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Turning the page

Nursing in the digital age and beyond

Porter-O'Grady, Tim DM, EdD, APRN, FAAN, FACCWS

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Nursing Management (Springhouse): September 2019 - Volume 50 - Issue 9 - p 40-47
doi: 10.1097/01.NUMA.0000579012.32858.2b
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As I work to outline the characteristics of the future that will affect nursing leadership and practice to celebrate the 50th anniversary of Nursing Management, I'm reminded that my first-ever published article some 40-plus years ago appeared in Supervisor Nurse, the precursor to this journal.1 I remember 1977 as another time of great change, with shifts in healthcare financing laws and the introduction of diagnosis-related groups. And here we are again at a seminal moment in America's history as we confront a host of dramatic changes and shifts in our economic, technologic, social, and political environments.2 These drivers represent the convergence of many forces that enumerate a painful, noisy, and emotional response to change as we surrender attachment to the industrial age within which most of us were born and engage the digital age into which all of us are now moving.3 The momentum of such a transformation has picked up steam and moved us substantially enough forward that we're beyond the tipping point of ever going back.4 Healthcare is forever redefined and now reflects a fundamentally different foundation for offering, linking, and integrating health services and the nursing role that lies at their center.5 (See Figure 1.)

Figure 1:
Figure 1::
New model of 21st-century health

Technology transforms experience

The introduction of the silicon chip, which led to the miniaturization and portability of technology, has transformed our world to the extent that contemporary life experiences not only reflect technologic influences, but are essentially driven by them. These days, the largest concerns regarding survivability relate more to protecting the electronic grid than the undertaking of physical human conflict. Concerns related to hacking the internet, polluting software scripts, and shutting down power grids can result in significant social trauma.

In healthcare, management and efficacy of electronic medical processes and records create an information aggregation that's become quite overwhelming. Big data not only provide a huge potential for advancing the veracity and vitality of health services, but also raise concerns about how data are stored and managed. The multiplicity of platforms and vehicles for the generation and management of data systems creates all kinds of “noise” in the health system, calling for the devotion of massive amounts of human and fiscal energy and resources to manage them appropriately.

New applications and digital technologies have helped facilitate the discovery and delineation of the smallest units of human life, becoming an essential part of contemporary medical research and therapeutics to advance the management of human anomalies and disease. For example, pieces of the DNA structure can now be clipped and altered, rearranging the very fundamentals of life.6 These technologic advances not only provide opportunities for improving human life, but also raise ethical and moral challenges regarding the definition of that life and questions related to the potential and limits of technology.7 There's also increasing concern about the influence and control of technology developed to a level beyond the human capacity to manage it.

Value replaces volume

Industrial age models of commercially based healthcare delivery have emerged as the frame of reference for the private, profit-driven, American approach to health services. Out of this approach came significant innovations in disease management, along with a considerable number of health products, insurance companies, vendors, service conglomerates, and agents/agencies, expanding to a degree that's made American healthcare the single largest and most expensive system in the world.8 Although this approach arguably created some of the most significant health innovations in human history, it also created what many people have now identified as a bloated, convoluted, complicated, inefficient, and ineffective delivery system.

Multiple public initiatives have attempted to address the confusing and expensive array of health service delivery mechanisms and models, yet they've only had a marginal impact on cost and efficacy.8 Over the past decade, a strong national argument has been made and related initiatives undertaken to generate value in healthcare delivery.9 There's now a growing understanding of the strong need to establish a direct cause-and-effect relationship between the delivery of healthcare services and the attainment of the sustainable health of citizens and communities across the US at a reasonable price.

Over the next 2 decades, the commitment of resources and energies for establishing a definitive relationship between healthcare delivery and the net aggregate health of the nation will be the overwhelming driver of health systems leadership. This increasingly important driver of value is the centerpiece of healthcare's financial and service infrastructures and will become the prevailing contextual framework within which service provisions unfold. The establishment of the relationship between the generation and application of resources (money, technologies, skills, providers, researchers, innovators, insurers, suppliers, purveyors, and so on) will create a convergence of energies around the value of sustainable health rather than simply the treatment of disease. This “value equation” emphasizes the efficacy and effectiveness of the necessary effort to both produce and sustain health from all who are engaged in its pursuit. (See Figure 2.)

Figure 2:
Figure 2::
The health value equation

The convergence of forces identified here has created a context for clinical nursing practice that looks entirely different from any context experienced by nurses to date. Indeed, the story yet to tell is one so different that there's little in our language to adequately capture its import and impact. All the emerging elements of transformation will need to be addressed and will have a direct and sustained impact on the future of nursing education and practice. (See Figure 3.)

Figure 3:
Figure 3::
Creating the future context for nursing

Learning redefined

Like all the other characteristics of human transformation, education and learning are undergoing a powerful renaissance. The history of two-dimensional learning and the organized effort “to know” led to learning processes meant to transfer knowledge from one brain to another through the medium of the spoken and written word. Education in America is grounded in that same process today. Although higher education is using the online environment for learning, many of the applied tools are similar to traditional classroom learning. However, newer digital tools using simulation and artificial intelligence (AI) vehicles (see the article on AI in this issue) provide the opportunity to move from simply learning facts and figures to applying both thinking and acting in scenarios and processes that mirror the real use of such knowledge. The current major progress in simulation models and the growing use of simulation labs, which now include highly evolved virtual tools for learning and competency testing, underpin further new and transformative approaches to learning and development. Interacting with virtual images, using avatars as personal agents in real-time scenarios, and virtual participation in group dynamics from one's own home are becoming commonplace. Participating in patient care scenarios where the variables can be altered to reflect real-life events in demonstrations and examinations better reveals the useful products of learning and their safe translation into practice. Over the next 2 decades, there will continue to be a broadening of approaches to learning in clinical education for nurses and other healthcare professionals.

Transdisciplinary professional and clinical education will become more integrated and shared. Basic sciences and clinical foundations classes will be taught with the major disciplines of nursing, medicine, and pharmacy together, building a stronger team and collegial appreciation for each other. They'll return together in the final course(s) to develop the partnership and team skills necessary to work effectively as colleagues and partners.

Team learning won't require personal presence to interact with others in a deep and meaningful way. Through multiple digital media methods, students will be able to dialogue with and demonstrate to each other in real time. Collective virtual interactions and processes will help the learning community experience the realities of practice in an environment that matches any conceivable context for nursing care or patient experience. The opportunities to work in community, family, and outpatient/inpatient settings are now unlimited in this virtual environment, and students can meet in these digital workspaces to hone skills and develop relationships as though they're physically present in the room with each other.

Most learning content will be standardized by digital designers and vendors with the capacity to develop and monitor its use and impact on proficiency and competence. They'll be able to quickly and immediately adjust content and incorporate innovative learning technologies into educational processes. Testing will include the use of biometric tools to record how students are responding to the learning dynamics of the specific courseware or program of study.

There will be stronger interaction between learning and practice to emphasize the kind of competencies that demonstrate relevance and currency. In an evidence-based practice (EBP) environment where the signals of appropriate practice impact can be assessed quickly and effectively, it will be important to ensure that curricula reflect best practice standards currently in evidence. These just-in-time approaches will redefine the primary role of the healthcare provider from “having” knowledge toward a capacity for “accessing” knowing with all the attendant skills this competency requires. Universities and health systems will either merge or partner in a much stronger symbiotic relationship that ensures a more seamless pipeline between learning and practice environments. Larger health systems will create their own nursing and medical schools for a stronger alignment between the mix of clinicians they need and the flexibility to effectively prepare them in a timely manner.

The role of women is changing rapidly in the contemporary world. The move to inclusion and equity now involves acknowledging that there are no remaining excuses for gender disparity. This will influence nurses' role in policy and practice, especially in education and learning technology. Competency and contribution expectations for men and women will no longer be arbitrarily differentiated, and the requisites of comparability will be imbedded in the outcomes and impact of work. Vertical subordinance has been a vehicle for limiting nurses' power and role. Going forward, this will no longer operate to constrain effort and contribution. However, nurses will need to be educated to “step up to the plate” and deliver the definable impact on the nation's health that nursing practice has promised.

Diversity will continue to be an issue in our profession. Representing the full breadth of the American population in the ranks of nursing faculty and students will no longer be optional. As American becomes a “majority-minority” country, cultural and social adjustments in educational structures and processes will be critical to facilitate access to learning.

Major shifts in practice

Many of the key shifts in education also have significant implications for practice. So much of nursing practice has become ritualized and rote. The broad effort to standardize safety and practice, such as Lean and related quality control mechanisms from other industries, has done almost everything but completely wring out the capacity of nurses to make judgments (a central skill for licensure), handle variability, take risks, and innovate. There's no doubt that nurses, as with any profession, need standards as a platform for practice norms and patient safety. We certainly have a long way to go—there are still those who see 100% universal hand washing as a measure of excellence. The central skill of the nurse is to be able to make judgments about the circumstantial and personal variances that make up the health vagaries in a patient population. Although procedures may clearly need to be standardized for safety and efficacy, the nurse's role is most exemplified and validated by variance—the unexpected, unplanned, and incidental. For the most part, the nurse's function is adaptation, adjustment, and accommodation to the myriad individual variances from the norm that challenge the standard and call on his or her capacity to make the right decision under a variety of intervening circumstances.

More tools will emerge over the next decades to help nurses with both the standard and exceptional activities of everyday nursing practice.10 From whole systems of care transformations to interventional technologies, the nurse will have tools and technologies available that make the work of nursing more rewarding and challenging. Use of clinical tools for decision and action in the practice setting, such as predictive analytics and clinical decision support, depend directly on the efficacy and effectiveness of the informatics infrastructure of health networks and service settings. AI and mobile technologies will continue to become more common, freeing nurses from being anchored to instruments and devices. Many diagnostic and assessment tools will be digital, such as BP measurement, heart monitoring, and glucose management. These are just a small sample of the portable and mobile technologies (most attached to smartphones) that patients will use or wear to participate in self-management and inform clinical response.

Newer clinical dynamics will dramatically change the focus of practice. In the next decade, 3D printing will replace organs, doing away with kidney dialysis, heart surgery, and a host of other organ-based surgical procedures once a staple in hospital care. Genetics/genomics will create a tighter fit between pharmacotherapeutics and increasingly specific diseases. Whole classifications of conditions that previously required hospitalization will diminish, reducing total bed use and increasing the complexity of the services required when patients are admitted for institutional nursing care.

As micro-digitalization continues to advance, patients will be increasingly in control of the tools that manage their health. These tools increase the opportunity to customize or personalize healthcare and treatment—individually and remotely—reducing patients' dependence on others to manage health services or clinical activities and giving them more control and interaction with their own health data and the digital records that document their health journey. Increasing changes in public policy and regulation will continue the trajectory leading to patient ownership, portability, and interoperability of personal health information in a medium that will make access and utility the normative process for managing this information. With value the goal, more “early engagement” health services will emerge as the usual and ordinary vehicles for maintaining health and avoiding decline. When these new tools reach the tipping point, the script for service design and clinical work will be irretrievably altered. Nurses will need to examine what will be the predominant character/content of their work and where that work will primarily be done. To be sure, most of the nurse's work will no longer be inside hospitals in the same way that's defined the nursing workplace for the past 80 years.

As the health service team begins to converge around the continuum of care, it will become the predominant clinical care model in the short term. As procedures and practices reflect a price set point, services will have to operate within the constraints of the financial and quality measures that define them. Teams of providers will link their services in an integrated clinical care plan that will evidence sustainable value reflected in satisfaction, good resource stewardship, and high service quality. (See How must nurses be different?) And who will be coordinating these teams, making sure that all the pieces come together in a good fit to make a difference in the patient's health? Of course, nurses will continue to meet the demands that characterize their unique role, coordinating, integrating, and facilitating the patient's journey toward desirable health outcomes.

How must nurses be different?

As the technology that influences nursing education grows more sophisticated, nurses can expect to find these tools imbedded in the practice environment. The nurse's capacity to demonstrate knowledge application will be equally as important as obtaining that knowledge. Translating knowledge into action and value is the cornerstone of good practice. However, historically this hasn't always been a key element of the learning process inside the nursing workplace. By using digital tools, nurses can now demonstrate their successful translation of learning into practice and its impact on value.

In addition, as EBP becomes the norm and the technical infrastructure for big data management becomes more precise, clinical practice will need to “change on a dime.” Gone will be the days of policy and procedure committees with the luxury of 3 to 6 months to deliberate on a change. Practice change will take place the minute that data are available to suggest the efficacy of a different or new practice. Big data management processes will change the content of assessment, decision-making, action, and evaluation and shorten the critical response time for updating nursing practice. Speed will itself become a tool of practice and will be a great differentiator of the value, quality, and effectiveness of healthcare.

The community is the foundational locale for sustainable health. Increasing focus on the social determinants of health, such as housing, finances, access to healthy food, and relationships, shows that they have as much of an impact on an individual's health as any other factor. Nurses will increasingly be the connection between the community and the health system, providing the access point to resources. From community health educator and care facilitator to the interface between resources and populations, nurses will expand their presence at the community point of service and become a central link between the healthcare infrastructure and the individuals and communities who will use it “in place.” In this circumstance, the major work will be in bringing the health system to the user rather than the user to the system.

What defines nursing practice is dramatically shifting. Increasingly, nurses are policy makers, politicians, administrators, primary care providers, informaticists, health planners, geneticists, engineers, community resources, and a host of edge-runner roles not yet fully evolved. Nursing will continue to embrace innovative roles that better reflect future demands for health services but remain grounded in the universal value ensconced in the ethos, standards, regulations, and practices of the profession to coordinate, integrate, and facilitate all activities and dynamics that lead individuals and communities to obtain and sustain health.

Becoming what's next

As nurse leaders, I ask you to reflect on the shifts and transformations outlined here and the vast array of resources that suggest the changes in the science and practice of healthcare to come over the next 2 to 3 decades. For nursing, the opportunities remain unlimited as nurses fill more creative roles to extend sustainable health to individuals and communities. The wide variety of specialties that now incorporate the nursing role strongly suggests the viability of nursing for many decades to come. Leaders willing to engage the future with the application of new technologies and roles and the delivery of value-based approaches to sustainable health will drive change in the profession, ensuring that nursing is relevant and responsive. (See Leading the future.) Effective leadership will be evidenced by our nimble response to making a future that's better than our past, enabling society to meet and realize its goal of a truly healthy America.

Leading the future

  • Read widely (even outside of nursing).
  • Make staff members aware of major tech innovations affecting their work (and lives).
  • Hold lunch/learn talks on specific new initiatives affecting the nursing experience.
  • Push staff into meetings/discussions/decisions affecting innovations in care delivery.
  • Check your own willingness/availability to embrace/model the emergent and innovative in care.
  • Make innovation work for staff members by holding them accountable for making a real difference in their patients' and their own lives.


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