about collaboration. West Central Ohio's FutureThink project began on March 4, 2003 at the statewide meeting held in Columbus , Ohio . Our region, which is made up of rural counties along the central Ohio Indiana border, was well represented at the meeting with participants from hospitals as well as from our education partner, Rhodes State Technical College . Since the intent of the statewide FutureThink summit was to kick off the development of regional pilot projects, the region seemed to be off to a good start. Collaboration was certainly possible since there was good representation of both education and service.

After discussion at the kickoff meeting, the West Central region came to consensus around the FutureThink strategic objective that health professional education programs share a common core curriculum, building collaboration among professionals and integrating students into practice. When the FutureThink design team developed the FutureThink vision, their thinking was that streamlined and transportable education for students entering health careers would decrease the current burdens students faced when trying to get through health care programs. The strategic objective also addressed the development of a core curriculum for all disciplines that would introduce a care delivery model in which all of the care team professionals understood and practiced collaboration, respecting the unique contributions of each. That piece of the vision resonated with the group for a variety of reasons. Because we had our education partners there at the regional breakout; it seemed logical to consider an effort that could easily involve them. Furthermore, because one of the members of the education team who was present at the meeting had been a respiratory therapist prior to becoming the vice president for academic affairs at Rhodes State , the strategic direction of collaboration among professionals seemed to be on an even stronger footing.

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Goals and DiscoveriesAlthough we had a good start to a collaborative effort after the FutureThink statewide summit, it took our team much longer than we had hoped for to galvanize the group and develop specific goals. In addition, the team did not solidify after the initial kick off meting. Three nurse executives and representatives of various levels of local health education programs — vocational, associate and baccalaureate — began work on the common core curriculum objective. Initial plans for intended outcomes included educating and training students of nursing and allied health programs together as much as their individual curriculums would allow. Obtaining funding for our project was the second intended outcome.

When the right individuals became a part of our taskforce, after a retirement of one of the educational partners and the addition of other members to the team, we quickly learned that one of our major producers of graduates in the associate degree nursing and allied health professionals programs already had a common core curriculum. That knowledge was a breakthrough for our efforts.

Language Matters Students in the allied health programs at Rhodes State took many of the pre-clinical courses together. However, the nurse executives on the task force were not seeing collaboration when the students attended their clinical experiences. The nurse executives had a different paradigm about the need for a common core curriculum as well as what it could do for practice. The vision of the nurse executives had been about the need for collaboration among the care team, hoping that education prior to employment would facilitate the collaboration. But that was the catch. The educator's paradigm was that the educational curriculum was not the place for developing collaboration; rather, they believed, it was really at the point of clinical training at the hospital during the clinical learning experiences. It was at that point in our work that the language changed from education to training , and this training needed to occur during the clinical rotations of the students. Creating the paradigm shift for the nurse executives created a breakthrough for the West Central Pilot Project, and it was then that true collaboration was born between education and service.

Building on ExperienceEven though the West Central chapter of FutureThink initiative did not meet the first deadline, the accomplishments attained will carry us forward for completion of our taskforce project, along with any needed projects in the future for our region. We are currently working on the development of a course to offer to associate degree graduates, post obtainment of licensure, that will include components of both a didactic lecture and clinical practicum. This course will be taken by nurses and allied caregivers. With this course; collaboration will be built within the settings where future nurses and allied caregivers will practice.


To accomplish the next steps of the West Central's regional project, a grant proposal is being developed to request support for a pilot study of the care delivery model to measure outcomes related to collaboration, respect within the care team professionals and integration into practice. The pilot study results will then be used as a model for the Ohio Board of Regents as well as for regions of the state wishing to build a model for collaboration of health professionals early in their careers. The funding for such efforts will be related to both the development of a curriculum the support of a pilot program.

Lessons learned as a facilitator include emphasizing the need to clearly communicate intended outcomes. Words have different meanings to different professionals — such as education and training. Planning and collaboration within differing institutions may take longer than typical project planning timelines developed for a single institution. Being open to the possibilities of a project, rather than being determined to accomplish a preset strategy, can save time in the long run and open up the potential for a real breakthrough with problem solving. Therefore, the next lesson learned is that it's wise to create a reasonable timeline that allows relationships to be formed and possibilities to be considered. Lastly, the use of storytelling will improve communication when mere terms and concepts cannot.

Reflections on LeadershipAs a nurse executive, the participation in this FutureThink taskforce of West Central Ohio has challenged me in my role as a leader. Leading like-minded individuals, as I do every day in my role, could be considered coordinating rather than leading. The West Central Ohio's FutureThink task force is not a group of like-minded individuals. Instead, it is a group of leaders who are passionate about creating solutions to workforce shortages. Leading this group, which includes various types of professionals outside of clinical care, toward a common goal has helped me develop a necessary skill set that's important for all successful nurse leaders. In fact, this skill set will be needed for all health care professionals and leaders who want to inspire the creation of a future in which all members of the team are valuable and their skills and abilities are maximized in order to create a better work environment for both patients and health care providers.

There is much work to be done towards improving the health care system in our state and in our nation. One way to get started is through the collaboration of a variety of stakeholders. Participating in this FutureThink initiative has, in a small way, allowed me to appreciate and have hope that with true collaboration we can be exponentially successful in the work that lies ahead. Author BiographyDebra McKee is vice president of Patient Care Services at Joint Township District Memorial Hospital in rural Northwest Ohio. As the regional representative for the West Central Chapter of the Ohio Organization for Nurse Executives (OONE) and a member of the FutureThink design team, she has been a part of this statewide initiative from its inception. She currently serves as president of


OONE. Debra is also a board member of the Lima Area/Medical College of Ohio Health Education Center, which has the mission to improve the supply and distribution of health professionals through community and academic partnerships. A graduate of Christ Hospital School of Nursing, Debra earned her BSN from Bluffton College and her master's in health service administration from St. Joseph 's College.



Linda Miller, RN, MSNVice President, Patient ServicesThe Jewish HospitalCincinnati, [email protected]

Darla Vale, RN, DNSc, CCRNChairperson and Associate ProfessorDepartment of Health SciencesCollege of Mount St. JosephDarla [email protected]

Linda Miller

ESP (Enhancing Strategic Partnerships)

As FutureThink envisions a preferred future, it draws on programs and ideas that are working right now. Read about how nurses and educators in the Cincinnati area are collaborating to raise enrollment and enhance capacity in clinical education.

The Ohio Hospital Association (OHA) and the Ohio Organization for Nurse Executives (OONE) are leading an effort to create a preferred future for clinical care in Ohio. This initiative, called “FutureThink,” is comprised of a shared vision statement and five strategic objectives. The vision and strategic objectives are a result of collaboration among regional health care leaders across the state. Each region of health care professionals is addressing a strategic objective that pertains to challenges in its area.

In the southwest region, the Greater Cincinnati Health Council Nursing Workforce Initiative and the Greater Cincinnati Nurse Executives are working toward the FutureThink strategic objective that states: Health care organizations are recognized for creating an environment that attracts and retains bright, diverse, and talented individuals. The creation of positive work environments in the Cincinnati area is contingent upon getting an adequate supply of registered nurses working in the area and reducing the vacancy rate in the area's hospitals.

High Vacancies in the Midst of Growing Interest Health care institutions and nursing colleges around the country are searching for creative solutions to increase the number of registered nurses in response to the growing nursing shortage. Budgetary constraints, a limited pool of nursing school faculty, insufficient clinical sites, and a lack of scholarship monies have all been identified as barriers to expanding student capacity and meeting the projected demand for nursing care (AACN Issue Bulletin, 2002). The nursing shortage in the greater Cincinnati area mirrors the national dilemma. The Greater Cincinnati Health Council 2003 Vacancy Survey showed a vacancy rate of registered nurses in hospitals to be 17%. This is up from 16% from 2001 (2003 Vacancy Data Released).

The hospitals in the Greater Cincinnati Health Council rely on the 18 registered nursing programs in the TriState region to provide

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mailto:Darla [email protected]

Darla Vale

new nurses. While a past problem was the lack of qualified students, the current situation is just the opposite. Nursing programs cannot keep up with the recent increase in interest in enrollment in nursing programs . There were waiting lists reported for admission to clinical courses in almost every nursing program for the fall semesters of 2003 and 2004. A study by the Greater Cincinnati Health Council (2003) showed the primary barrier to expansion in nursing programs is the lack of qualified faculty.

To overcome this obstacle for expansion, nursing leaders from the Nursing Workforce Initiative and the Greater Cincinnati Nurse Executive organization came together and developed a proposal called “ESP — Enhancing Strategic Partnerships.” The goals of the project are to increase the capacity of nursing programs and support the clinical experience of students.

Measurable outcomes of the project include:

● Increased enrollments in nursing programs ● Hospital staff serving as clinical faculty ● Students having a satisfying clinical experience ● Increased applicants at hospitals from new graduates ● Decreased hospital RN vacancy rates

Pilot: Identify Partnership Models That Are Working The partnership project is a long-term collaboration. The project began with a six-month pilot project designed to: identify best practice partnership models that can be implemented in the TriState region, build mutually trusting relationships between clinical partners and education, establish clear communication paths between partners, and create a shared vision of the benefits of cooperation.

The members of the committee looked in the literature to identify best practice models. We also sent out a survey to see what types of partnerships were already underway in the area. A variety of arrangements were being made, ranging from one health care system paying the salary of a full-time faculty member in a nursing program to another health care institution housing all the classes for the nursing program. However, the arrangements that were in existence to support these models did not have any data to evaluate the outcomes of the arrangement. Thus, the ESP committee developed four tools to assess satisfaction of the constituencies that would be involved in our project — the nursing students, clinical faculty, hospital administrators, and education administrators.

The requirements for nursing faculty in the state of Ohio were reviewed, and one hospital nurse executive offered to recruit a clinical educator who qualified to serve as a clinical faculty member for a BSN nursing program. The clinical educator's role would be to supervise the students at the hospital where she worked in order to enhance the students' education and potentially recruit the students for that facility.



The first semester in the project was a learning experience. The clinical educator experienced role conflict because nurses would page her while she was teaching clinicals and ask her to do things for her clinical educator role. The clinical educator felt pulled in too many directions at times, and the students felt neglected. The clinical educator was also learning new forms for student evaluation and experiencing the challenges that sometimes come with teaching college students. Communication between the college and the clinical educator was primarily done via phone or e-mail to save time, but the clinical educator did not feel “a part” of the faculty.

At the end of the first semester, the participants evaluated the experience. All parties were very supportive of continuing the project. A few changes were made for the next semester. The clinical educator became more comfortable at setting boundaries with her dual roles, and the education chairperson and faculty made a greater effort to enhance communication and visit the clinical site. The clinical educator gave a guest lecture at the college so students could also see her in that role, and the educator learned more about the entire program.

Progress in Key Areas This partnership arrangement has continued for three semesters, and the results continue to improve. Another hospital joined the project, so we are now able to collect data at two different hospital sites. The administrators and educators are committed to this partnership arrangement. Although this arrangement has been in existence for only a short time, some outcomes have already been met. Below is a list of the outcomes achieved thus far:

● Enrollments in nursing programs increased: The nursing program was able to accept 16 more students (two clinical groups) into the program due to the two extra clinical educators.

● Hospitals have staff serving as clinical faculty: The clinical educators think this clinical faculty experience is an important part of their role.

● Students have a satisfying clinical experience: While students continue to identify ways that the hospital staff could improve, they were very positive about the clinical educators and rated the question, “It was beneficial to have an instructor who was employed by the hospital” as an overall 3.8 on a 4-point scale with 4 being “strongly agree.”

● Hospitals have increased applicants from new graduates: This has not happened yet. We had only one year of graduates since the partnership began, so this outcome may take more time.

● RN vacancy rates in hospitals decrease: The rate has decreased slightly over the last year, but the influx of nurses does not seem to be related to this project.

An added benefit from the partnership arrangement has been the


increased collaboration between the clinical and educational nursing groups. With the hectic roles nurse leaders have, there is limited time to share what is happening in each others' institutions. These meetings have provided opportunities to discuss strengths, challenges, needs, and so on, and to brainstorm solutions. Trust, understanding, and mutual respect continue to grow through this process.

Looking Ahead While the program is going well, some suggestions have been made. Below are some suggestions for the future:

Burnout: A joint position is difficult, as the busy person always “serves two masters.” Clear delineation of roles is important, with opportunities for the clinical educator to step out of the teaching role for a semester during busy times at the hospital. Fortunately, the college schedule does allow for blocks of time between rotations so the clinical educator can get a break every few months. The clinical educator may choose to sit out a semester during especially busy times at the hospital.

Consistency: Having a consistent clinical educator for the program has enhanced the experience for the nursing students. Each semester the evaluations from the students have continued to improve. The clinical educators know more of what to expect from students and how the course they are teaching fits into the curriculum, and they are more experienced in responding to the challenges of teaching.

Payment: The college administrator is interested in the hospital absorbing some of the cost of the clinical educator. Currently the college pays the hospital the same amount of money that the college would pay a part-time faculty member. If the hospital absorbed part of the cost, the college could free up a faculty member to visit the clinical sites and communicate with the clinical educators on a more consistent basis. However, the hospital administrators have a tight budget, so this is still being negotiated.

Co-op Program: More than 80% of co-op students continue working at the place of employment after graduation, as shown by alumni surveys. The partnership program between the hospital and college may see additional recruitment if a nursing co-op program is added to the partnership between the hospital and college.

The OHA and the OONE offer a tremendous amount of ongoing support and encouragement for this project. While this ESP program is still in its infancy, the outcomes look promising. Problems with the nursing shortage will not be solved in isolation. Continuing collaboration between education and clinical partners can help to build student capacity and assist in meeting mutual needs in our community.

References


American Association of Colleges of Nursing Issue Bulletin (2002). Using strategic partnerships to expand nursing education programs.

2003 Vacancy Data Released, (2003). The Digest. Greater Cincinnati Health Council, 35(3), 5.

Greater Cincinnati Health Council (2003). “Survey of RN-preparatory nursing school programs in the Cincinnati tri-state area," unpublished study.

Author BiographiesLinda Miller. Linda Miller is the chief nursing officer for The Jewish Hospital, a 200-bed community hospital in Southwestern Ohio. She became involved in the statewide FutureThink initiative by virtue of her position on the board of the Ohio Organization for Nurse Executives (OONE). Linda is the Past President of the Greater Cincinnati Nurse Executives and is currently leading the Southwestern Ohio project “Enhancing Strategic Partnerships”—a collaborative effort between local hospitals and schools of nursing. In 2003, Linda received the “Distinguished Nurse Administrator” award from the College of Mt. St. Joseph. She received both her bachelor's and master's degrees in nursing from the University of Cincinnati College of Nursing and Health.

Darla Vale. Darla Vale is Chairperson and Associate Professor in the Department of Health Sciences at the College of Mount Saint Joseph . She alsO continues her clinical practice in the Coronary Care Unit at a local hospital. Darla earned her BSN from Morningside College in Sioux City, Iowa, her MSN from the University of Texas Medical Branch in Galveston, Texas and her DNSc from Rush University in Chicago, Illinois.



Cherie Spragg, RN, MEdVice President, Nursing ServicesFisher-Titus Medical CenterNorwalk, [email protected]

Cherie Spragg

Creating Healthier Consumers

Nurses are overcommitted right now, and the nurses of FutureThink are no different. Those commitments are obstacles, but they are not insurmountable. Read about how one FutureThink pilot project found its focus through fits and starts, then set a course on creating healthy consumers, one child at a time.

North Central Ohio Organization for Nurse Executives (NCOONE) is comprised of nurse executives from 13 hospitals of varying sizes, including large medical centers, rehabilitation hospitals, and critical access facilities. The North Central chapter encompasses a large geographical area in the north central section of the state.

Several nurses, including nurse executives, hospital CEOs, and staff nurses participated in our region's focus group meeting held in June 2002. The focus group was the beginning of our region's FutureThink journey. More of our leaders attended educational programs to develop a FutureThink pilot project, including the FutureThink summit held on March 4, 2003, in Columbus, Ohio. That is where our pilot project began. Our group, along with the other regional groups across the state, was asked to develop a pilot project that would meet the following conditions:

1. The pilot project aligns with the FutureThink vision and one or more of the FutureThink strategic objectives.

2. It can be completed within six to 12 months. 3. The pilot project is big and unpredictable. Unpredictable

means that the project would not have happened had you not worked on a FutureThink effort.

With a discussion of the interests of the participants and a review of the FutureThink strategic objectives, we had a discussion of possibilities, and our nurse executive group focused on the FutureThink strategic objective that stated: “Ohioans maintain physical, mental, and spiritual well-being through timely prevention and illness services in collaboration with health care workers.” This objective spoke to our commitment to our community's wellness. Since our region is comprised of mostly smaller hospitals, and even a few critical access hospitals, and also due to the fact that we have had many successes with wellness initiatives in our region, this FutureThink strategic objective was a natural choice.

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However, this is when our first roadblock was identified. Although the group was very interested in wellness, it had a very wide scope of interest in the topic, which made it very difficult to obtain commitment to a single project that could impact our community. Even though we had diverse interests, as a group, our pilot project group was finally able to form the initial goal of identifying preschool age children who were at risk for the development of obesity.

We then started with a community assessment and targeted providers of early child care. Each nurse executive interviewed day care providers within her or his hospital or facility's service area. Five very basic questions were asked in the survey:

1. Do you provide any nutritional education to the children? 2. What are the state requirements regarding nutrition and

exercise? 3. Do you provide a structured exercise program? 4. Does your facility allow parents to provide lunch? If so, do

you supplement to meet requirements? 5. As a day care provider, what are your thoughts about

childhood obesity? What have you seen at your facility?

By using these questions as guidelines for doing the community assessment, nurse executives in our chapter had the chance to get to know a potential community partner—their day care providers. During the interview process with the day care providers, no longer were nurse executives considered just nurses; they became recognized as being hospital leaders by those in the interviews. Furthermore, the nurse leaders also provided basic staff education about nutrition and exercise as needed.

Developing a relationship with day care providers was a definite success of our FutureThink pilot project. The development of relationships with day care providers certainly met the intent of being “unpredictable” or of creating something that never would have happened had our nurse executives not begun a FutureThink pilot project. FutureThink created outreach from our hospitals to day care centers, building bridges for future community collaboration on health and wellness issues.

However, based on our assessment of the community day care providers, we soon identified that the preschool child in a controlled environment was not the appropriate target population for our focus of reducing obesity. Instead it was noted that the risk factors begin to develop when children became school age. With the change in the target population, the group needed to refocus its attention on elementary schools, not on day care providers. Although this change might seem minor, it had the effect of creating another roadblock—a lack of time on the part of the nurse executive leadership. The lack of time committed to the project seemed to snowball into lack of commitment for the project overall, and the commitment to the project was fading due to a


variety of factors.

As the project moved into the spring of 2004, the group as a whole had lost commitment, except for one hospital that elected to continue to work toward the development of a program for at-risk school-age children. This was my hospital, and I became the champion of a project that interested not only me but the rest of my nursing leadership group who share a passion for community wellness.

The project at this point includes the development of a nine-week program for children in third, fourth, and fifth grades. The program includes an educational curriculum and an exercise curriculum. Our hospital has worked with the pediatricians, family practice physicians, and emergency department physicians to gain support for the identification of children at risk who would benefit from the education and exercise program. In addition, we have collaborated with the local recreation center to provide a setting for the program, and that has proven to be very successful. The core group is now in the process of securing a grant for funding of the program. The program is slated to start in early 2005.

In summary, there were two key factors to getting this FutureThink pilot project developed: having committed conversations and looking at the possibilities. I was able to have committed conversations with my peers by speaking of my commitment to wellness. By speaking of my commitment, I was able to enroll members into a team and begin development of the project with others who shared that commitment. In addition, having conversations for possibilities was very helpful in getting the group to stretch its imagination to develop the project. But, obtaining commitment from other members from the chapter of nurse executives—who are spread apart over a wide geographic area and have many competing commitments—was probably the most crucial, as well as limiting, roadblock we faced.

As we move toward the vision of FutureThink, where health is more than the absence of illness and where our citizens are informed, motivated, and personally accountable to actively participate in maintaining a healthy lifestyle, I am reminded of a saying from John F. Kennedy. President Kennedy once said, “Our task is not to fix the blame for the past, but to fix the course for the future.” Through FutureThink, I have had the opportunity to help develop the course for Ohio's future by creating healthy Ohioans, which is an essential element to get us at the bigger FutureThink vision of creating a preferred future for the delivery of clinical care.

Author BiographyCherie Spragg is the vice president of nursing at Fisher-Titus Medical Center and the president of the North Central Ohio Organization of Nurse Executives. Over the years, Cherie has directed several hospital-wide clinical performance improvement projects and has been active on several community boards. In the past year and a half, Cherie has been a driving force in the


development of North Central Ohio's regional, organizational FutureThink project that focuses on childhood wellness for children at risk for the development of obesity. This FutureThink study will be piloted at her facility. Cherie is a graduate of Kent State University and earned her master's degree from the University of Toledo.



Karen Gorby, RN, MBA, FAACHEAdministrative Director of Surgical ServicesKettering Medical CenterKettering, Ohio

Karen Gorby

Project BRIDGE: Keeping New Nurses

Keeping new nurses from leaving the bedside is a constant challenge, and this challenge doesn't begin on the first day in the unit. Read about how nurses in education and service collaborated on a FutureThink pilot project that generated several collaborative strategies to retain newly graduated nurses in the acute care setting for the first two years of their nursing practice.

As the pilot project leader for the Dayton Organization of Nurse Executives (DONE), I had the challenge of taking the conceptual ideas of FutureThink and making them reality. After listening to Dr. Leland Kaiser talk about achieving anything we can imagine, I began trying to imagine what FutureThink strategic objective Dayton could work on to have an impact on the future of health care delivery.

In the winter of 2003, the DONE group had its annual meeting with the Dayton Area Nurse Educators (DANE). During this meeting, the nurse leaders were surprised to hear from the educators that assumptions we held about what new graduate nurses wanted was not actually what they wanted! Reflecting on our discussion, I decided the DONE group needed to find out what is important to those new grads, and we chose the FutureThink strategic initiative related to creating an environment that attracts and retains bright, diverse, and talented individuals.

At the next DONE meeting, I provided an update on FutureThink as well as a survey I put together called “Imagine Nursing.” Imagine Nursing became the springboard for discussions regarding the project that would take FutureThink from the conceptual image to something real. After coming up with many possibilities, the group decided to work on the retention of graduate nurses in the acute care setting, and BRIDGE was born. (BRIDGE stands for Building Realistic Interventions for Developing Great Employees.) The goal of BRIDGE was to develop collaborative strategies to retain graduate nurses in the acute care setting for the first two years of their nursing practice.

The Work Was Just BeginningFortunately in the Dayton area, there were several strong associations already in place to help make BRIDGE a reality. Not

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only was DONE a strong association, but also DANE and the Greater Dayton Area Hospital Association (GDAHA) were both strong groups who were committed to improving health care in their community. We presented the FutureThink and the BRIDGE concepts to a joint meeting at GDAHA with the deans from the area schools of nursing and the nurse executives from the local hospitals. From this meeting, a FutureThink task force was created. This group was made up of highly motivated nursing leaders who were (are!) committed to changing the future. The task force is a good mix of nurse executives and nurse educators with assistance from the area hospital association. GDAHA agreed to be the sponsor and coordinator for the information collection to support the BRIDGE project.

Having strong community involvement prior to FutureThink allowed us to move quickly to working on goals for the BRIDGE project. Enrolling the group in the goals of FutureThink was easy. Each member came to the group with a vested interest in the future of health care. The educators wanted to ensure their programs met the needs of the acute care facilities, and the acute care facilities wanted to ensure that the educators were preparing the new graduates for the realistic demands of the nursing profession and the needs of consumers needing services in health care systems.

Within this team, the goals of BRIDGE were developed as follows:

● Develop an interview tool to incorporate key employment attributes.

● Identify current strategies used in acute care hospitals for retention.

● Identify the number of new graduates in hospitals within a two year span.

● Develop a tool to assess new graduate expectations. ● Develop a tool to assess new graduate staff nurses in the

acute care setting. ● Develop a survey for nurses who leave the acute care

setting.

The intended outcomes were to see if there was a gap between what new graduate nurses had expected from the acute care setting and what they actually experienced. If a gap was identified, what strategies could the nurse leaders use in order to retain the new graduate nurses in the acute care setting?

As with any project, BRIDGE has had its successes and breakdowns. First, I'll describe the breakdowns. After working several months on the survey tools, the task force decided that because we were collecting valuable data, we needed to seek approval to use the data for research. Sounds simple, but since some of the facilities needed institutional review board approval prior to sending the survey to staff nurses and others didn't, we had a tough time finding a sponsoring hospital. Even though that was a difficult and time-consuming step, we feel that paying special attention to that detail will make it easier to work with our


partners in academia to publish the results of the pilot project study. At last, this process has started! Other small breakdowns included defining an acute care setting, defining a graduate nurse, and deciding how we were going to track all this information. But, the breakdowns led to successes.

Our successes include a list of current strategies used by acute care hospitals to retain nurses, a list of interview questions to be used for new graduates, a new graduate survey, and a new graduate exit survey. These tools have been shared widely and have been used across area hospital systems, even though area hospitals tend to compete for some of the same nurses. The new graduate surveys will be implemented in June, and the new graduate exit surveys will start in July. The BRIDGE is beginning to be built!

While the task of FutureThink seemed overwhelming at first, each of the project leaders for FutureThink is having successes. These successes will change how we deliver and experience health care in the future. As Leland Kaiser said, “We can't adapt to reality. We have to create it.” Through FutureThink we are creating the new reality.

Author Biography Karen S. Gorby, RN, MBA, FACHE, is the current administrative director of Surgical Services and Surgery Serviceline Leader at the Kettering Medical Center, Kettering, Ohio. Karen's responsibilities include leading and managing the preadmission testing area, ambulatory surgery center, operative suites, post anesthesia recovery area, sterile supply, and the same day medical unit. The Kettering Medical Center is the anchor hospital for the Kettering Medical Center Network located in the Dayton, Ohio Metropolitan area. She is the immediate past president of the Dayton Organization for Nurse Executives (DONE) and is the FutureThink project leader for the Dayton area. She has been instrumental in the development and implementation of the BRIDGE project. Karen is also the chairperson for the membership committee for the Ohio Organization of Nurse Executives (OONE). Recently, Karen was named a Fellow in the American College of Health Care Executives.




Jean Scholz

The Question of Consultants

Even within a dynamic, innovation-driven organization such as the Ohio Hospital Association, the right people are not always in house. In fact, a clear marker of an innovative group is the level of willingness to introduce outside expertise to lead internal initiatives. That's what happened with FutureThink. In this essay, read about the decisions and the process that went with the use of consultants in the FutureThink initiatives.

Creating a new way to provide hospital care was not easily done within the confines of a traditional hospital trade association. Hospital trade associations are usually expert at advocating for their members, addressing specific educational needs for hospital staff, and offering advice on an as-needed basis, but causing members to change and consider possibilities of creating a new agenda for health care reform is not a typical project for a trade association.

Fortunately, the Ohio Hospital Association (OHA) isn't a typical trade association. With a dynamic, energetic, and successful president like Jim Castle, typical is not tolerated. Rather, innovation is encouraged and possibilities are created for people within the organization as well as outside the organization. When considering developing a long-term solution to fix the nursing and workforce shortage for good this time around, new thinking was encouraged and required. FutureThink was created to do just that—to build a better way of delivering health care that would maximize our available human resources and provide a stimulating and exciting work life for health care workers.

But within the traditional association walls, OHA did not have the expertise or skills to create the mechanism to make that happen; nor did our partner organization, the Ohio Organization for Nurse Executives (OONE). Enrolling outside consultants helped us maximize existing staff skills, bring in outside energy, bring in different ways of thinking, and bring in experts who could cause change to happen for Ohio's health care picture.

The Value of FutureThink ConsultantsScott Beckett and Nathan Rosenberg further taught us facilitation skills that OHA staff did not have, and they provided coaching to us

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before meetings and focus groups to help us successfully lead the discussions. Just as they did with the FutureThink leadership intensives designed for nurse executives in leading the pilot projects, The Rosenberg Group also created for OHA staff new ways of operating in order to develop breakthroughs. The Rosenberg Group characterizes breakthroughs as:

● Something that is unprecedented and unpredictable ● An interruption of the status quo ● Out of the ordinary ● A manifestation of leadership ● Something that forwards the vision ● A break in what's expected

Developing breakthroughs was a hallmark of our work with The Rosenberg Group. When one of our nurse executives led a team at her hospital to create a plan for using innovative technology, that was a FutureThink breakthrough. Developing successful FutureThink pilot projects in almost every OONE chapter was surely a breakthrough, and creating a new OONE chapter in Cleveland was yet another. These all were unpredictable given the status quo before our relationship with The Rosenberg Group.

To create the preferred future for the delivery of clinical care in Ohio, we also worked with Leland R. Kaiser, PhD. He is a dynamic, motivational speaker known for his ability to change the way organizations think. A recognized futurist and acknowledged authority on the changing American health care system, he is a provocateur and mentor to many hospitals and health care organizations in the United States.

Dr. Kaiser brought the FutureThink group even more ways of creating "out of the box" thinking. One example was the question he asked the focus group leaders at their initial meeting in 2002: “Do we really have a shortage of nurses, or do we have a shortage of hospitals who know how to really use the nurses we have?” He challenged our thinking and stimulated us to be creative in thinking about the future. Although The Rosenberg Group had provided us premier management consultation, Dr. Kaiser brought us a unique perspective on the future specific to the health care industry and gave us new ways of thinking about creating healthy workplaces, healthy environments, healthy hospitals, and a healthy world.

Having the name of Leland Kaiser associated with FutureThink elevated the initiative even higher. Hospital leaders in Ohio were familiar with Leland Kaiser, and we knew that he would draw a crowd if we were able to bring him to Ohio to meet our FutureThink leaders. Therefore we worked with him to present two seminars, one to start the focus groups in 2002 and one to kick off the FutureThink pilot projects in 2003. These seminars drew more than 200 participants including nurse educators, nurse executives, other hospital executives including several CEOs, and even the director of the Ohio Department of Health.


Working with these two consulting groups showed our members that we were serious about creating a success with FutureThink. These two consultants brought us credible expertise, training, and resources. They also demonstrated to our members how to design futures and create possibilities, including how the industry can create a preferred way of delivering patient care.

Choosing a Consultant A hospital administrator recently told me that there were too many consultants in his hospital. It seems that the many consultants engaged at this hospital were now consulting with each other and working to create even more projects for future consulting relationships. Crucial to considering the choice of a consultant is whether you need the consultant at all. One hospital in the southern part of Ohio rarely uses consultants. Rather, it relies on its staff to “fix” things. If staff members can't figure out a solution, the hospital sends them on a field trip to find out how other organizations are solving similar problems. Although this was not an option for OHA in developing FutureThink, we have used internal resources to the maximum in many circumstances before searching for outside expertise.

When choosing a consultant, the intended outcome of the consulting work must be first and foremost in your mind. If the consultant doesn't speak your language or a language you want to learn, she or he is not for you.

Furthermore, effective consultants bring something to your organization that is currently lacking. It might be tools, expertise, or even time that is not available within your current ways of operating. The Rosenberg Group brought us a “technology” to create a preferred future along with ways of operating to be successful in managing discussions. Leland Kaiser brought us a broad-based health care thinking that might have been within the OHA in bits and pieces, but certainly not to the extent or to the level of someone with his depth of experience. Find a consultant that can bring something to your organization and help you create breakthroughs.

When selecting a consultant, the person or agency should be a trusted entity. Positive recommendations from others who have worked with the consultant are valuable and essential. Asking the consultant about his or her assumptions about the problem will also help you determine if there will be a fit. Assessing the consultant's assumption about the work to be done will also help you determine when the consultant is trying to sell you more services than you may need.

If there are a variety of consultants for consideration of the work at hand, asking the candidates to complete a Request for Proposal (RFP) is a way for consultants to showcase their plans and timelines. From the RFP you can determine which consultants will meet your intended outcomes in the time allotted, and the information provided by the various consultants may also generate


new internal ideas for improving the project. The RFP can also then serve as the basis for developing a contract to meet those intended outcomes. Your legal counsel should be involved in developing and reviewing the contract, payment schedules, and what expenses will be paid by your organization to the selected consultant.

All staff may not appreciate or endorse the work of the consultant, and that's acceptable. However, if the organizational leadership does not support the recommendations or the work of the consultant, the consulting money is not well spent.

FutureThink became a reality through the partnership with OONE, member hospitals, and OHA staff, and with the relationship with our valuable consultants. The Rosenberg Group and Dr. Kaiser coached us for success and created new conversations that lead to enrolling more partners in the initiative. OHA took what we were taught and created an extraordinary effort to make breakthroughs for the delivery of clinical care in Ohio.

Author BiographyJean Scholz is Director of Health Policy for the Ohio Hospital Association, where her focus is health policy issues with an emphasis on nursing and the health care workforce. She has been instrumental in establishing FutureThink, a statewide initiative to solve nursing and health care workforce shortages by creating a preferred future for the delivery of clinical care. In 2003, FutureThink was given the American Organization of Nurse Executive's Affiliated Local Group Award in recognition of the work done through the OHA/OONE partnership to advance nursing practice that can serve as a model for other states.

Jean also spearheaded OHA's efforts to obtain a $1.2million workforce investment grant which will provide Ohio hospitals with funding to provide health care licensure education for incumbent workers. Jean serves on the Nursing Spectrum Midwest Advisory Board, Ohio 's Universal Newborn Hearing Screening Committee, the Columbus Chamber of Commerce Workforce Leadership Council, the American Hospital Association State Forum on Workforce, and the Arthritis Foundation Board of Directors. Jean has also been active with the Columbus Jaycees and is a founding member of two colleges' of nursing honor societies.

In May of 2003, Jean was named as a Robert Wood Johnson Executive Nurse Fellow. Jean was one of 20 nurse executives in the country who were named to the 2003 fellowship program.

Other awards Jean has received include the Dorothy Cornelius Congress Leadership Congress Award by the Ohio Nurses Association, Nurse Excellence Award from Riverside Methodist Hospital and Employee of the Quarter, Ohio Hospital Association. Jean earned her bachelor's degree from the Ohio Wesleyan University Riverside School of Nursing and her master's degree from the Ohio State University College of Nursing.


Pam Falasco, Rn, MSNVice President, Surgical and Rehabilitative ServicesParma Community General HospitalParma, [email protected]

Pam Falasco

Developing a Core Curriculum with FutureThink

The Greater Cleveland FutureThinkers envision a future in which an inspired workforce will be educated to be part of a care delivery model that promotes collaboration and respects the contributions of different caregivers. The vision was clear—how to reach that vision became a bit more challenging. Read about how nurses in one area began the delicate work of changing an entire educational system—one that is an establishment of its own.

Where Does One Begin?We chose to start with dialogue among those who were stakeholders in this vision. We formed a group that included the disciplines of nursing, education, pharmacy, physical therapy, respiratory therapy, and radiology. As we talked through our ideas, it became clear that care giving is care giving, whether you are a nurse, a physical therapist, or a radiology technician. There are certain essentials that need to be learned and mastered to be effective in the chosen field. However, the working of the human body and its chemical, physiological, and psychological reactions do not differ depending on who is administering care or treatment. Why are we so intent on segmenting the way we look at the individual by discipline? Can we not collaborate to improve the health of an individual we are caring for by looking at her or him in a holistic, collaborative manner, instead of the limited view of our discipline? Certainly each discipline has a different focus related to the treatment given. However, the ability to provide this specific treatment could be based upon education that is provided after a core knowledge base is obtained.

Our first meetings focused upon those core values we believed in and shared. We felt strongly that the shift we needed to make was to create an educational system that focused on the holistic nature of care giving and the essential need for respect and collaboration among all health care workers. Furthermore, we believed that there existed a core curriculum that all health care providers needed for completion of their basic preparation.

It was clear that those of us in service needed to partner with our colleagues in education. Recognizing that both sectors have different perspectives on the details of education and preparation

Developing a Core Curriculum with FutureThink Page 1 of 3


of health care workers, it was important to find a common ground. As we shared this concept with educators, we found that the concept made sense to them as well. However, taking a concept and applying it to reality in the here-and-now is a bit different. We in the service sector were suggesting that this would require a curriculum change. To make this happen, the old standards had to be questioned. As we continued to exchange thoughts, it was clear that if we kept the goal in sight, the details of what constitutes the correct curriculum change would follow. We began by building on the work that three of our local community colleges had done related to transferability. Their work saved us considerable tedious work in going through each and every course to determine what was core and what could be transferred to another program.

Our mutual goal was to increase the flexibility for students related to articulation and transfer. Through our networking efforts, we connected with the Ohio Board of Regents and found that the state of Ohio was also working on changing the health care educational system via the Ohio Articulation and Transfer Council. We were able to have four of our original committee members appointed to this council. The statewide appointment of our colleagues resulted in our work and ideas being shared at state-level meetings, resulting in a wider influence than we could have anticipated.

As the dialogue continued about developing a core curriculum, the nursing participants began to identify the need for continued professional conversation. Through this conversation, the group of professional nurses thought it might be time to form a chapter of the Ohio Organization for Nurse Executives (OONE).

Our region had a chapter in the past, but it disbanded about a decade ago when there was a restless health care and hospital marketplace in the Cleveland area. We are now ready to invite nurse leaders to a fall seminar and kick-off meeting to reestablish a Greater Cleveland Chapter. Therefore, the FutureThink initiative did accomplish very significant conditions for success for the health care workforce in our area. Plus, we had the added benefit of creating a new structure for future networking and sharing further dialogues within our own city. Our conversations around FutureThink have been rewarding, stimulating, and fruitful.

We now are a little over a year into the project. Our original team is working at the state level to continue the tedious task of identifying core transfer courses. There is yet another initiative being undertaken by one of our members. Her staff is working to develop the core curriculum between and among health care providers at her educational facility. We are hopeful that she will be successful in recreating the health care curriculum and that it can be used as a model to be shared with the state committee.

What have we learned? There is power in a shared vision. Margaret Wheatley in her book, Leadership and the New Science (1999), talks about “quantum interconnectedness.” This theory relates to the ability of individuals with a passion to work together to move


toward a shared vision. The momentum that is created thus results in change that is a direct response of the synergy of the group. When we began, we didn't possess a specific plan to bring about the changes we envisioned. However, by reaching out and sharing our ideas and values, we were able to connect with our stakeholders to initiate the beginning of changing a system that seemed unchangeable.

References

Wheatley, M.J. (1999). Leadership and the new science: Discovering order in a chaotic world. San Francisco: Berrett-Koehler.

Author BiographyPam is the vice president of surgical and rehabilitative services at Parma Community General Hospital. Her career in health care has spanned 36 years, 35 of them in management, and the past 10 at the administrative level. She serves as a clinical faculty member for the Frances Payne Bolton School of Nursing. Pam obtained her ADN from Lorain County Community College, her bachelor's degree from Kent State University, and her master's degree from Case Western Reserve University. She has been active with volunteering for the American Heart Association and was President of the Leadership Lorain County Alumni Association in 1991. She also served as the Regional Liaison Representative for the Ohio Tourette Syndrome Association. Pam became involved with FutureThink in 2001 when the Ohio Hospital Association conducted its focus groups. Her team choose to focus its efforts on revamping the health care educational system through project Renaissance.



Pat Martin, RN, PhDDean, College of NursingWright State [email protected]

Pat Martin

Educators as FutureThinkers

The FutureThink initiative has brought to the table nurses from clinical units and executive offices. These FutureThinkers recognized that nurses in academia deserved a place at the table, so academic nurses were invited to join the conversation. Read about what happened when diverse perspectives and peripheral stakeholders were included, as service and academic nursing begin working together on a shared future vision.

The ChallengeLed by very capable facilitators from the Ohio Hospital Association (OHA), the Dayton-area group of nurses first explored pessimistic future projections we felt we could anticipate if no change occurred and if no accommodations were made for the external and internal forces impacting health care. This initial, pessimistic exploration was the segue that allowed us to envision a “preferred future” for health care, along with the path needed to achieve that future. During this initial meeting, some expressed the concern that the nurses participating in this group were primarily baby boomers who were planning the future for the next generation. What reassured us was research that shows that baby boomers and the next generation have much in common concerning what these groups seek in their leaders (Wieck et al., 2002). Both groups (boomers and twenty-somethings) want honest, positive leadership, and that is what I saw throughout the FutureThink process.

The Dayton area FutureThink focus group interactions and outcomes fit very well within the definition of “positive situational focusing” (Lyon, 2001). Participants definitely saw the glass as half full. Creating the sense of hope at this early stage of the game presented a real source of energy for regional work that was to come. As a nurse, I noted that the work done through the FutureThink focus groups aligned closely with Sigma Theta Tau International President Dan Pesut's advice “to turn dispirited conversations around and shift the discourse to one that is more creative, thoughtful and inspiring” (Pesut, 2004, p. 24)

FutureThink Group CompositionLeaders from the Ohio Hospital Association met with local nurses from both hospitals and academia in the Dayton area. Initially, the two types of organizations, hospitals and academia, were invited separately. Due to a long history of successfully working collaboratively, the two groups opted to meet as a single unit. The Dayton group was initially composed of nurses mostly in leadership positions from hospitals/service (two-thirds) and academia (one-third). Later, staff nurses and faculty members were added. However, staff nurses' and faculty members' limited—though most helpful—participation reflected the shortage situation in both practice and education. The current shortage of staff nurses and faculty has indeed left

Educators as FutureThinkers Page 1 of 5


little flexible time for front-line workers to participate in outside meetings.

At the later, statewide design team meeting, I was the only representative of nursing academia. The group included mostly hospital nurse leaders, representing the geographic regions of the state (reflecting OHA's membership), with a sprinkling of physicians, hospital administrators, and other academics. Made up of only 15 members, the design team's purpose was to explore the input from the regional focus groups and create a vision and strategic directions to reach a preferred future for the delivery of clinical care in 2013. Taking more than 1,000 suggestions from the regional focus group meetings, including the Dayton area meetings, the design team created a challenging and exciting vision that has provided statewide direction for two years. This vision now leads regional pilot projects developed across the state of Ohio toward the creation of long-term solutions to the nursing and health care workforce shortage.

Strength in Diverse GroupsDiverse groups support the development of powerful solutions for complex problems. From the variety of experiences and knowledge bases of different members of the group, many sides of the issues could be presented, allowing for the development of many optional solutions. With diversity, a richer knowledge base can be tapped into, with members having exposure to more and varied journals and other literature, along with different personal knowledge and contacts—all of which brings a broader perspective to the group as a whole. Diversity of backgrounds also creates a diversity of resources that are critical to a project's success.

Furthermore, group diversity enlarges the stakeholder base that can be expected to buy into the outcomes. More constituents in the initial stages of change create opportunities for broader dissemination of ideas and new concepts. When different constituents are part of the group, they begin to create a symbiotic relationship and their own “inside” language. Involving both academics and service leaders in the FutureThink concept eliminated the us/them argument, and we actually all considered each other partners on the team! The diverse participants in the FutureThink groups created a richness in the dialogue, a more comprehensive look at a possible future, and also a more probable creation of the preferred future for the delivery of clinical care.

Academics—Essential Partners for Designing the FutureFaculty members teach students based on the needs of the delivery system now and in the future. We educators must never lose sight of either as we teach or plan curriculum improvements. Since some graduates may never return for further formal education during their 30 or more years of professional nursing, we must prepare them for a future that can only be projected. In graduate education, the mandate is even stronger to prepare for a future not fully detailed. Graduates from master's or doctoral programs are prepared specifically for leadership positions. Leaders in health care must have excellent skills in managing today's work and in preparing for the future. The FutureThink project has helped the academics on the team consider teaching toward a preferred future and has given us teaching ideas that utilize possibilities rather than predictabilities.

Reflection is an important part of developing transformational leaders (Freshwater, 2004; Johns, 2004). Graduate nursing programs strive to create nurses who are transformational leaders who reflect on today's needs and project a preferred future. These skills are helpful in a collaborative process to define and plan a better future for delivering health care.


Besides teaching, faculty members must have programs of research or scholarship that also build visioning skills. The investigator must formulate a framework for the relationship or possible relationships between the concepts of the research project. In building the conceptual framework for a project, the investigator must identify the variables and long- and short-term outcomes. These activities develop skills helpful to projecting and planning possible futures.

Working side-by-side with health care partners is exciting for faculty members. Unlike academics, health care delivery organizations have a stage for enacting possible futures. While faculty members can teach many skills to prepare for a possible future, they also believe they are preparing leaders to make a preferred future. When academics partner directly with today's health care leaders, the potential for creating a dynamic and effective preferred future can be realized.

OutcomesThe FutureThink vision for the preferred future for the delivery of patient care is found on OHA's Web site ( www.FutureThink.org). This vision reflects the diversity of groups involved in the planning process. The OHA facilitators were prepared and skilled. Maximizing the diversity of participants at the focus group meeting and the statewide design team meeting, they were careful to draw out the thinking and not lead too early toward a “group think.” The outcome of that discussion was the creation of a vision that resonates with diverse members of the health care delivery team.

The FutureThink vision represents the nursing point of view so well that I find it hard to critique because I share that viewpoint. However, I believe that the vision could be enriched further with more involvement and input from CEOs and other providers of health care. The work done by the local and statewide groups—led by well-prepared and skilled leaders—demonstrated a strong value placed on partnerships. Leaders carefully drew from suggestions made by group members to make a final consensus feel natural. Both the local work and the statewide development represented very good experiences in partnerships. Local work continues, and it continues to follow our tradition of partnership with hospitals and academia. We have been working on nurse shortage concerns, a single but major aspect of the future. I hope to see more multidisciplinary work on selecting other areas for attention so that we can, in 2013, arrive at our preferred future for delivery of high quality health care to patients. The outcome of our local work has been to strengthen the bonds between nursing service and nursing academics through working on a project that will create strategies for developing attractive environments that help retain bright, diverse, and talented individuals. Work thus far has shown that partnerships between service and academia can indeed make a difference for the future work life for nurses.

Lessons LearnedIn a project of this nature, the importance of a champion—the OHA in our case—is critical. Someone with an obvious organizational mission compatible with the group's work and the commitment to see it through is critical to a project of this magnitude.

The richness of diversity for solutions may be obvious to most, but it bears repeating. The complexity of the initiative demands that a diversity of stakeholders participate. We worked together and dared to dream, and then we planned how to make the dream a reality. We need the diversity


http://www.futurethink.org/

of viewpoint, resources, and contacts to a variety of peripheral stakeholders who will be necessary for success.

Collaboration should be tried more often. It is fun, it is productive, and it may be the only way to succeed.

REFERENCES

Freshwater, D. (2004). Tool for developing clinical leadership. Reflections on Nursing Leadership, 30(2), 20-22, 26, 38.

Johns, C. (2004). Becoming a transformational leader through reflection. Reflections on Nursing Leadership, 30(2), 24-26, 38.

Lyon, B.L. (2001). Positive situational focusing: Pollyanna or a powerful stress prevention strategy? Reflections on Nursing Leadership 27(2 ), 38-39, 45.

Pesut, D.J. (2004). Create the future through renewal? Reflections on Nursing Leadership, 30(1), 24-25, 56.

Wieck, K.L., Prydun, M., & Walsh, T. (2002). What the emerging workforce wants in its leaders. Journal of Nursing Scholarship, 34(3), 283-288.

Author BiographyDr. Patricia Martin has been a registered nurse for more than 30 years. The Christ Hospital School of Nursing, the University of Cincinnati, Wright State University, and Case Western Reserve University are her alma maters. In 1999, she was selected to participate in the Management Development Certificate Program at the Harvard University Graduate School of Education/Institutes for Higher Education. Most of Dr. Martin's clinical experience was in maternal-child nursing. Her research career began in 1980 when she accepted the position as nurse researcher at Miami Valley Hospital in Dayton, Ohio. After 12 years in this role, she spent her next six years as director of nursing research at Wright State University in Dayton. She is currently the dean of the College of Nursing and Health at Wright State University. She has served, including the chair position, on over 120 theses committees. Her own program of research has focused on the work environment of nurses. Her research included studying noise in the NICU as an American Nurses Foundation scholar. This year is the 13th year of her ongoing study on the perceptions of hospital nurses regarding their work environment. She is the author of more than 40 publications, including the column, “Ask an Expert,” that appeared in Applied Nursing Research for five years.

Dr. Martin is active in professional organizations, including the Ohio Nurses Association, the Midwest Nursing Research Society, the American Association of Colleges of Nursing (AACN), and Sigma Theta Tau International. In 2003, she received the Excellence in Nursing Education Administration Award from the Ohio Nurses Association; in 2002, she received the Nurse of the Year award from the District Ten-Ohio Nurses Association. She is a member of AACN's State Grassroots Liaison Program and meets with state and federal legislators on a regular basis to promote and improve the nursing profession. She has been on the editorial board of


Applied Nursing Research since 1993. She is also a board member at St. Leonard's, a senior living community located in Centerville Ohio.

Recently, Dr. Martin spearheaded a 16-county collaborative effort to create the Nursing Institute of West Central Ohio to address nursing workforce issues. The Nursing Institute, which received federal funding in 2004, will address improving the supply of nurses in West Central Ohio as well as improving the satisfaction and retention of practicing nurses in that region. The partners in the Nursing Institute include primary and secondary educators, representatives from colleges and universities with nursing programs, hospitals, and other employers of nurses.




Jean Scholz

Building a Future Pipeline in Nursing

Like many U.S. states, Ohio is responding to the nursing shortage with investigations and initiatives aimed at increasing enrollment in nursing schools and bolstering the teaching faculty. This work is also informing nurses of FutureThink as they lay foundations for building long-term solutions. It's policymakers and nurses communicating and collaborating.

Reports from the Ohio Board of Nursing (OBN) do not paint an optimistic picture for the future. Ohio's statistics, like many states across the nation, indicate a looming shortage of qualified nurses to care for its citizens. In 1995, Ohio nursing schools were educating an average of 6,000 students per year. In 2002, only about 5,000 nursing students were gaining licenses in Ohio. The board predicts a 20 percent shortage in 10 years. Furthermore, last summer the board surveyed all 180,000 licensed nurses. Initial results of this survey indicated that 40 percent of nurses plan to leave nursing in the next 10 years, mostly due to retirement. The challenge of replacing retiring hospital staff will be significant and may require hospitals and the health care system to reform the current way of delivering services.

In response to these statistics, the board developed Nursing Rewards, a new statewide public education campaign encouraging nursing as a career. The campaign kicked off on November 18, 2003, with a media event at the Ohio Statehouse in Columbus. The campaign will feature a comprehensive Web site and public service announcements on television, billboards, radio, and in print ads in an effort to educate the public on the benefits of careers in nursing. The campaign also seeks to increase public awareness of nursing as a fulfilling and challenging career for both men and women. The Ohio Hospital Association (OHA) sponsored the campaign in conjunction with the Ohio Health Care Association, the Association of Ohio Philanthropic Homes, Housing, and Services for the Aging; the Ohio Council for Home Care; and the Ohio League for Nursing. (Go to www.nursingrewards.com for more information on this initiative.)

And although the board is committed to attracting talented individuals to attend nursing school and obtain licensure in nursing, there is a major problem in our state — most schools of nursing

Building a Future Pipeline in Nursing Page 1 of 5


http://www.nursingrewards.com/

have extensive waiting lists. In fact, one baccalaureate degree program in the Dayton area has indicated that for the 2004-05 academic year they filled their class with those who had a high school GPA of 3.2 or higher. More than 60 qualified students, many with a 3.0 or greater high school GPA were denied admission because the school was full. Another large school in Ohio's central section indicated the following: Of the 661 applications that were received, 204 were accepted (30.9%), 257 were denied (qualified but not as competitive — 38.9%), and 136 were denied because they were not qualified (20.6%). The remainder of the applicants did not complete the prerequisites or withdrew.

It is very exciting to see our schools being able to attract such talented individuals. It is frustrating, though, that some students who would have been easily accepted in the 1990s when nursing enrollments were down are now not able to get into a program because of over enrollment.

Acting on its commitment to develop an appropriate nursing workforce, the board has collected additional pipeline questions on its annual survey of nursing programs. To collect data related to the supply side of the nursing shortage in Ohio, the 2002-03 academic year survey included questions about program capacity and intent to expand, or verification that the program had accomplished an expansion. In addition, for those programs that had been designated and implemented for expansion, answers were needed about the challenges faced in that process. Data to assist in projecting the need for future faculty was also collected. (For further information about the Ohio Board of Nursing's survey of schools of nursing, see the board's Web site at http://www.nursing.ohio.gov/.)

Data on the numbers of “seats” available to persons entering mainstream nursing education programs are collected. The leaders of professional nursing programs (RN programs) were asked to declare whether they had developed an “advanced standing” or “accelerated program.” An accelerated program is a track in the pre-licensure program designed for individuals who, at admission, hold a bachelor's degree in another field. As a rule, this is called “advanced standing.” The advanced standing tracks or options may follow a curriculum plan that is less than the two years minimum required of generic nursing programs so long as the program upholds the same rigorous standards.

Expansion of Ohio RN Programs The response rate to questions related to capacity and expansion issues was variable. While 100% of program representatives responded to the annual report survey, some were unable to provide data regarding the number of applications denied for academic reasons. A reason for non-response to questions was not required; however, a number of open enrollment institution representatives, particularly those from state-funded community colleges, indicated that they admit all applicants who are able to complete the application process on an available-space basis. They


http://www.nursing.ohio.gov/

http://www.nursing.ohio.gov/

then put the remainder on the waiting list for the next available admission time.

Program representatives were asked whether or not they could expand with available resources, including space, faculty, and dollars. They were also asked their intention to expand. If they answered in the affirmative to that question, they were asked to provide the number of seats that would be added.

Data were collated by program type, resulting in totals, averages, and percentages, where appropriate, for associate degree, diploma, and baccalaureate and higher degree programs. Totals and percentages for all professional nursing (RN) programs were then calculated.

Seat Availability Totals for all RN programs revealed that there are 8,103 available “seats” for students. Only 7,615 of those were filled at the time of the survey. This data yields a 94% “fill” for all Ohio RN programs. (The programs that were not full were generally those private schools with higher tuition costs.) However, while some programs were not full to capacity, a number of programs indicated lengthy waiting lists. The number of students wishing to gain admittance in an RN program but denied admittance was staggering. Totals for all RN programs showed that 2,241 individuals requesting admission did not meet academic admission criteria. An additional 3,356 individuals were denied admission due to space constraints. Nine programs reported 100 or more applicants denied because there were not enough seats to accommodate them. Four of those programs denied more than 400 potentially qualified students. These statistics indicate that nursing is a very attractive career choice for students to consider. To grow the future supply of nurses, the nursing pipeline needs to be expanded.

Expansion of Ohio's Nursing Pipeline Ohio's nursing schools have stepped up to expand the state's nursing pipeline. Schools that have expanded noted that the expansion required additional space and/or equipment, additional faculty, additional preceptors, and additional clinical placements for students.

Faculty Shortage Projections One of the main deterrents to enlarging the pipeline further is the shortage of nursing faculty. Program leaders were asked to indicate the number of faculty who had left their departments in the 2002-2003 academic year and to project the numbers who might leave in the next five years due to retirement or other factors. The survey indicated that 24 faculty members had left their positions after the academic year ending June 30, 2003, and 151 faculty members were expected to retire within five years. In addition, program leaderss were asked to indicate faculty who have left because of issues related to compensation—salaries that might not be commensurate with their credentials and experience—and have left nursing education to return to a clinical practice or administrative position. A total of 33


faculty members left to accept positions in clinical or administrative settings due to salary or other compensation issues.

New Opportunities: Accelerated Programs and Distance Learning A number of RN programs, primarily baccalaureate and higher degree programs, operate accelerated programs, special tracks in the prelicensure program that are designed for individuals who hold a minimum of a baccalaureate degree in another field. These programs compress the nursing major, and the curriculum may be completed in less than two academic or calendar years. One diploma program, one associate degree program, and seven baccalaureate program representatives indicated they have an accelerated track. Reports from the programs indicate that accelerated tracks are very popular and also have waiting lists for students interested in becoming nurses through this path.

Distance learning, including Web-enhanced methodologies designed to support existing classroom experiences, was also popular in the nursing educational programs. A few indicated that whole courses, such as bridge courses, or initial theory courses, could be taken online. No diploma program groups reported utilizing distance technology; however, 14 associate degree programs, and 11 baccalaureate and higher degree programs responded in the affirmative to the question.

Summary The Ohio Board of Nursing's 2002-03 Annual Report of nursing programs provides compelling data that may be helpful to the board in making future regulation and resource allocation decisions. In addition to helping the board, the data provide the FutureThink initiative some interesting thoughts... What stimulated potential students to consider nursing as an attractive career choice? What are the possibilities for maximizing the current nursing workforce if the pipeline cannot be enlarged? Will Ohio need the same number of nurses in the future as we do now? Furthermore, data provided by the board have helped FutureThink remain relevant. FutureThink conversations about the need to develop multi-pronged approaches to create long-term solutions to the nursing shortage are surely affirmed with the board's survey. With a keen eye on the future supply of nurses, FutureThink will continue to develop conversations and strategies to create long-term solutions to Ohio's nursing and workforce shortages.

Author BiographyJean Scholz is Director of Health Policy for the Ohio Hospital Association, where her focus is health policy issues with an emphasis on nursing and the health care workforce. She has been instrumental in establishing FutureThink, a statewide initiative to solve nursing and health care workforce shortages by creating a preferred future for the delivery of clinical care. In 2003, FutureThink was given the American Organization of Nurse Executive's Affiliated Local Group Award in recognition of the work done through the OHA/OONE partnership to advance nursing practice that can serve as a model for other states. Jean also


spearheaded OHA's efforts to obtain a $1.2million workforce investment grant which will provide Ohio hospitals with funding to provide health care licensure education for incumbent workers. Jean serves on the Nursing Spectrum Midwest Advisory Board, Ohio 's Universal Newborn Hearing Screening Committee, the Columbus Chamber of Commerce Workforce Leadership Council, the American Hospital Association State Forum on Workforce, and the Arthritis Foundation Board of Directors. Jean has also been active with the Columbus Jaycees and is a founding member of two colleges' of nursing honor societies. In May of 2003, Jean was named as a Robert Wood Johnson Executive Nurse Fellow. Jean was one of 20 nurse executives in the country who were named to the 2003 fellowship program. Other awards Jean has received include the Dorothy Cornelius Congress Leadership Congress Award by the Ohio Nurses Association, Nurse Excellence Award from Riverside Methodist Hospital and Employee of the Quarter, Ohio Hospital Association. Jean earned her bachelor's degree from the Ohio Wesleyan University Riverside School of Nursing and her master's degree from the Ohio State University College of Nursing.



An Entirely New Form of Excellence: Shaped by Your Peers. Shaped by You.There are no easy answers to the complex challenges nurses face. There is, however, an abundance of brilliant leaders armed with powerful ideas. And now their time has come. The focus of ENK will be squarely on the nurse leaders who are creating essential transformation where nurses work and learn. With each new issue, we'll hand the reins to a nurse at the forefront of change. In doing so, we're also creating a totally new kind of online publication.

Introducing the ENK Guest EditorsENK is a monthly, online publication that introduces readers to best practices and evidence-driven processes as identified by an individual nurse. Each month, a new ENK guest editor (GE) will use this forum to present and explore ideas that are improving care - and how care is delivered - in his or her institution. ENK will present the professional voices of evidence, tested by application, that offer value to the rest of nursing.

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Welcome to our second monthly issue of ENK!

In our debut issue, we explored the Synergy Model of professional practice, and we heard from many of you who applauded the quality and depth of the content. Kudos to Guest Editor Martha A. Q. Curley, RN, PhD, FAAN, director, CC/CV Nursing Research, Children's Hospital Boston, and her contributors. If you saw the value of ENK and subscribed, thank you. We believe the small subscription price will be returned many times over in relevant knowledge and insight.

We heard from many of you readers with a shared request: Make ENK articles easier to print. We've listened, and we're easily printable with this issue. That doesn't mean ENK is through evolving, though, so please, write me with your comments, your compliments, and even your complaints. ENK is both a publication and a conversation, and I want your ideas. It is my personal goal to get better with every issue of ENK, so subscribe now to see us grow!

This Month: If We Build It... As you read this month's issue, I ask you to put your inner critic on hold for a few minutes. The ideas emerging from FutureThink—the initiative this issue of ENK is built around—are partial and in-progress; yet the FutureThink ideas are transforming the current ways organizations think about nurses now and in the future, and about the roles of nurses in the leadership of health care delivery. These are long-term initiatives that aspire to survive a quick dismissal by people looking for short-term solutions. Regardless of what you think of the FutureThink initiative itself, we ask you to explore this issue for what it is: the story of nurses and other vested parties within health care creatively seeking answers to the same overwhelming problems you face everyday—shortages, burnout, patient access to health care, record keeping-dilemmas, and quick fixes that last no longer than a Band-Aid.

Looking into the future of health care with only today's known facts and trends to guide us can be a disheartening exercise. It's easy to see a bleak picture. The nurses behind FutureThink are determined to see it differently because they're imagining the future they want to inhabit, and they are starting the work of making this vision real. They're not policy wonks either; they're nurses working in leadership, clinical and academic settings.

From the Editor Page 1 of 2


http://www.nursingknowledge.org/Portal/main.aspx?PageID=3508&ContentID=55889


Pie in the Sky? Not if you take a few bites and begin to understand the process. Start anywhere in the issue, and see if you can get a flavor for how change can be steered when a goal is clearer on the horizon. The FutureThink vision offers that goal and provides a guiding light for needed changes in the way clinical care is provided to consumers.

There's no doubt that FutureThink creates many legitimate questions that it must eventually answer. The focus on prevention and wellness is laudable, and places nurses in powerful positions to shape outcomes, but acute care and the complex issues of access are not well-integrated here. Their exclusion is troubling, and the professionals involved in FutureThink must enlarge their scope over time. But this much is clear: The future of health care is not fixed.

Nurses have both enormous opportunities and important responsibilities, according to Jean Scholz, RN, MS, director of Health Policy for the Ohio Hospital Association. As the ENK guest editor this month, she has built an issue that takes our readers into the development of FutureThink as a strategic concept and then takes them outward into the future and the initial pilot projects that are beginning to succeed despite all odds—and beginning to show unexpected and expected ways that these projects are benefiting nurses, patients, and health care consumers in Ohio. It is anticipated that through the successes seen in the initial pilot projects, future directions will be built to keep momentum moving toward the vision for the year 2013.

These are not times for the faint of heart. They call for the maximum from each and every one of us—for the sake of our profession, our institutions, our communities, and our patients. No right answers or certain rules are on the horizon. Moment by moment improvisation is a reality, but not the only reality. Thinking ahead, imagining what is right and then making it happen are all a part of nursing today. FutureThink is one model, and we're pleased to present it here.

Greg PerryEditor


From the Editor Page 2 of 2


Jean Scholz

Jean Scholz

Jean Scholz is director of Health Policy for the Ohio Hospital Association (OHA), where her focus is health policy issues with an emphasis on nursing and the health care workforce. She has been instrumental in establishing FutureThink, a statewide initiative to solve nursing and health care workforce shortages by creating a preferred future for the delivery of clinical care. In 2003, FutureThink was given the American Organization of Nurse Executive's Affiliated Local Group Award in recognition of the work done through the OHA/Ohio Organization of Nurse Executives (OONE) partnership to advance nursing practice that can serve as a model for other states.

Jean also spearheaded OHA's efforts to obtain a $1.2million workforce investment grant that will provide Ohio hospitals with funding to provide health care licensure education for incumbent workers. Jean serves on Nursing Spectrum 's Midwest Advisory Board, Ohio 's Universal Newborn Hearing Screening Committee, the Columbus Chamber of Commerce Workforce Leadership Council, the American Hospital Association State Forum on Workforce, and the Arthritis Foundation board of directors. Jean has also been active with the Columbus Jaycees and is a founding member of two different honor societies at two different colleges of nursing.

In May of 2003, Jean was named as a Robert Wood Johnson Executive Nurse Fellow. Jean was one of 20 nurse executives in the country who were named to the 2003 fellowship program.

Other awards Jean has received include the Dorothy Cornelius Congress Leadership Congress Award by the Ohio Nurses Association, the Nurse Excellence Award from Riverside Methodist Hospital and Employee of the Quarter for the Ohio Hospital Association. Jean earned her bachelor's degree from the Ohio Wesleyan University Riverside School of Nursing and her master's degree from the Ohio State University College of Nursing.


Jean Scholz - Guest Editor Page 1 of 1


Annie BuchananDirector of Nursing and [email protected]

Andrew SmithConsultant Anaesthetist and Head of Research and [email protected]

Conference Report

Case Study: Nurse Anaesthetists in Morecambe BayIn early September, nurses and health care executives met in Manchester, England to attend the conference “Developing Effective Nurse Led Care.” Here we offer an overview of one of those sessions in which Annie Buchanan and Andrew Smith presented a case study exploring the challenges of positioning nurses to administer anaesthesia when physicians are not available.

The Morecambe Bay Hospitals NHS Trust is located in the United Kingdom (UK) where it serves a population of 350,000 people over a large geographical area in Cumbria and North Lancashire from three main hospitals. The staff of the trust are engaged in a number of projects relating to workforce redesign, including the Hospital at Night initiative, and they have past experience with nurse recruitment from overseas.

Anaesthesia is the largest single hospital medical specialty. In recent years the work of anaesthetists has expanded to encompass not only the provision of anaesthesia for surgery, but also intensive and high-dependency care, pain relief in labour, and acute and chronic pain services. Much of this activity takes place out of normal working hours. The provisions of the New Deal for junior doctors in the 1990s limited the number of hours they could work, and Calman's recommendations on training meant that more of these hours should be spent on training rather than on service delivery. The pressures have been intensified by the requirements of the European Working Time Directive, as it is now necessary to resort to shift work to achieve compliance, with more possible compromise to training.

One solution is of course to train non-physicians to administer anaesthesia. Nurse anaesthesia is successfully practiced in the USA and many European countries, but such a prospect was traditionally resisted by the Royal College of Anaesthetists and particularly the Association of Anaesthetists. However, in 2001 the Royal College began to work with the Changing Workforce Programme of the Department of Health. Together they visited hospitals in Sweden, the Netherlands, and the USA, and this led to further proposals for experimenting with non-medical anaesthesia roles in the UK.

Bids were invited to take this work forward within what was initially termed the “New Ways of Working in Anaesthetics” pilot. Five sites were selected: Morecambe Bay Hospitals Trust and Northumbria Healthcare chose to “import” fully-trained nurse anaesthetists from Europe; Hope Hospital in Salford, Birmingham Heartlands, and the Royal Devon and Exeter opted to begin training existing theatre staff to perform tasks

Conference Report Page 1 of 4








previously restricted to anaesthetists. Some sites began work near the end of 2003. Our nurse anaesthetists started in February 2004. The working title of this new role was anaesthetic and critical care practitioner (ACCP). These two aspects of the project are intended to inform the third, which is the design of a national training programme for future home-grown ACCPs. The particular contribution that we and Northumbria are expected to make to this is defining pre-existing knowledge and skills of the overseas ACCPs and provide early intelligence on matters such as scope and limits of practice, supervision, and accountability.

RecruitmentThe Trust had previously used agencies for recruitment of overseas nurses. This approach was unsuccessful for this new role. Andrew Smith used personal contacts within the European Society of Anaesthesiologists, and by chance, it was two Swiss doctors whose nurse anaesthetist colleagues showed interest in our project. Later, project staff from Northumberland visited nurse anaesthetists' conferences in Switzerland and the Netherlands. These yielded a lot of enquiries, and the two remaining posts were filled by this route. Salaries were more difficult. Both sites felt that the salary should be atttractive enough to ensure the success of the project—and so it is in excess of a nurse manager's salary—but this is still less than the Swiss nurses earn at home.

Adaptation and AssessmentInitially, we expected that our ACCPs would have to undergo a 3-month adaptation period to qualify for registration with the NMC. In fact, the regulations governing Swiss nationals had recently changed, and one candidate had already secured registration herself. Thus the detailed adaptation package we had previously used (for instance, for nurses from the Philippines) was not necessary. Instead, we devised a list of topics that we felt the ACCPs would benefit from knowing. These were non-clinical policies and information (for example, fire training), general clinical (drug-handling policies and infection control), and anaesthetic competencies. The ACCPs were also invited to think about other things that might help them understand the Bristish health care system, and they chose to spend time on intensive care, in A&E, and with the ambulance service. Their anaesthetic competencies were assessed by the anaesthetic department by three methods. First, working with the consultant body allowed us to form a departmental view of their competence. Second, we used the Royal College of Anaesthetists' basic competence assessment (designed for new trainees in anaesthesia after 3 months). Third, we invited the ACCPs to grade their knowledge and skills against a list of tasks and competencies already drawn up to help the design of the national curriculum referred to above.

Accountability and SupervisionAs this is a new role in the UK, and as the project is a high-profile and politically sensitive one, we did our best to work by the book. In addition to the formal adaptation programme above (in which both senior nurses and anaesthetists were involved), we prepared a document for the Trust Clinical Governance Group on the project. In contrast to many extended roles for nurses, this is a completely new role in the UK and could be said to have dual accountability. The responsibility for quality and safety in anaesthetic work rests with supervising consultants and ultimately the clinical director for critical care (all of whom are doctors). However, as our ACCPs are nurses, their professional accountability is to senior nurses. This is an anomalous situation in the UK and is likely to be resolved in the future by the creation of a new profession for anaesthetic practitioners under the allied health professions umbrella. Thus practitioners may keep dual registration—as anaesthetic practitioner and their original health care


profession. (It should be noted that science graduates have also been suggested as a source of trainee practitioners in the future, and so it would have to be possible to enter the role with no previous health care experience).

Proximity and RatiosSupervision has two distinct, albeit related, aspects: proximity and ratios. In Switzerland, there is usually a consultant anaesthetist present on induction of and emergence from anaesthesia. The nurse works more independently during the maintenance phase of the anaesthetic depending upon how complex the case is, but a consultant is immediately available if a problem occurs. In the UK, more attention has been paid to ratios of consultants to nurses, and this has been set at one consultant to a maximum of two anaesthetic practitioners. The choice of one to two has little relation to clinical quality (in some cases, a one-to-one ratio would be appropriate), but instead it represents an attempt to appease UK anaesthetists who fear that medical anaesthetists may become redundant if much of their work is lost to non-physician practitioners.

Practitioners' ExperiencesWe asked both practitioners to share their thoughts, feelings and experiences with us — good, bad or indifferent. What emerged was that there was a real need for pastoral support. Ornella and Monica needed help in dealing with things like banking facilities, living in a different culture, feeling homesick, communication issues, and lack of understanding of what their roles, skills, and competencies were professionally. What they did highlight are differences in all sorts of clinical situations. The British seem to be more focused on patient comfort and safety but have less-rigorous general hygiene standards.

Scope of RoleIt is self-evident that the more future anaesthetic practitioners can do independently, the more useful they will be as part of the anaesthetic workforce. While it is clear that our Swiss nurses are involved in anaesthesia for complex and specialized procedures including cardiac surgery, neurosurgery, and anaesthesia for renal transplantation and with small children, the proposed role in the United Kingdom is unlikely to encompass such areas of work. Again, this appears to be a political decision based on what is considered desirable rather than what is possible and/or safe.

Effect on Existing StaffThe theatre staff seem to have taken well to the new role, or rather to the two individuals who occupy it in Lancaster. There has been some confusion as to how it might relate to the operating department practitioner's (ODP) role, which has no equivalent in Switzerland. In Lancaster this has not caused problems, but nationally it has not escaped the attention of the Association of Operating Department Practitioners that, if there are two people present on induction of anaesthesia, the service of both may not be so necessary. There is a risk that in the future anaesthetic practitioners will be competing for training opportunities with medical anaesthetic trainees, but the trainees in Lancaster have generally taken to the idea with interest, and many have enjoyed working with them. The consultant anaesthetists — without whom the project could not have been run — have generally been in favour of taking part in this experiment, but as this is a short-term, time-limited, project there is no obligation on their part to make a public commitment to this role in the future. One of the main difficulties has been working out where to pitch our expectations of the practitioners' knowledge and skills. They are clearly not ODPs, in that their role includes many things ODPs do not do,


but also can't be compared with anaesthetic SHOs, as SHOs, although inexperienced, are expected to develop into a clinician with a wide range of independent capabilities. The issue here is not just what professional knowledge is held by nurses and doctors, but also the route that has been taken to achieve that knowledge.

SummaryIn this endeavor, we have learned that even though people are willing to help with the project, everything takes much longer than expected. It is also clear that due to national political constraints, the anaesthetic practitioner role is likely to be denied its full potential, at least for the next few years. We feel also that, at the time of writing, we have not used our anaesthetic practitioner nurses to their full capabilities. There is also an important, more general message: Many NHS staff upon whom the success of such projects as this depend are demoralized by constant change and modernisation fatigue. Current unresolved issues such as the Agenda for Change, the new consultant contract, and frequent bright ideas for increasing theatre throughput, which usually involves unwelcome changes to working patterns, make people more timid and wary of novel ideas. It has then to be a matter of speculation as to how, or indeed if, this role develops in the future.

Future Reading Reference List

Changing Workforce Programme Web site http://www.modern.nhs.uk/scripts/default.asp?site_id=65. Probably more simply accessed by typing “Changing Workforce Programme” into a search engine.

Smith AF, Kane M, & Milne R (in press). Comparative effectiveness and safety of physician and nurse anaesthetists: a narrative systematic review. British Journal of Anaesthesia. “The evidence” (such as it is) on this issue.

Kane M & Smith AF (in press). An American tale: professional conflicts in anaesthesia in the United States and implications for the United Kingdom. Anaesthesia. Interesting detour down a historical byway of great relevance to the current UK situation.

Smith AF, Goodwin D, Mort M, & Pope C (2003). Expertise in practice: an ethnographic study exploring acquisition and use of knowledge in anaesthesia. British Journal of Anaesthesia, 91, 319-28. Paper on how anaesthetic knowledge is learned (and shared). Hard going.

Seymour A (March, 2004). Non-medical delivery of anaesthesia. In Royal College of Anaesthetists' Bulletin (No. 24). Retrieved October 4, 2004, from http://www.rcoa.ac.uk/docs/bulletin24.pdf. Patient representative's questioning view of the “pilot” project.



http://www.modern.nhs.uk/scripts/default.asp?site_id=65

http://www.modern.nhs.uk/scripts/default.asp?site_id=65

http://www.rcoa.ac.uk/docs/bulletin24.pdf

Worldviews

Worldviews editors select 10 abstracts you should read from the evidence-based pre-conference that was held in Dublin in July.

In the fourth quarter issue of Worldviews on Evidence-Based Nursing, due out in December, we will present a picture of the evidence-based pre-conference "Evidence-Based Nursing: Strategies for Improving Practice” held in Dublin in July 2004.

More than 60 abstracts were selected for oral presentation, and more than 50 for poster presentation. Worldviews is committed to disseminating useful information for the achievement of evidence-based practice internationally and to providing a forum for the exchange of ideas supporting the fostering of potential collaborations.

With this in mind, the editorial team has selected some abstracts for publication in this issue. The abstracts published are those that were assigned the highest scores in the submission process for conference presentations and represent the top ten submitted.

As readers will see, these abstracts reflect a wide range and scope of practice, including, for example, implementing clinical guidelines, care of brain-injured patients, and the management of indwelling catheters. Hopefully the publishing of these abstracts will facilitate the harvesting of knowledge for improving patient care throughout the international community.


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http://www.blackwellpublishing.com/journal.asp?ref=1545-102X&site=1

http://www.blackwellpublishing.com/journal.asp?ref=1545-102X&site=1

ENK October 2004.pdf - Sigma Repository

Documents

Transcript of ENK October 2004.pdf - Sigma Repository