On Evolutions and Revolutions in Emergency Care: Commemorating the Emergency Nurses Association’s 50th Anniversary

Abstract

The year 2020 is a very special time of celebration for both the nursing discipline and for emergency nursing. This year has been designated as the World Health Organization and International Council of Nurses Year of the Nurse and the Midwife, celebrating the 200th anniversary of Florence Nightingale’s birth and honoring the contributions of nurses to health around the globe.1International Council of NursesInternational Council of Nurses and Nursing Now welcome 2020 as International Year of the Nurse and the Midwife. News 2019; ICN/PR2019 # 17.https://www.icn.ch/news/international-council-nurses-and-nursing-now-welcome-2020-international-year-nurse-and-midwifeDate accessed: November 8, 2019Google Scholar This year is also the 50th anniversary of the Emergency Nurses Association (ENA). Our anniversary year provides a critical time to examine the transformative upheavals, or revolutions, within the nursing discipline that have created the emergency nursing specialty as it exists today. This is also a crucial opportunity to explore how far our thinking and ideas have evolved along this journey. Our 50th anniversary commemoration provides an enlivening opportunity to contemplate how our progress to date will serve as the foundation for an ongoing trajectory of excellence over the next 50 years. There is no doubt that emergency nursing will continue to have an essential role in expanding the timeliness, reach, and effectiveness of health care. I’m writing this 50th anniversary editorial as a brief commentary on the emergency nursing specialty from an evolutionary perspective. In this issue of the Journal of Emergency Nursing (JEN), we have reprinted “Winds of Change.”2Anast G.T. Winds of change. Anita N. Dorr Memorial Lecture.J Emerg Nurs. 1975; 1 ([Reprinted in J Emerg Nurs. 2020;46(1):16-20. https://doi.org/10.1016/j.jen.2019.11.004.]): 10-13Google Scholar This is a transcript of Dr George T. Anast’s 1975 Anita N. Dorr Memorial Lecture. In this lecture, he relays a personal tribute to our ENA founders with a rare first-person historical account of the creation of our specialty organization’s predecessor, the Emergency Department Nurses Association. As I read the lecture transcript, I was struck by both the many similarities and the multiple differences in the commonly held patterns and beliefs about emergency nursing between 1975 and today. Dr Anast’s speech reveals a plethora of perpetual problems and several enduring strengths (Table) that continue to be extremely relevant today. Several of the differences between the context in 1975 and that today are also astounding.TableCommon themes from the 1975 winds to change lecture through today in emergency nursingPerpetual problemsEnduring strengthsInformation overloadWorkforce shortagesHealth care financingProtecting the role of nursesExpanding role of nursesEradicating secondary/subservient status of nursesShared interests of EMS and emergency nursesInterdisciplinary collaboration and support• American Academy Orthopedic Surgeons• Trauma Committees of physician organizations• American College of Emergency PhysiciansEnthusiasm for continuing education/professional developmentAccelerating change through advanced practice rolesAccelerating change through technology advancesOrganizing and expanding our professional organizationEMS, emergency medical services. Open table in a new tab EMS, emergency medical services. First, Dr Anast reveals that Anita Dorr was a chain smoker, practicing in a time when large commercial tobacco companies continued to successfully suppress information about the health-harming effects of cigarette smoking and perpetuate the addictive habit. Unfortunately, emergency nurses still deal with the human health consequences to morbidity and mortality that cigarette smoking, and now vaping, have on our patients and colleagues. Resources and support to quit smoking are a crucial part of every emergency discharge teaching plan for any patient who continues to smoke or vape.3Cheung K.W. Wong I.W. Fingrut W. et al.Randomized controlled trial of emergency department initiated smoking cessation counselling and referral to a community counselling service.CJEM. 2018; 20: 556-564https://doi.org/10.1017/cem.2017.345Google Scholar The next substantial difference between the 1975 context and today’s context is exactly who teaches courses to emergency nurses. According to the 1975 transcript, emergency nursing courses were taught almost exclusively by physicians. Fortunately, we have expanded our autonomy as a specialty and courses are now largely led, developed, taught, and evaluated by experts within our own specialty. We continue important interprofessional education collaborations with our interdisciplinary colleagues on an equal team footing.4O’Connor L. Carpenter B. O’Connor C. O’Driscoll J. An interprofessional learning experience for trainee general practitioners in an academic urban minor injuries unit with advanced nurse practitioners (emergency).Int Emerg Nurs. 2018; 41: 19-24https://doi.org/10.1016/j.ienj.2018.05.002Google Scholar,5Guay J. Erdley W.S. Raines D. Castner J. Readiness for interprofessional learning after participation in an obstetric simulation.Teach Learn Nurs. 2016; 11: 194-198https://doi.org/10.1016/j.teln.2016.06.004Google Scholar The evolution in our education was most notable as Dr Anast refers to nurses’ training as adequate preparation for medical school. With advanced practice nursing roles and degrees, the nursing profession has operationalized the educational preparation for nurses within our own discipline. Prescribing providers with nursing, and not just medical, graduate-level training, create an important advancement to meet the needs of society for high-quality health care. Advanced practice nursing providers are now a large portion of the emergency provider workforce.6Hall M.K. Burns K. Carius M. Erickson M. Hall J. Venkatesh A. State of the national emergency department workforce: who provides care where?.Ann Emerg Med. 2018; 72: 302-307https://doi.org/10.1016/j.annemergmed.2018.03.032Google Scholar Medical school is not necessary for advanced practice nurses, as Dr Anast had envisioned. Third, Dr Anast refers to a fear of speaking up for emergency nurses. Emergency nurses have a consistent and expert voice in shaping health care building on the strengths of (1) our professional organizations, (2) improved teamwork training (like TeamSTEPPS), and (3) the crucial role of nursing in advancing the Quadruple aim (patient experience, population health, reducing costs, and care team well-being).7Obenrader C. Broome M.E. Yap T.L. Jamison F. Changing team member perceptions by implementing TeamSTEPPS in an emergency department.J Emerg Nurs. 2019; 45: 31-37https://doi.org/10.1016/j.jen.2018.08.006Google Scholar, 8Peters V.K. Harvey E.M. Wright A. Bath J. Freeman D. Collier B. Impact of a teamSTEPPS trauma nurse academy at a Level 1 trauma center.J Emerg Nurs. 2018; 44: 19-25https://doi.org/10.1016/j.jen.2017.05.007Google Scholar, 9Bachynsky N. Implications for policy: the triple aim, quadruple aim, and interprofessional collaboration.Nurs Forum. 2019; ([published online ahead of print August 20, 2019])https://doi.org/10.1111/nuf.12382Google Scholar Last, Dr Anast uses traditional gender stereotypes to apply female pronouns to nurses and male pronouns to physicians. Fortunately, the health care professions and our specialty are actively tackling adequate gender representation and equality.10Yi M. Keogh B. What motivates men to choose nursing as a profession? A systematic review of qualitative studies.Contemp Nurse. 2016; 52: 95-105https://doi.org/10.1080/10376178.2016.1192952Google Scholar Although it is clear that we have evolved a long way since this stereotyping was acceptable, much work continues to ensure that structural gender barriers do not interfere with anyone achieving their full potential and professional dreams. Overall, what I found most delightful about Dr Anast’s speech were his descriptions of Anita Dorr as a unique individual with an impressive personality, who evidently swore profusely. The nature of the work of the specialty continues to tend to attract those of us who are comfortable in taking charge in the midst of previously unsolved problems, uncertainty, and chaos. Emergency nursing is often characterized by those with a passion for practice autonomy and reasoned professional risk-taking. Anita Dorr was a woman who changed the world with few to no resources, leaving a larger-than-life paragon of determination and perseverance for those of us who are privileged to carry on her legacy. Observing 50 years of past growth also allows us a special vantage point to imagine the next 50 years of innovation and change in emergency nursing. Several philosophers have provided guidance on procedures that we can follow to best wrap our minds around how disciplines, and ideas within disciplines, change and evolve. Within the nursing discipline, nursing philosopher Dr Beth L. Rodgers11Rodgers B.L. Knalf K.A. Concept analysis: an evolutionary view.in: Rodgers B.L. Knafl K. Concept Development in Nursing: Foundations, Techniques, and Applications. 2 ed. Saunders, Philadelphia, PA2000Google Scholar is best known for instilling an evolutionary perspective to thoughtfully examine changes and variations in ideas across time, disciplines, sociocultural contexts, and settings. Her evolutionary approach has been used to clarify ideas that are important to emergency nursing—ideas such as workplace bullying12Anusiewicz C.V. Shirey M.R. Patrician P.A. Workplace bullying and newly licensed registered nurses: an evolutionary concept analysis.Workplace Health Saf. 2019; 67: 250-261https://doi.org/10.1177/2165079919827046Google Scholar and practice readiness for new nurses,13Mirza N. Manankil-Rankin L. Prentice D. Hagerman L.A. Draenos C. Practice readiness of new nursing graduates: a concept analysis.Nurse Educ Pract. 2019; 37: 68-74https://doi.org/10.1016/j.nepr.2019.04.009Google Scholar skill mix,14Cunningham J. O’Toole T. White M. Wells J.S.G. Conceptualizing skill mix in nursing and health care: an analysis.J Nurs Manag. 2019; 27: 256-263https://doi.org/10.1111/jonm.12673Google Scholar harm reduction,15Denis-Lalonde D. Lind C. Estefan A. Beyond the buzzword: a concept analysis of harm reduction.Res Theory Nurs Pract. 2019; 33: 310-323https://doi.org/10.1891/1541-6577.33.4.310Google Scholar professional commitment,16Garcia-Moyano L. Altisent R. Pellicer-Garcia B. Guerrero-Portillo S. Arrazola-Alberdi O. Delgado-Marroquin M.T. A concept analysis of professional commitment in nursing.Nurs Ethics. 2019; 26: 778-797https://doi.org/10.1177/0969733017720847Google Scholar patient dignity,17Kadivar M. Mardani-Hamooleh M. Kouhnavard M. Concept analysis of human dignity in patient care: Rodgers’ evolutionary approach.J Med Ethics Hist Med. 2018; 11: 4Google Scholar patients’ values,18Karimi-Dehkordi M. Spiers J. Clark A.M. An evolutionary concept analysis of “patients’ values”.Nurs Outlook. 2019; 67: 523-539https://doi.org/10.1016/j.outlook.2019.03.005Google Scholar futile care,19Morata L. An evolutionary concept analysis of futility in health care.J Adv Nurs. 2018; 74: 1289-1300https://doi.org/10.1111/jan.13526Google Scholar shared decision-making,20Park E.S. Cho I.Y. Shared decision-making in the paediatric field: a literature review and concept analysis.Scand J Caring Sci. 2018; 32: 478-489https://doi.org/10.1111/scs.12496Google Scholar and emotional intelligence.21Raghubir A.E. Emotional intelligence in professional nursing practice: a concept review using Rodgers’s evolutionary analysis approach.Int J Nurs Sci. 2018; 5: 126-130https://doi.org/10.1016/j.ijnss.2018.03.004Google Scholar In regards to settings and contexts, JEN’s International Nursing section is especially relevant to applying an evolutionary perspective by comparing and contrasting emergency nursing practice across different global settings. We look forward to publishing manuscripts that continue to refine our ideas over time and introduce novel ideas of relevance to the specialty. Over the next 50 years, we have the responsibility and opportunity to guide the ongoing evolution of emergency nursing practice excellence, research, education, policy, and leadership. Will emergency nurse residency evolve to achieve similar government-funded support, graduate education requirements, and standardization that the medical profession has structured for their discipline’s residency? JEN is relaunching the Nurse Educator section in 2020, which provides an excellent venue to fuel the dissemination of relevant innovations and refine ideas. Furthermore, will the concept of triage continue to be a process of rapidly sorting patients to obtain the right resources at the right time,22Howard A. Brenner G.D. Drexler J. et al.Improving the prompt identification of the Emergency Severity Index level 2 patient in triage: rapid triage and the registered nurse greeter.J Emerg Nurs. 2014; 40: 563-567https://doi.org/10.1016/j.jen.2014.01.009Google Scholar or will the triage idea continue to evolve to represent a distinct physical area of the emergency department or broader interdisciplinary team’s initial intake into the acute care hospital setting?23Heslin S.M. Bronson S. Feiler M. et al.Team triage intervention, including licensed practical nurse, to increase HIV testing rates in the emergency department: a quality improvement project.J Emerg Nurs. 2019; 45: 685-689https://doi.org/10.1016/j.jen.2019.07.016Google Scholar JEN’s Triage Decisions section continues to relay evidence-based manuscripts to inform the ongoing evolution of triage. Will the concept of “telehealth” fully integrate into emergency nursing triage, assessment, treatment, discharge teaching, and referrals to follow up in other health care settings?24Hollander J.E. Davis T.M. Doarn C. et al.Recommendations from the first National Academic Consortium of Telehealth.Popul Health Manag. 2018; 21: 271-277https://doi.org/10.1089/pop.2017.0080Google Scholar We look forward to continuing to accelerate our specialty’s evolutions and expand the boundaries of our knowledge and innovations in all areas of JEN publications. Fifty years ago, emergency nursing as a specialty was an anomaly. Many emergency rooms and departments of hospitals, if they existed, were often staffed only as needed by ward nurses or nursing house supervisory staff for a brief period before assigning the patient to a specific inpatient ward or unit. The emergency care sector has revolutionized health care in 50 years from an anomaly to one of the most frequently utilized sectors of the entire health care system (roughly 1 emergency visit for every 6 outpatient office visits annually).25Rui P. Okeyode T. National ambulatory medical care survey: 2016 national summary tables.https://www.cdc.gov/nchs/data/ahcd/namcs_summary/2016_namcs_web_tables.pdfDate accessed: November 9, 2019Google Scholar,26Rui P. Kang K. Ashman J. National hospital ambulatory medical care survey: 2016 emergency department summary tables.https://www.cdc.gov/nchs/data/nhamcs/web_tables/2016_ed_web_tables.pdfDate accessed: November 9, 2019Google Scholar Philosopher Dr Thomas S. Kuhn’s book The Structure of Scientific Revolutions provides a fascinating perspective by which to examine how this whole new, tradition-shattering worldview of the health care system as a discipline and specialty with practice that is rooted in science came to be over time.27Kuhn T.S. The Structure of Scientific Revolutions. The University of Chicago Press, Chicago, IL2015Google Scholar Although Kuhn focuses on revolutionary scientific theories such as Newton’s first law of motion or Copernicus and Galileo's observations that the sun is the center of the universe, the process of modernizing a discipline’s shared commitments and mental models are relevant to emergency nursing. Kuhn’s overall premise is that the professional community with the system of ideas and tools best poised to solve pressing problems evolves to dominate the worldviews of the discipline and ongoing scientific endeavors. Clearly, the demand for emergency care over the last 50 years is a pressing problem characterized by a system that is overburdened, underfunded, and highly fragmented.28Institute of MedicineCommittee on the Future of Emergency Care in the United States Health System. Hospital-based emergency care: at the breaking point. National Academies Press, Washington, D.C.2007http://www.nationalacademies.org/hmd/Reports/2006/Hospital-Based-Emergency-Care-At-the-Breaking-Point.aspxGoogle Scholar Despite these challenges, the emergency care system offers access, efficiency, efficacy, convenience, and cultural competence that serves as an exemplar for primary care, telehealth, urgent care, and patient-centered medical home models.29Bornais JAK, Crawley J, El-Masri MM. One stop: examining the reasons patients use the emergency department for nonurgent care and the barriers they face [published online ahead of print November 1, 2019]. J Emerg Nurs. http://doi.org/10.1016/j.jen.2019.08.007.Google Scholar,30Weber J.J. Lee R.C. Martsolf D. Experiences of care in the emergency department among a sample of homeless male veterans: a qualitative study.J Emerg Nurs. 2020; 46 (http://doi.org/10.1016/j.jen.2019.06.009): 51-58Google Scholar Kuhn’s process of revolutions remains particularly relevant as we examine much needed reprioritizations in health care and crises that require new worldviews for adequate problem solving. The process of a discipline’s revolution includes recognizing an anomaly, crisis, discontent over status quo, debates over fundamental ideas and methods, rejecting an old system of thinking, a change of worldview, and a new “constellation of group commitments” within a discipline.27Kuhn T.S. The Structure of Scientific Revolutions. The University of Chicago Press, Chicago, IL2015Google Scholar In the acute care hospital systems of the past, the emergency room or emergency department was an anomaly in the usual workings of the health care system. Decades of rapidly increasing needs and demands for emergency care have created several crises linked to crowding, fragmentation, limited access to trauma specialists, diversion, limited considerations for specialized pediatric care, and inconsistency in workforce preparation standards.28Institute of MedicineCommittee on the Future of Emergency Care in the United States Health System. Hospital-based emergency care: at the breaking point. National Academies Press, Washington, D.C.2007http://www.nationalacademies.org/hmd/Reports/2006/Hospital-Based-Emergency-Care-At-the-Breaking-Point.aspxGoogle Scholar,31Institute of MedicineCommittee on the Future of Emergency Care in the United States Health System. Emergency Medical Services at the Crossroads. National Academies Press, Washington, DC2007Google Scholar,32Institute of MedicineCommittee on the Future of Emergency Care in the United States Health System. Emergency Care for Children: Growing Pains. Oxford Publicity Partnership, Washington, DC2007Google Scholar The capacity of emergency departments and the clinicians who provide care in this specialty evolved through repeated crises where the community need far outpaced the available resources. Before this crisis and as a professional discipline, nursing has had core problems that it considers as relevant and has established techniques.33American Nurses AssociationNursing’s Social Policy Statement: The Essence of the Profession. American Nurses Association, Silver Spring, MD2010Google Scholar, 34White K.M. O’Sullivan A. The Essential Guide to Nursing Practice: Applying ANA’s Scope and Standards in Practice and Education. American Nurses Association, Silver Spring, MD2012Google Scholar, 35American Nurses AssociationNursing: Scope and Standards of Practice. Silver Spring. American Nurses Association, MD2015Google Scholar However, conventional thinking about the fundamental knowledge, skills, and abilities of the generalist nurse were no longer sufficient to meet standards of care in the revolutionized emergency care arena. A specialized scope and standards with requirements for specialty certification were born and revised.36Emergency Nurses AssociationEmergency Nursing Scope and Standards of Practice.2nd ed. Emergency Nurses Association, Des Plaines, IL2017Google Scholar Likewise, priorities for emergency care–focused education, practice, and research challenged conventional thinking with new categories and worldviews.37Bayley E.W. MacLean S.L. Desy P. McMahon M. Emergency Nurses AssociationENA’s Delphi study on national research priorities for emergency nurses in the United States.J Emerg Nurs. 2004; 30: 12-21https://doi.org/10.1016/j.jen.2003.10.009Google Scholar,38Hoyt K.S. Coyne E.A. et al.ENA NP Validation Work TeamNurse Practitioner Delphi Study: competencies for practice in emergency care.J Emerg Nurs. 2010; 36: 439-449https://doi.org/10.1016/j.jen.2010.05.001Google Scholar ENA, as a specialty professional organization, routinely produces research, position statements, clinical practice guidelines, resolutions, and policy initiatives as an ongoing constellation of our ever-evolving group commitments as a community of emergency care specialists. Wow! Just look at how far we have come! Today, as we witness cotemporary crises in health care financing, where hospitals are increasingly taking insured patients to court to collect payments for copays and deductibles, nurses are in a trusted position of authority to lead the next reform revolution. With rural hospital closures, we also stand on the precipice of a new chapter of crises in access to emergency care. As new pressing problems in health care emerge in the future, how do we, as a specialty, continually revise our system of ideas and practice tools to remain well-poised to solve these new problems? What problems do we, as a specialty community, even consider to be our legitimate problems to solve? As evolution and revolution take place, an important change includes defining what constitutes legitimate problems in the specialty. For example, we have only just begun to address the predicted health effects of climate change as a legitimate problem, for which our specialty has an important role with key knowledge and solutions.39World Health Organization124th WHO executive board session.http://www.who.int/mediacentre/events/2009/eb124/en/Date accessed: November 9, 2019Google Scholar How do we ensure that we continue to evolve our standards and processes to solve these problems? Compared with 50 years ago, nurses today have a whole new way of seeing the world through the process by which the emergency nursing specialty evolved. Just imagine how different this worldview will be in 50 more years. The following examines workplace violence, nontransport emergency medical service (EMS) visits, and new models of holistic emergency nursing as examples of potential, ongoing revolutions. In my own first position as an emergency nurse, workplace violence was often dismissed or ignored as if it was not a legitimate problem. We were encouraged to consider that patient-initiated violence was just an expected and acceptable part of the job. Thankfully, workplace violence is now well established as a legitimate problem in our specialty, worthy of ongoing research resources and addressed with innovations in individual, organizational, and policy interventions.40Gillespie G.L. Gates D.M. Kowalenko T. Bresler S. Succop P. Implementation of a comprehensive intervention to reduce physical assaults and threats in the emergency department.J Emerg Nurs. 2014; 40: 586-591https://doi.org/10.1016/j.jen.2014.01.003Google Scholar,41Lenaghan P.A. Cirrincione N.M. Henrich S. Preventing emergency department violence through design.J Emerg Nurs. 2018; 44: 7-12https://doi.org/10.1016/j.jen.2017.06.012Google Scholar In this issue of JEN, Lee et al42Lee H. Han C. Redley B. Lin C. Lee M. Chang W. Workplace violence against emergency nurses in Taiwan: a cross sectional study.J Emerg Nurs. 2020; 46: 66-71https://doi.org/10.1016/j.jen.2019.09.004Google Scholar provide important data that workplace violence is a major problem for emergency nurses in international settings as well. Ensuring that work place violence will no longer be a persistent problem in 50 years for emergency nursing around the globe is a worthy goal. Currently in the United States, new nontransport guidelines, policies, and reimbursements for EMS fuel a revolution in the emergency nursing specialty. In this issue of JEN, we have published several manuscripts on the continually combining and evolving roles of emergency nursing, EMS, flight nursing, and ambulance nursing.43Nilsson J. Johansson S. Nordström G. Wilde-Larsson B. Development and validation of the ambulance nurse competence scale.J Emerg Nurs. 2020; 46: 34-43https://doi.org/10.1016/j.jen.2019.07.019Google Scholar, 44Leggio W.J. Miller M.G. Panchal A.R. Advanced placement paramedic education for health care professionals: A descriptive evaluation.J Emerg Nurs. 2020; 46: 44-50https://doi.org/10.1016/j.jen.2019.10.010Google Scholar, 45Menard K. Menard J. Thinking outside the box in rural trauma transport: a case review.J Emerg Nurs. 2020; 46: 99-101https://doi.org/10.1016/j.jen.2019.10.012Google Scholar As revolutions often integrate the crosspollination and novel combinations of ideas across disparate disciplines and specialties, we can anticipate that new models of emergency nursing care in 50 years will incorporate home health nursing, community paramedic programs,46Steeps R. Wilfong D.A. Hubble M.W. Bercher D.L. Emergency medical services professional’s attitudes about community paramedic programs.West J Emerg Med. 2017; 18: 630-639https://doi.org/10.5811/westjem.2017.3.32591Google Scholar free-standing mobile emergency departments, military nursing in austere environments,47Ogle L. Harville G. Nursing skills fair in an austere military environment.J Emerg Nurs. 2020; 46: 21-25https://doi.org/10.1016/j.jen.2019.10.014Google Scholar and telehealth solutions to address home-based, nontransport emergency treatment visits in all types of environments. With the exponential revolutions in the role of technology in health care, it borders on the unimaginable as to just how the emergency care sector will be able to stabilize and resuscitate human life from the imminent threats of death or loss of limb in the next 50 years. In this issue of JEN, London et al48London K.S. Hartwell C. Cesar S. Sarquella-Brugada G. White J.L. Can sudden cardiac death risk in the young be identified and prevented.J Emerg Nurs. 2020; 46: 105-110https://doi.org/10.1016/j.jen.2019.09.009Google Scholar provide an expert synthesis of clinical risk for sudden cardiac death. With the exponential proliferation of novel telehealth devices, it is not terribly difficult to imagine that emergency nursing in the future will include community-based rapid response to impending sudden cardiac death detected by a real-time, remote, wearable sensor. The holistic approach that characterizes nursing education has long been incorporated into the individual nurse–patient encounter. Now the entire emergency care system has begun to revolutionize standardized care processes and payment systems that account for social determinants of health. For example, in this issue of JEN, Bergenstal et al49Bergenstal T.D. Reitsema J. Heppner P. Geerts J. Cho A. Smallheer B. Personalized care plans: are they effective in decreasing ED visits and health care expenditure among adult super-utilizers?.J Emerg Nurs. 2020; 46: 83-90https://doi.org/10.1016/j.jen.2019.09.001Google Scholar developed personalized care plans to reduce the ED utilization of super-utilizers, or patients who were seen in the emergency department 4 or more times in the last year with the same presenting problem. In the next 50 years, I envision emergency nurses will continue to have key leadership roles to incorporate novel interventions into routine acute care encounters and personalized super-utilizer care plans. These care plans will incorporate holistic interventions that effectively address substandard housing conditions, unemployment, homelessness, food insecurity, lack of transportation, educational disparities, limited English proficiency, criminal justice involvement, intimate partner violence, social isolation, health literacy, stigma, and discrimination.50Spencer A. Freda B. McGinnis T. Gottlieb L. Center for Health Care StrategiesMeasuring social determinants of health among Medicaid beneficiaries: early state lessons.https://www.chcs.org/media/CHCS-SDOH-Measures-Brief_120716_FINAL.pdfDate accessed: November 9, 2019Google Scholar Since the founding of the ENA 50 years ago, the winds of change continue to rapidly evolve and revolutionize our ideas, specialty, and priority problems. There is a sense of renewal, inspiration, and motivation in reflecting on just how much has been accomplished in the last 50 years. May these reflections energize us to carry on this tremendous momentum and commitment to excellence well into the next 50 years. With the ingenuity, collective commitment, and resourcefulness infused in the origins of our specialty, one can only imagine how profoundly we will shape and influence the health care of the future over the next 50 years, together. Jessica Castner, Member, Western New York ENA Chapter, is the Editor-in-Chief of Journal of Emergency Nursing. ORCID identifier: http://orcid.org/0000-0001-9889-3844.