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This article provides an overview of lessons learned in the transformation of end-of-life care delivery in prison settings. The evolution of the program of research provides insights into the pathway toward the social innovation of prison work. The context of the prison setting is presented to provide an overview of the challenges faced in this care delivery system. Following a summary of the key phases of the program of research, relevant considerations for nurse scientists working to transform healthcare systems in any setting are discussed. 


As nurses work to transform the health care system, we face a myriad of issues. The aging of the population has shifted our attention to chronic co-morbidities and geriatric syndromes. End-of-life care and related decision-making have become more critical considerations as advanced medical treatments continue to extend life. Extending life escalates a focus on functional capacity and quality of life issues. Interdisciplinary teams are learning how to best communicate with each other to promote comprehensive high-quality health care. These issues and others are prominent in the free world as public media draws our attention to these significant concerns. Still, far less attention has been paid to a large, vulnerable population of incarcerated people facing similar system-wide issues. This article examines some of the lessons learned in our work to transform care delivery by changing the culture of care in a restrictive, challenging system --prisons. These lessons are relevant considerations for nurse scientists working to transform healthcare systems.

The Pathway to Innovation

Our preliminary studies explored end-of-life care from the perspective of providers and care recipients in the context of care delivery systems in the free world. We identified key components of the culture of care manifest in the system of care delivery for patients and families in three distinct illness trajectories: heart failure; advanced cancers; and amyotrophic lateral sclerosis.1 These illnesses were targeted due the differences in course of illness and related life/death expectations. It became clear that the provider networks’ shared values and beliefs shaped the culture of care in a given delivery system, and that culture significantly influenced the patient/family experience.2 Despite the fact that the average life expectancy was about the same in each illness trajectory, the course toward and through end-of-life care was dramatically different for those receiving care in the three different delivery systems. 

In sum, culture mattered -- values and beliefs were implicitly and explicitly communicated by providers during routine interactions. Patients, families, and care providers integrated values into the perception of the illness (i.e., terminal v. life-limiting); course of treatment (i.e., iterative cycles of fighting the war v. working through decline while enhancing quality of life), and expectations of the future (i.e., anticipated v. sudden death). The culture of care also influenced the timing and acceptability of the provision of end-life care. 

Based on this work, the notion of re-shaping the culture of care as a strategy for transforming care delivery systems to enhance end-of-life care was hatched. We seized an opportunity to take an alternate route in our program of research and the social innovation was launched. We argued that the context of corrections care was the ideal setting for understanding strategies for re-shaping the culture of care to enhance end-of-life care. The prison system is complex and is fraught with strongly held values and beliefs. Perhaps more importantly, prisons are facing a demographic shift that is similar to the free world. The prison system was a unique setting in which to study culture change to enhance end-of-life care delivery.

The Problem: The Context of Prisons

Most people imagine a prison population comprised of young, strong men. The facts tell us that this image of prison is not reality. In 2015, approximately 19 percent of the 2.1 million inmates in the U.S. state or federal correctional system were age 50 years or older.3 Still, many think, 50 is not “old” and many 50-year-olds are very robust. In the prison setting, chronological age and biological age are often quite different. As early as the 1990’s Aday described accelerated aging of inmates and suggested the typical inmate in their 50s have a physical appearance of free citizens 10 years older.4 More recent research suggests that prisoners over the age of 50 years have a health profile of community-dwellers 12 years older and are significantly more likely to have one or more chronic health conditions than their community-dwelling coutnerparts.5, 6, 7 .Older adult inmates, typically categorized as those aged 50 years and older, are the fastest growing inmate cohort in the federal system.8  Between 1993-2013, the number of state prisoners age 55 years and older has increased 400 percent.9 

Three main factors contribute to the aging inmate population. A greater proportion of older inmates are serving longer sentences; for example, life without parole means life in prison until death.10, 9, 11 The number of older adults admitted to correctional facilities have increased.9 Restrictive policies of early release and parole lead to inmates aging and dying in prison.10, 11 If current trends continue by the year 2030, 33 percent of the U.S. prison population will be age 55 years or older.12 

The continued rise in the number of older adults living in the correctional system creates new challenges and financial strains for the criminal justice system. The Federal Bureau of Prisons alone spent $881 million dollars (19 percent of total budget) to incarcerate older inmates.8  In 2011, nationwide, state prisons health care spending totaled 7.7 billion dollars.13 Health care costs for older adults are three times higher than younger prisoners.10, 14  

It is important to realize that the criminal justice system is responsible for the care, custody, and control of inmates. That is, once incarcerated, inmates are entitled to receive health care at the expense of the prison system. Medicare, Medicaid, or private insurance does not reimburse the care of inmates. The increasing number of older adults in prison has placed new burdens on the system. In 2011-2012, 50 percent of the corrections population reported having at least one chronic condition.15 Chronic conditions are three times more prevalent in the corrections population compared with free-world population.14, 15 The correctional health care system is underprepared to provide cost-effective quality care for the growing older adult population.16  


Correctional systems must find way to provide high quality, cost effective care with limited resources. Beyond quality and cost considerations, understanding the culture and the unique challenges faced by correction personnel is critical. The corrections environment presents unique challenges to implementing best practice initiatives; specifically, maintaining custody and control while addressing care needs.17 This program of research focused on the stimulating a change in culture that would promote a change in care delivery in the prison setting.

In the first study, Participatory Action Research (PAR) approaches were used to understand the culture of care and transform the delivery of end-of-life care (EOL) in correctional settings.18 PAR is a methodological approach that promotes sustainable change through research-participant collaboration. In the first phase of the project, the team focused on understanding the context of corrections, specifically in six state correctional institutes (SCIs) in a Mid-Atlantic State.19  In the next phase of the project, the collaborative team of researchers and research partners from inside the prison system prioritized needs and developed intervention strategies. These approaches were compiled into the Toolkit for Enhancing EOL Care in Prison and piloted in six SCIs.18 

The success of the pilot demonstrated proof of concept; however, dissemination was limited due to the cumbersome format of the Toolkit and the influence of the collaborative partnership between researchers and insiders. The next phase of the project shifted towards the development and testing of media rich, computer-based learning modules for broad dissemination and subsequent evaluation of effectiveness in stimulating change to the care delivery system.

Lessons Learned

Transforming healthcare systems is a change in the culture of care, regardless of the setting or context of that system. Efforts to launch sustainable transformation must be strategic and thoughtful. The lessons learned through this program of research are not limited to prisons; rather, these lessons provide relevant considerations for nurse scientists working to transform healthcare systems in any setting.

Understand the System

Understanding the current care delivery system is essential for planning sustainable transformation. Systems are inherently complex. A stakeholder analysis is a useful tool in the planning phase to determine whose interests or workflow should be taken into account in the planned change. Identify the segments or sectors involved in the current care delivery system and the “players” in each segment of the targeted system. Consider influence and power in each segment to begin to understand how the system currently functions. 

These preliminary considerations can be invaluable in planning change. Powerful stakeholders can be influential change agents or significant barriers to change. Alliances may be established to groom champions who will foster sustained change. Baseline understanding builds your capacity to anticipate challenges or barriers and to proactively plan strategies. While you may think that you understand a system, the stakeholder analysis often reveals nuances that warrant your attention throughout the transformation. Time invested in understanding the system is well-spent and may smooth the process of transformation.

It’s All About Relationships

Our work has demonstrated the importance of creating and fostering relationships with key stakeholders in the system. Researchers or change agents are often viewed as disruptive outsiders. Building a strong network of collaborative partners promotes access to the system and sets the stage for developing a shared vision of desired outcomes. We found that involvement of key stakeholders during the conceptualization of the project was critical to crafting a feasible approach that fit the context of the care delivery system. Gaining the support of leadership was only the first step in relationship-building. 

Gaining access to the setting promotes entry; however, access alone is insufficient for understanding the culture of care. Insiders or those who dwell within a given culture hold values and beliefs that are often implicit, not reportable or easily identified. The transformation of care delivery systems requires an in-depth understanding of providers’ values and beliefs. Influential stakeholders who exercise formal or informal power may be identified. This understanding helps uncover potential facilitators and barriers to change.  

Credibility is established through relationship building. Consider the currency of the system. Academic degrees, professorial rank, and clinical credentials are not highly valued in all systems. In fact, these indicators of status may contribute to the insider-outsider divide. It is essential that preliminary interactions with the system targeted for transformation build open communications that manifest trust. Our team’s immersion in the world of corrections was carefully orchestrated to expose usual practices and attitudes. Throughout these interactions with insiders, the staff members inside the system were positioned as our mentors or guides. We asked questions freely to untangle the many acronyms or slang phrases that held unique meaning in this context. Without this baseline understanding, efforts to change this system would have been misguided and ineffective.

Transformation Takes Time and Leadership

Systems are inherently complex and stimulating a sustainable transformation in care delivery can take time. Most projects are based on a timeline of benchmarks of progress toward goals. The timeline sets expectations of progress, but rarely does a project unfold according to plan. Our team learned to anticipate delays and re-organize our workflow to achieve our goals. For example, approval for the involvement of human subjects is one area that can upset the timeline early in the project. It is not uncommon for participating institutions to require review (if not approval) by an internal review board after the formal review/approval of the project is obtained. This process takes time; in some cases, the internal committee may meet quarterly or cancel meetings unexpectedly. The challenge for the project team is to avoid feeling “dead in the water” during such delays. Our team often used early delay-time to organize and summarize literature for future publications. Later, data cleaning and analysis peaked during delays. The trick is to avoid losing momentum during delays.

As the transformation is planned and implemented, the best estimates of time sometime prove inadequate. At the same time, funded projects have a definite start and end point. The capability to adapt to circumstances and meet objectives is a skill that is learned over time. Experienced, high functioning teams develop the capacity to anticipate challenges or delays and to respond nimbly. Less experienced teams may tend toward frustration or despair when challenges emerge. These situations require leadership skills to guide the project team through collaborative problem-solving to adapt the plan and meet major objectives. Leadership skills are often tested in transformation projects -- this is not a “one-man” show, leaders must know how to effectively engage a team. 

Build Awareness of the Need for Change

Many times, insiders are unaware or unconcerned with the proposed transformation. Insiders often focus on workflow patterns that become accepted routines. Transforming patterns of care is more effective when those involved understand why upsetting their usual routine is desirable. On first blush, one may think that a one-time educational program is adequate to set the stage for change. Rarely is this true.

It is critical to consider options that reach identified stakeholders to build an awareness of the need for system change. In our work in the prisons, we realized how multiple segments of the system influenced care delivery. Our work in end-of-life care was not limited to medical personnel. Security personnel controlled movement of inmates and influenced patterns of care. Counselors and clergy helped inmates interpret the illness trajectory. Volunteers or inmate-workers assisted with care and communicated with other inmates. Administrators could offer special dispensation for cases that were brought to their attention. Building an awareness of need emerged as a significant factor in stimulating change and a one-time in-service clearly was not the answer. Think carefully to craft your message and disseminate that message strategically to reach all stakeholders involved in the system change.

Sustainability Starts in the Conceptualization Phase

Too often a project leader assumes that all parties will see the wisdom of a planned change and will sustain the desired change over time. Yet, most professionals can cite a “flash in the pan” approach to change. That is, change agents come, they implement the change, and over time, the system reverts to business as usual. Sustainability of change requires careful consideration during project planning and throughout implementation. For example, the initial stakeholder analysis provides some insight regarding potential champions within the system who may monitor and sustain the desired change. Integrating stakeholders into the implementation phase helps to infuse the desired change into current practices most effectively. Grooming champions to promote sustained change is strategic. For example, consider the value of recognition of efforts. We learned that co-authorship of professional publications held little value for most of our partners. Institutional and peer recognition (e.g., newsletter stories) were valued more highly. Knowing these nuances can be very helpful in promoting sustained change.

Sharing results of the system change with all stakeholders builds appreciation of how the change has improved targeted outcomes or quality. We have learned that these communications are best tailored to each stakeholder segment in order to build continued support for the system change. We considered the “what’s in it for me?” question to ensure that our approaches and ongoing communications reflected values of importance to each segment of the organization. 

Final Thoughts

Nurses have been challenged to transform systems in order to improve quality outcomes. We have been called to step out of our comfort zone to take on new and innovative ways of thinking. This disruption is challenging, uncomfortable. Yet we have learned that following the pathway to innovation can be a very productive and meaningful experience. Expect to maximize your leadership skills as you face new challenges. Remember that transformation of a system often yields transformation of the leader. 

Works Cited

1 Penrod, Janice, Judith E. Hupcey, Brenda L. Baney, and Susan J. Loeb. "End-of-life caregiving trajectories." Clinical Nursing Research 20, no. 1 (2011): 7-24.

2 Penrod, Janice, Brenda Baney, Susan J. Loeb, Gwen McGhan, and Peggy Z. Shipley. "The influence of the culture of care on informal caregivers’ experiences." Advances in Nursing Science 35, no. 1 (2012): 64.

3 Carson, E. Ann, and Elizabeth Anderson. “Prisoners in 2015.” Bureau of Justice Statistics, December 2016. Link

4 Aday, Ronald, and Azrini Wahidin. "Older Prisoners’ Experiences of Death, Dying and Grief Behind Bars." The Howard Journal of Crime and Justice 55, no. 3 (2016): 312-327.

5 Bolano, Marielle, Cyrus Ahalt, Christine Ritchie, Irena Stijacic-Cenzer, and Brie Williams. "Detained and Distressed: Persistent Distressing Symptoms in a Population of Older Jail Inmates." Journal of the American Geriatrics Society 64, no. 11 (2016): 2349-2355.

6 Counsell, Steven R., Christopher M. Callahan, Daniel O. Clark, Wanzhu Tu, Amna B. Buttar, Timothy E. Stump, and Gretchen D. Ricketts. "Geriatric care management for low-income seniors: a randomized controlled trial." Journal of the American Medical Association 298, no. 22 (2007): 2623-2633.

7 Williams, Brie A., James S. Goodwin, Jacques Baillargeon, Cyrus Ahalt, and Louise C. Walter. "Addressing the aging crisis in US criminal justice health care." Journal of the American Geriatrics Society 60, no. 6 (2012): 1150-1156.

8 U.S Department of Justice. “The Impact of an Aging Inmate Population on the Federal Bureau of Prisons” last modified February 2016. Link

9 Carson, E. Ann, and William J. Sabol. Aging of the State Prison Population, 1993-2013. US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, 2016. 

10 Aday, Ron H. Aging prisoners: Crisis in American corrections. Penn State Press, 2003.

11 Kerbs, John J., and Jennifer M. Jolley. "A commentary on age segregation for older prisoners: Philosophical and pragmatic considerations for correctional systems." Criminal Justice Review 34, no. 1 (2009): 119-139. 

12 Williams, Brie A., Karla Lindquist, Rebecca L. Sudore, Heidi M. Strupp, Donna J. Willmott, and Louise C. Walter. "Being old and doing time: Functional impairment and adverse experiences of geriatric female prisoners." Journal of the American Geriatrics Society 54, no. 4 (2006): 702-707. 

13 The Pew Charitable Trust. "State prison health care spending: An examination."  Retrieved November 13, 2014.

14 Binswanger, Ingrid A., Patrick M. Krueger, and John F. Steiner. "Prevalence of chronic medical conditions among jail and prison inmates in the United States compared with the general population." Journal of Epidemiology & Community Health (2009): jech-2009.

15 Maruschak, Laura M., Marcus Berzofsky, and Jennifer Unangst. Medical problems of state and federal prisoners and jail inmates, 2011-12. Washington, DC: US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, 2015. 

16 Williams, Brie A., Jacques G. Baillargeon, Karla Lindquist, Louise C. Walter, Kenneth E. Covinsky, Heather E. Whitson, and Michael A. Steinman. "Medication prescribing practices for older prisoners in the Texas prison system." American Journal of Public Health 100, no. 4 (2010): 756-761.

17 Penrod, Janice, Susan J. Loeb, and Carol A. Smith. "Administrators' Perspectives on Changing Practice in End‐of‐Life Care in a State Prison System." Public Health Nursing 31, no. 2 (2014): 99-108.

18 Penrod, Janice, Susan J. Loeb, Robert A. Ladonne, and Lea M. Martin. "Empowering Change Agents in Hierarchical Organizations: Participatory Action Research in Prisons." Research in Nursing & Health 39, no. 3 (2016): 142-153.

19 Koch, Tina, and Debbie Kralik. Participatory Action Research in Health Care. John Wiley & Sons, 2009.

Author Bios:  

Dr. Janice Penrod is a nurse-researcher whose program of research evolved from studying end-of-life care to examining the transformation of end-of-life care delivery in the prison settings. In addition, Dr. Penrod has expertise in community engaged research, leadership, and building coalitions to promote system change.

Dr. Kitt-Lewis is nurse-researcher collaborating on the continued development and testing of media rich, computer-based learning modules for broad dissemination in corrections settings. In addition, Dr. Kitt-Lewis studies linguistic patterns to discern caregivers’ ascribed meaning in varied end-of-life caregiving situations.


The struggle is real. Nurses have a ton of ideas that can help shape the future of direct and indirect patient care. I sit with my colleagues each shift and conceptualize how life might be better if we did this one thing. We hold discussions on how a specific product or device might be make it easier to perform patient care.

The vast majority of those developing new technology are physicians, medical students, scientists, and those with more of an ease and programs tailored specifically to invite them to develop new innovations. Nursing is just starting to develop a culture within our fabric to invite new ideas and innovations to produce more fruitful outcomes. Take, for example, the Cleveland Clinic Nursing Innovation Summit, Kelly Hancock, DNP, RN, NE-BC, is absolutely correct when she says “innovation is all around us.”3

My ascent into innovation and development was a self-projection via a Boolean search on my organization’s intranet by searching “invention.” I always knew I wanted to be an inventor, among other things, since the time I was five and was conceptualizing how wait staff might have a better time serving the public if their trays were double sided. At that time, I also had zero concept of how gravitational pull worked.

I wrote an email at 3 am and a few days later received a response inviting me to a meeting. I threw my idea on the table of a simple, more ergonomically designed neck brace. The idea spawned into three years of navigating through people, technology, meetings, and ultimately a provisional patent. Throughout this process, a lot of self-growth happened, like my learning that innovation was so much more than my idea and that collaboration was the best thing that could carry a new idea to fruition.

As an ICU nurse, I rely on so many others to help do many things. Help with turning patients, help providing life-saving treatments, and even help directing patients towards new health goals so that I may, respectfully (and hopefully), never see them again. Without collaboration, I wouldn’t have the energy or time to do all of my tasks during my shift and moreover, without collaboration -- new ideas would not happen.

Collaboration: A New Challenge

A few months ago, a new challenge presented itself, to develop a collaborative innovation to help a specific patient population. My friend and colleague, Dr. Sarita Said and I dreamed up an app that could provide free or low-cost services to help prevent cost burdens on stroke patients.

With the concept of our new idea, we took a look into population health. Population health is a rapidly growing field of health care with its importance of proactive application of strategies and interventions, finding opportune and cost-effective solutions to complex health-based problems and producing an asset that can be marketed and shared with healthcare financing organizations. Population health focuses on the health outcomes of a group of individuals, including the distribution of such outcomes within the group.1

In the coming years, more will be required to develop novel and unique tools to help assist patients. This complex and comprehensive need will require the use of collaboration not only within health systems and large focus areas but also collaboration between health organizations. Nurses are at the forefront of those efforts.

Forming partnerships with our resident-physicians and attending physicians is of singular importance to help foster unique and creative solutions. The ANA Nursing Scope and Standards of Practice define interprofessional collaboration as “Integrated enactment of knowledge, skills, and values and attitudes that define working together across the professions, with other health care workers, and with patients, along with families and communities, as appropriate to improve health outcomes.”2

According to the Robert Wood Johnson Foundation, pillars of interprofessional collaboration include: putting patients first; a commitment from leadership to make interprofessional collaboration an organizational priority; a level playing field that values contributions from all practitioners; effective team communication.  Researchers from the University of Tennessee found that innovation and collaboration are not mutually exclusive. Innovation happens through collaboration. As more healthcare organizations contribute to new ideas, innovation will be the new economy and collaboration will be the new currency. Companies can create value from the business process, marketing, and governance through innovation and collaboration. 4

Collaboration also doesn’t have to be a person to person transaction. At companies like Pricewaterhouse Coopers, utilization of humans and machines to collaborate on projects has produced innovative solutions that are part of a virtual organization. Meetings for these companies happen in a virtual setting with global clients and the utilization of new social tools enable the meetings to become more productive as opposed to spending hours with phone and email exchanges.6


Nurses can utilize collaborative approaches to successfully do the following: form associations and professional affiliations between common and uncommon networks; speed up the work process of patient care, come up with new ideas and increase the backend work for things like comprehensive literature reviews; provide new exciting energy that can produce new avenues of thought; and increase the speed at which the group reaches the implementation phase.

As Dr. Said and I move towards development of our app, we will utilize a lot of resources through collaboration including different academic medical centers, grants, process mapping and lean tools, virtual meetings, and many other social apps. The future of innovation is bright for nursing and the constant is collaboration. 

Works Cited







Author Bio

Nicole E. Sunderland, MSN, RN, SCRN, CCRN is a professional staff nurse at Penn State Health and a Penn State Health Systems Science Academy Scholar. Her work on the app mentioned in this article was selected by the PA Action Coalition through a video contest to enter the Nursing Innovation Corps, a year-long mentorship and networking fellowship for nurse-led, interprofessional teams of innovators.

 Executive Summary

There exists an emotional disconnect between managing an emergency situation in practice versus managing an emergency in real-life. The Center for Resuscitation Science (CRS) at the University of Pennsylvania is exploring ways in which Virtual Reality (VR) can enhance current emergency trainings for Sudden Cardiac Arrest (SCA), while also increasing the dissemination potential of cardiopulmonary resuscitation to communities that are at increased risk of SCA. VR is a computer-programed, 3D environment where users interact with immersive realities, allowing learners to experience, in real-time, their decisions and actions in high-stress, seemingly realistic environments. The CRS is focusing their efforts on adapting traditional VR technologies for mobile devices, allowing greater dissemination of these technologies for social good. The creation of an effective VR SCA mobile training system has the potential to improve both the number of people trained in CPR and the accessibility of trainings. 


Standard cardiopulmonary resuscitation (CPR) classroom trainings have been utilized for more than 50 years, yet in that time survival from cardiac arrest has only incrementally increased.1 A Sudden Cardiac Arrest (SCA) is the abrupt cessation of cardiac function and blood flow in the out-of hospital setting requiring CPR. In the U.S., greater than 350,000 people suffer from an SCA annually, and survival is low, just 12 percent.2-4 Bystander CPR could double to even triple survival rates, however, only 18 percent of the lay public are trained in CPR.5-7 Consequently, most victims of an SCA, roughly 60 percent, often do not receive this life-saving intervention.8-9 Further, large disparities exist within SCA care. Studies have shown that the rate of bystander CPR nationally is significantly lower in low-socioeconomic status (SES) communities, even though the incidence of SCA is two times higher in these communities.10-14 A study published in the New England Journal of Medicine examining 29 U.S. sites found that low-income Blacks were less likely to receive bystander CPR when compared to their high-income White counterparts.11 This study highlighted the increased risk SCA poses to low-income communities. 

One potential reason for the low bystander CPR rates, and the existing disparities in SCA response, can be linked to the current CPR training paradigm. Lay bystander CPR trainings are costly to participants, limited in their locations, and long in duration, thus inhibiting widespread participation. Additionally, lay bystanders are trained in a classroom setting where they watch a training video and then briefly practice CPR skills on a plastic manikin. They complete a CPR skills test and a written exam to determine if their knowledge of resuscitation skills meets the current guideline standards. This type of classroom training does not simulate the stress of a real SCA event or enhance knowledge translation.15-17 Underscoring these issues, the American Heart Association and the National Academy of Medicine both acknowledge that efforts to improve outcomes from cardiac arrest in the U.S. are falling short, and have emphasized the need for innovation, and the integration of technology, into bystander response training.8,18-19 One such innovation that has the potential to better prepare individuals for emergency situations and, if further developed, allow for widespread applicability, is Virtual Reality (VR). 

VR is a computer-programmed, environment where users engage with multi-sensory, immersive 3D realities using VR headsets and haptic sensors.20 These VR systems allow learners to experience, in real-time, their decisions and actions in a seemingly real and high-stress environment. Studies have found that subjects who learned on VR had an increase in learning effectiveness, along with better recall, than those taught with traditional methods. Additionally, clinical trials using virtual reality exposure therapy (VRET) found that patients who underwent VRET had significantly better behavioral assessments post intervention. Such research shows that VR immersion can significantly change behavior in real-life situations. Many healthcare domains that manage high-acuity illnesses and injuries, such as neurosurgery, general surgery, and psychiatry are already using VR technologies for a range of training applications.9, 21-25 An inherent power of VR for lay bystander training is that it can simulate high-stress, rare-occurring events in a dynamic, yet safe environment. This allows trainees to not just be prepared with the knowledge and skills to save a life, but to be emotionally and mentally prepared to respond if needed.

Our team at the Center for Resuscitation Science (CRS) at the University of Pennsylvania is exploring ways in which VR can enhance current CPR trainings for SCA. Supported by grant funding from the Medtronic Foundation and the Laerdal Foundation, the CRS created and studied a three-minute long VR SCA system to determine the effectiveness of using this technology to improve bystander response.26-27 Subjects were equipped with traditional VR goggles, integrated with a CPR feedback manikin, and “transported” to an urban city street. In the simulation, an avatar collapsed, and subjects had to decide how to respond. The subjects could communicate with other avatars, and if they chose to perform CPR, a real-life manikin was placed where the avatar fell to provide tactile feedback. The team held a debriefing with subjects to discuss how they could have improved their response had the simulation been a “real” SCA event. The CRS feels VR SCA trainings hold great promise in improving the quality of bystander response; however, they recognize that traditional VR technologies, which are cumbersome and costly, must be developed further to allow for more widespread applicability.

Therefore, the CRS is currently focusing its efforts on adapting the VR SCA technology into a mobile application, which will allow for greater dissemination of trainings for social good. As over three-quarters of Americans, including more than half of low-income individuals, own smartphones, mobile training applications serve as an ideal platform for cost-effective, widespread community CPR trainings. Mobile VR applications work in conjunction with low cost, standalone, VR “devices, ” which are currently available from companies such as Google for around $15. The devices combine with a mobile phone to create VR immersion, allowing a higher dissemination training modality with the increased realism of VR. The CRS recently created a mobile VR SCA training application to be used with the low-cost cardboard VR devices; this work was supported by a grant from the Astrazeneca Foundation to begin a community-wide campaign to disseminate the free VR SCA training application in low-SES communities throughout Philadelphia. The creation of an effective mobile VR SCA training application could greatly improve the quality of bystander CPR and increase the percentage of the lay public prepared to respond to an SCA. 

VR technologies have the potential to change the paradigm of CPR training and could have broad applications in preparing lay bystanders for rare-occurring, time-sensitive, emergencies. Further, VR mobile applications are able to offer immediate, widespread access to immersive, multisensory emergency trainings. If these types of trainings prove to be more effective than current classroom trainings, it could revolutionize emergency response training models and increase survival rates. Such a potential for social good warrants continued exploration and development of these technologies. 

Author bios

Ariel Karwat holds a B.S in Psychobiology from the University of California, Los Angeles and is currently an accelerated BSN/MSN candidate at the University of Pennsylvania’s School of Nursing. Prior to attending nursing school, she worked as a Clinical Research Coordinator in Breast Oncology for the University of California, San Francisco. This past year she joined the team at the University of Pennsylvania’s Center for Resuscitation Science to explore more innovative approaches to healthcare.

Marion Leary is the Director of Innovation Research for the Center for Resuscitation Science at the University of Pennsylvania and the Innovation Specialist at Penn’s School of Nursing. In addition she is an Instructor in the Penn Master of Public Health program. Ms. Leary has focused her research and education on cardiac arrest with the current goal of developing innovative strategies to improve CPR and resuscitation training. Ms. Leary currently serves on the Science Subcommittee of the American Heart Association (AHA)’s Emergency Cardiovascular Care Committee and was a member of the AHA’s Education Innovation Summit. Ms. Leary is a contributor to the Huffington Post, and is the founder of the ImmERge Labs, LLC, focusing on using mixed reality platforms to reimagine how the world prepares for emergencies. Ms. Leary was recently named Philadelphia’s Geek of the Year for 2017. 

Conflict of Interest Statement

Marion Leary has received research support from the Medtronic Foundation, Laerdal Foundation, the American Heart Association and the Astrazeneca Foundation. Ms. Leary has received in-kind support from Laerdal Medical. Ms. Leary has ownership in ImmERge Labs, LLC a University of Pennsylvania UPstart company.

End Notes

1 Mark L. DeBard. “The history of cardiopulmonary resuscitation.” Annals of Emergency Medicine. 9, no 5 (1980): 273-5

2 Akshay Bagai, et al. “Temporal differences in out-of-hospital cardiac arrest incidence and survival.” Circulation, 128, no. 24 (2013): 2595-2602

3 Ian Stiell, et al. “Advanced Cardiac Life Support in Out-of-Hospital Cardiac Arrest.” New England Journal of Medicine, 351, no. 7 (2004): 647-656

4 Jasenka Demirovic “Cardiopulmonary Resuscitation Programs Revisited: Results of a Community Study Among Older African Americans.” The American Journal of Geriatric Cardiology 14, no. 4 (2004): 182-187

5 Alan S. Go, et al. “Executive summary: heart disease and stroke statistics—2014 update: a report from the American Heart Association.” Circulation, 129, no 3 (2014): 399-410

6 Audrey Blewer, et al. “Cardiopulmonary Resuscitation Training Disparities in the United States.” Journal of the American Heart Association, 6, no. 5 (2017)

7 Audrey Blewer, et al. “The majority of laypersons trained in CPR do not maintain current certification training.” Circulation. (2016): 134:A15787

8 Peter A. Meaney, et al. “Cardiopulmonary resuscitation quality: improving cardiac resuscitation outcomes both inside and outside the hospital a consensus statement from the American Heart Association.” Circulation, 128, no. 4 (2013): 417-435

9 Pierre Pasquier, et al. “A Serious Game for Massive Training and Assessment of French Soldiers Involved in Forward Combat Casualty Care (3D-SC1): Development and Deployment.” JMIR serious games, 4, no. 1 (2016): e5

10 Comilla Sasson, et al. “Increasing cardiopulmonary resuscitation provision in communities with low bystander cardiopulmonary resuscitation rates: a science advisory from the American Heart Association for healthcare providers, policymakers, public health departments, and community leaders.” Circulation 127, no. 12 (2013): 1342-1350

11 Comilla Sasson, et al. "Association of neighborhood characteristics with bystander-initiated CPR." New England Journal of Medicine 367, no. 17 (2012): 1607-615

12 Jasenka Demirovic “Cardiopulmonary Resuscitation Programs Revisited: Results of a Community Study Among Older African Americans.” The American Journal of Geriatric Cardiology 14, no. 4 (2004): 182-187

13 Wallace, et al, “Band Racial Differences in Prehospital Care of Out-of-Hospital Cardiac Paper” (presentation, Society of Academic Emergency Medicine Annual Meeting, Chicago, IL, 2012

14 Thomas Rea, et al. “Increasing use of cardiopulmonary resuscitation during out of-hospital ventricular fibrillation arrest: survival implications of guideline changes.” Circulation, 114, no. 25 (2006): 2760-2765

15 Lauren W. Conlon, et al. “Impact of levels of simulation fidelity on training of interns in ACLS.” Hospital Practice, 42, no. 4 (1995): 135-141

16 Lindsey E. Davis, et al. “High-Fidelity Simulation for Advanced Cardiac Life Support Training.” American Journal of Pharmaceutical Education, 77, no. 3 (2013): 59

17 Tara M. Serwetnyk, et al. “Comparison of Online and Traditional Basic Life Support Renewal Training Methods for Registered Professional Nurses.” Journal for nurses in professional development, 31, no. 6 (2015): E1-10

18 John S. Rumsfeld, et al. "Use of Mobile Devices, Social Media, and Crowdsourcing as Digital Strategies to Improve Emergency Cardiovascular Care." Circulation 134, no. 8 (2016)

19 Robert. Graham, Margaret A. McCoy, and Andrea M. Schultz. "Strategies to Improve Cardiac Arrest Survival." National Academies Press, 2015. 

20 Gilson Giraldi, Rodrigo Silva, and Juavane deOliveira. “Introduction to Virtual Reality.” LNCC-National Laboratory for Scientific Visualization and Virtual Reality Laboratory. Link

21 Alaraj A, et al. “Virtual reality cerebral aneurysm clipping simulation with real time haptic feedback.” Neurosurgery, 11, no 2. (2015): 52

22 Albert Rizzo, et al. “Virtual reality goes to war: a brief review of the future of military behavioral healthcare.” Journal of Clinical Psychology in Medical Settings, 18, no. 2 (2011): 176-187

23 Anthony Gallagher, et al. “Virtual reality simulation for the operating room: proficiency-based training as a paradigm shift in surgical skills training.” Annals of Surgery, 241, no. 2 (2005): 364-372

24 Felix Nickel, et al. “Virtual reality training versus blended learning of laparoscopic cholecystectomy: a randomized controlled trial with laparoscopic novices.” Medicine, 94, no. 20 (2015)

25 Nexhmedin Morina, et al. “Can virtual reality exposure therapy gains be generalized to real-life? A meta-analysis of studies applying behavioral assessments.” Behavior Research and Therapy, 74 (2015): 18-24

26 Marion Leary, et al. “Using Immersive Virtual Reality to Observe Differences in Lay Provider Response to an Unannounced Simulated Sudden Cardiac Arrest Based on Demographics.” Circulation. (2017);136:A14891

27 Alfredo Almodovar et al. “Examining Lay Provider Response to an Unannounced Simulated Sudden Cardiac Arrest Using an Immersive Virtual Reality System.” Circulation. (2017);136:A14871



State, federal, and commercial payer policies have been enacted to reward organizations who meet the Triple Aim by providing better care, better health, and lower costs. Healthcare organizations have adopted technology with aim to advance the delivery of care. Some of the largest costs incurred in healthcare are associated with the delivery of care in intensive care units (ICUs). Telemedicine intensive care (teleICU) has emerged as a technological advance to improve clinical outcomes by reducing variation and clinical complication in ICU populations. Healthcare organizations are strategically achieving scalable and sustainable teleICU programs with innovative approaches to healthcare delivery by strengthening clinician relationships across telemedicine platforms to ensure efficient and effective resource utilization that is essential in a value-based care environment.


As healthcare organizations move from fee-for-service reimbursement models to value-based care models, expeditiously, clinicians are feeling the downstream effects of the realization that the healthcare sector in the United States is changing. Clinicians who provide hospital services, and every point of clinical service along the care continuum thereafter, are mindful of emerging themes -- improving the health of populations, enhancing the patient experience of care, and reducing the per capita cost of healthcare -- these and other transformational changes are essential to ensuring healthcare organizations attain fiscal sustainability in the 21st century. 

To meet the demands of a growing, medically-complex, elderly population in the United States, a challenge that is compounded by an anticipated shortage of physicians that coincides with an anticipated shortage of registered nurses, hospital organizations are collaborating to leverage resources and implement clinical support strategies. Care models have evolved to endorse advanced practice registered nurses and other clinicians practice to the fullest extent of their education, training, and licensure. Telemedicine intensive care (teleICU) has emerged as a technological advance to improve clinical outcomes in critical care populations. TeleICU services are well-positioned to meet broad demands for intensivist physician coverage, expert critical care nurse reconnaissance, compliance with best practice protocols, and thereby uphold efficient utilization of ICU resources within a healthcare organization.  

In a centralized operation room (COR), distant from the bedside operations, board certified intensivist physicians and critical care registered nurses (CCRNs) remotely monitor clinical activities in real time using audio, video, and electronic means. Cameras and monitors are installed at the bedside in the ICU rooms and teleICU software is interfaced with patient’s electronic medical record (EMR). The software enhances teleICU efficiencies for real time monitoring of physiological, laboratory, pharmaceutical, and radiological data. The objective is relentless surveillance to identify and avert impending or worsening conditions that may benefit from earlier intervention. From an organized and focused office setting (See Figure 1), the teleICU team can detect trends that may otherwise be missed by bedside clinicians who work in a challenging environment often fraught with high-priority competing demands. TeleICU services have shown to be effective in reducing ICU mortality, reducing hospital length of stay, and lowering rates of preventable complications by reinforcing timely response to physiological trends and adherence to critical care best practice protocols. 1, 2 

From a technology standpoint, there are three information systems (IS) components necessary. First, teleICU clinicians require full access to the clinical information at the bedside, which includes the EMR, the physiological waveforms, and any handoff information that may be communicated outside the EMR. Second, teleICU software is essential in conducting real time enterprise-wide surveillance by organizing the clinical details so that intellectual processing can occur in rapid logical sequence. Two vendors predominately hold the market for teleICU software, the Philips VISICU technology and the InTouch Health Remote Presence technology. However, in a time of high demand for systems integration, EMR vendors such as Epic Systems are gaining market share by offering an integrated teleICU module solution. Third, a connection network is essential for the remote clinicians to communicate with the bedside clinicians. While older systems provide one-way camera functionality where remote clinicians can be heard but not seen, more robust video platforms have become the clinical standard with two-way camera functionality, essentially a bidirectional audio-video experience, where colleagues see each other when they are communicating. Two-way camera functionality is far superior in building the interactive, collaborative relationships that are necessary for teleICU programs to succeed. 

Successful teleICU programs capture robust returns on investment (ROI) by focusing on measures to reduce ICU mortality and ICU length of stay, increase compliance with best practice protocols, decrease time on the ventilator, decrease rate of ICU complications, and synchronize ICU bed management to include triaging patients in-and-out, thereby augmenting throughput and tendering an increased capacity for admissions, ultimately driving revenue3, 4, 5. Despite the lack of a direct reimbursement model, there are significant indirect financial benefits of deploying teleICU services as a cost avoidance, cost savings approach. Fifer et al. demonstrated that the capital investment and first year operating cost of teleICU was recoverable in approximately one year6. Franzini et al. confirmed that teleICU services were cost-effective in caring for the sickest of patients7. Deslich & Coustasse showed the implementation of teleICU to be more beneficial than costly and denoted the strategic advantage to providing telemedicine services8. Kahn & Rubenfeld reflected using teleICU to sustain best practice compliance9.

The University of Pennsylvania Health System (UPHS) commenced PENN E-LERT® teleICU program in 2004 as one of the first programs in the nation. By 2017, UPHS completed a multimillion dollar expansion of corporate IS infrastructure to support teleICU services enterprise-wide. Today, collectively, PENN E-LERT remotely monitors 245 ICU beds within the Hospital of the University of Pennsylvania, Penn Presbyterian Medical Center, Pennsylvania Hospital, and Good Shepherd Penn Partners. As a world-class academic university health system, a major differentiator for PENN E-LERT is the mission, which is uniquely founded on guiding principles of excellence in quality, and merit in quality improvement, thereby supporting safer and higher-value outcomes that benefit patients, families, clinicians, and payers. Beyond the active and engaged remote monitoring of physiological trends, PENN E-LERT team provides real time clinical decision-making support. Some bedside clinicians utilize PENN E-LERT more than others but the teleICU service is available 24/7/365 for all clinicians. For example, advanced practice providers (APPs) such as a nurse practitioners (NPs) or a physician assistants (PAs), interns, residents, and/or physicians in fellowship can conduct an “on demand” consult with the teleICU intensivist physician overnight. New to practice registered nurses or experienced registered nurses can conduct an “on demand” consult with the teleICU nurse.  In essence, at the push of an e-Lert button from the ICU room, bedside teams can connect immediately via telemedicine with the PENN E-LERT team who is well versed in the finer intricacies of critical care operations at UPHS. 

You may ask, what are some examples of real time clinical decision-making support? An exemplar for the PENN E-LERT intensivist physician may be evaluating an admission that arrives overnight, answering a clinical question during an emergency, consulting on a complicated critically ill case, reviewing a radiology image, overseeing a procedure, collaborating on an end-of-life discussion, or appraising a newly published best practice research article. From the PENN E-LERT nursing perspective, real time clinical decision-making support may be guiding the titration of an infusion drug, interpreting, evaluating, or advocating a physician order, troubleshooting a crucial piece of equipment, discerning a waveform, consulting alarm management, responding to a request to keep an extra set of eyes on a restless patient, or answering to an emergency when bedside resources are busy with another emergency on the unit. The PENN E-LERT team effectively and efficiently supports the healthcare system’s essential critical care operations, they are an added layer of clinical support who uphold Penn Medicine’s commitment to excellence. 

The second major differentiator for UPHS is that PENN E-LERT clinicians are UPHS employees who are centrally located on campus in Philadelphia. Many of the PENN E-LERT intensivist physicians are the medical directors of the ICUs in the health system, which helps to drive the collaborative, collegial, cohesive relationships between the teams. As well, many of the PENN E-LERT nursing team, who are CCRN prepared and have an average 15 plus years’ critical care experience, have transferred to teleICU after a long-standing ICU career in the health system. By contrast, there are ICUs in the nation who receive teleICU services from programs that are located out-of-state, or even out-of-country, which adds an additional challenge -- that is, how to ensure there is systematic integration of the teleICU operations into the broader quality initiatives of the enterprise wide ICU operations.

In summary, healthcare organizations across the nation are contending with intensified scrutiny. State, federal, and commercial payer policies have been enacted to reward organizations who provide better care, better health, and lower costs. Some of the largest costs incurred in healthcare are associated with ICU care delivery. Healthcare organizations have adopted technology with aim to advance the delivery of care in ICUs. TeleICU programs have acclaimed the opportunity with aim to reduce variation and clinical complication. While there is mounting support for teleICU services as an ICU standard of care, there is work that remains to discern the full advantages and potential consequences of services. Regardless, it is clear that critical care medicine is operationally high stakes and an ICU culture who embraces the technical and human capital available will successfully leverage resources to attain superior outcomes. Healthcare organizations are strategically achieving scalable and sustainable teleICU programs with innovative approaches to healthcare delivery by strengthening relationships across telemedicine platforms to ensure efficient and effective resource utilization that is essential in a value-based care environment. 

Critical care registered nurse (CCRN) reconnaissance at PENN E-LERT® Telemedicine Intensive Care Unit,
a division of Penn Medicine Center for Connected Care. 

Photo Credit: Penn Medicine Department of Marketing Communications

Works Cited

1 Lilly, Craig M., Shawn Cody, Huifang Zhao, Karen Landry, Stephen P. Baker, John McIlwaine, M. Willis Chandler, and Richard S. Irwin. "Hospital mortality, length of stay, and preventable complications among critically ill patients before and after tele-ICU reengineering of critical care processes." Jama 305, no. 21 (2011): 2175-2183. 

2 Lilly, Craig M., John M. McLaughlin, Huifang Zhao, Stephen P. Baker, Shawn Cody, and Richard S. Irwin. "A multicenter study of ICU telemedicine reengineering of adult critical care." CHEST Journal 145, no. 3 (2014): 500-507. 

3 Rogove, Herb. "How to develop a tele-ICU model?." Critical care nursing quarterly 35, no. 4 (2012): 357-363.

4 Kruklitis, Robert J., Joseph A. Tracy, and Matthew M. McCambridge. "Clinical and financial considerations for implementing an ICU telemedicine program." Chest Journal 145, no. 6 (2014): 1392-1396. 

5 Lilly, Craig M., Christine Motzkus, Teresa Rincon, Shawn E. Cody, Karen Landry, and Richard S. Irwin. "ICU Telemedicine Program Financial Outcomes." CHEST Journal 151, no. 2 (2017): 286-297.

6 Fifer, Sheila. Critical care, critical choices: the case for Tele-ICUs in intensive care. New England Healthcare Institute; Massachusetts Technology Collaborative, 2010. 

7 Franzini, Luisa, Kavita R. Sail, Eric J. Thomas, and Laura Wueste. "Costs and cost-effectiveness of a telemedicine intensive care unit program in 6 intensive care units in a large healthcare system." Journal of critical care 26, no. 3 (2011): 329-e1. 

8 Deslich, Stacie, and Alberto Coustasse. "Expanding technology in the ICU: the case for the utilization of telemedicine." Telemedicine and e-Health 20, no. 5 (2014): 485-492. 

9 Kahn, Jeremy M., and Gordon D. Rubenfeld. "The myth of the workforce crisis. Why the United States does not need more intensivist physicians." American journal of respiratory and critical care medicine 191, no. 2 (2015): 128-134.

Author bio

Ann Marie Huffenberger, DBA, MBA, RN, NEA-BC 

As Director of the Penn Center for Connected Care, and principal advisor to the senior executive team, Ann’s a visionary leader who has tactically instituted telemedicine operations to support patients across the care continuum at Penn Medicine. She oversees business development to ensure financial integrity and superior clinical outcomes, and holds multi-program, multi-entity, and multi-state accountability. As chief implementer in operationalizing one of the largest connected health centers in the nation, Ann’s an expert in deployment of technologies, processes, and actions to advance strategic initiatives and promote prosperities in a value-based care environment. Ann’s passion for clinical excellence is the driving force in fostering her dynamic and efficient workforce who embraces the changes necessary in achieving the Quadruple Aim. Ann’s presented nationally on connected health operations and innovative change management, she’s received a range of awards and honors, and has contributed to many academic committees. Moreover, she’s a peer-reviewed published author. Holding a bachelor’s degree in nursing, a master’s degree in business administration, and a doctorate in business administration, Ann is prepared to lead the organizational, transformational changes necessary in achieving healthcare sustainability in the 21st century. 

Chronic homelessness is a major public health issue that decreases life expectancy by approximately 30 years (Vázquez et al. 2005, 35-56). This decrease is due, in part, to inadequate access and use of preventative health services and a five-fold increase in reliance on emergency medical services over housed individuals (Aspinall, 2014). Our organization, Up and Running Healthcare Solutions, partnered with the Bethesda project, a Philadelphia-based nonprofit homeless care provider, to implement an innovative solution to address this social issue. The Bethesda Project actively houses 2,000 chronically homeless individuals in Philadelphia yearly; 60 percent of the residents served have mental illnesses identified by staff, 65 percent have serious medical conditions, and 45 percent have a history of addiction-related factors that increase their risk for poor health outcomes. The national and local statistics of homelessness are alarming and we sought to address this major issue (Zlotnick and Zerger 2009, 18-26; Kushel, Vittinghoff, and Haas 2001, 200-206; Bernstein et al. 2015, e60; Koegel et al. 1999, 306-317; Jones et al. 2009, 69-77; Henwood et al. 2017, 1-4; Levitt et al. 2009, 978-981) . Homeless individuals are among the most vulnerable experiencing a myriad of health disparities and inequities that adversely impact quality of life.  

We were first exposed to homelessness when we were nursing students at the University of Pennsylvania (Penn). It started during Ian’s Sophomore year of college. He had recently joined Old First Reformed Church, a congregation that focuses on outreach ministry with Philadelphia’s homeless individuals in partnership with the Bethesda Project. As he became more familiar with the population and gained their trust they began to present him with their health questions. A lot of questions went above the scope of what two years of nursing education could handle, however the majority of issues were resolved through referrals to primary and mental health care. 

At the time, we both worked at the Center for Health Equity Research at Penn’s School of Nursing. We worked separately at the time, Marcus with Dr. Janet Deatrick focusing on advancing health equity research and Ian with Dr. Terri Lipman on community based fitness solutions to improve health outcomes. Ian applied for and received a research grant from the Office of Nursing Research to study factors impacting the delivery of health to homeless individuals in Philadelphia. With both of us having an interest in health equity and developing a solution to address homeless health, we applied for a position in the highly competitive Philadelphia Social Innovations Lab (PSIL). Marcus believed this idea incubator could be the springboard to turn the theoretical results of the research study into practical improvements in health for homeless individuals. 

We worked through PSIL to further develop our fledgling proposal into a fundable and sustainable model for care delivery. Over the course of the program, we learned a variety of social enterprise, financial, and entrepreneurial competencies from leaders in social and health care innovations. PSIL equipped us with the skills necessary to further develop our idea to improve healthcare delivery and address health disparities for homeless individuals. With the help of experts in the field at PSIL we refined our pitch, addressed possible problems, and prepared for our final presentation alongside other upcoming social innovators in Philadelphia. 

Following our time with the PSIL, we prepared to apply for the President’s Engagement Prize, a $100,000 grant available to graduating seniors at Penn to launch a social innovation to engage with the community on a local, national, or global level. More than 50 people applied for this prestigious prize and our project, Homeless Health and Nursing: Building Community Partnerships for a Healthier Future, was one of the three selected for funding. 

This award enabled us to establish Up and Running Healthcare Solutions, a homeless healthcare case management organization. Our program of services provides individuals experiencing homelessness in Philadelphia with the tools, partnerships, and support that they need to achieve their health goals. 

This organization seeks to mitigate the effects that the social determinants of health can have on homeless individuals’ health. These social determinants include the factors of where people live, work, sleep, play, and pray and the subsequent impacts on their health. Up and Running Health addresses these determinants using Community Health Workers, specially trained community members who understand homeless healthcare delivery on a personal level. Community Health Workers are individuals that have the unique ability to gain trust and build therapeutic relationships due to their deep understanding of the community’s needs, values, and beliefs. 

Our model is unique because it was developed primarily from the voices of the homeless individuals that it serves through focus groups and ongoing feedback. While the academic literature on homeless healthcare is well developed, it often leaves out the voices and personal experiences of homeless individuals. We integrated the lived experiences of these homeless individuals with existing academic knowledge to create a program that will be successful at providing for the needs of this population.

Up and Running Health collaborates with the Bethesda Project to better serve the homeless individuals of Philadelphia. This collaboration allows us to provide complimentary packages of service to this population. The organization seeks to work with individuals who have fallen into homelessness to assist them in achieving their health goals as one step toward an improved quality of life. 

Up and Running Healthcare solutions currently employs three Community Health Workers who serve as the hands and feet of our healthcare initiative. The organization provides healthcare in three distinct ways:

  1. Individual Medical Case Management 
    This aspect of our program consists of daily CHW interactions with a defined cohort of clients who require continuous intensive case management. CHW partners closely with these individuals to determine the unique challenges that they face in receiving adequate care and develop personal health-based goals. Our CHW’s serve as a patient advocates and care coordinators. 
  2. Confidential Support Groups
    A large portion of the population served through the Bethesda Project have expressed difficulty in coping with mental health and substance abuse. Each week, two groups are conducted focusing on specific topics related to mental health and addiction. These groups are predicated on confidentiality and allow for the homeless individuals to share their thoughts, opinions, and feelings in a safe space. These groups are conducted when the shelter is open to the general population including those who do not reside at the Bethesda Project. This allows our organization to have a wider reach among the community. 
  3. “Ask the Nurses” Table
    This is designed as a space to allow individuals at the Bethesda Project to seek more advanced health education. The purpose of this program is to provide a space where the individuals can talk to the nurse leaders of Up and Running Health to ask more complex health questions. 

Our program is currently in the pilot stage, but has already shown promising results. Homeless individuals are among the highest utilizers of emergency medical services and our program prevents unnecessary emergency department visits and inpatient admission through active care coordination and education. With the use of community health workers, we can decrease emergency medical costs and bolster the role primary care plays in individuals' lives. 

Our next steps will be to establish a plan to sustain our organization after our seed funding from the President’s Engagement prize have been expended. Throughout this period, we will be leaning heavily on our experiences and expertise gained from the PSIL. We have established a partnership with Philadelphia VIP, a pro-bono legal service organization, to work toward gaining 501(c)(3) tax-exempt status. This will allow us to seek out larger grants to continue providing this vital service. We have also partnered with the National Nurse-Led Care Consortium (NNCC) to work with public health nurse leaders throughout Philadelphia that provide care to vulnerable populations and have a focus on ameliorating the social determinants of health. This partnership has allowed us to identify care systems that work for homeless individuals, who require a unique level of provider support, care coordination, and education. In addition, NNCC is actively engaged in the development of our organization’s strategic plan and sustainability model. 

Another important future step for Up and Running Health will be to establish effective methods to evaluate the impact that our organization has had. This will take place through a series of defined factors to indicate the progress that individuals are making as well as the community served as a whole. We have worked with the community and existing academic literature to create a system of documentation that will provide the information needed to evaluate the effectiveness of the program and disseminate it to prospective funders, the academic community, and the individual’s whom we are serving. 

Our program seeks to transform the way we think about homeless healthcare. Our healthcare system has begun to shift its focus to preventative care, however community-based programs are still lacking and underfunded. These programs provide much needed support to educate and empower individuals and community members. Our program provides a cost-effective community based program to empower individuals and communities to take control of social determinants affecting both their health and the community’s. Innovative solutions such as ours can begin building a culture of health locally and globally. 

Works Cited

Aspinall, P. 2014. "Hidden Needs: Identifying Key Vulnerable Groups in Data Collections: Vulnerable Migrants, Gypsies and Travellers, Homeless People, and Sex Workers." Canterbury: University of Kent.

Bernstein, Rebecca S., Linda N. Meurer, Ellen J. Plumb, and Jeffrey L. Jackson. 2015. "Diabetes and Hypertension Prevalence in Homeless Adults in the United States: A Systematic Review and Meta-Analysis." American Journal of Public Health 105 (2): e60.

Henwood, Benjamin F., John Lahey, Harmony Rhoades, Hailey Winetrobe, and Suzanne L. Wenzel. 2017. "Examining the Health Status of Homeless Adults Entering Permanent Supportive Housing." Journal of Public Health: 1-4.

Jones, Charlotte A., Arjuna Perera, Michelle Chow, Ivan Ho, John Nguyen, and Shahnaz Davachi. 2009. "Cardiovascular Disease Risk among the Poor and Homeless-what we Know so Far." Current Cardiology Reviews 5 (1): 69-77.

Koegel, Paul, Greer Sullivan, Audrey Burnam, Sally C. Morton, and Suzanne Wenzel. 1999. "Utilization of Mental Health and Substance Abuse Services among Homeless Adults in Los Angeles." Medical Care 37 (3): 306-317.

Kushel, Margot B., Eric Vittinghoff, and Jennifer S. Haas. 2001. "Factors Associated with the Health Care Utilization of Homeless Persons." Jama 285 (2): 200-206.

Levitt, Aaron J., Dennis P. Culhane, Joe DeGenova, Patrick O'quinn, and Jay Bainbridge. 2009. "Health and Social Characteristics of Homeless Adults in Manhattan Who were Chronically Or Not Chronically Unsheltered." Psychiatric Services 60 (7): 978-981.

Vázquez, Carmelo, Manuel Muñoz, María Crespo, Belén Guisado, and Michael L. Dennis. 2005. "A Comparative Study of the Twelve-Month Prevalence of Physical Health Problems among Homeless People in Madrid and Washington, DC." International Journal of Mental Health 34 (3): 35-56.

Zlotnick, Cheryl and Suzanne Zerger. 2009. "Survey Findings on Characteristics and Health Status of Clients Treated by the Federally Funded (US) Health Care for the Homeless Programs." Health & Social Care in the Community 17 (1): 18-26.

Executive Summary

Nurse educators with specialized education in simulation and debriefing, traditionally use standardized patients for teaching communication, empathy, and care skills to graduate and undergraduate students. Standardized patients are lay people or professional actors trained to portray specific illness or care situations that may be experienced by future nurses. New educational innovations include the use of nurse educators and standardized patients (SPs) to train future elementary and secondary school teachers for parent-teacher conferences using simulated parent teacher conferences. A second emerging innovation is the use of nurse educators and SPs to prepare business executives for difficult conversations with peers and employees.    


Communication -- the human connection -- is the key to personal and career success.

- Paul Meyer

Professional and empathetic communication is a major life skill required for many disciplines, including nursing. Miscommunication between nurses and their patients can lead to poor patient outcomes resulting in a prolonged hospital stay, readmission to the hospital, injury, or death.  A major focus of undergraduate nursing education is teaching students the art of listening to patients and communicating effectively with their patients.

Standardized patients (SPs) are people trained to portray various illnesses and patient care situations for both undergraduate and graduate nursing students. The focus of these interactions is for the SPs to provide practice and feedback to students, before the students interact with real patients. Students practice communicating without using medical jargon that patients might not understand, picking up on unspoken patient questions and concerns, body positioning for effective communication1, and practice comforting behaviors such as therapeutic touch, and various empathetic responses. 

Standardized patients have been commonly used in medical schools since the mid-1960s to provide realistic but simulated patient encounters for students to practice communication and diagnostic skills. SPs provide the ability to standardize a patient encounter for multiple students. Research indicates that practice with live actors prior to real patients decreases learner anxiety and increases the quality of communication1 when a student interacts with a “real patient.”

Standardized patients may be lay people but are often also aspiring or professional actors who supplement their income by portraying patients. Many SPs engage in this work because of the satisfaction they feel in making a contribution to improving patient care and safety through developing practical and communication skills of healthcare providers. In preparation for a typical educational encounter, an SP receives a script with a character description and a health history, coaching, and training in providing feedback to students, as they prepare for their roles. The use of a SP allows an educator to provide a standardized patient care experience for a number of students, which is not possible in the traditional clinical environment.  

Students prepare for simulation in the on-campus simulation lab by reviewing learning objectives and skills required within a scenario. They receive a pre-briefing about the patient they will care for and about what they are expected to accomplish in the patient care scenario, which lasts about 10-20 minutes. The faculty, student, and SP typically meet, along with other students in the class, for a formal debriefing session immediately after the completion of the scenario. This typically lasts about twice as long as the actual simulation. Students can ask SPs about how their words, actions, and demeanor appeared to the “patient,” and what the student might do, to improve his/her skills and bedside manner.  

Students’ first encounters with a “patient” are often SPs, in foundational nursing courses. Objectives for these encounters may involve taking vital signs and talking with the patient to discover something “new and not necessarily on the chart,” about the patient. If students are skilled in their communication, they may find out things like the SP loves the Steelers and has a dog named Skip. 

Students may experience SPs portraying acute untreated major psychiatric diagnoses such as depression, mania, and schizophrenia, during a mental health course. Acute mental illness is rarely experienced by students in the clinical setting thus, these encounters help prepare students, in a safe environment, for what they might encounter, in the real world setting.  

Standardized patient simulations not only provide students with realistic patient care experiences; the scenarios are easily adjusted to reflect changing clinical, and program objectives or goals.  Simulations occasionally reveal program content gaps. Missing content or skills are added to future simulations to provide the needed content. Safer patient care is integrated into the students’ mental models as they practice nursing care under the eye of experienced nurse instructor facilitators.  Best practices in nursing care and communication are learned through a combination of quality feedback from the SPs and skilled debriefing by simulation instructors. Students are encouraged to thoughtfully reflect on their actions and patient communication in the simulation room.  Any practice gaps or errors are caught and corrected in the moment.  

Standardized patients are also trained to be standardized family members for students in the School of Education. In these scenarios, students preparing to be teachers practice writing and presenting student-specific Individual Education Plans (IEP). The SPs receive scripts preparing them to discuss their “children” and information about their fictional family background, current and past home situation, and life experiences. They provide feedback for students about how their verbal and non-verbal communication and questions were perceived by the “parents.” This practice before the first real experience allows students to try various “scripts” for conducting IEP presentations to parents or guardians of children with learning or behavioral challenges and to receive feedback on their approach, just as the nursing students do. 

The RMU Regional Research and Innovation in Simulation Education (RISE) Center is one of the first health care-based simulation programs to begin training business executives. RISE Center faculty recently used SPs to portray “standardized” workers and executives, to provide teamwork and communication opportunities for mid-level executives during a one-day corporate simulation training experience. The process for the preparation of the SPs remained the same; scripts were developed around the top 10 problems in business teamwork and communications. Scenarios were written and scripts were prepared for the actors. The corporate managers and executives were oriented to the simulation and debriefing process.  SPs participated in the debriefing process providing feedback to the executives about their experiences as the employee. The experience was so well received that more simulation opportunities are being built into the executive training program.


Effective communication is a major life skill required by multiple professions. The RMU Regional Innovation in Simulation Education (RISE) Center is accredited by the Society for Simulation in Healthcare and staffed with credentialed health simulation educators (CHSEs). Simulation centers using SPs are well positioned to increase their interdisciplinary and social impact by capitalizing on their communication expertise to providing meaningful interactive educational opportunities to other disciplines. Regardless of the discipline, outcomes are consistent. Learners report an appreciation of the human interaction, a decrease in stress and an increase in their ability to handle difficult conversations, demonstrate increased empathy and overall improved communication skills. 

Works Cited

1 Sarikoc, Gamze, Celale Tangul Ozcan, and Melih Elcin. 2017. “The impact of using standardized patients in psychiatric cases on the levels of motivation and perceived learning of the nursing students. Nurse Education Today, 51:15-22. Doi: 10.1016/j.nedt.2017.01.001

Author bios

Suzan Kardong-Edgren PhD, RN, ANEF, CHSE, FSSH, FAAN is professor at Robert Morris University and Director of the RISE Center. She is internationally recognized for her work in simulation research and education. 

Jan Barber, MSN, RN CHSE, manages the standardized patient program at Robert Morris University School of Nursing and Health Sciences, Moon Township, Pennsylvania. She received her BSN from the University of Pittsburgh School of Nursing and her MSN from LaRoche College.  

Val Howard EdD, MSN, RN is Dean of the School of Nursing and Health Sciences at Robert Morris University. She is a past-president of the International Nursing Association for Clinical Simulation and Learning and founding Director of the RISE Center.



The Independence Blue Cross Foundation’s Nursing Internship Program is an innovative approach to preparing nurses to be future leaders in healthcare. Through its unique model that emphasizes experiential learning and competency-building, the Nursing Internship Program provides undergraduate nursing students with experiences and skills to not only provide exceptional patient care, but to lead efforts to change the way healthcare is delivered.


In today’s evolving healthcare environment, there is one constant: nursing. As the largest profession in the healthcare workforce, nearly three million registered nurses are the backbone of the healthcare system.1 They are often the first point of contact for patients, coordinating and providing direct care at the hospital, in primary care offices, at community health centers, and everywhere in between. Their knowledge of the healthcare system and diverse practice settings make them well positioned to lead changes to improve the way care is delivered. That’s why in its landmark 2010 report, The Future of Nursing: Leading Change, Advancing Health, the Institute of Medicine recommended that nurses be part of a collaborative, interdisciplinary effort, alongside physicians and other healthcare professionals, to reform healthcare.2

Nurses as Leaders

It is not easy to change a system as large and complicated as healthcare and nurses who join the effort must be prepared to take on leadership roles and new responsibilities. Nursing education programs prepare nurses for patient care and are focused primarily on the development of clinical skills, as they should be. However, nurses need opportunities for leadership development, as well. The Institute of Medicine recommended that leadership competencies be integrated into nursing curricula and that supplemental opportunities be made available to nurses at all levels.

Independence Blue Cross Foundation Supports Nurses

A longtime supporter of nurses, the Independence Blue Cross Foundation (Foundation) understands the important role nurses play and has several programs that advance their education and professional development. Since 2011 through its Nurses for Tomorrow scholarship program, the Foundation has awarded more than $8 million to 23 accredited nursing schools in the Southeastern Pennsylvania region to support scholarships for undergraduate, graduate, and doctoral nursing students. The Foundation also supports a Nurse Practitioner Residency Program and will focus on increasing diversity in nursing in future programs. However, the program that has the greatest impact on the next generation of leaders in nursing is the Foundation’s Nursing Internship Program.

An Innovative Internship Program for Future Nurse Leaders

The Foundation’s Nursing Internship Program (Program) immerses undergraduate nursing students in two unique practice settings. For 10 weeks during the summer, nurse interns are placed either in a community health center (supported through the Foundation’s Blue Safety Net grant program) or in a business area (i.e. Clinical Services, Risk Analytics, etc.) at Independence Blue Cross, and are supervised by registered nurses. Through these practice settings, nurse interns are exposed to career paths that are beyond hospital floors, in the communities where patients live. This experience alone is exceptional for nursing students who spend many of their clinical hours in traditional healthcare settings. What makes the Program truly innovative, though, is the competency-building opportunities weaved throughout it. 

The COPA Model

In 2015, using the Institute of Medicine’s report as a strategic guide, the Foundation aligned the Program with the Competencies, Outcomes, and Performance Assessment (COPA) Model of nursing education to provide a more enriching, competency-building experience to its nurse interns. The COPA Model is a conceptual framework that was created as a way to build competencies in pre-licensure nursing students. The framework emphasizes eight core practice competencies, including communication, critical thinking, human caring and relationships, leadership, and knowledge and integration.3 To help the nurse interns build these competencies, the Foundation began convening them outside of their practice settings by facilitating Leadership Labs. 

The Leadership Labs, which occur three times throughout the Program, are full-day sessions related to core practice competencies listed in the COPA Model framework. For example, in a public speaking session, the nurse interns share a significant moment or lesson learned from their internship experience in front of an audience, and receive constructive feedback. In another session the nurse interns learn techniques to building a professional network. Through the Leadership Labs, nurse interns also learn how to further their education and find their nursing passion, learn how to care for patients in a culturally competent manner, are paired with a mentor, and complete a group volunteer project with a local non-profit organization. 

Outside of the Leadership Labs, nurse interns build their critical thinking skills through an informal, observational research poster project in which they identify a problem or issue at their practice setting, conduct a brief literature review, gather information through observation and informal interviews with staff, and make a recommendation. Nurse interns then present their research posters at a recognition event attended by Independence Blue Cross leadership, Foundation staff and leadership, nursing school leadership and faculty, mentors, and their nurse supervisors. The research posters are highly admired and have led to opportunities for nurse interns to present at events like the Children’s Hospital of Philadelphia’s Nursing Research and Evidence-Based Practice Day.

Validating, Scaling, and Replicating

The Program was evaluated in 2017 by Widener University’s Leadership Center for Nursing Education Research to evaluate its model, impact, and the potential to scale and replicate it. The evaluation resulted in numerous outcomes including:

  • The leadership building experiences provided throughout the program are unique compared to those in traditional nursing education programs.
  • Many of the experiences are transformative, and influence nurse interns’ attitudes about their leadership capabilities.
  • Supervisors who have been a part of the Program for many years are highly supportive of and dedicated to its continued success.

With the model validated, the Foundation seeks to expand the Program and replicate it on a national level.

Why it works

The Foundation’s Nursing Internship Program works for three reasons: strong partnerships, invested staff, and a meaningful purpose. The Foundation is fortunate to have a network of community health center partners and partners at Independence Blue Cross who provide exceptional practice settings for the nurse interns, and dedicated supervisors to work with the nurse interns day-to-day. The Foundation also has a staff that is highly invested in the nursing profession. Most importantly, The Foundation has yet to come across another internship program that provides a meaningful experience to undergraduate nursing students through both diverse practice settings and leadership development opportunities. Many nurse interns who have completed the program are already leading local efforts to improve the health and wellbeing of communities in the region, including a health literacy program in Philadelphia’s public libraries, and an after-school program for Latino youth in South Philadelphia that addresses the social determinants of health. The Foundation is proud of their accomplishments, and is looking forward to seeing them and all of its nurse interns become the next leaders not only in nursing, but in healthcare.

Works Cited

1”Registered Nurses: Occupational Outlook Handbook." U.S. Bureau of Labor Statistics. Accessed January 02, 2018. Link.

2“The Future of Nursing: Leading Change, Advancing Health,” Institute of Medicine (2011), accessed January 2, 2018, Link.

3Lenburg, Carrie B., EdD, RN, FAAN. "The Framework, Concepts and Methods of the Competency Outcomes and Performance Assessment Model." The Online Journal of Issues in Nursing 4, no. 2 (September 30, 1999). Accessed January 02, 2018. Link.

Author Bio

Zaynah Henry joined the Independence Blue Cross Foundation in 2016 as a program specialist. In her role she works with the Foundation’s nursing programs, which advance the healthcare workforce through supporting the education and professional development of nurses. Prior to joining the Foundation, Zaynah worked for the President’s Cancer Panel at the National Cancer Institute. Zaynah received her BS in Health Behavior Science and MS in Health Promotion from the University of Delaware.

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