REFLECTION is identified as integral practice for any self-knowing organization as a process that supports an organization's ability to learn and thrive.1 Malloch and Porter-O'Grady2 describe reflective capacity as an awareness and respect for those who went before us, while valuing what worked and what did not, as leaders seek to build a better future. The Kaiser Foundation School of Nursing (KFSN) legacy offers wisdom, knowledge, and insights on disruptive innovation, and its story is inextricably linked to the well-documented history of the Kaiser Foundation Health Plan, Permanente Medical Groups, and Kaiser Foundation Hospitals. These are the organizational entities that make up Kaiser Permanente (KP) today. Kaiser Foundation School of Nursing emanated from a symbiotic culture with a unified mission, vision, and values. The school further validated the critical importance of organizational alignment, courageous leadership, and interprofessional collaboration in nurturing innovation across the continuum of care.3 In reflecting upon the KFSN journey and the stories shared by alumni, distinct patterns and practices emerge that serve to inspire and inform nurse leaders as they explore the merits of disruptive innovation in defining their own personal and professional legacies.
IDENTIFYING DISRUPTIVE INNOVATION
As an iterative and creative process, disruptive innovation leads to new frontiers and authentic change. Innovation can be described as either evolutionary or revolutionary. Evolutionary innovation is a gradual reform and adaptive advancement of existing concepts over time. Disruptive innovation requires active leadership and involves the emergence of an entirely new and value-added concept that moves people and systems beyond the status quo.4 In boldly reimagining health care, KP and KFSN became major disruptors of conventional sick care models and contemporary views of nursing education and professional practice.
A FRAMEWORK FOR DISRUPTIVE INNOVATION
Today's successful technology companies rely upon a continuous flow of disruption and innovation. Innovation frameworks used by high-tech companies can help inform nurses' understanding and translation of core concepts into health care systems. A technology model describing 4 distinct phases of innovation offers added insight into the disruptive innovations that shaped both KP and KFSN cultures. The 4 stages of disruptive innovation include the following:
- Disruption: A disruption occurs when an existing solution is replaced by a new or innovative approach fueled by a compelling vision and a willingness to take a risk.
- Evolution: Rapid evolution occurs as teams persist along a successful trajectory by working the plan and focusing on early adopters.
- Convergence: An appealing evolution of convergence results as the initial innovation matures, gains momentum and acceptance, and begins to replace the incumbent view.
- Reimagination: Complete reimagination involves learning from old and new, testing assumptions and cocreating a completely new and future solution.5
PRAGMATIC SOLUTION LEADS TO DISRUPTIVE INNOVATION
Innovation's success is ultimately measured by outcomes, but it begins by seeing a problem differently. The vision and origins of the KP integrated health care model and later the Kaiser Foundation School of Nursing began when industrialist Henry J. Kaiser partnered with a young pioneering physician, Dr Sidney R. Garfield. They wanted to explore new ways to care for the growing workforce at monumental civil engineering projects and the wartime shipyards along the West Coast. Garfield introduced a pragmatic solution and radical concept for shifting the focus of care to prevention of industrial injuries and promotion of worker safety. Incumbent medical practices were focused on treating injuries and sickness retrospectively, so Garfield introduced a key distinction that exists between “health care” and “sick care” to this day.6
Garfield continued to refine his original idea, and a new prepaid health plan and group medical practice model focusing on wellness emerged. The result was disruptive innovation and the genesis of a very different health system with distinct beliefs in health care and added value to people and communities served. Offering low-cost access to prevention, health promotion, and early medical treatment helped keep the Kaiser workforce healthy, productive, and on the job.7 The benefits to patients and families, as well as a solid return on investment for Kaiser's experience, created a win/win and lent credence to Benjamin Franklin's axiom “an ounce of prevention is worth a pound of cure.”8
Kaiser Permanente evolved rapidly through constant, and sometimes turbulent, growth. The organization remained steadfast in the continued advancement of preventive health care, continually adapting and gradually overcoming, considerable external opposition, early financial threats, and internal discord.9
A central part of KP's continued evolution and growth in Northern California was related to the wartime demands on the Kaiser Shipyards in Richmond, California, that attracted thousands of workers and their families. Rapid growth and increased demand for health care services led to the opening of the first Kaiser Hospital in Oakland, California in 1942.10 The new hospital experienced challenges related to persistent nursing shortages in the 1940s, which hampered access to skilled nurses while simultaneously creating new opportunities for innovation.
CONVERGENCE AND A NEW PARADIGM IN NURSING EDUCATION EMERGES
Kaiser Permanente established value with its growing membership and gradually achieved acceptance and legitimacy with its focus on access, affordability, prevention, community-based services, and quality outcomes. A strong nursing organization could only enhance the continued evolution and convergence into a new model, supporting the success of the new KP health system. Kaiser Permanente nurses would need to approach care from a broader perspective beyond the hospital setting and into the community. They also needed to frame their care within a new paradigm, centered on prevention and wellness. A new Kaiser School of Nursing presented the ideal opportunity to reimagine nursing education while addressing known disparities in traditional hospital-based nursing programs. Hospital-based, or apprentice models of nursing education were prevalent across the United States, while degree programs were less common and costlier. Postwar socioeconomic, political, and cultural trends influenced the climate for nursing education. This included the exploitation of student nurses to fill hospital staffing gaps, gender inequality, segregation, and rapid growth in medical technology and new patient treatments.11 Aware of these complex disparities and potential challenges, KP's leaders identified core values to reinforce the culture they envisioned and removed barriers that were viewed as incongruent.
Dr Garfield's vision included establishing a school to educate nurses to care for patients (members) and families in a prepaid health care model versus the conventional fee-for-service approach to patient care. The new school of nursing would offer education and training for nurses that would be on par with that of physicians, with a focus on science and community health. The 1945 second Annual Report of the Permanente Hospital Foundation described the vision for KFSN:
We are planning an accredited school of nursing which will be free from the traditional pressure of economics on nursing education, and permit proper emphasis and time in the purely medical aspect of instruction, carrying this on to nursing specialization in the various fields and medical care on a parallel with resident physician training in medicine.12
Dr Sidney Garfield, 1945
Kaiser Permanente's founders and trustees were instrumental in the structure, design, and culture for the new school. Dr Garfield firmly believed that Kaiser nurses would be instrumental in actualizing the KP-integrated health care model. Henry J. Kaiser and his wife, Bess, took the lead in securing funding and essential resources for KFSN. A strategic and essential addition was the appointment of Dr Dorothea Daniels, the nursing director for Kaiser's Oakland Hospital, as the director of the KFSN. A doctorally prepared educator from New York City, Dr Daniels possessed the leadership skills, education, experience, and character required to lead disruption and establish a culture of innovation and professional practice for generations to come.13
Curative medicine gives place to preventive medicine, so must (the nurse) be prepared to understand and apply intelligently the principles of prevention....13
Dorothea Daniels, EdD, RN, Founding Director KFSN
Dr Daniels worked with Dr Garfield and key stakeholders to systematically disrupt traditional barriers and introduce a new paradigm for hospital-based nursing education. In 1947, the Permanente Foundation Hospital in Oakland, California, received approval from the California Board of Nurse Examiners to establish a 3-year diploma school of nursing.14,15
Kaiser Foundation School of Nursing introduced several bold and innovative concepts, particularly in the areas of leadership, culture, diversity, and curriculum. The classroom was designed to serve as a learning laboratory for experimenting with new procedures and approaches to nursing care.
Dr Daniels worked in partnership with a medical director but held equal authority and control for nursing administration, operations, and policies governing both KFSN and the Oakland Hospital. Dr Daniels's dual leadership responsibilities ensured that the school and student experience remained separate and independent from the hospital. Kaiser Foundation School of Nursing values, policies, curriculum, and pedagogy were unprecedented, disruptive, and innovative when the school opened in 1947.13,14
The nurse of the future must exemplify health, and teach it. Humanity is ready to cast off sickness.13
Dorothea Daniels, EdD, RN, Founding Director KFSN
Eliminating socioeconomic stress and barriers, KFSN offered tuition support and stipends to allow students to fully focus on their education. Alumni describe a caring “family-like” environment balanced with rigorous standards for deportment and academic performance. Collaborative, collegial, and team-based working relationships between physicians, nurses, and providers were central to the KP culture and KFSN expectations of professional practice.12–14
The whole atmosphere of KFSN was that this endeavor is going to create a place where we are all family and we are going to produce the very best nurses.
Phyllis Moroney, BSN, NP, RN, KFSN Class of 1957
Body, mind, and spirit consciousness was taught and modeled by faculty. Faculty reinforced the importance of a proper diet, regular exercise, sufficient rest, spiritual connection, and extracurricular activities to support balance and resilience in professional development and personal health.13
Being able to feed one's soul is so important to be able to continue going on with what one's doing. And you can't give constantly unless you have something coming back in return.
Deloras Jones, MSN, RN, KFSN Class of 1963
The school boldly rejected racial barriers and became one of the first nursing programs to openly recruit and admit minority students in Northern California. Kaiser's black students and alumni were actively engaged in the founding of the National Black Nurses Association and Bay Area Black Nurses Association. Black student nurses participated in initiatives to address health care disparities in the black community and to promote inclusion, diversity, and health equity for all patients.10,16
I think one of the basic skills [of a nurse] is to look at the humanity of the person, respect and listen to the patient.
Helen Robinson, MSN, RN, FNP, KFSN Class of 1965
The core curriculum was grounded in the art and science of nursing. It integrated the latest advancements in medical science, therapies, and preventive care. Critical thinking was embedded in all aspects of the curriculum. Kaiser physicians and specialists served as faculty in classroom and clinical settings. The outcome of this interprofessional educational model was the development of collegial relationships between physicians and KFSN graduates, foundational to team-based care. Compassionate patient- and family-centered care and holistic aspects of prevention, health promotion, and wellness were integral to advancing the new KP preventive health care model. These concepts helped students educate patients on how to prevent and manage chronic illness.10
Nurses have to be caring, they have to want to be there. They have to really feel the spirit of taking care of that patient's needs. (D. Lovrin, June 3, 2017)
Dorris Lovrin, RN, KFSN Class of 1950
Alliances were established to offer college credit in general education and science, removing academic barriers and encouraging graduates to pursue baccalaureate and graduate degrees. Nursing courses were enriched by diverse clinical experiences that spanned the continuum of care. Clinical rotations evolved as KP's need for new nursing specialties emerged. Occupational health and rural nursing were early rotations, as was rehabilitation nursing. Outpatient/ambulatory care and home care clinical experiences ensured that students were well grounded in community-based care.
The school of nursing became independent from the hospital, with a separate board of trustees. As a result, clinical rotations were limited strictly to experiential learning, uncommon in traditional diploma nursing programs. Students were not assigned to supplement operational gaps in hospital staffing. Leadership theory and practices were integrated into the curriculum as a means of preparing students to assume future leadership roles.12–14
We were taught to be nurse leaders from the very beginning. That prepared me for my leadership trajectory. The environment in the school fostered this.
Deloras Jones, MSN, RN, KFSN Class of 1963
CONVERGENCE AND INFLUENCE OVER INCUMBENT VIEWS
Kaiser nurses played a major role in the convergence of disruptive innovation by partnering with physicians to continually innovate, evolve, and actualize the KP model of care. They served as leaders in the advancement of new practice models, demonstrating the belief that properly educated nurses contribute to improved health care outcomes. The first KP nurse practitioners and advanced practice nurses designed early discharge models for maternity care; offered physical examinations in the community; and led many strategic patient care innovations over the years. One Kaiser physician and leader summed up the influence of KFSN graduates by stating, “Kaiser nurses were practicing the kind of medicine in the 1950's that we are trying to get to today!”17
Kaiser Permanente is now considered a leading model in achieving high-quality, cost-effective, integrated care, which aligns with the original priorities of the Affordable Care Act of 2010.18 The KFSN legacy and Kaiser's current professional practice culture serve as exemplars for integrated health care while guiding the discipline and practice of more than 54,000 nurses in 39 hospitals and 677 medical offices across 8 regions today. As one of the largest not-for-profit health plans, KP serves more than 11.8 million people and has effectively overcome incumbent views on sick care.19
REIMAGINING THE FUTURE
Kaiser Foundation School of Nursing graduates embraced change, forged new frontiers in nursing, and influenced generations of Kaiser nurses and physicians. They established a proud legacy and strong professional identity. They nurtured a culture of innovation that, to this day, continually seeks to reimagine itself and explore new solutions to complex and uncertain political, economic, social, and population health challenges. One researcher observed, “Kaiser's success is its investment in professional nursing, which may not be evident to systems seeking to achieve Kaiser's advantage.”20 This study outlined the similarities in education, work environment, and outcomes between Magnet and Kaiser hospitals, concluding that Magnet and Kaiser hospitals perform at the same optimal level, with results highlighting that Kaiser nurses were even less likely than Magnet hospital nurses to leave their jobs.20
A LEGACY IS FORGED
Kaiser Foundation School of Nursing was consistently in the top 3 performing schools on state board examinations. New faculty, many with doctoral degrees, were drawn to the school for its reputation and high accolades from accreditation agencies. Kaiser Foundation School of Nursing graduates became early leaders, educators, and clinical innovators in KP. In the 1960s, diploma programs were on the decline, and the board of trustees set out to forge an academic partnership with a baccalaureate granting college. However, at that time, nursing accrediting agencies would not allow a college to partner with a health care system. The commitment to support baccalaureate education resulted in the difficult decision to formally close KFSN in 1976.15 Kaiser Foundation School of Nursing graduated 1,065 nurses over nearly 30 years. Forty years after its closure, alumni remain engaged as active advocates for nursing in annual and ongoing educational programs and nursing legacy projects across the enterprise (Figure).
CONCLUSION: PRESERVING THE LEGACY
The disruptive innovation that resulted in KFSN required courageous leaders who were impassioned and empowered to not only dream of what might be but supported to take calculated risks. They were able to boldly reimagine the future in ways that transformed systems and processes beyond the current reality of their time. The KFSN legacy lives on through leadership attributes that continue to honor and engage the “hearts and minds” of Kaiser nurses. Evidence of this includes investments in academic partnerships and professional practice programs that advance clinical excellence, nurture future leaders, and support opportunities for continued innovations in value-based care.21 The Kaiser Permanente School of Medicine will prepare future physicians and interprofessional care teams who will be better prepared to move beyond traditional health care settings and influence positive change through total health. The school is scheduled to open in 2020 pending accreditation.22
The accomplishments and interconnected legacy of KP and KFSN over the years evoke the pioneering spirit of shared vision, optimism, and hope required to build and sustain a culture of innovation.23,24 Efforts to preserve the legacy of KFSN through photograph and narrative archives, video interviews, and publications are an important part of ensuring that the knowledge, wisdom, and voices of Kaiser's first nurses live on and remain accessible for generations to come.25
You've got to maintain your integrity, your sense of being a human being. You can't lose that. If you lose that, then you become an automaton. It just doesn't work. (C. Lisker, June 3, 2017)
Clair Lisker, RN, MSN, KFSN Class of 1951
The KFSN legacy offers insight and learning for today's nurse leaders as they face unprecedented challenges and continuous change. Lessons from the past offer hope and guidance in establishing foundations for disruptive innovation that support and empower nurses as they seek to transform systems and processes beyond the present reality. A sample of key leadership learnings from the KFSN legacy project includes the following:
- Ensure alignment of proposed innovations to the organization's overarching mission and vision. Doing this will require the establishment of linkages, generation of buy-in, and executive support for essential funding and resources.
- Model the way. Be bold, take calculated risks, nurture collegial relationships, and practice self-care.
- Identify talent and empower nurses to critically think, innovate, and practice in ways that challenge the norm and promote evidence-based approaches to value-added care.
- Inculcate values-based leadership at all levels of the organization. Place a high value on diversity, advanced education, professional practice, interprofessional collaboration, and personal wellness.
- Envision care beyond the traditional acute care settings. Focus on new and innovative possibilities to promote wellness, prevent illness, and support healthy communities.
An enduring legacy is the highest honor for any nurse leader. This is accomplished not by accepting what merely is but by inspiring and challenging themselves and those they lead to move beyond everyday problem solving into an expanded realm of infinite solutions. The KFSN legacy was deeply rooted in KP's early mission and vision of total health. The contributions of these early nurse leaders, educators, and clinicians live on in the many innovative systems, processes, and care practices KFSN and its alumni helped establish more than 70 years ago. Some of these practices have been emulated by other systems. Reviewing our history is a reminder to all nurse leaders that innovations today will make a difference in the future for all those we serve now and tomorrow.
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2. Malloch K, Porter-O'Grady T. The Career Handoff: A Healthcare Leader's Guide to Knowledge & Wisdom Transfer Across Generations. Indianapolis, IN: Sigma Theta Tau International Honor Society of Nursing; 2016.
3. Porter-O'Grady T, Malloch K. Innovation leadership and professional governance: building the structure for transformation. In: Quantum Leadership: Creating Sustainable Value in Health Care. (5th ed) Burlington, MA: Jones and Bartlett Learning; 2018:111–113.
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5. Sinofsky S. The four stages of disruption. Recode. https://www.recode.net
/2014/1/6/11622000/the-four-stages-of-disruption-2. Published 2014. Accessed November 9, 2017.
6. Debley T. Replacing “sick care” with “health care”: national reform dialogue. A History of Total Health|Kaiser Permanente History Blog. http://www.Kaiserpermanentehistory.org
. http://kaiserpermanentehistory.org/latest/replacing-%E2%80%98sick-care%E2%80%99-with-%E2%80%98health-care%E2%80%99-dr-sidney-garfield%E2%80-%99s-ideas-in-the-national-reform-dialogue/. Published 2010. Accessed November 9, 2017.
7. Gilford S. A special Kaiser Permanente Anniversary. In: Build ‘Em by the Mile, Cut ‘Em off by the Yard: How Henry J. Kaiser and the Rosies Helped With World War II. Richmond, CA: Richmond Museum of History & Richmond Museum Association; 2011:153–206.
8. Ringwall K. An ounce of prevention is worth a pound of cure. Ag News from North Dakota State University. Ag.ndsu.edu. https://www.ag.ndsu.edu
/news/columns/beeftalk/beeftalk-an-ounce-of-prevention-is-worth-a-pound-of-cure/. Published 2017. Accessed November 9, 2017.
9. Cutting CC. History of the Kaiser Permanente Medical Care Program. An oral history conducted in 1985 by Malca Chall, Regional Oral History Office, The Bancroft Library, Berkeley, CA: University of California; 1986.
10. McPartland G. Old Oakland hospital holds memories of Kaiser Permanente's dynamic past. A History of Total Health | Kaiser Permanente History Blog. Kaiserpermanentehistory.org. http://kaiserpermanentehistory.org/latest/old-oakland-hospital-holds-memories-of-kaiser-permanentes-dynamic-past/. Published 2014. Accessed November 9, 2017.
11. Roux GM, Halstead JA. Nursing education: past, present, future. In: Issues and Trends in Nursing: Essential Knowledge for Today and Tomorrow. Burlington, MA: Jones and Bartlett; 2009:32–35.
12. Jones D. Nursing school alumni commission sculpture to honor profession. A History of Total Health | Kaiser Permanente History Blog. Kaiserpermanentehistory.org. http://kaiserpermanentehistory.org/latest/nursing-school-alumni-commission-sculpture-to-honor-profession/. Published 2014. Accessed November 9, 2017.
13. McPartland G. Iron nurse Dorothea Daniels had a soft spot for nursing students. A History of Total Health | Kaiser Permanente History Blog. Kaiserpermanentehistory.org. http://kaiserpermanentehistory.org/latest/iron-nurse-dorothea-daniels-had-a-soft-spot-for-nursing-students/. Published 2011. Accessed November 9, 2017.
14. Lincoln C. Kaiser Foundation School of Nursing highlighted in Oakland history. A History of Total Health | Kaiser Permanente History Blog. Kaiserpermanentehistory.org. http://kaiserpermanentehistory.org/latest/kaiser-foundation-school-of-nursing-highlighted-in-oakland-history/. Published 2013. Accessed November 9, 2017.
15. KP School of Nursing history. Kaiser Permanente Nursing: nursing pathways: Northern California. Kpnursing.org. http://kpnursing.org/_NCAL/professionaldevelopment/alumni/history.html. Published 2017. Accessed November 9, 2017.
16. Cushing L. Black nurses get together to forge their own future. A History of Total Health | Kaiser Permanente History Blog. Kaiserpermanentehistory.org. http://kaiserpermanentehistory.org/latest/black-nurses-get-together-to-forge-their-own-future/. Published 2014. Accessed November 9, 2017.
17. Eytan T. Photo Friday: where we came from: Kaiser Foundation School of Nursing. https://www.tedeytan.com
/2016/11/04/20489. Published 2016. Accessed November 9, 2017.
18. Tumulty K. Obama: ‘We've provided more guidance than advertised’ TIME.com. http://content.time.com/time/politics/article/0,8599,1913363,00.html. Published 2009. Accessed November 9, 2017.
19. Fast facts about Kaiser Permanente. Kaiser Permanente Share. https://share.kaiserpermanente.org
/article/fast-facts-about-kaiser-permanente/. Published 2017. Accessed November 9, 2017.
20. McHugh M, Aiken L, Eckenhoff M, Burns L. Achieving Kaiser Permanente quality. Health Care Manag Rev. 2016;41(3):178–188. doi:10.1097/hmr.0000000000000070.
21. D'Alfonso J, Zuniga A, Weberg D, Orders AE. Leading the future we envision: nurturing a culture of innovation across the continuum of care. Nurs Adm Q. 2016;40(1):68–75. doi:10.1097/naq.0000000000000141.
23. Zuber CD, Alterescu V, Chow MP. Fail often to succeed sooner: adventures in Innovation. Perm J. 2005;9(4):44–49.
24. Chow M, Liebermann J, Crawford C. Kaiser Permanente's Garfield Center: using human-centered design for nursing innovation. AONE Voice of Leadership. January 2017:12–15.
25. Kaiser Permanente Nurse Scholars Academy. The legacy of nursing at Kaiser Permanente. Nursescholars.kaiserpermanente.org. https://nursescholars.kaiserpermanente.org
/nursing-legacy/. Published 2017. Accessed November 9, 2017.