The Impact of Emerging Technology on Nursing Care

LAMPIRAN The Impact of Emerging Technology on Nursing Care: Warp Speed Ahead Carol Huston, MSN, DPA, FAAN Abstract While myriad forces are changing the face of contemporary healthcare, one could argue that nothing will change the way nursing is practiced more than current advances in technology. Indeed, technology is changing the world at warp speed and nowhere is this more evident than in healthcare settings. This article identifies seven emerging technologies that will change the practice of nursing; three skill sets nurses will need to develop to acquire, use, and integrate these emerging technologies; and four challenges nurse leaders will face in integrating this new technology.Technology is changing the world at warp speed and nowhere is this more evident than in healthcare settings. While myriad forces are changing the face of contemporary healthcare, one could argue that nothing will change the way nursing is practiced more than current advances in technology. Technology is changing the world at warp speed and nowhere is this more evident than in healthcare settings. This article identifies seven emerging technologies that will change the practice of nursing; three skill sets nurses will need to develop to acquire, use, and integrate these emerging technologies; and four challenges nurse leaders will face in integrating this new technology. Emerging Technologies That Will Change the Practice of Nursing There are many emerging technologies that will change the practice of nursing in the coming decade. Seven are discussed here; genetics and genomics; less invasive and more accurate tools for diagnosis and treatment; 3-D printing; robotics; biometrics; electronic health records; and computerized physician/provider order entry and clinical decision support (See Table 1 for a discussion of the benefits and challenges of each). Table 1. Seven Emerging Technologies that Are Changing the Practice of Nursing Technology Benefits Challenges Genetics and Genomics The majority of disease risk, health conditions and the therapies used to treat those conditions have a genetic and/or genomic element influenced by environmental, lifestyle, and other factors therefore impacting the entire nursing profession (Calzone et. al, 2010). Many nurses currently in practice know little about genetics and genomics and lack the competence needed to effectively counsel and teach patients in this regard. Less Invasive and More Accurate Tools for Diagnostics and Treatment Non-invasive and minimally invasive tools for diagnostics and treatment generally result in lower patient risk and cost. The rate at which noninvasive and minimally invasive tools are being introduced makes ongoing competency regarding their use a challenge for nurses. 3-D Printing Bioprinters, using a "bio-ink" made of living cell mixtures can build a 3D structure of cells, layer by layer, to form human tissue and eventually human organs for replacement (Thompson, 2012). Healthcare is just beginning to explore the limits of this technology. There are limits to the materials which can be used for printing and materials science is a laggard in 3D printing (Nusca, 2012). Robotics Robotics can provide improved diagnostic abilities; a less invasive and more comfortable experience for the patient; and the ability to do smaller and more precise interventions (Newell, n.d). In addition, robots can be used as adjunct care providers for some physical and mental health care provision. More research is needed on comparative effectiveness of robotics and human care providers. Many healthcare providers have expressed concern about the lack of emotion in robots, suggesting that this is the element that will never replace human caregivers. Biometrics Biometrics increase the security of confidential healthcare information and eliminate the costs of managing lost passwords. The measurement of biometric markers may occur in less than ideal situations in healthcare settings and in a rapidly changing workforce, cost may become an issue. Electronic Healthcare Records (EHR) Healthcare providers have access to critical patient information from multiple providers, literally 24 hours a day, 7 days a week, allowing for better coordinated care. Implementation costs, getting computers to talk to each other and debates about who “owns” the data in the EHR continue to challenge its required implementation. Computerized Physician/Provider Order; Entry (CPOE) and Clinical Decision Support CPOE and clinical decision support fundamentally change the ordering process resulting in lower costs, reduced medical errors, and more interventions based on evidence and best practices. The introduction of CPOE and clinical decision support requires providers to alter their practice. Resistance is common due to the time spent on order entry. Implementation and training costs are often significant. Genetics and Genomics The American Cancer Society (2011) suggests that genetic testing is already being used for many reasons. Some of these reasons include: its predictive value (identification of gene mutations that might put a person at risk of developing a disease such as cancer, cystic fibrosis, sickle-cell anemia, or Tay-Sachs disease) its ability to determine carrier status or whether a person has a gene mutation which could be passed on to a child prenatal screening to diagnose some conditions in utero newborn screening (to determine the existence of a variety of inherited conditions such as phenylketonuria [PKU], cystic fibrosis, or sickle cell disease) as a means for checking cancer cells to determine prognosis or potential benefits of certain types of treatment. Future applications of genetics and genomics will transform the health care system even further. Carroll (2011) suggests that by the year 2020 the healthcare system will have transitioned from one which “fix[ed] people after they were sick” (para. 1) to one of preventive, diagnostic, genomic-based medicine where patients will be treated for conditions we know they are likely to develop. Health care professionals already encounter patients who arrive for diagnosis or treatment with their genotyping or genetic sequencing in hand. Health care professionals already encounter patients who arrive for diagnosis or treatment with their genotyping or genetic sequencing in hand. With websites such as 23andMe (2012), patients can send in a saliva sample and receive a comprehensive genotyping (DNA analyzed by genetic variants) with periodic updates on the latest biomedical literature for less than $100. Clearly, having genetic data can ultimately lead to better care and patient empowerment. But of concern are the ethical dilemmas associated with safeguarding such personal information and potential emotional consequences of uncovering unknown medical data without the guaranteed support of a primary care provider. Dilemmas such as these, and others we may not yet imagine, will pose significant challenges for all healthcare professionals, including nurses. Despite these concerns, there is no doubt that genotyping and genetic sequencing will continue to significantly improve diagnostic and interventional medicine. Gene therapy is expected to make significant inroads in curing cancer and preventing birth defects within the next two decades (American Association for Cancer Research, 2012; Manchester University Scientists, 2013; Pearson & Flake, 2013, Pelletier, n.d.). Genetic advances are likely to eliminate the need for organ transplants since new organs will be able to be grown from a patient’s own tissues. Genetic advances are also likely to eliminate the need for organ transplants since new organs will be able to be grown from a patient’s own tissues. Researchers are already beginning to grow individual tissues, tendons, and cartilages from stem cells and several years ago, a kidney-like organ was grown from scratch in the lab and used successfully in animals (Coghlan, 2012). In January 2013, Japanese researchers announced that they had succeeded in growing human kidney tissue from stem cells for the first time; a potential breakthrough for millions with damaged organs who depend on dialysis (Japanese Researchers Grow, 2013). Similarly, thyroid cells can now be grown in the lab, a new ear has been grown in the skin of a woman’s arm, and cells are being reprogrammed so that they can turn into a variety of cell types. Leading scientists suggest that there may be no limit to the kinds of organs and body parts that can be grown from stem cells (Complex Body Parts, 2012). This ability to grow major organs and body parts will eliminate the need for external donors, and since organs are genetically matched to the patient, the chance of rejection should become minimal or non-existent. Stem cells and new biologic treatments will also impact the future of joint repair. Rath (2012) suggests that stem cells will be used to generate replacement cartilage tissue to repair damaged joints, especially for osteoarthritis patients. The process of autologous chondrocyte implantation (ACI)  involves removing a small piece of healthy cartilage from the knee and growing millions of new cartilage cells (chrondrocytes) in a lab, before reinjecting them back into the knee. ACI will help people aged 15 to 50 with single cartilage defects no larger than 10 centimeters. Similarly autologous cartilage tissue implants, which use a combination of cell therapy and tissue engineering techniques, will be the next logical step in tissue regeneration. Such experimental implants are already in clinical trials (Rath, 2012). The ability to clone teeth is also expected in the near future. Experts suggest that “dentures are the past, dental implants are the present, and teeth grown from stem cells could be the future” (Cloning Teeth, 2012, para 2). Clinical trials are already underway in Europe, where a fully functional and living tooth can be re-grown in around two months. In addition, Onion (2012) notes that scientists hope that by locating the right biological triggers people may one day be able to grow several sets of teeth instead of just two — much like the way sharks, rodents or stingrays grow several generations of teeth to replace teeth that are worn out or damaged. Less Invasive and More Accurate Tools for Diagnosis and Treatment Less invasive and more accurate tools for diagnostics and treatment will also change nursing practice in the future. Less invasive and more accurate tools for diagnostics and treatment will also change nursing practice in the future. For example, heart disease is likely to be diagnosed by a new blood test that eliminates the need for risky diagnostic angiograms. A new 23-gene blood test checks for certain blood proteins linked to heart disease (Howard, 2011). In a recent trial, the blood test was 85% accurate in detecting potentially harmful blockages among patients. Tattoos have been developed that can monitor blood glucose without a finger prick, a huge advancement for the 26 million Americans with diabetes (Howard, 2011). The miniature tattoo, which is only a few millimeters in size, is made up of nanosensors that contain a yellow-orange dye. The dye lights up when glucose levels are high and becomes darker when the levels drop. The tattoos are applied once a week and are being piloted at Northeastern University in Boston (Tattoos That Improve Health, 2010). Tattoos have been developed that can monitor blood glucose without a finger prick, a huge advancement for the 26 million Americans with diabetes. Magnets are also increasingly likely to be used as a treatment for major depression (Howard, 2011). Cleared by the FDA in 2008, small electromagnets are now placed on the scalp behind the left forehead as a therapeutic intervention for depression. These magnets deliver a tiny electric current to the part of the brain linked to depression. It seems to work, although the mechanism for action is not fully understood. In fact, a large study found these magnets were three times more effective than a placebo and most importantly, they had no serious side effects (Howard, 2011). Scanning technology is predicted to improve to the point that images of soft and hard tissues in the body will be so clear that exploratory surgery and invasive procedures will virtually be eliminated within a few decades. The Nuclear Energy Institute (n.d.) notes several current examples of state of the art nuclear medicine. Myocardial perfusion imaging maps blood flow to the heart, allowing doctors to diagnose heart disease and determine the most effective course of treatment. Today’s bone scans can detect the spread of cancer six to 18 months before X-ray imaging. Researchers are also making strides to develop vaccines for some types of cancer. For example, Howard (2011) notes that researchers are using the same technology used to create childhood vaccines to develop a prostate cancer vaccine known as Provenge®. Doctors remove some of a patient’s white blood cells, expose them to a protein found in prostate cancer, and then inject the cells back into the body, where they prime the immune system to attack the cancer. So while Provenge® doesn't cure prostate cancer, it does reduce a patient’s overall risk of death by 24% in a three year period. The drug was approved in 2010 for use with patients with metastatic prostate cancer which had stopped responding to hormone treatments (Howard, 2011). 3-Dimensional (3D) Printing 3D printing, also known as additive manufacturing, "is a method of building objects layer by microscopic layer, fusing each cross section of molecules until a complete object is formed" (Pellet, 2013, para. 2). Typically, this requires scanning an existing object with a 3D scanner which gathers the data necessary to print on a 3D bioprinter. The bioprinter prints the object by adding layer after layer of materials such as plastics, glass, metal, or ceramics. Thus, three dimensional solid objects can be created from a digital model (Thompson, 2012). The application of 3D printing in healthcare literally makes the body into a system of interchangeable parts The application of 3D printing in healthcare literally makes the body into a system of interchangeable parts (Banham, 2013). For example, in February 2013, doctors and engineers in the Netherlands collaborated on the 3D printing of a prosthetic lower jaw, which was subsequently implanted into an 83-year-old woman who suffered from chronic bone infection. The printer produced the prosthetic jaw from 33 layers of titanium powder that were heated, fused together, and then coated with bioceramic artificial bone (Banham, 2013). Artificial limbs can be created by the same technology, as can custom hearing aids and dental fixtures (Thompson, 2012). In February 2013, Scientists at Cornell University used 3D printing to create an ear remarkably similar to a natural one. Using 3D images of a human ear, they printed a mold to be injected with gel containing collagen from rat tails and then added cartilage from cow ears. It took half a day to design the mold, about a day to print it, 30 minutes to inject the gel, and the ear was removed 15 minutes later (Cantor, 2013). In addition, human organs can be “bioprinted” for transplant by 3D printing. This technology involves the creation of replacement tissues and organs that are printed layer-by-layer into a 3-dimensional structure. The parts are made from the organ recipient's own genetic matter, and precisely match the tissue or organ they replace (Banham, 2013). To date, 3D printers are able to print simpler tissues like skin, heart muscle patches, and blood vessels, although the printing of solid organs like hearts and livers is expected within a generation (Banham, 2013). Thompson (2012) agrees, noting that “printing off a kidney or another human organ may sound like something out of a science fiction novel, but with the advancements in 3D printing technology, the idea may not be so far-fetched” (para. 1). Robotics Growth in robotics is expected due to workforce shortages, a growing elder population, and a call for higher quality care not subject to human limitations. Robotics, as an emerging field in healthcare, will also greatly impact how nursing is practiced in the future. Growth in robotics is expected due to workforce shortages, a growing elder population, and a call for higher quality care not subject to human limitations. Areas of projected robotic growth include nanomedicine, biomechatronics, and the use of robots as direct care providers. Nanomedicine, which is the application of nanotechnology (the engineering of tiny machines or robotic devices) to the prevention and treatment of disease in the human body, is an evolving discipline has the potential to dramatically change medical science (Whatis.com, n.d.). Nanomedicine should be commonplace in another 2 to 3 decades, with engineered nanodevices, or nanomachines, repairing damage accumulated as a result of metabolism (being alive) by performing nanorobotic therapeutic procedures on each of the ~75 trillion cells that comprise the human body (Healthcare in the 21st Century, n.d.). Microbots and nanodevices, which will circulate in the bloodstream, should be able to identify and repair systems early in disease processes to greatly reduce or eliminate the risk of cancer. Theoretically, nanobot technology could become the effective end of aging... By the early 2020s, molecular manufacturing will enable the first nanobots to be inexpensively produced for use in medicine. Once in common clinical use, nanobots will have an enormous positive impact on the lives of billions of people (Healthcare in the 21st Century). Theoretically, nanobot technology could become the effective end of aging as well as the reversal of one's current biological age to any new age that is desired. There will also be more mergers of humans and machines through biomechatronics, which means creating machines which replicate or mimic how the body works. For example, it’s likely by 2020 that pancreas pacemakers for diabetics, mentally controlled electronic muscle stimulators for stroke and accident survivors, as well as miniature cameras and microphones that can be wired into the brain, will exist, allowing blind people to see and deaf people to hear (Huston, 2014). Electroencephalography (EEG) technology already exists that uses mathematical algorithims to read minds, restore brain-controlled ambulation to the paralyzed, move experimental wheelchairs by brainwaves alone, and explore game control without a joystick (Isaacson, 2012; Anderson, 2012). Philip Low, the mathematician and biology student cited as being the inventor of this EEG technology, plans to introduce Low's "iBrain 3" as the first FDA-approved EEG device in 2013. This device, the size of a U.S. quarter, can be used for medical as well as recreational purposes and is expected to possibly sell for less than $100 (Isaacson, 2012). The first prototype of a bionic eye should be available by 2013 (Howard, 2011). The bionic eye works by having a tiny camera is mounted on a person’s glasses. The camera sends signals to an implant on the retina, which sends impulses to the brain, which are perceived as images. About 30 individuals have received artificial retinas so far and the technology continues to improve. Future adaptations of this eye have the potential to change lives for people with macular degeneration, a disease that impacts 1.75 million Americans (Howard, 2011). We expect to see many more robotics, and they will have developed to the point that the differences between what these life forms and humans can do will be smaller than ever. For example, more robots will be used in surgical procedures, since already they are more accurate and steadier than human caregivers (Huston, 2014) Robots will also increasingly be used to provide direct patient care. Service robots are being developed for use as caregivers in Japan, particularly for the elderly. These robots help with tasks such as washing or carrying elderly patients, although they are still not yet developed for commercialization. In July 2012, iRobot Corp unveiled its most humanlike device yet: a 5-foot, 4-inch tall mobile robot which allowed doctors to examine diagnostic data in real time and interact with patients anywhere in the world (Seiffert, 2012). The robot features a flat-screen on top which pivots like a human neck, showing the physician's face and allowing him to look around the room and talk to patients, family members, and other healthcare professionals. It includes sensors for mapping and navigation and even carries a stethoscope. It’s the use of robots as direct service providers, however, that may most impact nursing in the future It’s the use of robots as direct service providers, however, that may most impact nursing in the future (Huston, 2014). Currently, prototypes of physical care robots are in development, but commercial production may still take some time. Mental service robots are already here and in use as therapeutic adjuncts in mental health care. One such mental service robot is Paro, the seal. Paro is fitted with sensors beneath its fur and whiskers and it responds to petting by opening and closing its eyes and moving its flippers. Paro is used in Japanese nursing homes and by autistic and handicapped children as a therapeutic robot. It retails for about $6,000 and several thousand have been produced since 2004. Paro was used to provide comfort and reduce stress in nursing home residents located near the tsunami- crippled nuclear power plant leaking radiation in Fukushima (Kyung-hoon, 2011). Residents named two of the Paro robots “Love” and “Peace” and treated them more like real animals than robots. Many healthcare providers have expressed concern about the lack of emotion in robots, suggesting that this is the element that will never replace human caregivers. New technology in Japan, however, has resulted in a kind of robot intelligence known as “kansei,” (KEN-ZI), which literally means “emotion or feeling.” Kansei robots monitor human expressions, gestures, and body language and listen to people. They also sense human emotion through sensors that monitor pulse rate and perspiration. When Ken-zi hears a word, it searches through its database of more than 500,000 words and then it displays one of 36 expressions it thinks matches the word (Huston, 2014). Robots will also increasingly be used as couriers. Robot couriers find and deliver medications, supplies, equipment, and other goods so that scarce, valuable human resources do not have to leave the patient care area. There will continue to be more high fidelity, robotic simulation used in nursing education to supplement clinical nursing experiences. The newest simulation robots sweat, cry, turn cyanotic, and speak. But as with other robotics, nurse leaders will be challenged to figure out how much simulation may be too much. Perhaps by 2020, simulation will be so highly developed that most of student’s clinical learning can be done in a simulation laboratory. It would certainly be safer for patients and could eliminate the scramble to find enough clinical facilities. The nursing leadership challenge, however, is to determine the degree of real human interaction needed for students to develop the art of professional nursing. Biometrics The healthcare environment will also continue to be rapidly transformed by new technology as a result of the need to provide confidentiality and security of patient data, i.e., to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) (Huston, 2014). Experts suggest that biometric signatures will become common place in most healthcare organizations since they will provide the needed security for medical records HIPAA calls for a tiered approach to data access in which staff members have access to only the information that they need to know to perform their jobs. To that end, developers of new technology must assure that access is both targeted and appropriate. Biometrics, or the science of identifying people through physical characteristics such as fingerprints, handprints, retinal scans, palm vein prints, voice recognition, facial structure, and dynamic signatures, is often suggested as a solution to the information access problem. Experts suggest that biometric signatures will become common place in most healthcare organizations since they will provide the needed security for medical records (Krawczyk & Jain, n.d.). Fingerprint biometrics is still the most common type of biometrics in healthcare, primarily because of its ease of use, small size, and affordable price. Detection of facial geometry through facial landmarks such as approach angles; eyebrow and mouth contours; skin texture analysis; and hairstyles, however, is also beginning to make inroads into healthcare as a biometric measure (Huston, 2014). Electronic Health Records Even health records continue to evolve as a result of technology. Any changes in documentation of care have a significant impact on nursing practice. The electronic health record (EHR) is a digital record of a patient’s health history that may be made up of records from many locations and/or sources, such as hospitals, providers, clinics, and public health agencies (Huston, 2014). The EHR is available 24 hours a day, 7 days a week and has built-in safeguards to assure patient health information confidentiality and security. In January 2004, President George Bush set a goal that most Americans would have an EHR by 2014. This goal was endorsed by President Barack Obama and supported financially with $30 billion in stimulus funds to support hospital implementation over the next several years. As a result, this optional improvement has become a near-mandatory initiative (Haughom, Kriz, & McMillan, 2011). Many federal programs currently exist to support EHR adoption, including those around meaningful use (capturing the right data that can improve patient outcomes); the implementation of electronic information exchange; consumer e-health; and workforce training (Centers for Medicare and Medicaid Services, 2010; Take 5 with a Nurse Leader, 2012).  Challenges continue to exist in understanding and demonstrating meaningful use; capturing the relevant data electronically as part of clinical workflows; and not having the appropriate certified technology (Miliard, 2012). In addition, most hospitals and health systems continue to doubt their ability to meet new mandated EHR standards, with only 48% of healthcare leaders in a recent survey feeling confident in their organization’s readiness to meet Stage 1 meaningful use requirements (Miliard, 2012). Thirty-nine percent said they were somewhat confident; three percent said they were not confident at all; and 10 percent indicated that they did not know their level of readiness. Even with these concerns, nearly three-quarters (71 percent) of hospital and health system leaders said they are more than 50 percent of the way to completing EHR system adoption (Miliard, 2012). Computerized Physician/Provider Order Entry and Clinical Decision Support Computerized physician/provider order entry (CPOE) is a rapidly growing technology as a result of its designation as one of three key patient safety initiatives by the Leapfrog Group, a conglomeration of non–health care Fortune 500 company leaders committed to modernizing the current health care system (Huston, 2014; The Leapfrog Group, 2013). In addition, the Institute of Medicine (IOM, 1999) study To Err Is Human recommended the use of CPOE to address medical errors. Clinical Decision Support will likely be commonplace within a decade... CPOE is a clinical software application designed specifically for providers to write patient orders electronically rather than on paper. With CPOE, providers produce clearly typed orders, reducing medication errors based on inaccurate transcription. CPOE also gives providers vital clinical decision support (CDS) via access to information tools that support a health care provider in decisions related to diagnosis, therapy, and care planning of individual patients. Clinical decision support is defined broadly as “a process for enhancing health-related decisions and actions with pertinent, organized clinical knowledge and patient information to improve health and healthcare delivery” (Healthcare Information and Management Systems Society, 2011, para 2). Like CPOE, CDS will likely be commonplace within a decade, giving providers the promise for access at the point of care to cutting-edge research, best practices, and decision-making support to improve patient care. Further research is needed, however, about the impact of CPOE on nursing and physician workflow. In addition, adoption of emerging technologies is challenging as well as expensive. The Healthcare Information and Management Systems Society [HIMSS] (2012) notes that by the end of 2011, only six percent of U.S. hospitals had achieved the desired stage 6 or stage 7 on their Electronic Medical Record Adoption Model (EMRAM). Stage 6 requires full provider documentation/charting (using structured templates) and the use of clinical decision support related to protocols and outcomes in the form of variance and compliance alerts. A full complement of radiology Picture Archive and Communication Systems (PACS) which displace all film-based images for radiology services must also be available to physicians via an intranet. In stage 7, the hospital no longer uses paper charts to deliver and manage patient care and has a mixture of discrete data, document images, and medical images within its electronic medical record environment. Clinical data warehouses are used to analyze patterns of clinical data to improve quality of care and patient safety and clinical information can be readily shared via standardized electronic transactions with all entities within a integrated delivery system, or a health information exchange. Furthermore, there is a continuity of data flows for patients between the inpatient, emergency department, and outpatient service modalities (HIMSS, 2012). Leaders often ask how organizations can be better ready to respond to emerging technologies such as those described above. The answer to that question, at least in part, is forecasting what skills sets will be needed to meet these emerging technologies and proactively addressing any skill set deficits of the human capital employed in those organizations. Nursing Skill Sets Needed to Appropriately Respond to Emerging Technologies The capacity to manage human knowledge, and to convert it into useful products and services, is fast becoming the "critical" leader skill of the age (National Defense University,  n.d.). Leadership skills that will be required of nurses to appropriately respond to emerging technologies include being able to use technology to facilitate mobility, communication and relationships; having expertise in knowledge information, acquisition, and distribution; and understanding and using genetics and genomics in nursing (see Table 2 for select examples of these skill sets). Table 2. Three Nursing Skill Sets Needed to Appropriately Respond to Emerging Technologies Nursing Skill Set Select Examples Being able to use technology to facilitate mobility, communication, and relationships Email, telehealth and telemedicine, internet, cellular technology, text messaging, video conferencing, smart phones, 3-dimensional printing, high fidelity simulation, virtual realities such as Second Life Virtual World, social media networking, embedded sensor networks, global positioning systems, bio-electronics Having expertise in knowledge information, acquisition, and distribution Information literacy, evidence-based practice, clinical decision support, sensemaking, commercially purchased expert networks, distributed expertise, boundary spanning knowledge management, knowledge engineering, standardized guidelines, fuzzy case-based reasoning, understanding of cognitive science theory and complex adaptive systems theory Understanding and using genomics in nursing Understanding of the Human Genome Project, genetic sequencing, service delivery models that promote safe, efficient, and effective utilization of genetic/genomic information in care decisions (First Genetics, 2008); ethical issues related to genomics encountered throughout the life continuum and around the world (First Genetics, 2008); ethno-cultural beliefs and practices for utilization of genomic-based care; and resources available to arm nurses with information to learn about and teach genetics (First Genetics, 2008). Using Technology to Facilitate Mobility, Communication, and Relationships One leadership skill set that is increasingly recognized as critical for nurses in the 21st century is the ability to use technology which facilitates mobility as well as relationships, interactions, and operational processes One leadership skill set that is increasingly recognized as critical for nurses in the 21st century is the ability to use technology which facilitates mobility as well as relationships, interactions, and operational processes (Huston, 2014). This skill set is predicted to become even more critical in the approaching decade. One goal identified in the Healthy People 2020 initiatives is use of health communication strategies and health information technology (IT) to improve population health outcomes and health care quality, and to achieve health equity (Healthy People 2020, 2012). Healthy People 2020 suggests that communication and health IT that supports shared decision making between patients and providers can result in social support networks. In addition, health IT can deliver accurate, accessible, and actionable health information that is targeted or tailored; facilitate meaningful use of health IT; and promote exchange of health information among healthcare and public health professionals. Finally, well developed health IT can enable quick and informed action to health risks and public health emergencies; increase health literacy skills; provide new opportunities to connect with culturally diverse and hard-to-reach populations; and provide sound principles in the design of programs and interventions that result in healthier behaviors (Healthy People 2020, 2012). Nurses will need the skills to use IT at the advanced level required to support these goals. Having Expertise in Knowledge Information, Acquisition, and Distribution One theory put forth to estimate how quickly knowledge information, acquisition, and distribution have grown with computing technologies is Moore's law. This law, named after Intel co-founder, Gordon E. Moore, notes that over the history of computing hardware, the number of transistors on integrated circuits doubles approximately every 18 months to 2 years. (National Defense University, n.d.) While Moore’s law was originally intended to apply to only semiconductor circuits, many futurists have applied the law to digital computers and thus to knowledge acquisition and reporting. This has led futurists such as John L. Peterson to suggest that memory capacity will continue to double every 18 months for at least the coming decade and that knowledge growth is exponential (National Defense University, n.d.). Carroll (2011), another futurist, goes so far as to suggest that “learning is what most adults will do for a living in the 21st century” (para. 1). Computers will also continue to play a significant role in knowledge acquisition and distribution since they have significant potential to dramatically extend our memory capability and memory and cognitive capacity, two elements that form the basis of our thinking process. As such, they will become a powerful tool to help nurses become more efficient and effective and to leverage strategic leadership and decision making when properly applied (National Defense University, n.d.). In a profession where knowledge doubles every six years, nurses can no longer be the keeper of knowledge. Clearly then, nurses increasingly need to be experts at information management, including knowledge acquisition and distribution. In a profession where knowledge doubles every six years (Carroll, 2011), nurses can no longer be the keeper of knowledge. Instead, they must become the master of collecting and sharing that knowledge with others. The IOM (2010) agrees, suggesting that the ways in which nurses were educated during the 20th century are no longer adequate for dealing with the realities of healthcare in the 21st century. As patient needs and care environments have become more complex, nurses need to attain requisite competencies to deliver high-quality care including leadership, health policy, system improvement, research and evidence-based practice, and teamwork and collaboration. Understanding and Using Genomics in Nursing Calzone et al. (2010) suggest that despite a burgeoning body of evidence regarding the contribution of genetics and genomics to health or illness, the evidence specific to outcomes of genomically-competent nursing practice and the impact on the public’s health is extremely limited—if not entirely absent. Yet, individual anecdotes point to the remarkable potential for transforming health care by the genomically-competent nurse. Calzone et al. (2010) go on to suggest that “in order for people to benefit from widespread genetic/genomic discoveries, nurses must be competent to obtain comprehensive family histories, identify family members at risk for developing a genomic influenced condition and for genomic influenced drug reactions, help people make informed decisions about and understand the results of their genetic/genomic tests and therapies, and refer at-risk people to appropriate health care professionals and agencies for specialized care” (p. 27) Education will, however, be required to “assure that the revolutionary advances in genetics and genomics reach the patients and families for whom they were developed” (Calzone et al. 2010, p. 28). Calzone et al. (2010) argue that bringing all 2.9 million nurses in the U.S. workforce to the forefront of genetics/genomic healthcare practice is needed, as nurses must elicit health related information, recognize what is important, and subsequently act upon that information in caring for the patients they serve. In fact, Calzone et al. (2010) suggest that nurses, other health care professionals and their employers will ultimately face liability if they fail to incorporate genetic/genomic discoveries into practice. Thus this skill set is fast becoming essential. Nursing Leadership Challenges in Integrating New Technology What leadership challenges will nurses face in integrating new technology with the caring part of nursing? Who will determine what cost-benefit ratio justifies the development and use of expensive technological innovations? Who will be charged with overseeing the initial training of a technology enabled nursing workforce and for assuring continuing competence in technology aided practice? Finally, what role will nurses play in helping to establish the ethical parameters of technology in healthcare? This section discuses four nursing leadership challenges (table 3) that exist in integrating new technology in nursing and healthcare. Table 3. Four Nursing Leadership Challenges in Integrating New Technology Balancing the Human Element with Technology Balancing Cost and Benefits Training a Technology Enabled Nursing Workforce and Assuring Ongoing Competency Assuring that Technology Use is Ethical Balancing the Human Element with Technology What does all this expanding technology mean for nurses? Many things, but perhaps most importantly, nurses need to make sure that the human element is not lost in the race to expand technology. The human connection is the art of nursing and nurses need to be actively involved in determining how best to use technology to supplement, not eliminate, human resources. One of the most significant challenges nurse leaders will face then in the coming decade then will be to find that balance between maximizing the benefits of using the technology which exists, while not devaluing the human element. Balancing Cost and Benefits There are other leadership challenges that nurses must address in conjunction with a health care system so driven by technology, such as cost. The U.S. health care system is already the most expensive healthcare system in the world and technology is one of the leading cost drivers. These technologies are without a doubt saving lives and improving the quality of life for millions, but sometimes technology development comes first and then a need is created simply because the technology exists. In addition, access to technology is often dependent on a person’s ability to pay for that technology; many healthcare disparities still exist in this regard. Training a Technology Enabled Nursing Workforce and Assuring Ongoing Competency Judy Murphy, deputy national coordinator for Programs and Policy at the Office of the National Coordinator (ONC) for Health Information Technology, Department of Health and Human Services, in Washington, DC stated that “I used to think we [nurses] provide healthcare first, and that the need for health information was secondary” (Take 5 with a Nurse, 2012, para. 8). But, Murphy now argues that nurses cannot provide good care without having the right information to make the right decisions when caring for individual patients (Take 5 with a Nurse, 2012). She concludes then that nursing is an information-based profession that provides health care, and that it is technology that helps us bring all that information to the point of care. Who is going to train all the healthcare professionals who will work with new emerging technologies? More importantly, who will need to be responsible for assuring ongoing competency in a digital era where half of what someone knows is obsolete in three years? Cipriano (2011) suggests that as technology and computing become ubiquitous, all nurses will have to demonstrate competencies to maintain cutting-edge practices and that the call to lead this change will likely fall to nurse informaticians. These leaders with expertise in informatics will be critical to bridging the divide between clinicians and technology as well as leading delivery model transformation through application of health IT (Cipriano, 2011). Assuring that Technology Use is Ethical Finally, nurse leaders must increasingly ask “how” and “why” technology should be implemented. What parameters need to be put into place to determine its ethical use? Just because something can be done does not mean that it should be done. In fact, the problems faced by organizational leaders regarding technology will increasingly be what is called “wicked”- meaning that they have many causes, they are tough to describe, and there is no right answer. In a recent speech, Thomas Baldwin, a professor of philosophy at Britain's York University, suggested that new technologies bring significant hopes of curing terrible diseases as well as fears about the consequences of trying to enhance human capability beyond what is normally possible (Kelland, 2012). Baldwin concluded that the blurring of the line between man and machine will continue to pose concerns about the ethics of emerging technologies in medicine and other fields. It is important for nurses to be a part of conversations to address these ethical concerns. Conclusions Clearly, planning for the future is difficult even when environments are relatively static. When they are as dynamic as healthcare and technology, the challenges multiply exponentially. National Defense University (n.d.) agrees, suggesting that: As the future is uncertain, the only thing relatively clear is that much of what we will experience in the future will be different from the past. We must understand it is not information or even technology that will produce this unprecedented change, but the impact of technology on all aspects of human life; not computers or even bits and bytes, but the ability to apply and integrate rapid technological change (para. 1). The (2010) IOM report, The Future of Nursing, suggested that it is nurses who will be called up to fill expanding roles and to master technological tools and information systems while collaborating and Nurse leaders must begin thinking now about how emerging technologies will change the practice of nursing...  coordinating care across teams of health professionals. Nurse leaders must begin thinking now about how emerging technologies will change the practice of nursing and proactively create the educational models and leadership development programs necessary to assure that nurses will have the competencies they need to address these emerging technologies. It must be nurses who are at the forefront in planning for and preparing for these challenges. Nursing as a profession must not be reactive and allow others to assume this leadership role.