Technology and the Future of Nursing — A Virtual Panel
Much is written about disruptive change in healthcare as a result of new technology, but little has focused on the impact these changes may have on the nursing role. We assembled a virtual panel of national nursing leaders to talk about technology and its impact on the future of nursing. The panel included:
Shawna Butler, RN, MBA, Nurse Economist at Radboud University Medical Center in the Netherlands.
Marilyn Chow, RN, Ph.D., FAAN was the Vice President of Patient Care Services and Innovation at Kaiser Permanente, now retired.
Connie White Delaney, Ph.D., RN, FAAN, FACMI, FNAP is the Dean of the School of Nursing at the University of Minnesota.
Christy Dempsey, MSN, MBA, CNOR, CENP, FAAN is the Chief Nursing Officer at Press Ganey Associates, Inc.
Karen Drenkard, Ph.D., RN, NEA-BC, FAAN is the SVP, Chief Nurse and Chief Clinical Officer at GetWellNetwork.
Gail Latimer, MSN, RN, FACHE, FAAN is the Executive Nurse Consultant and Strategist at Allegheny Health Network. She is also the Former Chief Nursing Officer of Cerner Health Services and the VP CNO of Siemens Healthcare.
Molly McCarthy, BSN, MBA, RN-BC is the Chief Nursing Officer at Microsoft.
Patty Mullen Reilly, BSN, CRNA is the Director of Strategic Sales as Medtronic.
Joyce Sensmeier, MS, RN-BC, CPHIMS, FHIMSS, FAAN is the VP of Informatics at HIMSS.
Cassie: Let’s begin by asking how the current state of health technology. impacts nurses’ ability to deliver compassionate care? Does it enhance it or hinder it?
Shawna: Both. It has enabled us to digitize our data and made it storable, searchable, and shareable in novel ways that enhance and expand compassionate care. But we are spending a lot of time on screens and keyboards.
Joyce: I think it’s helping. We now have access to information at the point of care, whereas back in the day when I was on the unit, we didn’t. The chart is virtually available at all times. But I agree the information isn’t always presented in a way that’s easily accessible or streamlined. There’s room for improvement.
Gail: If someone is a compassionate nurse, technology doesn’t get in his or her way. The patient information we gain from technology is part of our assessment skills, there’s both touch assessment and gathering data assessment. Think of our patients today. They scan their own groceries, they pay bills online, they date online. Personally, I would be frightened if I was in a hospital that was documenting on paper.
Molly: The big piece that’s missing across the technology world is interoperability, so it creates a very disjointed environment for the provider (nurses and doctors) but also for the patient, especially those with chronic conditions.
Christy: When we look at our Press Ganey clients, and healthcare in general, everyone is on a transformational journey. We have a lot of point solutions, a lot of pieces and parts that don’t fit together.
Eventually, we will pull all of this together and recognize that they are all connected. Not just the technology is connected, we’ll understand that outcomes — patient safety, patient experience, workforce engagement, clinical quality — are also connected.
Shawna: Tech like voice recognition is rapidly improving in capability and reliability. We’re reaching a point where we can be having a conversation with a patient fully present, hands-free, and the technology is just running in the background capturing it all.
Joyce: As individuals, we have everything in the palm of our hand with our smartphone. That’s where healthcare is going, just more slowly. I agree with Shawna, we’ll use voice capture to transcribe into the system so it’s less cumbersome.
Cassie: At HIMSS 2019, Premier CEO Susan Devore talked about the need to move from data overload to actionable data. She said, “Now that big data is here it’s overwhelming.”¹ What do you think we will do with all the data that is starting to flood in?
Connie: You focus on an essential area. We are at that fault line where the single individual brain cannot comprehend the immensity of the data required for complex decisions. Many people in the current workforce have not been prepared to work in partnership with technology, comprehend the vast growth in data and information available through the quantified self and the internet of things. They need to be able to partner in teams and leverage the information or analytic tools that have emerged to enable us to extend beyond our individual intelligence.
Molly: I think once the information is provided in the right form and at the right time, to the provider, or to the nurse — we’re absolutely capable of handling it and would welcome it. We’re not equipped to filter all of it — AI, machine learning really will be necessary to funnel and filter that data.
Patty: I think technologies will get better and better, especially monitoring technologies. Technology is becoming wireless, smaller and more intuitive. AI can make it even better.
Cassie: Let’s talk more about AI and the impact you see it having on the roles on the care team.
Molly: I think with AI and machine learning (ML) will help us do what we were schooled to do, rather than the trivial components that are part of our job. They will help us work to the top of our license.
Cassie: I see the phrase “augmented physician” in the press these days, but in our model, Artificial Intelligence at the Point of Care (AIPoC), we talk instead about the “augmented team.” Here are two examples that signal what’s coming. In 2018 two AI-enabled technologies received FDA approval. The first is IDX-Dr, a device that can scan and interpret a retinal image, diagnosing diabetic retinopathy using its AI algorithm. This scanning work is currently done by ophthalmologists, and now it can be done in a primary care setting by nurses or frankly even by medical assistants.² The second example is Bay Labs, which uses AI algorithms and GPS technology to perform an ultrasound echocardiogram exam. It is currently being tested with RN’s at Stanford and with medical assistants at Northwestern.³In the first example, diagnosis is done entirely by the machine, and in the second, diagnosis can be done by different members of the care team. How do you think this will impact nursing, as we look forward?
Christy: This is suddenly becoming a really interesting conversation.
Shawna: These are great examples of how AI is shifting Who does What, When and Where. Machines, data, and 5G are changing how we think about making a diagnosis — it’s definitely shifting the capabilities of our workforce.
Gail: Nurses will do more diagnosis and more careful treatment planning. I’m hesitating here because I don’t have an advanced practice license, so I’m always cautious about using the word “diagnosis”. I don’t make a diagnosis using that word, but I certainly remember reviewing a CT Scan and saying to the physician “You need to get in here.” I think nurses know what a patient needs and the Al technology will supplement or reinforce this critical thinking.
Molly: Maybe this is a gigantic leap — I think NP’s will really embrace and take over primary care, the physician role there will be more of a specialist. Because of the information we have and know and the ability computers will have to present information to us. In terms of patient outcomes and affordable care — that’s where I see the market moving.
Karen: Look, this is not a phenomenon we’re going to stop. There are 270,000 NP’s in this country and 87% of them work in primary care. — 66% of them are in Family Practice. They are certified from birth to death, they are primary care experts and their outcomes are equal to internists and family practice physicians on primary care.
Marilyn: Let’s take an anesthesiology example. CRNA’s can do a big chunk of what anesthesiologists can do, just like NP’s can do about 80% of what a primary care physician or pediatrician can do.
As nurses, we may find ourselves with some of the same issues. We should also be prepared to think about the fact that LPNs will be able to do what some of what RNs do today.
Karen: If the construct is — every clinician practices to the top of their license, then the top of that license will move up. “All boats shall rise.” The emergence of community health workers has created a new role set of care activities, and they are getting certified, although state by state the requirements vary.
Christy: What happens to nursing when AI starts to give us the diagnosis? This is perhaps controversial, but that’s not the crux of what nurses do. You’re going to be hard-pressed to replace the ability to provide compassionate, connected care to a person.
I think we are more and more looking at the team approach to care across the continuum. Perhaps AI becomes another partner on the augmented team Cassie mentioned. AI will augment the whole team.
Marilyn: Ginny Romity (IBM) recently gave a presentation, talking about the way AI will destroy and create jobs. She believes that AI will fundamentally reshape business and society. If that’s true, we have to develop a roadmap to know what it will take to get from point A to point B, let alone from point A to point I.
Cassie: Karen talked about care moving into the community. Can we talk a little bit about the changing location of care?
Connie: The Intensive Care Units in the home, dialysis in the home, telehealth, telesurgery are a few examples of change in traditional settings. The evolution of self-care, access to self-monitoring devices and reliable healthcare information are changing not only what professionals do where, but what professionals do at all.
Gail: Absolutely — defining “the community” as care in my home. I see it in my own family — my granddaughter had a rash, her mother took a photo of it and sent it to her pediatrician, who told her what to get to treat it. Done.
We’re already here but we’re not ready for it. To me, the care has already left the hospital but maybe we haven’t.
Marilyn: No question the location of care will shift and the acuity of hospitalized patients will increase. Those things that used to be handled in the hospital or even in the clinic, will be handled at home. Where do privacy and ethics come in? There are so many questions, will people not care that you can watch me in my home all the time? Oh, look, she’s not going to the refrigerator anymore!
Christy: I would much rather stay home and receive care at home, whether that’s with a person or a computer monitor. I think I am not alone. We are looking at compassionate, connected care that can be delivered through a monitor and still have a human connection.
Shawna: Let’s not miss this opportunity to mention schools, where children’s health, well-being, and conditions are monitored by school nurses. There is a range of technologies that will help school nurses screen, detect, predict, and intercept communicable disease, diabetes, cancers, eating disorders — we will be able to pick them up in lower acuity wellness spaces like schools.
Cassie: Can we talk about barriers to execution? What gets in the way of implementing these exciting new ideas? Research tells us that it takes between 13 and 17 years to go from discovery of best practice to widespread adoption.
Shawna: There’s a lot of fear, execution complexity, and not enough courageous leadership who finds safe ways to experiment, take risks, and let go of outdated thinking. Seriously, why are we still using fax machines? We must foster a culture of experimentation, invention, and innovation.
Cassie: Do you think nurses are afraid of these new technologies?
Shawna: It’s hard to automate the caring piece, so most of the nurses I’ve run into are not afraid — it’s more intimidation. And also disillusionment, when you say “technology” many nurses equate that with the EHR. That’s all they know, and that’s a barrier.
Patty: AI moves the decision making down the chain, but the nurse has to be ready for that. Nurses have to be educated and trained that it’s okay to make certain decisions. It’s not the skill, it’s not a lack of knowledge — it’s knowing that it’s safe to decide.
The issue is — are we educating the workforce for what’s coming?
Joyce: We need to provide as many examples as possible to turn the light bulbs on, or people will think, “It doesn’t apply to me, I can ignore it.” When I presented at the Nursing Management Congress last Fall, I asked participants if they thought AI would hit within 5 years. Very few members of the audience said yes at the beginning. After my presentation, I asked again and more said yes.⁴ This is something we can’t ignore.
Shawna: Healthcare is driven by the academic world which is more comfortable turning everything into a research project, and that’s too slow. We need to step up our pace of learning and adoption and make bolder moves. While there are risks of moving swiftly, there can be greater risks and suffering from hesitation and moving too slowly.
Cassie: That’s a great segue, let’s talk about the workforce transformation that this technology will require. How do we get our workforce from point A to point B or point I?
Connie: Our current workforce includes digital immigrants and digital natives. Many in the workforce, including many leaders, are uncomfortable with technology — we have needed to learn, adopt, adapt. The way we approach digital immigrants and digital natives will need to be differentiated.
Additionally, there is a robust need for teamwork occurring simultaneously. This too requires a transformation in the way we educate.
Shawna: Our most digitally fluent team members are the youngest people in our organizations and they have the least amount of authority and influence. These technologies level the playing field. We’re all learning together, and the person with 20 years practice experience doesn’t have an advantage over the person who has been practicing for 5 years.
Patty: How do we help the current workforce through this? I just saw a statistic about nurses burning out in the first or second year.
Christy: We recently did two studies, one analyzing resilience in the multi-generational nursing workforce⁵ and the other examining intent to stay across the lifecycle in the nursing workforce⁶ because burnout in the nursing workforce is up to 63% for RN’s working in hospitals.
We also need to do a better job of teaching people to practice outside of the acute environment. A large part of the way we educate is still done in the hospital. There is a lack of comfort and lack of practice in the community setting. There are so many new roles and locations of care for nurses, yet we still educate nurses in the hospital.
I taught in the Baccalaureate program at Missouri State — it is a community-based program. Clinical experience is provided in hospitals, but a lot of rotations are done in the community, not just in doctors’ offices but in homeless shelters. We need to see more programs like that.
Molly: I agree. Because care is moving outside into clinics, into same day [sic], into patient’s homes. I hope the old school thinking of “you have to work in a hospital before you do anything else” falls away. We need different skills and different interests. Doing virtual care, doing care in the home, all this means there’s no longer one flavor of nursing.
Christy: I do think we have to push in the academic setting as well as in the professional setting. The only way to prepare nurses is to prepare faculty for this brave new world of population health. If your faculty is used to being in the hospital, and it’s been a long time since they actually practiced, they won’t be able to prepare students for this brave new world.
Molly: I agree, undergraduate schools have to focus on these varied roles, and we also have to teach informatics classes in nursing school. I’ve guest lectured in programs where they don’t have anything on technology. We need to teach the concepts around technology, and how that impacts healthcare.
Connie: Nursing education has identified the need for informatics (data and information) competencies for some time. Both the priorities of the American Association of Colleges of Nursing (AACN) as well as the American Nurses Association’s (ANA) have supported the integration of these competencies into curricula and ongoing professional development. Leading informatics associations like AMIA and HIMSS have supported this evolution as well.
A persistent challenge has been the shortage of informatics educators and leaders to meet this demand. Schools of nursing such as the University of Minnesota have made it a priority not only to integrate informatics competencies into all curricula but also have doctoral programs to prepare informatics leaders.
Cassie: There are a number of important calls to action in this discussion. Any closing thoughts about what needs to come next?
Marilyn: I want to leave with this insight — in 1993 I moved back to California. The internet was just starting, it was this huge black box. A consultant who gave me a wonderful insight. She said, “The internet is like going into a cave. There’s a flashlight shining in one part of the cave, we have to wait for more flashlights to come together to see what the whole picture will be.”
With AI, we’re just seeing glimmers in specific areas. This is huge, and the opportunity for nursing is huge.
Shawna: The enormity and transformation can’t be overstated. Nurses absolutely need to jump in and become leaders and partners in experimenting with new technologies and nurses need to become developers of how we use them.
Joyce: Agreed, it’s critical for nurses to be involved with this wave of technology development and implementation or it won’t be useable or adoptable.
Shawna: If we want to shorten the discovery-to-adoption cycle, we need our enthusiasm for follow-through to match our enthusiasm for discovery and we need to prepare nurses as technology leaders and engage them as change agents.
Karen: I hope there’s a call to action — chief nurses, deans, and other influential nursing leaders and organizations need to step into this space. Not to let it happen to us but to be leaders, to be co-creators of it. We really do need nursing leadership to lean in on technology. Where can nursing lead?
Summary Of Themes from the Panel Discussion:
- Current technology both supports and hinders nurses in their ability to provide compassionate care for patients. Access to detailed information is invaluable, but the way the information is currently delivered creates a tremendous documentation burden. Voice recognition, voice to text technology and seamless interoperability will alleviate today’s burdens and enable nurses to focus on their patients.
- As the amount of data available to care for patients increases exponentially, machine learning (ML) and artificial intelligence (AI) will become necessary, trusted and critically important members of the augmented care team.
- As ML and AI-infused technology becomes commonplace, decisions about diagnosis and care treatment planning will increasingly be made by nurses; some decisions will even be made by LPN’s, community health workers and patients augmented with these tools.
- The location of care is rapidly moving out of the acute care setting and the clinic into the community and into people’s homes. Patients and their caregivers will be empowered to use data supported by telepresence to take a much more active role in their own care. Nursing education must keep pace with this shift, providing ways to learn and train outside the hospital.
- Nursing education must also double down on teaching informatics and technology courses to prepare nurses for the practice of the future.
- Workforce development efforts will be critical to upskill the current nursing workforce, which is composed of digital immigrants and digital natives, each of whom will need to be taught differently.
- Inter-professional education and training will be key to understanding the way that technology shifts the roles on the care team.
- To speed the time to adoption of new technology nurses must become technology leaders and change agents.
Acknowledgment: Thanks to Sue Hassmiller, RN, Ph.D., FAAN at the Robert Wood Johnson Foundation, Senior Adviser for Nursing, and now Senior Scholar-In-Residence and Senior Adviser on Nursing to the President of the National Academy of Medicine, for inspiring this session.
For more from Cassie Solomon please visit The New Group Consulting.
¹ Sullivan, T. (2018), Premier CEO Susan DeVore: We have ‘a higher calling’ to improve the U.S. healthcare system
² Solomon C., Shea G., Schneider M. (2018 ), How AI-based systems can improve medical outcomes
³ Northwestern Memorial Healthcare (2018), Bay Labs and Northwestern Medicine launch artificial intelligence-guided ultrasound study
⁴ Sensmeier, J. (2017), Harnessing the Power of Artificial Intelligence