IN 2009, Weberg defined innovation in health care as “something new, or perceived new, by the population experiencing the innovation, that has the potential to drive change and redefine healthcare's economic and/or social potential.”1(p235) Most innovations hailing from Weberg's context are sustaining innovations, which are innovations that improve existing products among an established consumer base. For example, increasing the number of razor blades in a commercial razor from 4 to 5 blades or improving the resolution quality of a flat-screen TV is an example of sustaining innovations.2 Larger incumbents in the market typically produce these or generally represent advances in engineering, technology, and manufacturing to make goods, products, or services better.2 Disruptive innovation, on the contrary, is defined as an improvement that originates in low-end or new-market footholds and pushes incumbents closer to the top of the market or out of the market altogether.2,3 Nurses, as vital participants in leading change that improves outcomes for patients, are essential partners in conception and implementation of both types of innovation.
Nurse leaders are positioned as influencers, validators, and strategic advisors inside and outside of health care systems (Table 1). They occupy these 3 key pivotal roles in health care disruption and are perfectly positioned to introduce, test, and validate disruptive innovations to improve the safety, quality, and affordability of health care around the world. Because of the innate need to revolutionize the health care industry in the United States, intentional avoidance of disruption while relying on market incumbents to lower costs is essentially an oxymoron. Disruptive innovation holds promise, especially in nursing, to facilitate better outcomes at lower costs with improved experiences.
DISRUPTIVE INNOVATION: WHAT IS IT?
Christensen et al2 expertly articulated the difference between a sustaining innovation and a disruptive innovation (Table 2). Their example of 2 well-known companies, Uber and Netflix, provide an easily understood exemplar. Uber is a popular ride-sharing platform that connects consumers who need rides with drivers willing to provide them. Uber emerged as an industry leader in the incumbent taxi business but is not technically a disruptor. Uber did not enter the market in rural areas where underserved passengers could not find taxis. Instead, Uber launched in the mainstream market of San Francisco and offered a sustaining innovation to the existing taxi market and created a seemingly better service with easier access, cleaner vehicles, and more relevant payment methods.2 Uber did not enter the low-end and underserved markets until after it had established its business in the mainstream.
Netflix, on the contrary, is a well-known provider of online media and showcases a textbook story of disruptive innovation. As Netflix made an early appearance in the media world, its business model consisted primarily of a subscription service for mail-order DVDs. Video store giants such as Blockbuster paid very little attention to the company. Netflix's initial model struggled with slow postal delivery and niche customers made up mainly of movie buffs and early adopters of DVD technology. However, as Netflix continued to evolve its business model and became an early adopter of advances in streaming technology, Blockbuster found itself behind the curve with this disruptive competitor. Net-flix was able to reach the masses through a cheaper, easier-to-use platform that challenged brick-and-mortar Blockbuster all the way to its demise.2
Health care parallels of sustaining innovation versus disruptive innovation can easily be identified. For example, digital radiography is a sustaining innovation. It represents a technological advancement that enables more timely clinical decision-making.3 Once hailed as an in-house function for most acute care organizations, radiography readings impact clinical decision timelines. With the advancement of Internet technology, radiography readings can be completed across continents by remote providers in a matter of minutes versus hours. This type of innovation has improved processes and access to information.
Disruptive innovations in health care are less common. Perhaps, the most recent example is the emergence of retail organizations into primary care. Traditional visits to a primary care clinic are often wrought with friction-inducing barriers such as scheduling, commutes, and long wait times for a condensed provider visit that carries a high price tag.4 Now, health care consumers can visit commercial giants such as Walgreens, CVS, and Walmart where they will experience primary care in a very different way. Patients often travel much shorter distances to reach the nearest retail health care clinic, are greeted by an advanced practice provider or a self-registration kiosk, and are typically evaluated within minutes of arrival for a fraction of the cost. Even better, patients experience comparable clinical quality and outcomes.3 Retail entrants into primary care are similar to Netflix in that they exhibit characteristics of a disruptive innovator. Clinics appeal to underserved consumers in the marketplace, offer a comparable or slightly better product, and do so while reducing the overall price.
Although health care represents more than one-sixth of the US economy, it has been stifled with status quo from a disruption perspective. Health care continues to be dominated by high costs, variable access, questionable quality, and inconsistent outcomes across the country.5 Even with advancements in electronic medical record technology, high-end imaging, and more sophisticated monitoring equipment, most health systems exhibit slow adoption of technology along with an aversion to disruptive business models. As a result, in a race to meet the new regulatory and payer demands of value-based care, entrepreneurs have identified a market ripe for disruption.
It is relatively easy to understand why sustaining innovation is more prevalent than disruption in health care. Most disruptive innovators are small-scale companies with fewer resources that can rarely compete with reigning health care giants. Many early products created by disruptive innovators lack the quality, validation, and scalability that health care purchasers demand in a highly regulated and somewhat archaic business model.5 In health care, sustaining innovations are much safer plays from a purchasing and user adoption standpoint. These realities create a real barrier for disruptor entry.
LEADERS AT THE HELM: ACTING AS INFLUENCERS
Researchers have applied the concept of “dominant logic,” or organizational mind-set, to nurse leaders and their potential inability to foster innovation advancement. Dominant logic illustrates deeply institutionalized corporate cultures that pervade nursing and create serious barriers to change. Reinforcers of dominant logic include policies, procedures, regulatory enforcement, accreditation standards, and other legacy influencers. Together, these create a mind-set of innovation aversion that is difficult to overcome without significant stakeholder support.6 Dominant logic defends the status quo and can easily prevent new ideas from emerging in teams, systems, and the larger discipline of nursing. Ultimately, dominant logic can prevent improvements that would reduce costs, improve outcomes, or both.
To effectively embrace disruptive innovation in any form, nurse leaders must first act as influencers. This requires them to evaluate and challenge the dominant logic that exists in the organization. Asking the tough questions like “If we redesigned this process today, how different would it look from our current process?” or “Is this practice even relevant anymore?” is a great place for nursing leaders to begin evaluating the innovation environment. Also, nurse leaders must consider factors that create a more “innovator-friendly” environment. Does the organization leverage generationally diverse teams at all levels of leadership? What mechanisms attract entrepreneurs? Is there a process to engage in short-term partnerships, beta tests, and validation exercises that test potential new innovations? Has the company forged any partnerships or made investments into start-up accelerators, venture firms, or other types of entrepreneurial incubators? Nurse leaders may find an entire ecosystem has already been established to foster more rapid exposure to innovation. Nurse leaders should advocate for nursing to have a voice in these processes and should encourage participation in all ideation that impacts patient care. Status quo may be maintained, simply by the absence of the nursing perspective in organizational decision-making.
Nurse leaders across the organization must assess for innovation competence within their leadership team. Clement-O'Brien and colleagues7 found in a study of 106 chief nursing officers in New York that those with more leadership education had implemented significantly more types of innovations than those with less education in the art and science of leading. Studies have demonstrated that the top 5 competencies needed for innovation by nursing leaders include the ability to convey a compelling vision; resilience; ability to recognize an opportunity; tenacity and perseverance; and interdisciplinary teamwork. However, according to White and colleagues,6 their study showed that only one of these competencies, tenacity and perseverance, was commonplace among the respondent sample.
Nurse leaders are perfectly positioned to identify evolving business models that may offer true disruptive innovation and leverage influence in the existing operating infrastructure. As suggested in the work of complexity leadership theory, the tension that is created inside organizations between the embryonic entrepreneurial system and the incumbent operating system is quite possibly the pivotal intersection where true innovation occurs. Nurse leaders are often positioned as conflict managers in these competing systems and may more aptly be utilized as innovation leaders.8 In the lens of disruptive innovation, nurse leaders have keen insight and ability to “connect the dots” between incidents that appear to be unrelated.6
NAVIGATING INNOVATION: ACTING AS VALIDATORS
The task at hand may appear overwhelming, considering that health care is ripe for disruption. As influencers, nurse leaders can expose and clarify areas prone to disruption. From there, they can act as validators to increase the adoption of disruptions into their macrosystems. Validators move the organization forward by removing barriers to disruption such as the adoption of artificial intelligence (AI) and virtual reality (VR).
AI-informed talent management
AI is likely to be a disruptor in the management of human resources, including the patient care staff. For the past decade, human capital strategies have gleaned copious attention from health care leaders nationwide. Wages for nurses continue to rise nationally, and health system operational budgets are significantly influenced by the dominant direct and indirect nursing labor costs.9,10 Health care employers strive to be smarter, more agile, and more informed about hiring decisions and talent management operations. AI, the ability of machines to mimic adaptive decision-making, presents numerous potential benefits to employers. Tough questions like “Are we attracting the right candidates?” or “Are we offering jobs to those who will be the best employees?” are being addressed through advanced algorithms that personify employee types and predict success with job functions.
Companies such as IBM leverage AI technology to inform employees about training courses that may be useful to them, based on the experiences of similar employees. Some vendors have created technology that can match employees with benefits packages that suit their individual needs, much like Netflix or Amazon matches consumers with products based on prior behaviors.11 Advancements in big data and analytics technology allow employers to glean greater insights into potential hires. This informs hiring decisions, potentially leading to better hires and reduced turnover. The monetary impact of turnover reduction alone is exciting to nurse leaders.
However, most companies struggle to make any real use of big data analytics. Forty-one percent of CEOs state they are not prepared to make use of new data analytics and AI tools.11 Health care's paralytic rate of technology adoption in comparison with other industry sectors makes the promise of big data informing this sector's hiring decisions seem like a distant dream. Nurse leaders, as the largest procurer of labor in most health systems, may be the ideal proponents for these types of technology decisions, despite the business function being “owned” by human resources departments. Nurse leaders should consider participating in vendor demonstrations, creating cross-departmental teams to evaluate products, and commit to beta testing new and emerging technologies that present low-risk/high-reward options for health care hiring.
VR and nurse competency
Perhaps, the nursing area most well-suited for the disruption of VR is the onboarding and training of the clinical staff. Nurse leaders recognize that clinical training and simulation are key educational components of a patient safety strategy. As a result, Johns Hopkins Medicine allocates more than 5% of its annual budget for nurse training and education.12
Traditional content and methodologies rely heavily on hands-on experience and legacy high-fidelity simulation. At more than $70 000 each, high-fidelity simulation manikins are often intangible assets for parsimonious health systems. Educators trained in simulation pedagogy are necessary for this type of education to be effective. However, many nursing professional development specialists lack this competence.13 Furthermore, in-house education teams often lack access to immersive, experiential content that is budget-friendly and widely available. E-learning and screen-based learning have offered plausible alternatives to bridge the gap between costly classroom offerings and hands-on experiences. Unfortunately, neither option provides the learner with a truly immersive experience and both options reinforce a one-size-fits-all approach to education and training.
A relatively new player in the health care space, VR is beginning to gain traction in nurse onboarding and training. Once profiled as a technology for video game enthusiasts and entertainment connoisseurs, VR has potentially found a disruptive path into health care that is worthy of nurse leader attention. The cognitive, emotional, and behavioral learning dimensions exhibited with extended reality technologies (such as VR, augmented reality, and cross-reality) have been shown to improve training experiences for users over traditional methods.14 A recent study at the University of Maryland found higher recall and spatial awareness with head-mounted VR displays than desktop-based learning.15 For high-risk areas such as operating rooms, VR simulation has demonstrated improved performance in a risk-free learning environment. A study published in 2017 found a 250% learner improvement using VR over traditional reading and lecture training when preparing the perioperative staff for the management of surgical fires.16
Available at a fraction of the cost of high-fidelity simulation manikins, VR training possesses all the traits of a disruptive innovation: low-end price entry, fringe customer engagement to the higher end of the market, scalability to the masses, and a new market creation in health care. As nurse leaders think of ways to train tens of thousands of new nurse employees entering health systems in the immediate years to come, VR training should command serious inquiry and consideration.
LEADING IN DISRUPTION: ACTING AS STRATEGIC ADVISORS
Nurse leaders play a critical role in disruptive innovation by acting as strategic advisors. By influencing policy at the organizational, local, state, and national levels, the nurse leader can effect changes to status quo practices that potentially impede the ability for health care to evolve to a better future state. In addition, the expertise of the nurse leader can influence a diverse realm of matters that ultimately impact patient care or care delivery models. One example of an area in need of disruption is undergraduate nursing education, and the nurse leader, as strategic advisor, can play a critical role in advancing this work.
Nursing prelicensure curriculum redesign
Although the academic-practice gap is well-documented and growing, there has been minimal disruption in this area of nursing. Nursing's prelicensure curriculum has remained primarily focused on inpatient medical-surgical nursing for decades and reflects a status quo dilemma institutionalized by the National Council for State Boards of Nursing's NCLEX-RN examination, along with other highly institutionalized processes within the discipline of nursing. The high-stakes emphasis on NCLEX-RN pass rates has essentially forced academic institutions to concentrate on examination pass rates more than the overall competency of new graduate nurses.17 It has also limited innovation and disruptions by mandating that all prelicensure students gain knowledge in multiple nursing specialties prior to graduation (including obstetrics, pediatrics, mental health, and adult care). This has become a problem for modern nursing programs that are only 1 to 2 years in duration. Ultimately, the result is that graduates applying to health care systems are underprepared to transition into employment in any specialty without expensive and time-consuming training programs.18–21 When this is coupled with the retirement trend of experienced nurses, current and future shortages of nurses in specialty areas (including perioperative, behavioral health, ambulatory, and perinatal nursing) are likely to increase.19,20,22,23
Nurse leaders from both academia and practice must collaborate as strategic advisors on disruptions that aim to improve initial graduate clinical competency as well as workforce readiness to fill gaps in specialty nursing practice. Disruptions must also lower the cost of education and training for both students and health systems. Short-term solutions include microdisruptions such as those that have occurred at the Jefferson College of Nursing, Seattle University College of Nursing, and Western North Carolina School of Nursing. Curriculum redesign in these institutions has addressed the need for additional education in community-based and primary care nursing.24 For example, the Jefferson College of Nursing has redesigned its curriculum to a concept-based curriculum where prelicensure students are now exposed to a broader range of clinical settings, including acute care, continuing care, outpatient rehabilitation, pediatric offices, homeless shelters, and accountable care organizations.25 Jefferson has accomplished this while still preparing student nurses to successfully pass the NCLEX RN examination.25 Another example of disruption is collaborative academic-practice partnerships that provide externships and clinical immersion experiences in areas with inadequate prelicensure exposure such as perioperative services.23 Emulating a version of the medical education model, which leverages academically driven residencies that continue formal education post–initial licensure, should also be considered as a disruptive model for nursing.
Despite the growing complexity of health care and nursing practice, the status quo places the onus of nurse residency on the health system and its clinical education teams. Is there a better way to prepare nurses to enter the workforce? Is this model of education still relevant in our evolved discipline? Both of these questions need to be addressed. Residencies of the future should initiate prior to graduation, reflect a competency-based orientation, and leverage interprofessional learning throughout the program.26
Nurses need to gain focused academic education in their areas of specialty to improve their preparation and readiness for practice. Health system clinical education teams must be responsible for ongoing training and development of nurses. However, most clinical education teams are not trained or staffed to provide the foundational knowledge required to perform the minimum job functions of specialty practice. As a result, specialized positions dedicated to training and developing new graduates are costing health systems additional resources, time, and money. On the basis of the current quality of American health care, that money should be invested in improving patient care outcomes, not training new nurses. Academic faculty members are almost certainly better positioned than clinical education teams to deliver didactic and clinical instruction in formal postbaccalaureate programs that bridge the academic-practice gap. Health systems could leverage existing partnerships with universities and provide clinical training sites to evolve their nurse residency models. Although this idea is not new, and is well cited in the literature, it remains to be the exception and not the rule.
INNOVATION IS A SOCIAL PHENOMENON
Given the regulatory nature of health care, disruptive innovation requires ecosystem-level change encompassing customers, partners, media, analysts, and experts. Each constituent in the process occupies a strategic role in the evolution needed to form a new disruptive infrastructure. In a cycle described as the “disruptor's gambit,” the disruptor reveals its intentions early on and follows rapid adaptation cycles to respond to customers and partners while leveraging them as force multipliers in the new ecosystem.27
Researchers have pointed out that various actors inside an emerging ecosystem can play important roles in legitimizing the new business models forming around them.27 In the case of health care disruption, nurse leaders occupy a strategic role in the disruptor's gambit by actively building frames for the next adaptation cycle. Nurse leaders are critically positioned in the feedforward and feedback loops of rapid adaptation cycles to provide critical insight into the framing of disruption. Based on nurse leaders' attention, oversight, and quality validation of the disruptive model, the momentum can accelerate and initiate a positive cycle that is very difficult to reverse. Without nurse leader support, disruptive innovation in health care will degenerate into a vicious cycle of stagnation and incumbent-constraint.27
Given the size, scale, and dissemination of the global nursing workforce, nurse leaders have the necessary influence to function as force multipliers. This is true not only in the creation of external ecosystems but also in the internal adoption of emerging disruptive models. Nurse leaders often leverage social capital through connections with other constituents in the health care system to influence change. Understanding that innovation is often a social phenomenon, nurse leaders are positioned to broker innovation within highly connected groups, such as nurses, by using social capital, group cohesion, and cultural influence to drive adaptation cycles and rapid advancement of a disruptive model.8
Every day, nurse leaders navigate the health care conundrum of balancing cost, quality, and resources while relentlessly focusing on positive experiences for all stakeholders. As they facilitate the daily demands of leading the nursing workforce, they understand why innovation in health care is so hard to accomplish. Barriers include a plethora of stakeholders with different agendas, lack of capital resources, growing consumer empowerment, and a highly regulated environment. In addition, there is an innovation competency gap among nurse leaders.
Healthcare has experienced a myriad of innovations over the past decade, including electronic medical records, portable medical equipment, and advanced bedside communication. Nurse leaders are often an initial point of entry for these innovations into their systems. They carry significant decision influence when an organization is purchasing new products or designing new processes. However, most of the changes introduced in the preceding decades represent sustaining innovations rather than disruptive innovations.
The health care world is facing competition from other who are not tied to the status quo. Megamergers of insurers and retail chains, such as Aetna and CVS, illustrate one disruption that will capture a new market of health care consumers. Google, Amazon, and Apple are bringing new perspectives, innovation competency, and deep financial resources as they enter the sector. Collectively, these disruptors present a clear and present danger to incumbent institutions. Organizations can, and should, expect these new players to continue to define their position as disruptive innovators in health care.
As discussed earlier, Blockbuster enjoyed incredible success until its market was disrupted by Netflix. Once a household name, Blockbuster is quickly becoming a relic of the past as Netflix continues to soar in stock market value and consumer popularity. The health care industry is beginning to see these same types of disruptions that occur across many facets of our business. As influencers, validators, and strategic advisors, nurse leaders can navigate and lead changes that enable their systems to evolve more rapidly based on emerging trends and evidence in the literature. Ultimately, organizational agility is no longer optional, and those leaders and health systems that do not begin to adapt quickly are at risk to become the next “Blockbuster” of health care.