In February 2001, 22 nurse leaders in South Dakota met in Sioux Falls to discuss the future of their profession. Working with a facilitator from New Jersey, the group designed four health care scenarios. In one, the gap between the haves and have-nots became so wide, almost no one could afford health insurance. Some nurses worked for the "haves" who could afford health care-the group envisioned "hip-replacement cruises" in which wealthy people had surgery while working on their tans-but most nurses did what they could for the rest of the population, who had almost no health care coverage.

A second scenario portrayed a national health care system that distributed care equally, although it created a nurse's nightmare of documentation and regulations. A third focused on a barter economy of communes and small communities. Nurse practitioners took lead roles, brokering health care in exchange for vegetables or services.

The fourth scenario, a "techno-fix," had people undergoing checkups in line at the supermarket. Computers read vital signs as they tallied groceries, and a nurse in the coffee shop answered questions.

The group eventually decided the future probably would be not one, but some combination of these four scenarios. The nurse leaders meet every three months to compare notes. They exchange news clippings, pointing out, "Here's a techno-fix" or "This looks like the road to national health care."

"We had a good time playing around with the future," said Marge Hegge, Ed.D., RN, director of the South Dakota Colleagues in Caring project at South Dakota State University, which helped organize the workshop. Colleagues in Caring is a nursing workforce development project that allows different regions to share ideas and information about attracting, educating, retaining and keeping track of nurses. "Just by virtue of having done this, we're looking at the world differently," she said.

Hegge and other nursing leaders around the country are doing more than playing around. They are giving the future of nursing some serious thought. They're attending seminars and workshops. They're creating think tanks. They're crunching numbers and studying trends to figure out where the profession is going.

Their conclusions: Nursing in 10 or 20 years will look nothing like the nursing of today. New technologies and new drugs, changes in public attitudes toward health care and a shrinking workforce will force the profession to remake itself, probably several times over.

Just what role the nurse will play in the future, according to some, depends on everything from how well the profession can recruit new blood to how much money the public is willing to spend on health care. Others say no matter how much money is spent or how many more new nurses are brought in, there's no getting around it: Out of necessity, machines will do much of the work that nurses do now. The nurse's primary job will be to provide a human touch-whether in the hospital, private practice or the community.

So, what will nurses of the future be doing, and what will their workplaces look like? We asked nurse leaders, educators and futurists what they thought. Based on their answers, we've come up with our own scenarios of where nurses might be in 10 to 20 years.

> In the hospital <

Our hospital nurse of the future works with two other nurses and a nurse-technologist on a cardiac unit, where three patients have just received new mechanical hearts.

The hospital nurse starts his day by meeting the families of these patients to explain how the hearts work and what sort of care their loved ones will need when they get home. The families meet in a patient care resource room, where the nurse uses a computer program to illustrate the workings of the new hearts. He reassures the families that they can contact him anytime by computer phone if they forget something or need more information.

In the middle of his explanation, his personal data assistant beeps and flashes a message across the screen. A monitor has registered an increased heart rate and slight fever in one of his patients. The most probable cause is the beginning of an infection. Should antibiotics be given? Which ones? The patient's information scanned into the computer shows she is allergic to some.

The nurse calls up a picture of the patient in her room. She is sleeping and the nurse decides against waking her. He makes his recommendation and sends it by computer to a physician, who also has been paged. Their recommendations concur. The medications are automatically adjusted and entered into a patient care database. The nurse continues his talk.

His PDA beeps him again to report that the patient is responding to the medication.

As a result of the nursing shortage, hospitals will be forced to use their nurses judiciously, nursing leaders say. "There will be fewer RNs in the hospitals of the future," said Sean Clarke, Ph.D., RN, associate director of the Center for Health Outcomes and Policy Research and assistant professor at the University of Pennsylvania School of Nursing. "In the presence of this shortage, hospitals are going to have to make some hard choices about the nurses they already have."

Some see hospital nurses spending more time at the bedside as educators and care coordinators. "When they do get food trays, it will be because they decide that's an important part of patient care," said Nancy Dickenson-Hazard, MSN, RN, FAAN, chief executive officer of the Sigma Theta Tau Honor Society of Nursing, based in Indianapolis. "They'll refocus on the patient and what's important to the patient."

Nurses might spend more time as administrators and supervisors, much as they do in public health or long-term care facilities now, said Jean Ann Seago, Ph.D., RN, researcher at the Center for the Health Professions and assistant professor at the University of California, San Franciso School of Nursing.

As the lengths of patient stays shorten, nurses will have to make the best use of a shrinking amount of time with their patients, said Tim Porter-O'Grady, Ed.D., RN, FAAN, professor at Emory University in Atlanta and the head of Tim Porter-O'Grady Associates Inc., a consulting firm that works with health care organizations in crisis.

Nurses of the future will need to know how to access knowledge and transfer it to a patient or family in a matter of hours, he said. Now, "education and knowledge transfer are something nurses do when they have time. But the things we don't have time for are the things the patient really needs now."

Most nurse leaders thought many factors that now take up so much of a hospital nurse's time-documentation, patient care information, the constant walking to get meals or medications-would finally be done by technology.

Smart beds might monitor vital signs, said Kathleen Sanford, RN, vice president of nursing at Harrison Memorial Hospital and administrator at Harrison Silverdale in Bremerton, Wash. Bar codes and automatic medicine carts could reduce the time and errors in giving medications. Voice-activated technology would eliminate the need to constantly write things down.

Technology has promised such fixes in the past. Phil Authier, MPH, RN, vice president of patient care at St. Mary's Healthcare Center in Pierre, S.D., and president of the American Organization of Nurse Executives, recalls how in 1987 he talked about how his workplace would be paperless in five years. His staff keeps asking, "Your five years start when?"

But the nursing shortage is pushing hospitals to find ways to save time for nurses, nurse leaders said. Researchers are focusing on nursing in a way they never have, with time-motion studies and evidence-based research on nursing practices. Some said the increasing technology might attract more men into the profession, something hospitals must do if they hope to have enough nurses. They also must find ways to bring in more minorities, Seago said. "If we can't tap into these populations, then I think the profession of nursing is in trouble."

Sanford, who worked on a nursing future project as part of a three-week fellowship for nurse executives, envisioned a unit of patients monitored by machines and a technician, with two or three nurses to coordinate care, teach patients and families, and provide a "human face" as a bridge between people and technology.

In the future, people will honor nurses because they represent that human side of health care, she said. "People are getting more and more detached. They don't have friends and they're desperate for human touch and human relationships," Sanford said. "People who can make us feel human are going to be needed and valued."

> In private practice <

Our future nurse entrepreneur is a 65-year-old nurse practitioner who contracts with 50 families, mostly in rural areas. She works as part of a nurse cooperative and a nurse-run insurance company.

One of her clients, a 90-year-old woman who lives alone, is calling on a voice-activated computer phone with a direct emergency line to the nurse. She has had a terrible cough for several days and now is having trouble breathing. Using a home lab designed by a nurse, the nurse practitioner registers the woman's vital signs and has her take a blood sample. (Soon she will be able to get all this information from an implanted microchip, but the technology isn't quite there yet.) The patient has a respiratory infection that is highly resistant to antibiotics, but her genetic information shows that her immune system can fight it off with a new bolstering drug.

The nurse orders the drug, which will be delivered from the nearest pharmacy, as well as a soothing herbal tea. Then she talks to her patient for a while. The woman says she's been feeling a little depressed. She can't seem to do things like she used to. The nurse suggests she try a community service that provides meals, housekeeping, transportation and face-to-face counseling, run by a retired hospital nurse who specializes in working with older people.

The patient agrees and tells the nurse she feels better after talking. The nurse promises to call later in the evening to check on her. As they say goodbye, the patient's doorbell rings. Her medication has arrived.

In the next 20 years, if trends continue, hospitals will be reserved for the sickest patients only, Porter-O'Grady said. Outpatient visits have doubled from 300,000 to 600,000 between 1990 and 2001, he said. More and more health care is happening in clinics and homes. Home diagnostic kits, such as pregnancy tests and glucose meters, allow people to perform more routine health procedures without having to go to a laboratory or doctor's office. Telehealth devices like computer phones and monitors allow care providers to work with patients who live miles away.

In the meantime, nurses have found not one but many niches for themselves outside the hospital. Nurses run clinics and work in design companies. They serve as consultants to legal firms, software manufacturers and insurance companies. In the future, nurses could run software companies, insurance companies and design companies, nurse leaders said.

Nurse practitioners have a bright future, Sanford predicted, especially in geriatrics and age-related issues. "A good computer and an advanced practice nurse could do a lot of patient care," she said. Technology "is going to make a nurse practitioner stronger."

Baby boomer nurses, who may decide they've had enough of the stress of hospital work but aren't ready to retire, may find their niche as entrepreneurs, said Renatta Loquist, MN, RN, FAAN, project director of South Carolina's Colleagues in Caring and clinical associate professor at the University of South Carolina School of Nursing in Columbia.

"I don't see them as employees," she said. As independent contractors, "they can forge a path that's more connected with their passion for nursing."

Carol Bickford, Ph.D., RN, senior policy fellow in the department of nursing practice and policy for the American Nurses Association, sees 60- and 70-year-old nurses becoming the geriatric providers of choice. Being more mature, they might have a better understanding of aging, she said.

As technologies such as robotic surgery and telehealth improve, nurses increasingly will be working with patients they can't touch, Porter-O'Grady said. They must search for ways of conveying care to patients who are not in the same room.

"When the laying on of hands is no longer the symbol of caring, even caring has a new set of questions," he said. "What will touch look like when you're caring for a patient that isn't present?"

> In the community <

Our community health nurse of the future is the director of a health education and wellness center, paid for partly by a tax on junk food and partly by a biotechnology corporation that employs many people in the area. Because the population the center serves originally showed high rates of obesity, high blood pressure and stress, the center has focused on nutrition, exercise and stress reduction programs in combination with genetic technology that identifies people at greatest risk.

Today, the nurse is working with a group of primary-grade nurses to fine-tune a program that identifies young children at risk for obesity and helps them develop healthy eating and exercise habits. Later, she will meet with the center's complementary and alternative medicine committee to talk about hiring additional massage therapists because a study the center is conducting shows certain types of massage considerably lower blood pressure and reduce depression in health-tech workers, especially when combined with genetic therapies.

Finally, she will meet with a group of legislators to present a report on how diabetes and heart disease have almost disappeared in the community-and how health costs have dropped-since the center opened five years ago. Because she is starting her own campaign for public office, on a community wellness platform, she also hopes to enlist their support.

Nurses in the future probably will do much more population-based health care, Porter-O'Grady said. They will identify risks and establish priorities for specific populations and groups. They will provide community education and work with employers and insurance payers to develop programs that save money as well as promote health, he said.

Given the research linking many chronic illnesses to behaviors, nurses will focus more on preventing those illnesses than treating them, Loquist said. Authier believes the nursing shortage and rising health care costs will put pressure on the health care system to change from an illness model to a wellness and prevention model. He envisions an integrative system that uses complementary and alternative therapies along with traditional Western medicine.

Rebecca Rice, Ed.D., MPH, RN, deputy director for the national office of Colleagues in Caring in Washington, D.C., foresees preventive care enhanced by drugs designed for genetic structures that combat diseases before they start, or at least, identify risks for those diseases.

"People are going to have to learn to take care of themselves," she said. "I'd love to see a nurse in every school in the United States. That's the place to get them."

Nurse educators from three schools of nursing in Corpus Christi, Texas, created future scenarios featuring nurses as gatekeepers and policy-makers for national health, said Lois Barry, MPH, RN, project manager for the Electronic Learning in Nursing Education project in Corpus Christi. In one scenario, nurses had established their own political party-the Holistic Health Party-by 2030, and a nurse was president.

"There's a role for the nurse at the bedside and there always will be," Barry said, "but there's so much more."

No matter what the future brings, she said, nurses must prepare to keep learning and growing. "We're beyond the point where we accept the workplace for what it is," she said. "In any of these scenarios, there is no one role for the nurse. There are a variety of options. We think it can only expand."

Contact Cathryn Domrose at kaguilar@well.com.