1. Adams, Jeffrey M. PhD, RN, NEA-NC, FAAN


This department highlights emerging nursing leaders who have demonstrated leadership in advancing innovation and patient care in practice policy, research, education, and theory. This interview profiles Alex Hoyt, assistant professor at Massachusetts Institute for Health Professions


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Adams: Hello, Dr Hoyt. Can you talk a little about yourself, your career, and influence trajectory?

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Hoyt: I have had a nontraditional path in nursing. My bachelor's degree was in sociology, and I went from college right into the direct-entry nurse practitioner program at the MGH Institute of Health Professions. I practiced as a family nurse practitioner in Rockport, Massachusetts, and then in a nurse-managed primary care practice that was part of the Penn Nursing Network at the University of Pennsylvania. My PhD is in social policy from the Heller School at Brandeis University. Currently I am on the faculty at the MGH Institute of Health Professions, where I teach policy and economics. My influences are found throughout my career path. As an undergraduate, Kent Maynard ignited my interest in studying healthcare systems; in graduate work, Linda Andrist illuminated the history of nursing ideas, and in my doctoral study, Stuart Altman's intellectual DNA is found in the way I think about cost, quality, and access and the value of objectivity in health policy research.


Adams: Your education and experiences do span boundaries, can you speak to this?


Hoyt: I think it is helpful for nurse leaders to hear from boundary spanners. I have aimed to have one foot in nursing and one foot in policy and show that you don't need to do the splits to accomplish this. I hope that my teaching and research expand perspectives and help nurses to anticipate the changes that policy will have on their practice.


Adams: Can you speak a little more about your work across policy, practice, education, research, and theory?


Hoyt: My scholarship is focused on the role and utilization of advanced practice providers (nurse practitioners, nurse midwives, and physician assistants) and the multilevel policymaking process governing their work. In particular, I think there is opportunity to further define the measurement of scope of practice. States set a boundary in the form of scope of practice statutes and regulations. Organizations set policies within the state's boundary through privileging and credentialing. Practices set policy by making resources available and establishing rules about who does what work. In theory, scope of practice can't be any more expansive than the level above dictates. In reality, organizations and practices may find workarounds or comply with statutes only on paper. Conversely, organizations may chose a limited role for advanced practice providers based on financial incentives, social pressures, or clinical concerns. Policy set at the state, organization, and practice level has impact on workforce and health outcomes. I have been purposeful to work across these areas, and I'd like to think that my best work is still ahead of me.


Adams: What would you say is the most prominent issue for nurse administrators?


Hoyt: Any business is striving to deliver a good or service that is faster, cheaper, and better. In healthcare, we call those values access, quality, and cost. The relative importance of each changes from era to era. In the pre-Affordable Care Act era, the pressing issue was access, and we expanded the size of the patchwork we use to provide insurance (eg, Medicaid, subsidies for market plans, etc). In the post-Affordable Care Act era, we were responding to financial incentives to improve quality of care (eg, penalties for readmissions and rewards for better patient experience). In the next era, I think healthcare leaders will be asked to further reduce the costs of care because it threatens the sustainability of gains made in access and quality.


Adams: How best can we prepare the next generation of nurses to lead and advance the profession?


Hoyt: All healthy industries undergo creative destruction. There is no promised-land steady state at which point healthcare will stop recreating itself with new technology, innovative practices, or policy transformations. At a minimum, the next generation of nurses must adapt to changes so their work doesn't become redundant, and their patients receive the best care available. However, the goal is to create a generation who can drive the change from a disease treatment system to a health system. The next generation needs to understand how the current system is organized, financed, and delivered and be encouraged to develop innovations that will promote a culture of health. Achieving a culture of health sounds lovely, but getting there will involve the creative destruction of our present state.


Adams: How do you foresee the development of evidence to increase the influence and visibility of nursing? What is the role of the nursing administrator?


Hoyt: I think true North is expanding access, reducing cost, and improving quality. Nurses should be creating evidence about how to achieve those objectives, and they are critical to transforming the healthcare system. That conversation should be in service of society and not in service of the profession.


Adams: What is one thing you'd like the JONA readers to know/think about?


Hoyt: Policymakers talk about reforming healthcare as if it is 1 thing. But healthcare is not 1 animal-it is a zoo. Another way to clarify this point[horizontal ellipsis] Jonathon Bush, founder of Athena Health, recently observed that healthcare is not one $3 trillion market, but hundreds of billion dollar markets. Healthcare services differ in their efficacy, urgency, and observability of benefit. This means that policy changes impact services lines differently. For instance, efforts to encourage patients to think like consumers make more sense for pregnant women who can predict when they will need services than those with crushing chest pain who need services immediately. Nurses are positioned to communicate with policymakers about the actual impact of policies. They see the range in patients and circumstances and how policies are impacting real life.