The nursing profession must be transformed in terms of practice, education, and leadership to fulfill its role in the delivery of U.S. healthcare. The IOM report addresses nursing at all practice levels, with the greatest emphasis on advanced practice. The report identifies barriers, describes new structures and opportunities, and provides an overall specific vision regarding the vital contribution of advanced practice nurses (APNs) to the healthcare system.
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Making the case for practicing at highest education, training
The report offers three examples of how utilizing nurses' full potential has already resulted in higher quality care and care delivered with higher value. By "expanding and re-conceptualizing the roles of nurses," we can achieve positive results with respect to quality, access, and value by maximizing the scope of nursing practice relative to training and education.1 Marilyn Chow, vice president of the Patient Services Program Office at Kaiser Permanente, is quoted in the report as saying, "The future is here, it is just not everywhere."1 The Department of Veteran's Affairs (VA), the Geisinger Health system, and Kaiser Permanente are used as examples of care delivery organizations that maximize nursing scope of practice. These organizations implemented programs that resulted in "real-world evidence" of how nurses practicing at the highest levels of their scope of practice can positively impact patients and the system as a whole.
The transformation of the VA from a hospital-based system into a primary care-focused organization is based on the maximization of nurse practitioners (NPs) as primary care providers (PCPs). NPs at the VA practice across the continuum within a culture of professional collaboration. As a result, by 2007, VA patients experienced higher quality and significantly lower-cost care compared with similar Medicare populations. The private nonprofit Geisinger is noted in the report as an organization that transitioned from a high-cost, specialty-focused medical facility to an organization of high value. Geisinger's vision includes "having staff work up to the limit of their license" and to "redistribute caregiving work to increase quality and decrease cost."2 Under this model, nurses in call centers shifted to primary care sites and established relationships with patients and families, resulting in the creation of more effective care plans, thus reducing hospitalizations. Additionally, Geisinger created its own NP-staffed convenient care clinics.
Kaiser is noted for its experimentation with nurses' roles to improve quality and patient satisfaction, and to lower costs. The organization established the discharge nurse role, which has full authority over the discharge process from acute care through home care, hospice, or palliative care. Positive outcomes include increasing the number of discharged patients who see a home health provider within 24 hours of discharge from 44% to 77%. Other innovations at Kaiser include the use of general RNs and LPNs in clinic settings to provide healthcare coaching and education for patients with chronic conditions such as congestive heart failure, diabetes, depression, and hypertension. RNs provide care management-related services within the primary care setting.
Barriers to transforming practice
The report discusses in detail the numerous "historical, regulatory, and policy barriers" that have limited "nurses' abilities to contribute to widespread transformation."3 The barriers preventing APNs from working up to their full education and training are especially limiting in the overall transformation strategy and justify the report's emphasis. These barriers include regulatory restriction to expanding scope of practice, professional resistance to expanded roles, fragmentation of the healthcare system, and outdated insurance policy and regulations.
1. Regulatory restriction: Scope-of-practice regulations are generally overly restrictive and vary substantially from state to state. Although some states are certainly more favorable than others, scope-of-practice issues remain a concern for all APNs, including certified registered nurse anesthetists (CRNAs), NPs, and clinical nurse specialists.4
The report notes that as early as 1985, an analysis by the Office for Technology Assessment showed that NPs "safely and effectively provided more than ninety percent of pediatric primary care services and seventy-five percent of general primary care services," and CRNAs could provide 65% of anesthesia services.5 However, regulations that define scope of practice vary widely by state limitations to practice, and may be embodied in the statutes or in the subsequent regulations, which may be open to interpretation. Although 14 states and the District of Columbia impose no restrictive requirements on NPs, the majority of states require at least some level of collaboration agreement for nurses to diagnose, treat, and prescribe. Some sites have specific requirements for "on-site physician oversight, chart review, or maximum ratios for physicians to APNs."6
The report provides a detailed list of examples of APN restriction found in various states. Examples include:
* A nurse may not examine or certify for worker's compensation, school physicals, do-not-resuscitate orders, or disability benefits.
* A nurse may not order diagnostics and labs or make a referral for occupational or physical therapy, durable medical equipment, or respiratory therapy except by a physician-approved protocol.
* A nurse may not treat chronic pain, examine new patients, set simple fractures, suture a laceration, perform abortions or sigmoidoscopies, admit patients to a long-term-care facility, or provide anesthesia services unless supervised by a physician.
* A nurse may not have his or her name on a prescription label as the prescriber, accept or dispense samples, prescribe specific medications, prescribe controlled substances with his or her own DEA number, or admit or attend patients in hospitals.7
Regarding compensation, nurses are restricted from being empanelled as PCPs for Medicaid- or Medicare-managed care, or worker's compensation. Additionally, APNs are paid at reduced rates by Medicaid, Medicare, and other providers, and are often unpaid for services unless supervised by a physician. APNs' prescriptions often aren't covered by insurance unless the collaborating physician's name is on the prescription, and hospitals aren't compensated for APN teaching of medical students as they are for medical students and physician residents.
2. Professional resistance: The IOM report documents in detail the organized, systemic, and long-standing physician resistance, and general opposition, to role expansion of APNs. Specifically, the Scope of Practice Partnership (SPP), an alliance of the American Medical Association and six specialty physician associations, has been an active lobbying force against APNs and other midlevel providers since 2000.8 The SPP has lobbied against any role expansion at the state and federal levels and serves as a clearinghouse and advocacy center for its member organizations in efforts to limit the APN role. The SPP has supported legislation such as the American Academy of Family Physicians' Health Care Truth and Transparency Act of 2010, which aims to prohibit misleading and deceptive advertising or representation of healthcare professionals' credentials and training. If passed, this bill would've restricted the use of the title "doctor" and further restricted states from expanding the APN role.
3. Fragmentation of the U.S. healthcare system: This splintering has been well described in the literature, and numerous highlights are noted in the IOM report. The system is characterized by multiple series of disconnects between patients and providers, public and private services, providers or different disciplines, what patients need and how providers are trained, the need for acute care versus chronic care, and patients with insurance versus the uninsured.9 Reimbursement structures that favor acute care physicians and hospital care tend to adversely impact NP reimbursement.
4. Outdated insurance practices: Insurance company reimbursement practices may be more restrictive than the practice act or even the Medicaid policies in a particular state.10 In Massachusetts, for example, private insurers wouldn't extend PCP privileges to APNs as provided by the state's Medicaid program. Nurse managed-health centers currently qualify for coverage though Medicare and Medicaid, yet insurance companies generally don't recognize APNs as PCPs, which results in nonavailability of this important resource to the privately insured. RNs are prohibited from managing the organization by The National Committee for Quality Assurance, the agency that accredits patient-centered medical homes. Without this public recognition, nurse-led medical/health homes can't qualify for insurance reimbursement.
Nursing workforce-related issues
High turnover rates; difficulties associated with transition into practice; the aging of the nursing workforce; and limited racial, ethnic, and gender diversity are workforce-related issues that negatively impact the overall health system and outcomes. High turnover rates are cited in the report as a destabilizing element in the U.S. nursing workforce. Drawing heavily on the Health Resources and Services Administration (HRSA) surveys and some private workforce studies, the report identifies many specific destabilizing trends.11 Nursing retention is negatively affected by nurses retiring, or leaving the profession for personal reasons or for other opportunities. In a 2008 HRSA survey, almost 25% of nurses expressed the intent to leave the profession within 12 months, and another 16% expected to leave within 3 years.
Turnover with respect to new graduate RNs is addressed within the report, with citations from numerous national reports and initiatives to address this long-standing issue. Since 2002, The Joint Commission has recommended nurse residency programs "to provide planned, comprehensive periods of time during which (new graduates) can acquire the necessary knowledge and skills" required for effective practice.12 Benner's 2009 Carnegie study on nursing is cited for its support of nurse residency programs.13 In fact, the Carnegie study, the first comprehensive nursing education study in over 30 years, proposes extensive and fundamental changes in our preparation of nurses for practice. The American Association of Colleges of Nursing has adopted accreditation standards for postbaccalaureate residency programs, and the National Council of State Boards has recommended transition programs based on its transition to practice regulatory model.14 Residency programs are only one component of the comprehensive transition model. The IOM report recommends expanding the residency programs, in general, and also developing programs outside acute care to include community-based and long-term-care settings.
The report draws from HRSA data and studies by Buerhaus to demonstrate the severity of the aging problem with respect to the nursing workforce.15,16 Older middle-aged nurses represent almost 75% of the nursing workforce, and less than 26% are age 34 or younger. The demand for nurses resulting from increased retirements, reductions in hours of older nurses, and increased demand for nursing due to the higher percentages of older patients is likely to not be offset by a commensurate increase in supply. The report recognizes that the percentage of men has remained largely unchanged since 1981, with men comprising just over 7% of all nurses. No specific recommendations or strategies are identified to address gender inequality. Finally, the aging nursing workforce and limited ethnic diversity are cited as additional examples of issues that negatively affect our healthcare system.
New structures and opportunities
The Accountable Care Act (ACA) provides several major opportunities for nurses in new and expanded roles. The report discusses four current initiates designed to address and overcome barriers and challenges previously identified.17 Accountable care organizations (ACO), the medical/health home, the community health center (CHC), and nurse managed health centers (NHMCs) are identified in and discussed in detail. ACOs are legally defined entities that allow healthcare organizations, providers, and insurers to share financial risk and rewards to provide quality care at fixed or bundled prices. ACOs are now permitted by the ACA and are receiving serious attention by healthcare organizations. ACOs are positioning themselves in the redefined healthcare marketplace, designed to shift the primary emphasis from fee-for-service for the acute and chronically ill to shared savings or capitalized payments for improved quality care at lower overall costs through effective care management and increased care coordination across the continuum. APNs can easily be used to the fullest extent of their education and training in roles such as health coaching, chronic disease management, transitional care, and health prevention. ACOs will likely maximize the use of APNs to meet the lower cost targets.18
Medical homes are indentified in the report as a concept that began in pediatrics over 40 years ago to create a single place to house all of an individual child's records of care.19 This consolidation was deemed especially important in the care of special needs children, who often use multiple clinicians and services. Since the late 1960s, however, the medical home has evolved to include primary care practice, in general, resulting in organizational models that allow for the coordination and provision of comprehensive care based on strong relationships between the patient and provider. The ACA forwarded the concept by referring to medical home, health homes, and primary care medical homes. In general, the ACA encourages medical/health homes to be community-based interprofessional teams that include physicians, nurses, and other healthcare professionals.
CHCs also have a long-standing, successful history of providing high-value primary care to poor and underserved populations. As of 2009, 20 million patients receive care at CHCs in 2,500 communities.20 CHCs have enjoyed significant federal support over the years, including an additional $11 billion in funding through the ACA. Nurses are well positioned in CHCs to provide primary care, preventive services, home visits, and administrative leadership for the centers.
The ACA has also authorized increased funding for NMHCs, another long-standing, successful model for delivering primary care to underinsured and uninsured populations. Over 250 NMHCs provide care to over 1.5 million people in centers predominantly affiliated with a nursing school or a community-based nonprofit organization. Often started with HRSA need grants, this model has demonstrated that patients managed within an NMHC environment experience significant reduction in ED visits, hospital days, and prescription drug use.
Transforming practice with technology
Drawing on previous IOM reports, the Future of Nursing Report explores information technology (IT) as related to the provision of care and as an aid to documentation and decision making. Effective collaboration among and between multiple disciplines will require successful integration of information systems. Restructured teams with nurses at the forefront will be facilitated by expanded use of IT applications such as mobile workstations for visiting nurses, remote biometric monitoring of patients, and streamlining of current processes related to medication reconciliation, giving or receiving reports, and planning care.
Telehealth is recognized as a modality with potential and promise, yet is complicated by the variability in state regulations, especially when online communication crosses state lines. TelEmergency is a system led by APNs in a 12-hospital consortium in rural Mississippi, in which board-certified emergency medicine physicians are brought in as needed for patient care. The APNs have successfully managed 60% of the patient-care needs.20
The report cites studies that identified the value of including nurses in the design, planning, and implementation of healthcare IT systems. Including nurses in every stage of IT projects leads to more robust systems and fewer problems during implementation. The Technology Informatics Guiding Educational Reform is a collaborative effort of over 1,400 nurses from numerous organizations working together for transparent use of technology in practice.21
Look to the evidence
In the conclusion of the Transforming Practice chapter, the report summarizes the argument that "the ability of nurses to better serve the public is hampered by the constraints of outdated policies," particularly rules and regulations at the state and federal levels that limit the scope of APNs.22 The report calls for the consideration of the current evidence that nurses, including APNs, are able to provide safe, high-quality care without the need for physician supervision.23 Such consideration will lead to adoption of practice acts based on agreed-upon standards for APN education, training, and regulation.