Nursing in Contemporary Healthcare Practice (Transforming Nursing Practice Series)

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The report also notes that the overall ratio of claims against NPs is 1 for every NPs in the nation, compared with 1 for every 4 physicians Pearson, A mother brings her son for an appointment with nurse practitioner Cheryll Jones, who provides high-quality care in the rural community of Ottumwa, IA. Likewise, physical therapists are challenging traditional scope-of-practice boundaries established by chiropractors Huijbregts, The AMA has consistently issued resolutions, petitions, and position papers supporting opposition to state efforts to expand the scope of practice for professional groups other than physicians.

The SOPP in particular, an alliance of the AMA and six medical specialty organizations, was an effort on the part of organized medicine to oppose boundary expansion and to defeat proposed legislation in several states to expand scope of practice for allied health care providers, including nurses Croasdale, ; Cys, The SOPP, with the assistance of a special full-time legislative attorney hired for the purpose, spearheaded several projects designed to obstruct expansion of scopes of practice for nurses and others.

These projects included comparisons between the medical profession and specific allied health professions on education standards, certification programs, and disciplinary processes; development of evidence to discredit access-to-care arguments made by various allied health professionals, particularly in rural areas of a state; and identification of the locations of physicians by specialty to counter claims of a lack of physicians in certain areas Cady, Other organizations, such as the American Society of Anesthesiologists and the American Association of Family Physicians AAFP , have also issued statements that do not support nurses practicing to their fullest.

See for example, AMA. Action has been taken at the state level as well. At the time of release of this report, the case had not yet been heard. A study by Dulisse and Cromwell found no increase in inpatient mortality or complications in states that opted out of the CMS requirement that an anesthesiologist or surgeon oversee the administration of anesthesia by a CRNA.

caring in nursing practice

As noted earlier in this chapter, the contention that APRNs are less able than physicians to deliver care that is safe, effective, and efficient is not supported by research that has examined this question Brown and Grimes, ; Fairman, ; Groth et al. Opposition to this expansion is particularly strong with regard to prescriptive practice. Similar questions have been raised about the content of nursing education see the discussion of nursing curricula in Chapter 4.

Some individual physicians support expanded scope of practice for NPs. In addition to support for expanded scope of practice for NPs among some physicians, public support for NP practice is indicated by satisfaction ratings for retail-based health clinics. Approximately 95 percent of providers in these clinics are NPs, with the remaining 5 percent comprising physician assistants and some physicians.

Such public support can be backed up with high-quality clinical outcomes Mehrotra et al. Despite opposition by some physicians and specialty societies, the strong trend over the past 20 years has been a growing receptivity on the part of state legislatures to expanded scopes of practice for nurses.

There simply are not enough primary care physicians to care for an aging population now, and their patient load will dramatically increase as more people gain access to care. This initiative has had an important impact on access to care. For this study, respondents were randomly recruited to participate in the IOM survey activity via e-mail; others were allowed to join the survey by volunteering when they visited the site.

The majority of respondents have specialties in cardiology 6 percent , family medicine 35 percent , internal medicine 26 percent , and oncology 4 percent. The remaining physicians surveyed are distributed across a wide range of specialties. States with broader nursing scopes of practice have experienced no deterioration of patient care. In fact, patient satisfaction with the role of APRNs is very high. Nor has expansion of nursing scopes of practice diminished the critical role of physicians in patient care or physician income Darves, With regard to the quality of care and the role of physicians, it is difficult to distinguish states with restrictive and more expanded scopes of practice.

Finally, the committee believes that the new medical home concept, based on professional collaboration, represents a perfect opportunity for nurses and physicians to work together for the good of patient care in their community. A fragmented health care system is characterized by weak connections among multiple component parts. Fragmentation makes simple tasks—such as assigning responsibility for payment—much more difficult than they need to be, while more complex tasks—such as coordination of home health care, family support, transportation, and social services after a hospital stay—become more difficult because they require following many separate sets of often contradictory rules.

As a result, people may simply give up trying rather than take advantage of the services to which they are entitled. An examination of fragmentation in hospital services explores its origins in American pluralism, historical accident, and the hybridization of business and charity Stevens, A review by Cebul and colleagues identifies three broad areas of fragmentation: In the United States, there is a disconnect between public and private services, between providers and patients, between what patients need and how providers are trained, between the health needs of the nation and the services that are offered, and between those with insurance and those without Stevens, Communication between providers is difficult, and care is redundant because there is no means of sharing results.

For example, a patient with diabetes covered by Medicaid may have difficulty finding a physician to help him control his blood sugar. If he is able to find a physician, that individual may not have admitting privileges at the hospital to which the patient is transported after a hypoglycemic reaction. After the patient has been admitted to the emergency room, a new cadre of physicians is responsible for him but has no information about previous blood sugar determinations, other medications he is taking, or other health problems.

The patient is stabilized and a discharge is arranged, but he is. Home follow-up is needed, but the visiting nurse agency is certified to provide only two visits when the patient could use five. No one calls the initial primary care physician to share discharge planning or information, and no one gives the patient a summary of the visit to take to that physician.

The ophthalmologist will not accept the patient because of his status as a Medicaid recipient. A major challenge to repairing this fragmentation lies in the fee-for-service structure of the payment system, which indiscriminately rewards increasing volume of services regardless of whether it improves health outcomes or provides greater value MedPAC, Within this system, the contributions of nursing are doubly hidden.

Accounting systems of most hospitals and health care organizations are not designed to capture or differentiate the economic value provided by nurses. Thus, all nursing care is treated equally in its effect on revenue. The effect on the provision of health care is difficult to document, but a closer look at staffing ratios suggests some of the consequences. Barriers to measuring and realizing the economic value generated by nurses exist outside the hospital setting as well. In many states, APRNs are not paid directly but must be reimbursed through the physician with whom they have a collaboration agreement.

Payments are funneled through the physician provider number, and the nurse is salaried. For years, professional nursing organizations have sought to counter the inequitable aspects of the fee-for-service payment system by lobbying to increase the types of services for which NPs can independently bill Medicare, Medicaid, and other providers.

They have had some success in that regard in the past Sullivan-Marx, As McClellan and Wilensky testified to the committee in September , while fee-for-service is not going to disappear any time soon, its future is severely limited in any sustainable health care system. A full exploration of all the benefits and caveats of such alternative payment proposals is beyond the scope of this report. Yet the tendency of human nature is to follow the practices and behaviors with which one is most familiar.

Without the presence of nurses in decision-making positions in these new entities, the legacy of undervaluing nurses, characteristic of the fee-for-service system, will carry over into whatever new payment schemes are adopted. The services of nurses must be properly and transparently valued so that their contributions can fully benefit the entire system.

Expanding their services to the private insurance market is another matter altogether. The health care reform experience of Massachusetts shows the extent to which corporate policy can negate government regulation. NPs are required to collaborate with a physician and may prescribe drugs only under a written collaborative agreement with a physician Christian et al.

As a matter of policy, one major New England carrier stated that it would not list NPs as PCPs unless required to do so by the legislature. Eventually, Massachusetts passed a second health care reform law in that amended the.

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Massachusetts was thereby able to expand the supply of its PCPs without changing its scope-of-practice laws Craven and Ober, The actions of private insurance companies toward APRNs are having an effect on government-funded programs as well. However, federal and state governments are increasingly turning to the private sector to manage these programs Hansen-Turton et al.

NCQA, which administers the recognition for the medical homes, is a physician-dominated organization receiving its member dues from physicians. Its board, although currently reconsidering its stance on whether NPs can lead medical homes, has decided that physicians are more able to serve in PCMH leadership positions. The original concept for the medical home came from physicians, and NCQA adopted their principles of operation.

NCQA has appointed an advisory committee to review the policy that medical homes must be physician led. Meanwhile, the Joint Commission is developing a competitive certification program that will allow for leadership by NPs. As the health care system undergoes transformation, it will be imperative that patients have highly competent nurses who are adept at caring for them across all settings. It will be just as important that the system have enough nurses at any. Both having enough nurses and having the right kind of highly skilled nurses will contribute to the overall safety and quality of a transformed system.

Although the committee did not focus solely on the upcoming shortage of nurses, it did devote time to considering how to retain experienced nurses and faculty. Some solutions have been researched, proposed, and reproposed for so long that it is difficult to understand why they have not yet been implemented more widely. High turnover rates continue to destabilize the nurse workforce in the United States and other countries Hayes et al. Figure indicates some of the reasons that have been cited for not working in the nursing profession. For nurses under 50, personal or family reasons were most frequently cited.

The costs associated with high turnover rates are significant, particularly in hospitals and nursing homes Aiken and Cheung, The literature shows that the workplace environment plays a major role in nurse turnover rates Hayes et al. Staff shortages, increasing work-. Percents do not add to because registered nurses may have provided more than one reason. Includes only RNs who are not working in nursing. Tables and , respectively, show the intentions of nurses with regard to their employment situation e.

Much of the data showing the impact of reducing turnover by focusing on workplace environment comes from the acute care setting. Nonetheless, these data are instructive in their demonstration of a triple win: For example, the Transforming Care at the Bedside TCAB initiative is a national program that engages nurses to lead process improvement efforts so as to improve health outcomes for patients, reduce costs, and improve nurse retention Bolton and Aronow, TCAB relies on nurses developing small tests of change that are continuously planned, assessed, and rapidly adopted or dropped, with each round building on previous successes.

Some employers have also discovered that making it easier for nurses to obtain advanced degrees while continuing to work has increased retention rates. Chapter 4 includes an example of this phenomenon from the Carondelet Health Network in Tucson, Arizona. Based on workforce data Carondelet regularly collects for use in its strategic planning, the network has concluded that its educational efforts have had a positive effect on recruiting and retention.

Its percentage of staff as opposed to contract nurses has increased from Because so many newly graduated nurses have begun seeking work at Carondelet, the average age of its staff nurses fell from 50 years in to High turnover rates among newly graduated nurses highlight the need for a greater focus on managing the transition from school to practice Kovner et al. Some turnover is to be expected—and is even appropriate if new nurses discover they are not really suited to the care setting or employer they have chosen.

However, some entry-level nurses who leave first-time hospital jobs leave the profession entirely, a situation that needs to be avoided when possible. In a survey of entry-level nurses, those who had already left their first job cited reasons such as poor management, stress, and a desire for experience in a different clinical area Kovner et al.

In , the Joint Commission recommended the development of nurse residency programs—planned, comprehensive periods of time during which nursing graduates can acquire the knowledge and skills to deliver safe, quality care that. This recommendation was most recently endorsed by the Carnegie study on the nursing profession Benner et al. Versant 24 and other organizations have launched successful transition-to-practice residency programs for nurses in recent years, while the University HealthSystem Consortium UHC and the American Association of Colleges of Nursing AACN have developed a model for postbaccalaureate nurse residencies Goode and Williams, ; Krugman et al.

These needs included developing skills in ways to organize work and establish priorities; communicate with physicians, other professionals as well as patients and their families. In addition, nurses and employers indicated the need for nurses to develop leadership and technical skills in order to provide quality care Beecroft et al. Meanwhile, the National Council of State Boards of Nursing, after reviewing the evidence in favor of nursing residencies, has developed a regulatory model for transition-to-practice programs, recommending that state boards of nursing enforce a transition program through licensure NCSBN, Residency programs are supported predominantly in hospitals and larger health systems, with a focus on acute care.

This has been the area of greatest need since most new graduates gain employment in acute care settings, and the proportion of new hires and nursing staff that are new graduates is rapidly increasing Kovner et al. It is essential, however, that residency programs outside of acute care settings be developed and evaluated. Chapter 2 documents the demographic changes on the horizon; the shift of care from hospital to community-based settings; and the need for nursing expertise in chronic illness management, care of older adults in home settings, and transitional services.

In this context, nurses need to be prepared for new roles outside of the acute care setting. It follows that new types of residency programs appropriate for these types of roles need to be developed. Several community care organizations are already acting on their own perceived need for a residency-type program lasting 3 months or longer for new employees.

At the Visiting Nurse Services of New York, nurses receive a great deal of education and training on the job. There are a few successful transition-to-practice initiatives in the field of public health, although they are commonly called internships, orientations, or mentoring programs. For example, the North Carolina State Health Department has begun a pilot effort with four public health departments in an effort to educate new nurses about population-based health.

The 6-month mentoring program is being used as a recruitment and retention tool and has very explicit objectives, including an increase in retention and understanding of population health and a willingness to serve as a mentor as the program goes forward. Two public health departments and three community health centers not only collaborated to diversify the nurses entering public and community health settings, but also offered them paid traineeships to transition into their settings.

The public health departments partnered with the Wisconsin Center for Nursing and a collaborative of five baccalaureate schools of nursing to first boost the community health curriculum in those schools and then help with the development of the internship upon graduation for 17 nurses.

The program has been successful in recruiting more minorities into community and public health settings with the knowledge they need to practice successfully outside of the acute care setting. Financial support was secured from a variety of sources, including foundations, corporations, and partnership members themselves. The program is new and is currently undergoing an evaluation to deter-.

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Much of the evidence supporting the success of residencies has been produced through self-evaluations by the residency programs themselves. For example, Versant has demonstrated a profound reduction in turnover rates for new graduate RNs—from 35 to 6 percent at 12 months and from 55 to 11 percent at 24 months—compared with new graduate RN control groups hired at a facility prior to implementation of the residency program Versant, Other research suggests residencies may be useful to help new graduates transition into practice settings Goode et al.

The committee focused its attention on residencies for newly licensed RNs because these residencies have been most studied. Looking forward, however, the committee acknowledges the need for RNs with more experience to take part in residency programs as well. Such programs may be necessary to help nurses transition from, for example, the acute care to the community setting.

The committee believes that regardless of where the residency takes place—whether in the acute care setting or the community—nurses should be paid a salary, although the committee does not take a position on whether this should be a full or reduced salary. Loan repayment and educational debt should be postponed during residency, especially if a reduced salary is offered. The intensity and demands of providing service in the complex setting of a federally qualified health center FQHC , Flinter testified, often discourage newly graduated NPs from joining an FQHC and the clinics from hiring newly graduated NPs.

The goal was to ensure that new NPs would find the training and transition support they needed to be successful as PCPs. Residency provides a continuing opportunity to apply important knowledge for the purpose of remaining a safe and competent provider in a continuous learning environment. Paying for residencies is a challenge, but the committee believes that funds received from Medicare can be used to help with these costs. In , about half of all Medicare nursing funding went to five states that have the most hospital-based diploma nursing programs Aiken et al.

The diploma programs in these states directly benefit from receiving these funds. Most states, however, and most hospitals do not receive Medicare funding for nursing education. The committee believes it would be more equitable to spread these funds more widely and use it for residency programs that would be valuable for all nurses across the country. As discussed in Chapter 2 , the population of the United States is growing older and is becoming increasingly diverse in terms of race, ethnicity, and. Over the past three decades, there has been a profound shift in the age composition of nurses.

In , approximately 50 percent , full-time equivalents [FTEs] of the workforce was between the ages of 20 and 34, while only 17 percent , FTEs was over the age of Since the s, the number of FTEs in the nursing workforce has doubled, and there has been a dramatic increase in the number of middle-aged and older RNs. From to , the number of nurses over age 50 more than quadrupled, and the number of middle-aged nurses aged 35—49 doubled to approximately 39 percent , These older and middleaged nurses now represent almost three-quarters of the nursing workforce, while nurses younger than 34 now make up only 26 percent Buerhaus et al.

Figure shows the age shift in the nursing workforce that has occurred over the past two decades. The figure shows that since , the nursing workforce has grown older, as reflected by more RNs reporting that they fall within the older age categories with each successive survey. At the same time, the figure indicates that in both and especially , the number of young RNs in the workforce was growing relative to earlier years.


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As other similar recruitment initiatives followed, more, younger people chose to become nurses, reversing a year trend of declining entry into nursing by young people. The shift in the age composition of the nursing workforce can be attributed in part to the large number of baby boomers who became RNs in the s and s, followed by much smaller cohorts in the later decades Buerhaus et al. These smaller cohorts were a result of not only the decrease in births, but also a decrease in interest in the profession during the s and s when women began entering other professions that had typically been dominated by men Staiger et al.

The physician workforce has also been aging, but in much smaller numbers. Figure compares the average age of nurses with varying levels of education with that of physicians and physician faculty. Between and , the number of physicians aged 50—64 grew by 77, FTEs, while the number of RNs in that same age group grew by almost five times as many , FTEs Staiger et al. Compared with the size of the nursing workforce, however, the size of the physician workforce is less dependent on interest in profession.

The supply of physicians is influenced more by institutional factors that govern the number of available slots in medical schools and residency. For example, the supply of physicians was deliberately expanded in the s with the introduction of the Medicare and Medicaid programs but has remained fairly constant since then.

This pattern has resulted in large successive cohorts of physicians who are replacing smaller groups of retiring physicians Staiger et al. As the coming decades unfold, nurses and physicians will continue to age. Many of the large numbers of older RNs will retire, and increasing numbers of middle-aged RNs will enter their 50s. Although the number of younger RNs has recently begun to grow, the increase is not expected to be large enough to offset the number of RNs anticipated to retire over the next 15 years Buerhaus et al.

To fill gaps created by retirement and the increasing demand for nursing services, resulting in part from an aging population and increased rates of insurance coverage, the nursing workforce will need to expand by attracting younger. Throughout much of the 20th century, the nursing profession was composed mainly of women. While the absolute number of men who become nurses has grown dramatically in the last two decades, from 45, in to , in HRSA, , men still make up just over 7 percent of all RNs HRSA, Overall, male RNs tend to be younger than female RNs, with an average age of Men are also more likely to begin their careers with slightly more advanced nursing degrees HRSA, Efforts to recruit more men into the civilian nursing profession have had minimal success, and a body of research indicates gender-based reasons for entering the nursing profession.

The evidence is generally thin, but men tend to list factors associated with security and professional growth that led them to the nursing profession: By contrast, women tend to list factors that represent social encouragement from family or friends Zysberg and Berry, To better meet the current and future health needs of the public and to provide more culturally relevant care, the current nursing workforce will need to grow more diverse.

Previous IOM reports have found that greater racial and ethnic diversity among providers leads to stronger relationships with patients in nonwhite communities. These reports argue that the benefits of such diversity are likely to be felt across health professions and to grow as the U. Addressing Racial and Ethnic Disparities in Health Care identifies the diversification of the health care workforce as an important step toward responding to racial and ethnic disparities in the health care system IOM, Because nurses make up the largest proportion of the health care workforce and work across virtually every health care and community-based setting, changing the demographic composition of nurses has the potential to effect changes in the face of health care in America.

Although nurses need to develop the ability to communicate and interact with people from differing backgrounds, the demographic characteristics of the nursing workforce should be closer to those of the population at large to foster better interaction and communication AACN, a. Numerous programs nationwide are aimed at increasing the number of health professionals from underrepresented ethnic and racial groups.

It is managed by nurses with the help of a volunteer family practice physician. Since its inception, a goal of the program has included attracting greater numbers of minority persons into nursing and other health professions and providing opportunities to enhance. This section draws on a September 8, , personal communication with Kay T.

Nursing careers and educational pathways are now formally included in job-related programs implemented by the Presbyterian Community Center PCC. For example, over the past 2 years, PCC has selected 50 community residents into the Changemaker program, which targets to year-olds to engage them in self-discovery, goal setting, and progress toward career goals, with the condition of giving back to the community. Each year about four to six Changemakers examine health careers in depth. HNC included nursing and health careers in the proposal that funded this pathway and provides supervised clinical experiences, mentoring, part-time job opportunities where possible, and education about nursing.

Community health students and faculty now provide education at the community middle school regarding careers in nursing. Last year no African American student was accepted. Dialogue with faculty led to an examination of policies that resulted in the omission of minority students. Literally hundreds of undergraduate and graduate nursing students from several academic institutions have supervised learning experiences in the community. These include at least 10 undergraduate community health nursing students each semester, a class of 30 graduate nursing students enrolled in a health promotion class each year, and 2 or more NP students based in the clinic each semester.

About 5 NP and 10 undergraduate students participate in a Back to School event each fall where Harambee offers school physicals and immunizations for underserved middle school students. The nurse workforce is slowly becoming more diverse, and the proportion of racially and ethnically diverse nursing graduates has increased by 10 percent in the last two decades, growing from Nonetheless, additional commitments are needed to further increase the diversity of the nurse workforce.

Steps should be taken to recruit, retain, and foster the success of diverse individuals. One way to accomplish this is to increase the diversity of the nursing student body, an issue addressed in Chapter 4. The ACA will bring new opportunities to overcome some of the barriers discussed above and use nurses in new and expanded capacities. All four initiatives have shown enough promise that they were selected to receive additional financial support under the ACA. Depending on their outcomes, these exemplars may lead the way to broader changes in the health care system.

They can also terminate or modify programs that are not working well. These types of decisions had previously been allowed only after congressional action. However, it wishes to emphasize to the Center for Medicare and Medicaid Innovation that each of these four initiatives depends on high-functioning, interprofessional teams in which the competencies and skills of all nurses, including APRNs, can be more fully utilized.

New models of care, still to be developed, may deliver care that is better and more efficient than that. Nursing, in collaboration with other professions, should be a part of the design of these initiatives by shaping and leading solutions. Innovative solutions are most likely to emerge if researchers from the nursing field work in partnership with other professionals in medicine, business, technology, and law to create them. The ACO is a legally defined entity consisting of a group of primary care providers, a hospital, and perhaps some specialists who share in the risk as well as the rewards of providing quality care at a fixed reimbursement rate Fisher et al.

Payment for this set of services, as provided for in the ACA, will move beyond the traditional fee-for-service system and may include shared savings payments or capitated payments for all services. The goal of this payment structure is to encourage the ACO to improve the quality of the care it provides and increase care coordination while containing growth.

ACOs that use APRNs and other nurses to the full extent of their education and training in such roles as health coaching, chronic disease management, transitional care, prevention activities, and quality improvement will most likely benefit from providing high-value and more accessible care that patients will find to be in their best interest.

The concept of a medical home was first developed by pediatricians in the late s AAP, Medical homes play a prominent role in the ACA, but the law is not consistent in its terminology for them. The latest phase of the broader nursing strategy at the VA, for example,. Previously, primary care providers physicians and NPs at the VA felt that they were not receiving enough professional support to do their jobs effectively. The new strategy calls for including staff nurses on the primary care teams.

The case study in Box illustrates how the medical home concept is being applied in the VA health system. CHCs have a long track records of providing high-value, quality primary and preventive care in poor and underserved parts of the United States. Many also offer dental, mental health, and substance abuse and pharmacy services as well. CHCs generally are very team oriented and depend on nurses to deliver services. Nurses provide primary care, preventive services, and home visits, and many serve in administrative and leadership positions. CHC patients are less likely to have unmet medical needs, visit the emergency department for nonurgent care, or need hospitalization relative to the general population.

W hen a veteran with diabetes who was experiencing hyperglycemia visited the Overton Brooks VA Medical Center in Shreveport, Louisiana, a nurse practitioner NP made adjustments to his medications. But that visit was different from others he had made: An NP made further medication adjustments, and Ms.

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Rasmussen called again in 2 weeks. Rasmussen has been a primary care nurse with the U. Department of Veterans Affairs VA for more than 12 years, and until recently, she said, she would not have had the time to make those followup calls; her caseload would have been too high. The PCMH is not a new concept. Four decades after the American Academy of Pediatrics developed the concept of a medical home, however, its meaning has evolved.

The patient is necessarily at the center of decision making. We realized that we needed to dedicate additional services to being patientcentered, or what I prefer to call patient-driven—really engaging patients in shared decision-making, developing a plan of care that is based on their informed decisions and their individual preferences.

Department of Veterans Affairs. The RN care manager works with others on a four-person team—including a primary care provider a physician or an NP and support staff—to help veterans better manage their illnesses and coordinate transitions in care, such as hospital admission. At the VA, the clinical nurse leader oversees the care provided by more than one team, while the RN care manager focuses on the care provided by just his or her team.

Now, she said, they visit a veteran in the hospital. As the name implies, they are run by nurses—although many employ physicians, social workers, health educators, and outreach workers as members of a collaborative health team. The majority of NMHCs are affiliated with a nursing school and about half with a community-based nonprofit organization King and Hansen-Turton, NMHCs report that their clients make 15 percent fewer emergency department visits than the general population, have 35—40 percent fewer nonmaternity hospital days, and spend 25 percent less on prescriptions NNCC, The case study presented in Box shows how an NMHC worked with community leaders to reduce health disparities in an underserved poor neighborhood in Philadelphia.

There is perhaps no greater opportunity to transform practice than through technology. Information technology has long been used to support billing and payments but has become increasingly important in the provision of care as an aid to documentation and decision making. Diagnostic and monitoring machines have proven invaluable in the treatment of cancer, heart disease, and many other ailments. Since that report was published, the expanded use of online communication has resulted in so-called telehealth services that are not limited to diagnosis or treatment but also include health promotion, follow-up, and coordination of care.

Delivery of telehealth services has, however, like that of APRN services, been complicated by variability in state regulations, particularly whenever online communications cross state lines. ARRA strengthened standards for maintaining the privacy and security of health information. ARRA provided grants to help state and local governments as well as health care providers in their efforts to adopt and use HIT. The meaningful use objectives will likely continue to be refined but outline core requirements that should be included in every EHR. By adopting these recommendations, users will be eligible for federal incentive payments and will be able to report information on the clinical quality of care.

States can add or modify additional objectives to this definition for their Medicaid programs CMS, A recent article in the New England Journal of Medicine summarizes the meaningful use criterion as follows: Given the nature of patient data collection, nurses will be integral to proper collection of meaningful use data. As EHRs become more refined and integrated, nurses will have the opportunity to help define additional meaningful use objectives.


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Care supported by interoperable digital networks will shift in the importance of time and place. Remote patient monitoring is expanding exponentially. An ever-growing array of biometric devices e. Some of these devices can also provide direct digitally mediated care; the automated insulin pump and implantable defibrillators are two examples.

The implications of these developments for nursing will be considerable and as yet are not fully understood Abbott and Coenen, It is not clear. L isa Scardigli, age 44, has suffered periodically from spasticity, a symptom of the multiple sclerosis she has lived with for more than 20 years. She had been receiving physical therapy at 11th Street Family Health Services in Philadelphia when she had a pump implanted for spinal infusion of a drug that reduces spasticity.

I was actually missed. And that may have something to do with the fact that it is run by nurses. This nurse-managed health center provides primary care and other services in a neighborhood in North Philadelphia where most of the 6, residents are African American, have low incomes, and are medically underserved. Nurse practitioners NPs and social workers make up teams that are augmented as needed by physicians, nutritionists, and others.

I describe the center as a healthy-living center. And that is what the residents wanted. From there, she met with area representatives to discover their visions for the community. A community advisory board was formed, and the search for funding began. Over the years the center has received funding from federal, state, and private sources. For example, behavioral health care has been incorporated into every primary care visit, with NPs and social workers closely collaborating.

The range of services provided is remarkably diverse. Scardigli undergo physical therapy. Patients with diabetes join cooking classes that make use of locally grown produce. First-time mothers receive home visits through the Nurse—Family Partnership. Six to eight mother—infant pairs meet through the Centering Parenting program.

A fitness center with a fulltime personal trainer is on site, full dental care is available, and chronic illness management groups provide peer support. Unpublished outcome data for patients with diabetes show that in an month period, the proportion who had glycosylated hemoglobin levels below 7 percent doubled and that low-density lipoprotein cholesterol and blood pressure levels fell as well.

Also seen were reductions in depression and low-birth-weight infants and increases in immunization and breast cancer screening. A nurse at 11th Street Family Health Services uses the food pyramid to educate patients about a healthy diet. Lisa Scardigli is so impressed by all the center does that she now sits on the community advisory board. Recently, she brought in a neighbor of hers who needed new dentures.

That is, for this proportion of care, nurses need not be in the same locale or even the same nation as their patients. As new technologies impact the hospital and other settings for nursing services, this phenomenon may increase. HIT will fundamentally change the ways in which RNs plan, deliver, document, and review clinical care. The process of obtaining and reviewing diagnostic information, making clinical decisions, communicating with patients and families, and carrying out clinical interventions will depart radically from the way these activities occur today.

Moreover, the relative proportion of time RNs spend on various tasks is likely to change appreciably over the coming decades. While HIT arguably will have its greatest influence on how RNs plan and document their care, all facets of care will be mediated increasingly by digital workflow, computerized knowledge management, and decision support. In the future, virtually every facet of nursing practice in each setting where it is rendered will have a significant digital dimension around a core EHR. Biometric data collection will increasingly be automated, and diagnostic tests, medications, and some therapies will be computer generated and managed and delivered with computer support.

Patient histories and examination data will increasingly be collected by devices that interface directly with the patient and automatically stream into the EHR. Examples include automated blood pressure cuffs, personal digital assistant PDA —based functional status, and patient history surveys. In HIT-supported organizations, a broader array and higher proportion of services of all types will be provided within the context of computer templates and workflows.

There will likely be greater opportunities for such interventions as counseling, behavior change, and social and emotional support—interventions that lie squarely within the province of nursing practice. Adoption of HIT is expected to increase the efficiency and effectiveness of clinician interactions with each patient and the target population. HIT will lead to greater efficiency if it takes less time for a clinician to provide the same unit of service or if a lowercost clinician practicing with extensive HIT support can deliver the same type of care as a higher-cost non-HIT-supported provider.

Controlled time and motion studies that have compared clinicians performing the same task with and without HIT support have produced mixed findings on time efficiencies gained across clinicians and settings. One area with emerging evidence is hospital nursing time spent in documentation, with studies showing a 23—24 percent reduction Poissant et al. On the other hand, these efficiency gains may be partially offset by the information demands of quality improvement initiatives and similar programs undertaken by a growing number of institutions DesRoches et al.

According to a review of the literature conducted for the committee, although research on the impact of HIT on the quality of nursing care is limited, documentation quality and accessibility generally improve after the implementation of HIT. Medication errors almost always decrease after the implementation of bar code medication administration Waneka and Spetz, No differences were found in time spent on patient care activities for nurses in hospitals with and without minimally functioning systems. Technology is also used to measure patient outcomes, with varying results.

While measuring outcomes is critical to the provision of 21st-century health care, complications have developed in ensuring that outcome measures from different institutions and organizations are, in fact, comparable. Even ensuring that outcome measures from different parts of the same organization are comparable can be problematic.

They found that variations in the way information was entered in the EHRs accounted for significant variations within the institution and could be responsible for as much as a fold difference in outcome measures among hospitals Kahn and Ranade, A longitudinal study of hospitals found that those that had implemented more advanced EHR systems over the time period had higher costs and increased nurse staffing levels Furukawa et al.

Patient complications increased in these hospitals, while mortality for some conditions declined. It should be noted, however, that these results may be difficult to interpret because of the implementation of minimum nurse staffing regulations at the same time that the implementation of EHRs ramped up. During that time, nurse staffing rose, and thus costs per patient rose, and if there is any correlation between implementation of EHRs and increased nurse staffing due to the ratios, the results may confound the two.

In addition, the study did not control for hospital ownership e. Finally, a systematic review of the literature fewer than 25 articles showed that the time spent on documentation of care may increase or decrease with EHRs Thompson et al. Furthermore, interoperable EHRs linked with personal health records and shared support systems will influence how these teams work and share clinical activities.

It will increasingly be possible for providers to work on digitally linked teams that will collaborate with patients and their families no longer limited by real-time contact. Similarly, many types of care previously provided by physicians and other highly trained personnel can be provided effectively by APRNs and other specialty trained RNs. Increasingly, technology is allowing nurses and other health care providers to offer their services in a wider range of settings.

For example, the ability of the Visiting Nurse Service of New York to tap into mobile technology, as described in Chapter 2 , allowed that organization to provide ever more complex care in the home setting IOM, a. As the largest segment of the health care workforce with some of the closest, most sustained interactions with patients, nurses are often the greatest users of technology.

In many instances, they may know what will work best with regard to technological solutions, but they are asked for their opinions infrequently. Studies show that involving nurses in the design, planning, and implementation of technology systems leads to fewer problems during implementation Hunt et al. Nurses have also invented new technology to help them care for their patients.

For instance, Barbara Medoff Cooper, professor in pediatric nursing and director of the Center for Biobehavioral Research at the University of Pennsylvania School of Nursing, developed a microchip device that is situated between the nipple and the rest of the baby bottle. Another effort, called TelEmergency, brings a certified emergency room physician to 12 rural hospitals in Mississippi from the University of Mississippi via a T-1 line, but only when needed.

The system is managed by a group of 35 APRNs who provide care in these rural communities, including management of the technology as a referral system. The case study in Box shows how nurses at one institution are working to ensure that they spend their time in patient care and not on the technology associated with delivering modern health care. The nursing profession has evolved more rapidly than the public policies that affect it.

Evidence does not support the conclusion that APRNs are less able than physicians to provide safe, effective, and efficient care Brown and Grimes, ; Fairman, ; Groth et al. The roles of APRNs—and the roles of all nurses—are undergoing changes that will help make the transformative practice models outlined at the beginning of this chapter a more common reality. Such changes must be supported by a number of policy decisions, including efforts to remove the existing regulatory barriers to nursing practice. If the current conflicts between what nurses can do based on their education and training and what they may do according to state and federal policies and regulations are not addressed, patients will continue to experience limited access to high-quality care.

While medicine and a number of other professions enjoy practice regulations that are comparable across states, this goal has been elusive for nurses, particularly those working in advanced practice. With the availability now of a consensus document that offers agreed-upon standards for APRN education, training, and regulation, states that have been reluctant in the past may move toward broader scopes of practice. Such a move, however, considered by the committee to be a critical one, is not guaranteed.

And while the committee defers to the rights of states to continue their regulation of health. The primary reason the federal government has a compelling interest in state regulation of health professionals is the responsibility to patients covered by federal programs such as Medicare and Medicaid. If access to care is hindered, if costs are unduly high, or if quality of care could be improved for these millions of patients through evidence-based changes to the ways in which professionals may practice, the federal government has a right to explore the options and encourage change.

Certain federal entities may both defer to the states in adopting their own practice regulations and encourage the adoption of regulations that are consistent with current clinical evidence and comparable across the country. Congress, CMS, OPM, and the FTC each have specific authority or responsibility for decisions that either must be made at the federal level to be consistent with state efforts to remove scope-of-practice barriers or could be made to encourage and support those efforts.

While no single actor or agency can independently make a sweeping change to eliminate current barriers, the various state and federal entities can each make relevant decisions that together can lead to much-needed improvements. Moreover, an important priority in national health care reform is achieving better value for the expenditures made on health care services.

Since health care is labor intensive, getting more value from the health care system will depend in large part on enhancing the productivity and effectiveness of the workforce. Nurses therefore represent a large and unexploited opportunity to achieve greater value in health care.


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The committee believes that any proposed changes in the responsibilities of the nursing workforce should be evaluated against their ability to support the provision of seamless, affordable, quality care that is accessible to all. In particular, the committee argues that now is the time to finally eliminate the outdated regulations and organizational and cultural barriers that limit the ability of nurses, including APRNs, to practice to the full extent of their education, training, and competence.

The committee also believes that nurses must be allowed to lead improvement and redesign efforts see Chapter 5. Specifically, in order that all Americans may have access to high-quality, safe health care, federal and state actions are required to update and standardize scope-of-practice regulations to take advantage of the full capacity and education of nurses.

Cultural and organizational barriers should also be eliminated. States and insurance companies must follow through with specific regulatory,. I n January a California hospital was fined for the death of a man whose cardiac alarm had been set to an inaudible level; when his heart stopped, the emergency room nurses were unaware of it and failed to intervene California Department of Public Health, That same month a man died in a Massachusetts hospital after his heart rate declined over a minute period; nurses did not hear his cardiac alarm, investigators found, and a second alarm had been turned off McKinney, Nurses attend to a variety of alarms and alerts during a shift, and there is often no system in place for prioritizing urgency.

The problem has been shown to pose a danger to patient safety Graham and Cvach, , as have problems with clinical alarms in general ACCE Healthcare Technology Foundation, This system has replaced pagers and many bedside alarms, with promising results. Timely, Accurate Messag ing. The nurse can glance at the device, see that the alert is red, and reply immediately, eliminating several problems with overhead paging systems: The bed unit employs nine registered nurses RNs on the day shift and nine on the night shift and has been testing a variety of devices for more than 2 years.

Staff were involved from the beginning, Ms. Pileggi said, and everyone, including aides, received training from Emergin. An Investment in Safety. Use of the BlackBerry devices has cut the number of overhead pages on the unit by more than half. Nurses report less alarm fatigue and faster response times to alarms, and they receive critical laboratory values 10 minutes sooner under the new system than under the old one. Darren Dworkin, chief information officer for Cedars-Sinai, said the initial costs of purchasing the devices and training the staff have paid off in more efficient and safer care.

Los Angeles hospital Cedars-Sinai is a leader in using mobile devices for text message patient alerts and notifications. Few manufacturers are designing technologies with nurses in mind, and limitations of the available technology have meant that not all ideas for improving processes can be tested. For example, the unit could not incorporate IV pump alarms into the most recent test. Still, bedside nurses and patients are quite pleased. The nurses are looking forward to a test of iPhones, which will display cardiac rhythms on screen. The education and training of nurses support their ability to offer a wider range of services safely and effectively—as documented by numerous studies.

And nurses must respond to the challenge, reinventing themselves as needed in a rapidly evolving health care system. Nursing is, of course, not the only profession to confront the need to transform itself in response to new realities; similarly disruptive challenges have been faced in other fields, such as medicine, health care, publishing, education, business, manufacturing, and the military.

To facilitate the most effective transition to team practice, as well as practice that encompasses the full extent of their scope, all providers will require continual teaching and learning to facilitate the highest level of team functioning see Chapter 4. Going forward under the ACA and whatever reforms may follow, the health care system is likely to change so rapidly that building the adaptive capacity of the nursing workforce to work across settings and in different types of roles in new models of care will require intentional development, expanded resources, and policy and regulatory changes.

Therefore, the committee concludes that nurse residency programs should be instituted to provide nurses with an appropriate transition to practice and develop a more competent nursing workforce. White paper on the education and role of the clinical nurse leader. The essentials of baccalaureate education for professional nursing practice. Enhancing diversity in the nursing workforce. Nursing faculty shortage fact sheet. The aging of full-time U. Distance emergency care using nurse practitioners. The Harambee Nursing Center: Community-based, nurse-led health care. AARP policy supplement: Scope of practice for advanced practice registered nurses.

Physician-nurse practitioner restrictive collaboration requirements by state map. Globalization and advances in information and communication technologies: The impact on nursing and health. Nursing Outlook 56 5: A health insurer pays more to save. New York Times , June Impact of clinical alarms on patient safety. Nurse workforce challenges in the United States: Education policy initiatives to address the nurse shortage in the United States.

Health Affairs 28 4: The AMA scope of practice data series: The scope of practice of nurse anesthetists. Comparison of quality of care for patients in the Veterans Health Administration and patients in a national sample. Annals of Internal Medicine The timing of physiologic maturation of premature infants. Outcomes of a one-year pilot program. Journal of Nursing Administration 31 Bridging the gap between school and workplace: Developing a new graduate nurse curriculum. Journal of Nursing Administration 34 A call for radical transformation.

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New England Journal of Medicine 6: Current problems and proposed solutions. Health Affairs 29 5: The business case for TCAB: Estimates of cost savings with sustained improvement. American Journal of Nursing Smart technology, enduring solutions: Technology solutions can make nursing care safer and more efficient. Journal of Healthcare Information Management 22 4: The Permanente Journal 12 1: Her interests include creative approaches to teaching in online learning as a complementary form of education and international collaboration. Shirley is a co-founder of the European Academy of Caring Science www2.

Bach, Shirley Nurse sensitive patient outcomes In: Learning Matters, Exeter, UK. Bach, Shirley and Grant, Alec Communication and interpersonal skills for nursing 2nd. Albarran, John , Rosser, E. Bach, Shirley Exploring the development of a model of cultural care for European caring sciences In: Bach, Shirley Learning skills for nursing students [Edited Collections].

Bach, Shirley Medicines management in children's nursing [Edited Collections]. Bach, Shirley Nursing in partnership with patients and carers [Edited Collections]. Bach, Shirley Successful practice learning for nursing students [Edited Collections]. Bach, Shirley What is nursing?

Exploring theory and practice 2nd. Bach, Shirley Nursing and collaborative practice [Edited Collections]. Bach, Shirley Conflict of value or commercial sense: Bach, Shirley Evaluation of Easycare training programme. A five centre European centre project In: Bach, Shirley Finding the match: Bach, Shirley Medicines management in adult nursing [Edited Collections]. Bach, Shirley Passing calculations tests for nursing students [Edited Collections]. Bach, Shirley Evaluation of the training programme for the use of the Easy-care assessment method as part of the Standardcare Project In: Bach, Shirley Evaluation of the training programme for the use of the easy-care assessment method as part of the Standardcare project Journal of Nutrition, Health and Aging, 13 Supplement 1.

Bach, Shirley Development of a European academy of caring science In: Bach, Shirley Development of caring science and evidenced based care - European academy of caring science In:

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