Blog
Dec 22, 2009
In 2009, health care reform was the most widely discussed issue in the United States because it affects every single American in every corner of the country. Whatever shape final legislation in Washington might take, we can expect greater numbers of Americans seeking primary and preventative care and, regardless of reform, greater numbers of older Americans seeking care as the baby boom generation matures. Combine these factors with technological and other transformations in health care delivery and it becomes clear that nurses and the nature of the nurse workforce have never been more important.
The U.S. will face a shortage of as many as half a million nurses by 2015; there are roughly 140,000 unfilled nursing positions in hospitals and nursing homes combined; half of all nurses are planning to retire in the next 15-20 years just as a nation of baby boomers will put unprecedented demands on the nation’s health care system. And scores of studies demonstrate that when it comes to hospital patients, the more nurses on staff, the better the health outcomes and the lower the mortality rates—a fact that affects every American family.
But numbers are only part of the story. We know the importance of a nurse workforce with the skills required by a reformed health care system to serve the Americans who will be using it in ever greater numbers. Nurses occupy an increasingly central role on care delivery teams and they can and should have a more prominent role in the delivery of primary and chronic care management. There is abundant evidence that advanced practice nurses provide high quality—and highly affordable—care in areas where no regulatory barriers limiting their practice.
As the health care workers who spend the most time providing medical care, nurses must also have more advanced education and skills. This is why we devote so much attention to ways of expanding nurse education to create a pipeline of new nurses—and nurse educators. Faculty shortages, limited clinical sites and even classroom space resulted in nearly 100,000 applicants being turned away from nursing schools last year—qualified applicants who want to devote their careers to caring and advocating for patients. While there are innovative solutions to the education crunch being implemented around the country, expanding education will most certainly require increased funding. We have worked hard to make this happen.
We believe that every American deserves a highly skilled nurse when and where nursing skills are needed. A richly skilled, effectively integrated nursing workforce—with enough professionals to meet the need—is essential to delivering high-quality health care. We will continue to act as an information resource on health care reform. The Center is collaborating with our AARP colleagues to advance the roles of nurses in increasing access to primary care, transition care and chronic care management in a reformed health care delivery system.
0 comments
Dec 21, 2009
By Brenda Cleary, CCNA Director
As I look back on a very busy year with so many high points, one that especially bears mentioning was the opportunity to serve as the representative from the U.S. at an international policy and research roundtable in Sydney, Australia, in early September. Now I actually got to Sidney by default due to the misfortune of an esteemed colleague, Dr. Marla Salmon, Dean of Nursing at the University of Washington, who suffered a shoulder injury which prevented her from making the trip.
I joined nursing and health care leaders from Australia, Canada, and the UK, including the Chief Nurse of the Commonwealth of Australia and President of the International Council of Nurses, Rosemary Bryant; the Chief Nurse of Canada, Sandra McDonald- Rencz; and representatives of the UK Commission on the Future of Nursing and Midwifery, Commissioner Anne Marie Rafferty and Commission Support Office Joint Lead Jane Salvage. The visit was fully funded by the Worldwide Universities Network, a global research collaboration between 16 universities. Jill White, dean of the University of Sydney’s faculty of nursing and midwifery, hosted the four-day event to explore and develop health policy education and research priorities and strategies. For more information, go to http://www.nursing.usyd.edu.au/news_events/news/roundtable.shtml.
The group concluded that nurses and midwives need to build closer alliances with health care consumers and community groups, which is very consistent with our efforts at the Center to Champion Nursing in America. And they should "plot a course of action" that will serve as a catalyst to champion the need for higher quality, innovative healthcare services.
The group plans to further develop its international nursing policy network at a meeting in 2010. Among other things, it hopes to discuss the UK Commission’s report, due out in March and also follow the work of the Initiative on the Future of Nursing in the U.S.
What did I learn? I learned that a 4-5 day trip to Australia challenges human endurance (but it was so worth it). I learned what it was like to serve as the Chief Nurse of a national health system from colleagues at the roundtable. And I was reminded that nurses share much in common around the globe. Finally, I convinced myself that I could climb the Sydney Harbour Bridge. See the flag on top in the picture—I was there, thanks to arrangements made by my Australian friends and meeting hosts!!
Dec 18, 2009
By Marjorie Beth Henderson, RN, BSN, CHPN
Delicate and frail, the ninety-year-old woman lay quietly in the hospital bed, her shallow breathing barely discernible. Silvery hair framed her kind face where velvety wrinkles had been caressed by many-a-grandchild, and remnants of laugh-lines marked the corners of her mouth.
Shadows of evening had already fallen, and except for soft strains of a favorite song, “Blessed Assurance” playing from the CD, the room was silent. Death seemed imminent, and I tried not to look at the clock. Praying that this dear lady’s family would arrive in time, I gently placed her frail hand in mine. “Miss Elly, I’m still here. I’m going to stay with you until your family comes.”
Her eyelids flickered. I refused to look at the clock. Leaning forward, I caressed her fragile hand. My thoughts were filled with gratitude for Miss Elly’s life and for what she had brought to the world and also were filled with images of the loved ones she would leave behind.
In these moments, I want the world to stop. I try to forget that beyond this room I have other patients in the Hospice House, knowing my co-workers will take care of them. I pray that peace will prevail over pain and surpass all fear and unanswered questions. Nothing is more important than this one precious life and the passing that is taking place. Other pressing nursing duties fall away and priorities re-set themselves.
Without exception, the Hospice nurses I know view their work as not just a job, but a calling. While at work, these nurses place their personal worlds of problems and cares on hold to focus on patients who have six months to live—or six hours. They zero-in on families who face multiple responsibilities and the inevitable void that the absence of this loved one will bring. Along with other members of an interdisciplinary team, Hospice nurses strive to help patients and families “put the pieces together” as their world seems to be falling apart. Patients and families are encouraged to continue meaningful daily living, assisted to complete necessary tasks at hand, and offered support as they ride the emotional roller coaster of acceptance, denial, and life review that can stir up both treasured memories and bitter regrets.
A Hospice nurse’s role is tailored to each patient’s needs—for no family situation is the same and each patient is unique as well. The commonality is that we are all human beings. We are born . . . we live . . . we die. For Hospice patients, death is a process and end-of-life care becomes a major determinant in what their quality of life will be.
One must understand that this “dying process” is on an uncertain timeline that falls into the realm of “living”. In other words, we live until we die.
As a Hospice nurse, my goal is to truly help each of my patients “live until they die” - - to provide compassionate care that promotes the highest quality of life possible until that last breath is taken. May the passing of each person be with dignity, in the circumstances of their choice. And if at all possible—may there be at least one caring person present to hold their hand.
Marjorie Beth Henderson, RN, BSN, CHPN, is on staff at Hospice House, Florence, SC
Editor's note: November was National Hospice/Palliative Care Month, but we wanted to share this compelling account of a day in the life of a hospice nurse.
Dec 11, 2009
Here at the Center to Champion Nursing in America (CCNA), we discuss solutions to the nationwide nursing shortage in terms of "issue areas": skills for the future, education capacity, recruitment and retention, practice and access to care, and leadership. Of special interest to CCNA and AARP is the retention of older nurses in the workforce in ways that are rewarding and meaningful. This residency program at Massachusetts General offers new opportunities to deepen their expertise and redirect their careers. Retooling nurses in geriatric and palliative care also helps meet a fast growing societal need. A very important and timely twofer, as they say, or in other words, an innovative initiative that tackles more than one issue.
With a grant from the U.S. Department of Health and Human Services, Edward Coakley, MS, MEd, MA, RN, created and now directs a six-month residency program for staff nurses aged 45 and older who wish to improve their skills in order to deliver the best possible care to the health system’s geriatric patients. Not only does the RN residency program increase the quality of patient care, it does so by inviting older nurses to contribute their wisdom and experience, a strategy which has proven invaluable to health care institutions and the communities they serve.
The video features two nurses whose experience totals more than four decades and both have committed to extending their careers as a result of the residency program because it empowers them as professionals to not only provide better care, but to champion the needs of their older patients. Coakley and his colleagues agree that geriatric patients often receive unnecessary and disruptive care when what they most need is a patient and family centered plan of care that helps them understand and manage various treatment options in later life.
As strong patient and family advocates and champions, nurses are well positioned to offer that kind of care, and older nurses, with updated skills and a lifetime of experience, are proving to be some of the best providers of the palliative care this growing group of patients needs.
We are pleased to have documented this breakthrough program and showcase it as a model that retains older nurses in the workforce while expanding geriatric care capacity. We enjoyed filming the dedicated nursing professionals in this four minute video, and we hope you’ll take the time to watch it here. Also, we encourage you to view our other videos of nurses addressing access, quality and affordability of health care for all Americans.
Please share these video links with your friends, family, and colleagues.
Nov 30, 2009
By Susan Hassmiller, PhD, RN, FAAN, Director of the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine
Two million registered nurses are at the heart of American’s health care system and make up the largest segment of the health care workforce. Nurses provide care at every phase of life; they tend to coughs and sneezes in school and contractions during childbirth, annual physicals and daily home care.
On December 3rd a forum focusing on nursing in the community will take place in Philadelphia, featuring policy experts and real world practitioners discussing the role of nurses in our transforming health care system. This forum, the Future of Nursing: Community Health, Public Health, Primary Care, and Long-Term Care, is the second of three nationwide forums convened by the Robert Wood Johnson Foundation Initiative on the Future of Nursing at the Institute of Medicine (IOM). Because the year-long Initiative is looking at innovative ways to improve health care quality and address the nursing shortage in the United States, the other two forum topics are nursing across acute care settings and nursing education.
In the Initiative’s ongoing efforts to engage as many people as possible and include their voices, we will webcast the day's panels and accept real time comments from online viewers that will be integrated into the proceedings. We will also have a Twitter feed where people can follow the activities at @FutureofNursing. For the forums, we have been soliciting written comments from interested groups and individuals which will be featured in our panels, and, we are also planning listening sessions, a kind of "open mic" segment during which anyone in the room can offer impromptu thoughts or comments.
The Initiative’s series of public forums are about developing innovative solutions at all levels and engaging a broad array of stakeholders—including the public at large. Nurses work extends far beyond hospitals, and we want consumers to understand that with an increase in the number of well educated nurses, they will have access to a more affordable and higher quality of health care in their communities. We hope everyone reading this will tune in and participate in these forums, and in the evolving policy debates about nursing in the United States.
Susan B. Hassmiller, PhD, RN, FAAN, is Senior Advisor for Nursing, Robert Wood Johnson Foundation and Director, RWJF Initiative on the Future of Nursing, at the Institute of Medicine
Editor's Note: In Philadelphia, 11th Street Family Health Services, Drexel University, provides nurse-led, interdisciplinary health care in a previously underserved area of the city.
Nov 23, 2009
By Robert J. Egge, Alzheimer's Association Vice President of Public Policy
November is National Alzheimer's Disease Awareness Month, which traces its origins to November 1983 when then-President Ronald Reagan first signed a proclamation calling the nation's attention to this disease. Today more than 5 million Americans are living with Alzheimer's—a degenerative fatal brain disease.
Alzheimer's does not just impact the individual; families can also be quickly overwhelmed by the caregiving demands of the disease. There are now nearly 10 million caregivers dealing with the tremendous emotional, financial, and physical toll of caring for a loved one with the disease. With an aging baby boomer population, Alzheimer's is touching more and more American families.
Caring for a person with Alzheimer's or other dementia poses special challenges. Although memory loss is the most widely known symptom, the disease also causes loss of judgment, orientation, ability to understand and communicate effectively, and, frequently, changes in personality and behavior. Individuals require increasing levels of supervision and personal care, often resulting in high levels of stress and depression for caregivers in the family.
Nurses knowledgeable about the unique challenges of Alzheimer's and dementia care will play a critical role in helping patients achieve the best possible health outcomes. Nurses serve as the bedrock of support for families throughout all stages of the disease. Regardless of the setting—hospital, residential, home or community-based—nurses are trusted advisers for families. Their involvement and engagement help to reduce the stress and burden Alzheimer's disease creates. These exceptional nurses are not only trained to care for the complex health needs of their patients, they are immersed and invested in the lives and futures of these families. The importance of these nursing professionals cannot be underestimated.
By 2010, there will be nearly a half million new cases of Alzheimer's diagnosed each year, and nurses are the unsung heroes who will continue to play a vital role in caring for Alzheimer patients. Nurses prepared to deal with the unique challenges of caring for a person with Alzheimer's provide invaluable assistance to the individual and peace of mind for the family. This is why the Alzheimer's Association joins with the Center to Champion Nursing in America in championing the recruitment and education of nursing professionals to meet the demands of managing chronic diseases, such as Alzheimer's.
Nov 19, 2009
By Margaret Flinter, APRN
I was sitting in the Homer Babbidge Library at the University of Connecticut on a gorgeous fall day in 1973 when I read about a new nursing role, nurse practitioners, and how a group of nurse practitioners were making a big difference at a Boston clinic. Note to self: remember this! I went on to graduate with my Bachelor of Science in Nursing in June, and off I went, immersing myself in experiences from rural public health to ICU (in that order!) to genetics, but always still remembering that story about the “new” pediatric nurse practitioners in Boston who were making a difference for their patients.
Later, when I read Dean Donna Diers’s essay on the mission of the Yale School of Nursing—to radically change the American healthcare system—I knew I was headed to Yale. And when I read Health and the War on Poverty by Dr. Karen Davis, now President of the Commonwealth Foundation, I knew my work would be to improve the health of people and communities.
And so I did. The National Health Service Corps took me through a Masters degree at Yale and sent me to the Community Health Center, Inc. (CHC). At that time, in 1980, it was a 10-person neighborhood clinic in the north end of Middletown, Connecticut. I was blessed beyond belief to land in a setting with a brilliant community organizer /entrepreneur/activist, Mark Masselli, and a rock solid family practice physician, Carl Lecce. Much of what I learned about what it means to be a family nurse practitioner—and a primary care provider—I learned in those first few years, building on the lessons of Yale with the experiences of my practice partner, Dr. Lecce. It has been 30 since we began building a truly transformative primary care organization. CHC is now in twelve Connecticut cities, delivering care from well over a hundred locations with a staff of 500 and 70,000 patients.
The thrill—the total pleasure—of taking care of people, of being their primary care provider, of clinical, diagnostic and management challenges, is a feeling I relish. And although I am doing exclusively administrative and policy work right now, I take enormous pride and pleasure in the fact that my CHC colleagues and I started the country’s first formal Nurse Practitioner Residency Training program for new nurse practitioners who, like me and my colleagues, find service to the most vulnerable and underserved populations to be a professional calling.
These days, when I walk down Main Street in Middletown, I still see the patients I took care of over the years. Some were merely a blue spot on a pregnancy test when their mom was my patient. Some now have babies of their own. Some have had terribly, terribly hard lives, and I meet them at Main Street’s soup kitchen or homeless shelter. Sometimes they stop me. “Are you Doctor Margaret?” asked a woman just the other day. (I was Doctor Margaret, our physician, Carl, was Doctor Lecce.) “You took care of me and my sister when we were little girls, my name is Emily.” I remembered her immediately, and much to her surprise, I also remembered her sister, both of their birth weights, their major childhood highs and lows, and their mom. But it didn’t surprise me. Whether we are nurse practitioners, primary care providers or physicians’ assistants we form intensely strong bonds of caring for our patients. We know them in their lives, in their communities over time.
Margaret Flinter, APRN, is Vice President and Clinical Director, Community Health Center, Inc. Middletown, CT and Director, Weitzman Center for Innovation in Community Health and Primary Care, Middletown, CT
Nov 11, 2009
By Diana J. Mason, PhD, RN, FAAN and Julie Sochalski, PhD, RN, FAAN
We are both nurses and we know what good health care looks like. As patients and health care consumers, we seek out practitioners who focus on our whole health and not just disease. For many years we’ve been receiving that kind of care from excellent Nurse Practitioners (NPs) who are in practice with excellent physicians. As health care professionals, we also know that AARP, the national consumer organization representing the interests of Americans aged 50 and up, recognizes the value and contributions of NPs to assuring access to quality health care for the nation’s seniors. Unfortunately, millions of Americans still do not have access to these wonderful health care providers.
NPs are registered nurses with advanced education (master’s degree or higher) and clinical experience who offer a broad range of essential health care services. They diagnose common health conditions, manage chronic illnesses, prescribe medications and, importantly, they help patients promote their own health. In some areas, especially urban and rural communities, NPs are the exclusive providers of primary care, and research shows that their patients’ outcomes and satisfaction are excellent. Over the years, however, barriers to NPs providing these primary care services have arisen for several reasons.
First, states have a variety of regulatory and legal barriers to using them. Some states require that NPs practice under the supervision of physicians, even though it has not been shown to be necessary to ensure good clinical outcomes.
Second, even in states that permit NPs to practice without physician supervision, insurers may refuse to “credential” them, that is, NPs are not listed as approved providers. Instead, these same insurers will credential a physician who is in practice with an NP, pay the physician for the patients seen by the NP, and track the NP’s work and patient outcomes as if the physician had provided the services.
Medicare has also restricted NP practice by limiting their ability to order a variety of services, such as home care. This is particularly ironic since most of home care is nursing care, and an NP is ideally suited to knowing when and why to order such services.
Some of these restrictions rise out of concerns about the quality of NP care, but research has dismissed these concerns. NPs have also been seen as a source of competition to physicians, who sometimes support these regulatory barriers. Given the shortage of primary care providers, however, this is a counter-productive position.
Beyond these restrictions, there is the nationwide problem of inadequate funding for nurse education, a growing shortage of nursing faculty and a resulting bottleneck in the production of sufficient numbers of NPs. One of the major priorities of health care reform in the long run is to shift the focus from acute care to primary care and chronic care management. But every year, fewer medical students are choosing primary care and—as Massachusetts found out after extending health coverage to most of the state’s residents—we cannot meet the expected demand for primary care if we don’t remove the barriers to full utilization of NPs.
Some of the current health reform bills do include NPs in their definition of “providers” and prohibit insurers from refusing to credential them and other health care professionals solely on the basis of their title. These are important steps forward, but much more needs to be done to ensure that health care consumers throughout the country have access to the same excellent care we have.
Diana J. Mason, PhD, RN, FAAN, is the Rudin Professor and Director at the Center for Health, Media, and Policy, Hunter-Bellevue School of Nursing, Hunter College, City University of New York
Julie Sochalski, PhD, RN, FAAN, is an Associate Professor at the University of Pennsylvania School of Nursing and the AARP/American Academy of Nursing (AAN) Fellow in the Center to Champion Nursing in America at AARP
Nov 10, 2009
Lori Melichar, PhD, MA, a labor economist and senior program officer at the Robert Wood Johnson Foundation, writes about attending the second IFN technical workshop, held in Washington DC on November 2, 2009, and identifies a theme running through three different panels: the value nurses add across health care settings. Melichar writes that if we provide incentives for nurses to acquire the education and experience they need and allow them to practice in environments that enable, not hinder effective team work, we will both improve patient care and keep costs down.
This entry was originally published on the Future of Nursing Blog, part of the Robert Wood Johnson Foundation Initiative on the Future of Nursing at the IOM.
Read the full entry here.
Nov 9, 2009
Nurses as Partners in Primary Care
There is an inextricable link between increasing access to health care and nurses, but we don’t hear about it much. Web pages, airwaves and newspapers are filled with reports about health care reform, but rarely about the role of nurses in a reformed health care system.
You know the story. Over the next two decades the U.S. population is projected to grow by 20 percent; those 65 years and older will increase by 79 percent. Additionally, Americans increasingly will experience multiple chronic diseases, placing serious demands on an already stressed health care system. Add to that the potential influx of millions of health consumers into the system and we’re in a pickle. Meeting these demands will become all the more difficult given the significant shortage of primary care providers in the nation’s health care workforce today, and the gloomy projections for the future primary care workforce.
Nurses can be a significant part of the solution, but we’re not fully engaging them as partners in increasing access to care, particularly primary care.
Nurse practitioners already are providing common primary care services to diverse patients in a range of health care settings. They conduct physical exams; prescribe medicine; diagnose and treat common acute illnesses and injuries; provide immunizations; manage high blood pressure, diabetes, and other chronic problems; order and interpret X-rays and other lab tests; and counsel patients on adopting healthy lifestyles and health care options.
Nurses are key partners poised, along with physicians and other providers, to make a significant contribution to serving Americans’ health care needs. But in some states, a number of barriers prevent our access to highly-skilled nurses. While laws in 23 states permit advanced practice registered nurses (APRNs) to practice independently, 20 states require them to practice in collaboration with a physician, and seven mandate physician supervision. All states permit APRNs to prescribe medications, but many impose limits on this authority.
These are significant barriers to care, especially in rural areas where often little to no primary care is available. The Center is beginning to examine these barriers and consider strategies to overcome them. We are a consumer voice for nursing, and that means looking for solutions that increase consumer access to high quality care.
Editor's note: An example of nurses as partners in primary care and how a community benefits can be seen at the 11th Street Family Health Services in Philadelhis, PA.
