T • W • E • L • V • E

Nurses Leading Change: The Time Is Now!

Susan W. Salmond and David Anthony Forrester

Health care is operating in a bewildering new environment characterized by rapid change with fast-paced innovations occurring in information and medical technologies along with new expectations for better care for individuals, better health for populations, and lower per capita costs (Institute for Healthcare Improvement Triple Aim, 2015). Within this lightning-quick, ever-changing environment, there is great complexity, even greater uncertainty, and tremendous opportunities for nurses to lead change. Just as it was for Florence Nightingale, Clara Barton, and all of the other nurse leaders profiled in this book, nurse leaders of today and tomorrow will have to be visionary, highly intelligent, and politically aware as they address the challenges of a new and rapidly evolving health care system and society. Being an exemplary nurse leader within this new context will require abandoning structures and processes from the current ineffective and fragmented system and shifting our focus from a profit-first industry to a quality-first healing enterprise. We must move to a new vision of a health care system that is universally accessible, coordinated across all points of care, marked by a focus on health and wellness, and the delivery of high-quality, safe care at an affordable price. Accomplishing this daunting task will require nurse leaders to leave behind hierarchical, top-down, command and control styles, common in organized health care. It will require courageous leaders who understand and embrace collaboration, team-based care, partnerships, and an unwavering focus on excellence and the patient experience. These are the skill sets of exemplary nurse leaders and this is the time to find our voice and take an active role in shaping the future of health care. It is time for nursing to lead the revolution and for nurse leaders to be activist agents of change.

Although there is a rich legacy of leadership, political activism, and policy development illustrated by the life stories of the great nurse leaders shared in the preceding chapters, the surprising reality is that few contemporary nurses have moved beyond an internal focus on advancing the professional status of nursing and nursing science to lead and advocate for broad health policy (Mechanic & Reinhard, 2002). Other factors contributing to this scarcity of nurses at the “health care revolution” policy table is the fact that, in spite of the distinguished history of nursing leadership chronicled in this book, the public generally does not view nurses as leaders. Instead of seeing nurses as strategic thinkers who make informed decisions and act independently, nurses have been viewed as “following physicians’ orders” and it has been physicians who have been invited to the table. Creating a new future—a preferred future—for health care will require working hand in hand across professions with key stakeholders. The challenge of nurse leaders and other stakeholders will be to articulate a preferred future for health, health care, and society. Nurses, as the largest segment of the U.S. health care workforce, must be key contributors to this dialogue. In order to understand the importance and scope of this change and the need for nurses to take leadership roles, it is important to take a step back and examine the health care environment in which we have been operating.

AN UNSUSTAINABLE U.S. HEALTH SYSTEM: HIGH COST WITHOUT HIGH RETURN IN HEALTH OUTCOMES

Although many Americans believe that the U.S. health care system is one of the best in the world, the reality is something else indeed. An Institute of Medicine (IOM) report, To Err Is Human: Building a Safer Health System, released on November 29, 1999, shattered this misconception with the startling news that medical error was the eighth leading cause of death in the United States. In fact, it was estimated that between 44,000 and 98,000 people die each year from preventable medical errors (Kohn, Corrigan, & Donaldson, 2000). A major conclusion of the report was that this was not an issue of practitioner competence; rather, this represented an endemic system problem in which processes to prevent, recognize, and quickly recover from errors was lacking. The follow-up report, Crossing the Quality Chasm: A New Health System for the 21st Century, examined these systemic problems and concluded that “between the health care that we now have and the health care that we could have lies not just a gap, but a chasm” (IOM, 2001, p. 1). It reinforced that despite the best intentions of health care professionals, the system failed to reliably deliver efficient, high-quality care with a real focus on the patient. It asserted that improvements could not be achieved within the constraints of the existing system of care and that radical transformation of the health care system was needed. The report called for this revolution to be targeted toward six broad dimensions of health care performance: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity.

As a world leader in science and technology, we have invested our resources into an acute care model of health, treating highly specialized conditions after they have developed. We are known for our excellence in curative services, treating life-threatening emergencies that are acute exacerbations of chronic disease, and many routine health problems that require prompt action (Brownstein, 2014). This “disease care system,” the most expensive in the world, spends more than double as much money per capita on health care as the average developed country spends. In 2013, the cost of U.S. health care was $2.9 trillion or 17.4% of our gross national product. Of this amount, approximately “95 cents of every medical care dollar went to treat disease after it had already occurred” (Brownstein, 2014, n.p.). Alarmingly, despite being number one in health care spending, the United States does not have significantly better health outcomes compared to other economically developed countries. In fact, the 2014 Social Progress Index rates the United States as the world’s 16th most socially advanced country; however, when examining health and wellness specifically, the U.S. rank drops to 70th among 132 nations (Porter & Stern, 2015). A 2013 IOM report, U.S. Health in International Perspective: Shorter Lives, Poorer Health, ranks the United States near last among 17 high-income nations in several categories ranging from infant mortality and low birth weight to life expectancy. Similarly, the Commonwealth Fund analysis ranks the United States last among seven nations in health care and last among 16 developed countries in deaths that potentially could have been prevented by timely access to effective health care (2011). Clearly, U.S. citizens should be expecting a better return on investment than they are receiving.

Equally troublesome are the statistics on efficiency, variability, and waste. The United States scores “53 out of 100 on measures that gauge the level of inappropriate, wasteful, or fragmented care; avoidable hospitalizations; variation in quality and costs; administrative costs; and use of information technology” (The Commonwealth Fund, 2011, p. 9). The IOM report, Best Care at Lower Cost: The Path to Continuously Learning Healthcare in America (2012), highlights that 30 cents of every dollar spent on medical care in America is wasted, amounting to $750 billion annually. Components of this waste include inefficient delivery of care, excessive administrative costs, unnecessary services, inflated prices, prevention failures, and outright fraud. Moreover, it is estimated that between 40% and 78% of the medical testing, treatments, and procedures received are of no benefit—or are actually harmful (Prasad & Cifu, 2011).

The Dartmouth Atlas of Health Care clearly documents the variations in practice patterns/care, health care costs, and patient outcomes by individual practitioners, geographical regions, type of insurance coverage, and type of condition (http://www.dartmouthatlas.org/). Wennberg’s (1984) classic article, “Dealing With Medical Practice Variations,” showed that variations in children who underwent a tonsillectomy in the state of Vermont varied from a low of 8% in one community to a high of nearly 70% in another. In Maine, the variation in rates of women who underwent a hysterectomy by age 70 ranged from a low of 20% in one market to a high of 70% in another. These variations remain after adjustments are made for individuals’ age, sex, income, race, and health status. And of critical importance, there is little to no correlation between spending and health care quality. Just as incomprehensible is how a cholesterol test in Dallas, Texas, could range from $15 to $343 for the same test. Making it more egregious is that the highest prices are typically reserved for those least able to pay, such as the medically uninsured (Skinner, Fisher, & Weinstein, 2014). The Blue Cross Blue Shield study of cost variations for knee and hip replacement surgeries in the United States (2015) found similar cost variability. Using Dallas to illustrate market variations, a knee replacement could cost between $16,772 and $61,585 (267% cost variation), depending on the hospital.

The burden of health care cost is undeniably being felt by us all. The unrelenting increase in health insurance premiums has resulted in employers cutting health coverage and consumers being faced with high-deductible plans. Thirty-three percent of Americans choose not to seek care because of the cost. Up to 35% of Americans report trouble paying their medical bills and a major cause of bankruptcy is linked with an inability to pay medical bills as a result of being uninsured or underinsured (Treas, 2010). Adding to the inequity of the situation is that medical debt impacts the poor and uninsured more severely because they are charged the full inflated price, whereas those with coverage have their costs radically reduced through prenegotiated lowered rates.

RE-VISIONING HEALTH CARE

Enter Health Care Reform

Continued skyrocketing of health care costs, less-than-impressive health status of the American people, safety and quality issues within the health care system, and nearly 50 million Americans uninsured and 40 million underinsured ushered in the Patient Protection and Affordable Care Act of 2010. This act, along with the Health Care and Education Affordability Reconciliation Act, are collectively referred to as the Affordable Care Act (ACA). This is certainly the most significant health care reform since Medicare/Medicaid in 1965. The ACA is more than insurance reform; it is health care reform with an intense focus on quality. A central aim of the ACA is to increase the value in health care by achieving quality while lowering health care costs and expanding access. To achieve this, new payment models, care models, technology, and other tools that will positively impact quality and reduce unnecessary spending are being introduced. The ACA has tasked the Centers for Medicare & Medicaid Services (CMS) to lead this transformation in strengthening and improving the nation’s health care system to provide access to high-quality care and improved health at lower costs (CMS, 2013).

The Shift From Volume- to Value-Based Reimbursement

Historically, the U.S. health care system has used a fee-for-service payment model providing reimbursement for specific, individual services provided to patients. Consequently, there is an incentive to increase the number of high-cost services provided during each visit as well as the number of visits. There is no accountability for inadequate quality and little enticement to encourage “low-cost, high-values services, such as preventive care, coordination of care, or patient education” (Calsyn & Lee, 2012, p. 1). In contrast, the ACA ties payment reform to quality measures. Instead of asking, “How much did you do?” value-based reimbursement asks, “How well did the patient do?” (Berwick, 2011). A major goal for CMS is to provide better care (high-quality, coordinated, effective, efficient care) at lower costs and a key initiative to accomplishing this is to demand the move from volume-based care and payment toward patient-centered quality health care services that are accountable for outcomes achieved. Value-based reimbursement programs, such as nonpayment programs for “never events,” bundled payments, the hospital value-based performance program, and the hospital readmissions reduction initiative are driving this change.

Although never events, which are serious adverse events that are largely preventable and should never happen in health care, were introduced prior to the ACA, the act prohibits federal payments to states for any amounts expended for providing medical assistance for health care-acquired conditions. The final rule published by CMS requires that states implement nonpayment polices for “provider-preventable conditions” (PPCs), including “health care-acquired conditions” (HCACs, such as stage III and IV pressure ulcers, falls, and trauma) and “other provider-preventable conditions” (OPPCs). OPPCs are intended for conditions more likely to occur in settings outside hospitals, such as outpatient or office-based surgery centers, skilled nursing facilities, and ambulatory/office practice settings (Haas, n.d.). Never events are publically reported and the health care facility is accountable for correcting systemic problems that contribute to the events (Haas, n.d.).

Value-based reimbursement approaches include bundled payments for care improvement. Rather than paying “per unit of care delivered,” CMS will be paying for a “set of services”—the providers and/or health care facilities will receive payment for the full scope of treatment and care for a given condition (Porter & Lee, 2013). For an acute condition, such as a joint replacement, the bundled payment would cover the full care cycle, beginning prior to surgery and extending throughout recovery anywhere from 3 to 12 months after surgery. Bundled payment for primary or preventive care would be for a designated period of time (e.g., 1 year) for a specific population of patients (e.g., those with congestive heart failure). In this model, the provider receives a discounted payment, presets expected metrics, and assumes some of the financial risk for the cost of services. This incentivizes the provider teams to coordinate care, redesign care around patient need, and to innovate for maximal efficiency. As the providers’ reimbursement amounts would depend, in part, on meeting quality and patient experience measures, the entire team of providers will be focused on redesigning care around patient need, assuring coordination of care, and improving quality.

The Hospital Value-Based Performance Program is another compelling program designed to improve quality, reduce inappropriate care, and promote better health outcomes and patient experiences during hospital stays (CMS, 2015). This is achieved through a system of incentive payments or fiscal penalties above or below their diagnosis-related group (DRG)–based operating payments. Fiscal year 2016 value-based performance scores will be calculated according to four weighted domain scores. The highest weighted domain, at 40%, is “outcome measures,” which include data on inpatient safety indicators (e.g., 30-day mortality for acute myocardial infarction, heart failure, and pneumonia), and “patient safety indicators,” including a composite score based on the incidence of eight potential complications, and specific patient safety indicators for the occurrence of central line-associated bloodstream infections, catheter-associated bloodstream infections, and surgical site infections for surgical procedures of the colon and abdominal hysterectomy. The domain of “patient experience of care,” weighted at 25%, captures the patient’s perspective of hospital care as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. The survey items are based on what patients perceive to be important to their satisfaction with the hospital experience and include questions rating communication with nurses and doctors, responsiveness of hospital staff, communication about medications, and discharge information. Also weighted at 25% is the domain “efficiency,” defined as Medicare spending per beneficiary. The final domain, weighted at 10%, is “process of care measures.” These are quality-of-care measures used to gauge whether practice is based on evidence and reflects guidelines or standards of care. Twelve process measures are tracked within this domain. Examples of process measures include blood cultures performed in the emergency department prior to initial antibiotic received in the hospital and fibrinolytic therapy received within 30 minutes of hospital arrival.

As CMS identifies ongoing fiscal and quality issues, it has the authority under the ACA to set regulations aimed at controlling or minimizing the problems and imposing penalties for health care organizations not meeting the set standards. An example of this is the focus on preventing hospital readmissions. As 25% of Medicare patients were found to be readmitted within 30 days, there was a concerted effort to set a Hospital Readmissions Reduction Program, which required CMS to reduce payments to “inpatient prospective payment system” (IPPS) hospitals with excess readmissions, effective for discharges beginning on October 1, 2012 (Boccuti & Casillas, 2015).

A new wave of change will accompany the implementation of the Improving Medicare Post-Acute Care Transformation Act of 2014 (the IMPACT Act) passed in September of 2014. This requires long-term care hospitals, skilled nursing facilities, home health agencies, and inpatient rehabilitation facilities to begin the reporting process of standardized patient assessment data with regard to quality measures and resource use. Similar to hospital reporting, this data will be transparent and available to consumers. Examples of the standardized domains include data on skin integrity, functional and cognitive status, medication reconciliation, falls, discharge to community, and preventable hospital readmission rates. The Act requires that CMS develop and implement quality measures around five of these quality-measure domains using standardized assessment data.

New Care Models to Improve Quality and Reduce Cost

A second major goal for CMS is to address prevention and population health. The expectation is that Americans will be healthier and their care less costly owing to their improved health status, a direct consequence of their use of preventive benefits and necessary health services (CMS, 2013). This goal will be achieved through a shift in focus from care paid and provided for a single individual for a single episode of care at single points in time to paying and providing care for discrete or defined populations. Population health is defined as the health outcomes of a group of individuals, including the distribution of such outcomes within the group (Kindig & Stoddart, 2003). These groups are often geographic populations, such as nations or communities, but can also be other groups, such as employees, members of a health plan, ethnic groups, those with a common set of needs, such as disabled persons, older adults, those with multiple chronic illnesses, or any other defined group. Population health management shifts resources from acute care or “after illness or disease has occurred” to “up-front things such as primary and preventive care and public health services—that have a much bigger effect on the overall health of the population” (Brownstein, 2014, n.p.). It is more than sick care; rather it systematically addresses the preventive and chronic care needs of every patient in the population. Its goal is to keep the people within the population group as healthy as possible, minimizing the need for expensive interventions such as emergency department visits, hospitalizations, imaging tests, and procedures. New models of care, such as patient-centered medical homes (PCMHs) and accountable care organizations (ACOs), are being structured to achieve the quality and fiscal goals associated with population health.

PCMH, a designation awarded by the National Committee for Quality Assurance, is aimed at transforming the organization of primary care with a greater emphasis on preventive care, wellness, care coordination, patient education, and communication. Similar to other programs, it is expected to prevent unnecessary hospitalizations and lead to higher quality, lower costs, and improved patient and provider experience of care. The PCMH is fundamental to the care within another program, the ACOs.

ACOs aim to eliminate or minimize the fragmentation in the health care system. In this model, a network of groups of health care providers (e.g., primary care providers, therapists, specialists) and hospitals share responsibility for coordinating lower cost, higher quality care for a group of patients. Through this integration of acute care with preventive and primary care, there is a coordinated health care system that fully encompasses all essential aspects of health care delivery and is likely to have a much bigger effect on the overall health of the population. For an ACO to share in any savings created, it must demonstrate compliance with 65 processes and outcome quality performance measures spanning five quality domains: patient experience of care, care coordination, patient safety, preventive health, and at-risk population/frail elderly health. Several of the proposed quality measures align with those used in other CMS quality programs, such as the Physician Quality Reporting System (PQRS), a quality-reporting program for professionals and group practices to report information on the quality of care to Medicare, the Hospital Inpatient Quality Reporting System, and the electronic health record (EHR) incentive program.

New Care Settings and New Technologies

The 21st century has brought a fundamental shift in where and how patients access health care services. In sharp contrast to the institutionalized health care systems advocated and innovated by Florence Nightingale and Dorothea Dix, health care is now moving well beyond the walls of hospitals and primary care providers’ offices into communities and homes (Salmond & Atkins, 2015). This movement of health care from large institutions into the community would probably be very much embraced by Mother Mary Aikenhead, who in the early 19th century advocated for thoughtful, personalized, individual care for the sick and dying in their homes. Likely too, two activist agents of change in the early 20th century, Mary Breckenridge, an early advocate for rural health care and women’s health, and Lillian Wald, a pioneer in public health, would understand the timing of and the need for this evolutionary change.

Payment incentives and new models of care are being designed to prevent hospital admissions and readmissions and to move care out of expensive acute care settings into ambulatory care, community, and home settings. Consequently, it is predicted that outpatient volume will grow 17% over the next 5 years, whereas inpatient discharges may decrease 3% (Herman, 2013). With this swing in care delivery site, the hospital of the near future will become reserved for the sickest of the sick. It will be like a large intensive care unit and a site for acute trauma care and highly complex service lines. Ambulatory or outpatient care will become the hub for most service across the continuum of care in a variety of settings. Settings would include, but would not be limited to, hospital-based clinics/centers, solo or group medical practices, ambulatory surgery and diagnostic procedure centers, telehealth service environments, university and community hospital clinics, military and veterans administration settings, nurse-managed clinics, managed care organizations, colleges and educational institutions, freestanding community facilities, care coordination organizations, and patient homes (American Academy of Ambulatory Care Nursing, 2011).

The move in core volume from inpatient to outpatient or postacute care necessitates an adjustment in “culture, mindset, organizational structure, service distribution, care management, resource allocation, technology support, partner relationships, and payor contracting” (Remington, 2014, p. 4). It will necessitate retooling of staff with the knowledge, skills, and attitudes required to facilitate patient engagement, manage chronic conditions, prevent ambulatory care-sensitive admissions (e.g., admissions related to diabetes and hypertension), manage populations longitudinally to facilitate wellness and prevention, provide effective care coordination, expand care/case management, and integrate information technology driven by data analytics (Remington, 2014).

“The unprecedented spread of mobile technologies, as well as advancements in their innovative application to address health priorities” (World Health Organization, 2011, p. 5) has evolved into a new field of eHealth, known as mHealth and do-it-yourself medicine (DIYM). It is likely that mHealth will be a transformative force in the shift to an engaged, population-based approach to health care. Medical and public health practice is supported by mHealth through the use of mobile devices, such as mobile phones and their associated apps, patient-monitoring devices, personal digital assistants (PDAs), and other wireless devices. With the increasing availability and scope of apps and mobile devices to track health and illness metrics, greater self-regulation is achieved and the setting of care becomes a virtual house call rather than a hospital or primary care provider visit. The potential to change when, where, and how health care is provided is made possible by mHealth, which ensures that important social, behavioral, and environmental data are used to understand the determinants of health and to improve health outcomes.

A NEW CONTEXT: THE TIME IS NOW FOR NURSING AND NURSE LEADERS

Although the need for change has not been acknowledged by everyone in health care, the reality is that change is already happening. In fact, as such historic nurse leaders as Margaret Sanger clearly recognized, change is an inevitability, and it is well worth leading by challenging the process—even when this may involve breaking some rules. Today, CMS programs that pay for quality, not quantity, have galvanized people into action in challenging old processes, and change has begun. This offers many exciting opportunities in achieving the goals of transformation and requires a strong nursing voice—it is the time for nursing and nurse leaders! The context of factors driving this change have created the perfect storm for nursing and nurse leaders, a perfect storm in which the purpose and values fundamental to nursing align with the purpose and values of the transformation mandate. Nursing is being called to the table and nurse leaders are responding.

The change being called for is not for more interventions or treatments, which are the domain of medicine. It is for support with managing people’s human responses to illness, to removing their barriers to health, and coordinating their health and illness so they can experience maximal wellness and quality of life; this is the domain of nursing. This is the time for nursing and nurse leaders! We need new, visionary, innovative nurse leaders in the tradition of Florence Nightingale to model the way and lead change.

The American Nurses Association (ANA) Social Policy Statement: The Essence of the Profession defines the practice of nursing as the protection, promotion, and optimization of health and abilities; prevention of illness and injury; alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations (ANA, 2010). The Code of Ethics for Nurses with Interpretive Statements affirms that nurses act to change those aspects of social structures that detract from health and well-being (ANA, 2015). This is what is being called for in health care reform. Both the fundamental definition of nursing and the ethical imperatives demanded in the Code of Ethics clearly align with the mandates for health care reform. This is the time for nursing and nurse leaders! We need new, passionate, dynamic nurse leaders like Mother Mary Aikenhead and Clara Barton to inspire a shared vision of nursing and health care—nurse leaders capable of leading change so that we achieve our preferred future for nursing, health, health care, and society.

In pursuit of reform, we must make sure that the change is not simply to “rearrange the deck chairs on a sinking ship” in order to preserve the status quo. The revolution requires changing the power structure within organized health care from a physician-dominated system to a collaborative system that draws on the expertise of the entire team. It necessitates leaders with strong collaboration skills. This is the strength of nursing. Nursing has a core value of collaboration, recognizing that it is essential to address the complexity of health care issues of individual patients and the public effectively. This is the time for nursing and nurse leaders! We need new, committed, courageous nurse leaders like Margaret Sanger, Sister Elizabeth Kenny, and Clara Maass to challenge the process and lead in successfully achieving the changes that are needed.

Achieving the mandate to have coordinated, affordable, quality care that is safe, accessible to all, patient centered, evidence based, and leading to improved outcomes requires a strong nursing voice. Nurses are at the center of patient care. “Nurses are the professionals most likely to intercept errors and prevent harm to patients” (Hughes, 2008, p. iii). Nursing practice covers a broad continuum from acute restorative care to health promotion to disease prevention, to coordination of care, to cure when possible, and to palliative care when cure is not possible (IOM, 2012, p. 4). Nursing competencies of care management, coordination, and patient education are practiced across the continuum of settings from acute care, to home care, to communities, and are vital to the reenvisioned patient-centered, coordinated health care system. This breadth of knowledge and experience is the domain of nursing. This is the time for nursing and nurse leaders! We need new, energetic, determined nurse leaders like Dorothea Dix, Lillian Wald, and Mary Breckinridge to empower and enable others to act and strategically participate in the changes that are needed to improve nursing and health care.

The mandate calls for an accessible, affordable system with stronger primary care services that delivers wellness and prevention care and moves from care of individuals to care of populations. As described in this book, nursing’s legacy is rich with leaders in public health nursing. Public health nurses partner with the community to promote health and health equity. Advanced practice registered nurses (APRNs) serve as primary care providers and are at the forefront of providing preventative care to the public. Many APRNs are now prepared with doctor of nursing practice (DNP) degrees and have an expanded skill set to provide leadership in community health centers, serve on interdisciplinary teams, and advocate for and direct future health and social policy initiatives. This is the time for nursing and nurse leaders! We need new, committed, even heroic nurse leaders like Edith Cavell to encourage the heart as they lead change in nursing, health care, and society.

The power to change conditions in order to deliver better care does not rest solely with nursing but requires collaboration and interaction with other health professional, business, social, and policy groups. What makes this a unique time for nursing is that barriers that have limited nurses’ ability to generate widespread transformation are being addressed through a remarkable blueprint outlining how, by working together, we can strengthen our capacity in nursing so we are prepared to lead, partner, and assume roles in the transformed health care system.

THE FUTURE OF NURSING: LEADING CHANGE, ADVANCING HEALTH

In 2008, the Robert Wood Johnson Foundation (RWJF) and the IOM worked together on an extraordinary collaborative initiative to advance nursing and health care reform. Their work and the action that has followed is a shining exemplar of process leadership as described by Kouzes and Posner (2012). Their actions were grounded in a shared vision and shared values of health and quality health care for all Americans along with the belief that “high-quality care cannot be achieved without exceptional nursing care and leadership” and that “nurses have key roles to play as team members and leaders for a reformed and better-integrated, patient-centered health care system” (IOM, 2012, pp. ix, xii). These values were articulated and apparent and guided their actions and willingness to confront difficult issues and make recommendations, some of which would be upsetting to the status quo of traditional nursing and medicine. Their landmark report, The Future of Nursing: Leading Change, Advancing Health (IOM, 2011), is a compelling guide for change and leadership in nursing.

The IOM committee, a panel of distinguished leaders across a variety of disciplines, asked purposeful questions in their examination of the role of nursing in society within the context of health care reform. They asked, “What roles can nursing assume to address the increasing demand for safe, high-quality, and effective health care services?” (IOM, 2011, p. xi) and what was needed to strengthen the nursing workforce to be partners and lead in a transformed health care system. In the process of this work, the committee

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