Blog
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.
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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.
Nov 2, 2009
“The future is here; it is simply not widely distributed yet.” William Gibson
The number one cause of the bottleneck in nursing education is the faculty shortage. We need more nurses with advanced degrees so that they can become faculty members. And Americans need increased access to nurses with advanced degrees because they are prepared to meet our health care needs. Both faculty and advanced practice nursing roles require at least a master’s degree in nursing. Yet, the majority of practicing nurses (60 percent) enter the profession with an associate’s degree. This level of education, while making an important contribution to the nursing workforce, does not create a strong pipeline for graduate level education.
We must create new collaborations between community college and university nursing programs to produce more Bachelor of Science in Nursing degree (BSN) nurses, who are more likely to go on to receive the additional degrees in nursing. Moreover community college-university collaborations must redefine where nurses receive their clinical education to include learning experiences outside of acute care – in communities, homes and long-term care settings. The Oregon Consortium for Nursing Education (OCNE) has developed a model that accomplishes both objectives.
This month, the Center to Champion Nursing in America sponsored a conference and site visit in Portland, OR, that was designed and implemented by OCNE leaders. Ten other states joined Oregon to share best practices and lessons learned in creating nursing education partnerships between associate degree and baccalaureate programs in order to develop joint admission standards, faculty appointments, shared curricula and other resources with the common goal of increasing the education of the RN workforce. The work is aimed beyond the formal degrees received to the competencies necessary in 21st century health care.
Conferees had rich discussions around the following drivers of change:
- Aspiring nurses need accessibility to all levels of nursing education.
- Consumers need access to nurses at all levels.
- Health care needs of the American people are rapidly changing.
- Building capacity is more than simply increasing the numbers of nurses.
- Better use of scare resources in both nursing education and practice has never been more critical.
In order to ensure that all Americans have a highly skilled nurse when and where they need one, we must reexamine and redesign how nursing education is delivered in this country. Investing in the nursing education infrastructure and in the preparation of more APRNs who are prepared with the advanced skills necessary to provide primary and preventive care, transitional care, chronic care management and other nursing services to meet American’s health care needs are smart solutions.
Editor's Note:
Nursing Education Redesign: Preparing the New Nurse presentations are posted on the OCNE website: www.ocne.org CCNA also commissioned a video of the conference which will soon be available.
