If all goes well, and we have a new and improved health care system -- which will have to absorb millions of newly insured people, many of whom have been putting off needed care -- one thing we're going to need is more nurses. And once we have them, we need to use them well.

As the AARP's John Rother and RWJF's Risa Lavizzo-Mourey reminded us earlier this year in Health Affairs:

It is nurses -- of every stripe -- who will deliver, coordinate, and direct care in hospitals, clinics, and physicians' offices, and it is these same most necessary nurses who are in short supply...

Nursing has developed and implemented innovative models of care that promote the goals of policymakers for health reform: expanding access, improving quality and safety, and reducing costs, (but) extending these models of care to the general public will be difficult without action to bolster the future nurse workforce.

A nurse's primary job, as the nurse-of-all-nurses Florence Nightingale once said, is to take "charge of somebody's health." The Institute of Medicine found that nurses are more likely than any other health care professional to both catch medication errors and prevent hospital-acquired pneumonia (which can raise treatment costs by $28,000 and increase hospital length of stay by 5 days.) Research demonstrates that higher levels of hospital nurse staffing is directly associated with nearly 25 percent fewer adverse outcomes. Yet studies have also found that nurses spend perhaps only 30 to 35 percent of their time actually at a patient's bedside. The Institute for Healthcare Improvement would like to see this number double.

The Institute of Medicine and the Robert Wood Johnson Foundation are working on a joint initiative, The Future of Nursing, to develop a "clear agenda and blueprint for action."

We got a sneak preview of some of what they are thinking about through an IHI audio program. Taking part was the chair of the IoM panel Donna Shalala, PhD, former U.S. Secretary of Health and Human Services who is now president of the University of Miami; Sue Hassmiller, PhD, RN, FAAN, director of the RWJF Initiative on the Future of Nursing; and IHI vice president Pat Rutherford, RN, MS. (Listen to the program here.)

What changes can be made to address the nursing shortage (which some estimate could reach half a million by 2025), increase nurse retention rates (turnover is highest in hospital surgical units, and each time a nurse leaves, it costs the hospital  $50,000 to $65,000 to replace her), and enable nurses to do what they do best -- provide quality direct patient care?

Among the problems and solutions the experts noted:

• Stress and disruptive behavior is often reported within health care settings. Conflicts amongst nurses, and between doctors and nurses, lead to unsafe and stressful working conditions. Work environments should reduce waste and inefficiencies, improve communication and decrease the time nurses spend "hunting and gathering" for supplies and information etc.
• As we have written before, the widespread (and smart) adoption of health information technology will help improve the safety, efficiency and effectiveness of the U.S. health care system. Nurses should be involved in the design, and be thoroughly trained in using the technology.
• All nurses should go through quality improvement training with a focus on patient care.
• Health reform includes an emphasis on primary, preventive and patient-centered care -- and nurses should be central to this. Rutherford argued that it is wrong to think that we can substitute nurses for primary care physicians -- but  we can utilize nurses' skills to improve and expand the scope of primary care. 
• Nurses need to be more involved in transitional care; patients have better outcomes (and reduced rates of rehospitalization) when they have good transitional care following hospitalization. Hospitals, as an example, could establish nursing "SWAT teams." Nurses would go into a patient's home and ensure that it is adequate for the patient's post-hospitalization return. (Will the patient be able to easily get to the bathroom? Will the patient trip on throw rugs? Are the medications right?) Hospital nurses should also be encouraged to communicate more with community providers so they have appropriate information for successful patient "hand offs."
• Nurses should have a bigger voice in the boardrooms of organizations that oversee the health care quality agenda in the United States. Nurses learn quite a bit about quality and safety -- and they know "what works" on the ground, not just in theory. (Right now, only two percent of all health care company board slots are occupied by nurses.)
• One way to address the nursing school faculty shortage (which perpetuates the nursing shortage) may be to have top national nurse educators record lectures, webcasts and podcasts for widespread use, and have the local faculty focus on teaching students how to apply these classroom lessons directly in a patient care environment.
• Clinical practice and education need to be more closely tied together. Hospitals should encourage mentorship amongst experienced and newly-minted nurses -- a bit like young doctors have internships. (Studies demonstrate that on-the-job-training lowers turnover rates of nurses.)
• Nurses need more training in geriatrics because of the aging population.
• Health care settings need to permit flexible working schedules to encourage older nurses to remain in the workforce longer. (We don't recall hearing this on the audio, but flexibility might help more nurses with young children remain on the job at least part time.)

Several hospitals and states are already making efforts to improve the "future of nursing." For example:

• The Coalition to Protect Massachusetts Patients would like to restrict the number of patients that a nurse can care for at any time and ban mandatory overtime.
• The New Jersey Hospital Association's Institute for Quality and Patient Safety received a $732,000 grant from the Robert Wood Johnson Foundation to help New Jersey hospitals implement RWJF's Transforming Care at the Bedside program. This program will "provide education and training in performance improvement for front line staff nurses so that they can identify, test and implement improvements on their units."
• Mississippi and South Carolina have increased faculty salaries.
• As we wrote last year, in 2004, the Childrens Hospital in Los Angeles started a program to help train new nurses and combat the high turnover rates. The Versant RN Residency, which has now spread to more than 70 hospitals across the U.S., pairs up new nurses with more experienced nurses who guide them as they acquire more complex skills.

Too soon to know which of these the IoM group will consider to be top priority, or how quickly we can act on them. But if we're going to fix our health care system and give people the care they need, we're going to need more nurses and we're going to have to use them more wisely.