PATIENT SAFETY FIRST
The Future of Nursing and
Patient Safety: The Nurse’s
Role
SHARON A. McNAMARA, MS, RN, CNOR
E
very year from May 6 to 12, we recognize
nurses and the nursing profession. This
week culminates with the celebration of
Florence Nightingale’s birthday. I was fortunate
to visit the Florence Nightingale Museum at St
Thomas’ Hospital in London, England, recently.
It was an intellectual and spiritual experience that
helped me appreciate Nightingale as a nurse and
an accomplished statistician who used scientific
research to improve health and sanitation condi-
tions during the Crimean War. After the war, she
returned to England and established reforms in
civilian hospitals, workhouses, and homes through
the development of district nursing, health visit-
ing, and midwifery services. She was also active
in changing social policy and laws in England
and India. She created the nursing profession as
we know it today and was an admirable patient
safety advocate. Nightingale’s Notes on Nursing:
What It Is, and What It Is Not1 is packed with
patient safety knowledge. In the preface, she states
that the notes “are meant simply to give hints for
thought to women who have personal charge of
the health of others.”1(preface) Nightingale encour-
ages us to think about how we can expand our
knowledge and resources to promote and influ-
ence health care.
The AORN Journal is seeking contributors for the Patient Safety First column. Interested authors can contact
Sharon A. McNamara, column coordinator, by sending topic ideas to journalcolumns@aorn.org.
614 AORN Journal ● May 2011 Vol 93 No 5
In 2010, the Affordable Care Act2 was passed
into law. With its passage comes the opportunity
to transform the current health care system, to
provide improvements in quality and safety and
provide more accessible, affordable health care
for our citizens. At the same time that this law
passed, the Committee on the Robert Wood
Johnson Foundation Initiative on the Future of
Nursing, at the Institute of Medicine (IOM), re-
leased a report titled The Future of Nursing:
Leading Change, Advancing Health.3 This report
gives nurses an opportunity to do as Nightingale
did: think about what lies ahead and then act. It is
our opportunity as members of the nursing profes-
sion to contemplate the future and, in doing so,
advocate for the safety of our patients. Given the
number of nurses and their adaptability, the com-
mittee believes that nurses have the potential to
help effect the significant changes that are planned
for the health care system. Nurses close care of pa-
tients gives them an ability, in partnership with
other health care providers, to improve the system in
whatever environment they practice. The report
states,
Nurses thus are poised to help bridge the gap
between coverage and access, to coordinate
increasingly complex care for a wide range of
doi: 10.1016/j.aorn.2011.01.010
© AORN, Inc, 2011
PATIENT SAFETY FIRST
patients, to fulfill their potential as primary
care providers to the full extent of their educa-
tion and training, and to enable the full eco-
nomic value of their contributions across prac-
tice settings to be realized. In addition, a
promising field of evidence links nursing to
high quality care for patients, including pro-
tecting their safety.3(pS-3)
The report has four key messages that provide
the framework for the recommendations that ad-
dress the health needs of diverse populations and
the actions that should be taken by the nursing
workforce:
 Nurses should practice to the full extent of
their education and training.
 Nurses should achieve higher levels of educa-
tion and training through an improved educa-
tion system that promotes seamless academic
progression.
 Nurses should be full partners, with physicians
and other health professionals, in redesigning
health care in the United States.
 Effective workforce planning and policy mak-
ing require better data collection and an im-
proved information infrastructure.3(pS-3)
PRACTICING TO THE FULL EXTENT OF
EDUCATION AND TRAINING
The report acknowledges that these recommenda-
tions may not be comfortable, convenient, or easy
for nurses as individuals or nursing as a profes-
sion. We are committed to patient safety as indi-
viduals and as members of a profession, and we
have the art and the science of nursing to draw on
in developing innovative strategies to improve the
health care system, but we have barriers to break
through first.
State regulations defining a nurse’s scope of prac-
tice can vary widely from state to state and often
relate to the politics in a particular state rather than
the education, training, or ability of the nurse.
Should the federal government promote reforms that
ensure all citizens have access to a choice of health
care providers who use evidence-based practices and
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support the evolving practice abilities of licensed
providers? Will this require more support, time, and
money for individual nurses, the organizations for
which they work, and professional associations to
assist in these regulatory changes? Most likely, the
answer is yes.
The Joint Commission has recommended de-
velopment of nurse residency programs with em-
phasis on specific time frames to help establish
clinical knowledge and skills.3 These programs
would be based on specific organization or pro-
fessional association standards of practice. Nurse
residency programs could benefit new graduate
nurses transitioning from school to practice and
nurses completing advanced degrees or those tran-
sitioning into a new clinical practice area. These
residency programs also might help decrease high
turnover rates observed with new graduate nurses
and could help retain in the workforce the wis-
dom and knowledge of experienced nurses by
having them serve as mentors. Residency pro-
grams are a necessary component for producing
competent nurses who provide safe patient care.
Think about whether you apply all areas of your
education and training in your practice. How can
you enhance the patient care you provide? How
can you use your leadership skills to prepare for
the future?
IMPROVING NURSING EDUCATION
Nursing is a profession that requires lifelong
learning. This is not a new idea, but the current
education system is struggling. An innovative
overhaul is needed to prepare nurses to practice in
the health care system of the present and future.
Competency is needed for practice in the com-
plex, ever-changing settings in hospitals, commu-
nities, and schools. An imposing technological
revolution and a complex health care information
management system will provide ongoing educa-
tional challenges for nurses who strive to provide
safe, quality patient care.
Shortages of nurses at the bedside, nursing fac-
ulty members, and nurse researchers add to the
AORN Journal 615
May 2011 Vol 93 No 5 PATIENT SAFETY FIRST

problem. The IOM report projects there will be a ples of seamless matriculation programs that
need for an increase in nurses with baccalaureate should be accessible across the country. Funding
degrees from 50% to 80% and that the current to meet the goals of these programs will require
number of nurses with doctoral degrees will need that private and public agencies at the local, state,
3
to double by 2020. There is also a need for in- and federal levels step up and support nurses in
creased diversity in the nursing workforce. The achieving these higher levels of education, train-
committee emphasizes the need for more men and ing, and competency. The health and safety of our
members of minority groups to become nursing citizens is at stake.
faculty members, scientists, and researchers. The As a qualified perioperative nurse, are you
diversity of the nursing workforce should reflect ready to pursue additional education? Think about
gender, race/ethnicity, and geographic distribution where you are in your career and how prepared
to better address the needs of patients of all ages you are for the future. Is your career path fo-
and origins. cused on clinical practice, management, or edu-
Interprofessional cation? Will you
collaboration must be select formal educa-
addressed early in Pursuing either formal education through an tion through an ad-
the educational pro- advanced degree program or enhanced vanced degree pro-
cess, advanced con- competence in a specialty area requires gram, or will you
tinuously throughout finding an interprofessional program that enhance your compe-
the educational jour- integrates leadership theory and business tence in a specialty
ney, and carried principles. area so you are pre-
through to the clini- pared to precept or
cal health care envi- mentor new gradu-
ronment. Strategies to accomplish this might in- ates or seasoned nurses coming into perioperative
clude multidisciplinary classroom and clinical services? Either direction requires finding inter-
training in schools and collaborative continuing professional programs that integrate leadership
education requirements in the workplace. The theory and business principles. As a nurse, you
Commission on Collegiate Nursing Education and must be prepared to lead, and you must under-
the National League for Nursing must address the stand the business of health care to provide opti-
challenge by requiring all nursing schools to offer mal care for your patients.
academic pathways that promote seamless access Being an active member of AORN is also im-
to higher levels of education for nurses. portant. AORN is the perioperative nurse’s advo-
Linda Aiken, PhD, RN, FAAN, FRCN, a nurs- cate and is working collaboratively with other
ing professor and the director of the Center for stakeholders to implement the key recommenda-
Health Outcomes and Policy Research at the Uni- tions of the IOM report and move perioperative
versity of Pennsylvania, Philadelphia, and a leader nursing successfully into the future. As an active
in nursing and nursing education, agrees it is time member of AORN, you can help effect these
4
to refocus the lens on nursing education. She changes.
identifies a need for better use of public monies
to support nursing education and identifies as a NURSES AS FULL HEALTH CARE
priority changing the pattern of initial education PARTNERS
to one that has more nurses beginning their ca- Involvement of nursing leaders from clinical settings
reers with a bachelor’s degree. Registered nurse to the boardroom is critical to successfully trans-
to master of science bridging programs are exam- forming our health care system. Nurses must take

616 AORN Journal

PATIENT SAFETY FIRST
personal and professional responsibility for develop-
ing their leadership competencies, which are funda-
mental to advancing our profession. Nursing leaders
must be responsible for their own contributions
while working in concert with leaders from many
professions to achieve common goals.
In care environments, being a full partner in-
volves taking responsibility for identifying
problems in areas of waste, devising and im-
plementing a plan for improvement, tracking
improvement over time, and making necessary
adjustments to realize established goals.3(pS-6)
In the broader health policy arena, being a full
partner means nurses see policy as something
they can shape, not something that happens to
them. We need to be at the negotiating table and
engaged in implementation efforts for health care
reform. Nurses can volunteer to serve as re-
sources or members of advisory boards, commit-
tees, or commissions where policy decisions are
made. Nurses are in the health care environment
every day; who knows better what needs to be
done and whether an initiative will affect patient
care positively or negatively? Nurses have the
experience and expertise to make a difference.
Throughout this journey, nurses will need to net-
work and build their leadership competencies,
which they then must exercise in the collaborative
environment of health care and in the broader
community, political, and business arenas. As
nursing leaders and professionals, nurses must
develop partnerships, gain allies, and mentor oth-
ers to meet this challenge.
IMPROVED INFORMATION
INFRASTRUCTURE
Current data to guide strategic health care work-
force planning is lacking. Plans for the future re-
quire granular, reliable data on the numbers of
currently employed health professionals, their
roles, and the activities they perform. These data
will demonstrate what the current regional health
care workforce needs and enhance the ability to
plan and set targets for meeting the increasing
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needs of an aging population in the face of the cur-
rent shortage of health care professionals. Team-
based care will cause overlaps in the scopes of prac-
tice of primary caregivers (eg, physicians, physician
assistants, nurse practitioners), which necessitates
careful collection and analysis of data from health
professions. Systematic assessment of the current
nursing workforce (eg, age, skill, current practice
setting) and projection of the collected nursing data
must be made to determine needed changes in prac-
tice and education. Understanding the effects of in-
novations such as information technology, bundled
payments, and changes in surgical services technol-
ogy (eg, robotics, minimally invasive surgery, radio-
graphic and ultrasound interventions) is important to
fully understand the roles and needs of the future
nursing workforce.
The IOM report recommends building an im-
proved information technology infrastructure un-
der the oversight of the Workforce Commission
and the Health Resources and Services Adminis-
tration.3 These groups can coordinate with health
care professionals’ state licensing boards to im-
plement a standardized data set that can be used
to perform assessment, analysis, target setting,
and planning for the future of the profession. Set-
ting standards, housing data, and making the data
accessible to the public also must be accom-
plished. The Workforce Commission must coordi-
nate with the Department of Labor and include state
and regional educators, employers, and members of
nursing workforce centers to ensure adequate repre-
sentation in identifying regional needs, targets, and
plans to provide appropriate health care profession-
als. Nursing expertise must be adequately repre-
sented in the commission and in any regional
groups working to provide patients with patient-
centered, evidence-based, seamless, affordable, safe,
quality care that is accessible to all.
CONCLUSION
Success in this huge endeavor requires health pro-
fessionals; policy makers; national, state and local
government leaders; and members of licensing
AORN Journal 617
May 2011 Vol 93 No 5
bodies, educational institutions, and philanthropic
and advocacy organizations to work together as a
team to provide improved health outcomes for our
citizens. What part will the individual periopera-
tive nurse take in this exciting journey? Beck et
al remind us that “Nightingale called her work
her ‘must.’”5(p108) As nurses, we need to find the
compelling reason that will “keep us focused and
empowered.”5(p108) The IOM report, like the chal-
lenges for which Nightingale found solutions, “is an
invitation for nurses to remember the purpose of our
work, our sense of calling to service and our respon-
sibility for using our knowledge, skills and caring to
improve health worldwide.”5(p108) I implore you to
retrieve a copy of the IOM report at http://www.nap
.edu/catalog/12956.html and follow Nightingale’s
lead: think on it, decide to act, and make a differ-
ence for yourself and your patients.
References
1. Nightingale F. Notes on Nursing: What It Is, and What
It Is Not. Philadelphia, PA: Lippincott; 1992.
2. Affordable Care Act (ACA) Infrastructure to Expand
Access to Care (93.502). FeredalGrantsWire. http://www
This column was funded through a grant from the AORN Foundation.
618 AORN Journal
PATIENT SAFETY FIRST
.federalgrantswire.com/affordable-care-act-aca-advanced-
nursing-education-expansion-initiative.html. Accessed
January 18, 2011.
3. Institute of Medicine. The Future of Nursing: Leading
Change, Advancing Health [prepublication copy]. Wash-
ington, DC: The National Academies Press; 2010. http://
www.nap.edu/openbook.php?record_id_12956&page_1.
Accessed January 7, 2011.
4. Larson J. Major changes proposed in nursing education.
Nurse Zone. http://www.nursezone.com/printArticle.aspx?
articleID⫽35978. Accessed January 18, 2011.
5. Beck DM, Dossey B, Rushton CH. Florence Nightingale:
connecting her legacy with local-to-global health today.
Nurse.com. http://ce.nurse.com/CE598/Florence-Nightingale/.
Accessed January 18, 2011.
Sharon A. McNamara, MS, RN, CNOR, is
an independent perioperative consultant in
Raleigh, NC. Ms McNamara has no declared
affiliation that could be perceived as posing a
potential conflict of interest in the publication
of this article.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.