The Future of Nursing Leading Change, Advancing Health (2011) / Chapter Skim
Currently Skimming:
3 Transforming Practice
3 Transforming Practice
Pages 85-162
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 85... ...
Nurses have the opportunity to play a central role in transforming the health care system to create a more accessible, high-quality, and value-driven environment for patients. If the system is to capitalize on this opportunity, however, the constraints of outdated policies, regulations, and cultural barriers, including those related to scope of practice, will have to be lifted, most notably for advanced practice registered nurses.
|
From page 86... ...
THE IMPORTANCE OF TRANSFORMING NURSING PRACTICE TO IMPROVE CARE As discussed in Chapter 2, the changing landscape of the health care system and the changing profile of the population require that the system undergo a fundamental shift to provide patient-centered care; deliver more primary as opposed to specialty care; deliver more care in the community rather than the acute care setting; provide seamless care; enable all health professionals to practice to the
|
From page 87... ...
. Among the many innovations that a versatile, adaptive, and well-educated nursing profession have helped make possible are • the evolution of the high-technology hospital; • the possibility for physicians to combine office and hospital practice; • lengths of hospital stay that are among the shortest in the world; • reductions in the work hours of resident physicians to improve patient safety; • expansion of national primary care capacity; • improved access to care for the poor and for rural residents; • respite and palliative care, including hospice; • care coordination for chronically ill and elderly people; and • greater access to specialty care and focused consultation (e.g., incon tinence consultation, home parenteral nutrition services, and sleep ap nea evaluations)
|
From page 88... ...
2 APRNs include nurse practitioners (NPs) , certified nurse midwives (CNMs)
|
From page 89... ...
1 or more 0.50-0.99 0.25-0.49 0.00-0.24 No primary care MDs in county Data unavailable FIGURE 3-2 Map of the number of physician assistants per primary care MD by county, 2009.
|
From page 90... ...
(%) Primary care physician 55 34 11 Nurse practitioner 57 35 9 Physician assistant 59 34 7 Certified nurse midwife 77 19 4 NOTES: For evaluation and management services, low-complexity services are defined as those requiring straightforward or low-complexity decision making; moderate-complexity services are those defined as requiring a moderate level of decision making; and high-complexity services are defined as those requiring a high level of decision making.
|
From page 91... ...
The following subsections summarize the experience of the VA and Geisinger, as well as Kaiser Permanente, in expanding and reconceptualizing the roles of nurses. Because these institutions also measured outcomes as part of their initiatives, they provide real-world evidence that such an approach is both possible and necessary.
|
From page 92... ...
After adjusting for different mixes of population and demographics, the Congressional Budget Office determined that the VA's spending per enrollee grew by 30 percent from 1999 to 2007, compared with 80 percent for Medicare over the same period. Geisinger Health System The Geisinger Health System employs 800 physicians; 1,900 nurses; and more than 1,000 NPs, physician assistants, and pharmacists.
|
From page 93... ...
11 Personal communication, Marilyn Chow, Vice President, Patient Care Services, Program Office, Kaiser Permanente, August 23, 2010.
|
From page 94... ...
Through this model of care, nurses and pharmacists have become skilled users of health information technology to strengthen the primary care−based, patient-centered medical home. Nurses use disease management registries to work with assigned primary care physicians, and review clinical information that addresses care gaps and evaluate treatment plans.
|
From page 95... ...
. This is true of all RNs, including those practicing in acute care and public and community health settings, but is most notable for APRNs in primary care.
|
From page 96... ...
the tissues of human beings."14 Even more important were corresponding provisions making it illegal for anyone not licensed as a physician to undertake any of the acts included in this definition. These provisions 13 This and the following paragraph draw on a paper commissioned by the committee on "Federal Options for Maximizing the Value of Advanced Practice Registered Nurses in Providing Quality, Cost-Effective Health Care," prepared by Barbara J
|
From page 97... ...
As discussed in Chapter 1 and reviewed in Annex 1-1, APRNs provide services, in addition to primary care, in a wide range of areas, including neonatal care, acute care, geriatrics, community health, and 15 Sociologist Eliot Freidson has aptly characterized this statutory preemption as "the exclusive right to practice" (Freidson, 1970)
|
From page 98... ...
Because APRNs and physician assistants in specialty practice typically collaborate closely with physicians, legal scope-of-practice issues pose limited obstacles in these settings. Variation in Nurse Practitioner Scope-of-Practice Regulations Regulations that define scope-of-practice limitations vary widely by state.
|
From page 99... ...
. No studies suggest that care is better in states that have more restrictive scope-ofpractice regulations for APRNs than in those that do not.
|
From page 100... ...
100 THE FUTURE OF NURSING BOX 3-1* Variation in State Licensure Regulations Several states permit APRNs to provide a broad list of services, such as indepen dently examining patients, ordering and interpreting laboratory and other tests, diag nosing and treating illness and injury, prescribing indicated drugs, ordering or referring for additional services, admitting and attending patients in a hospital or other facility, and directly receiving payment for services.
|
From page 101... ...
101 TRANSFORMING PRACTICE Examination and Treatment A nurse may not: • reat chronic pain (even at the direction of a supervising physician) ; t • xamine a new patient, or a current patient with a major change in diagnosis e or treatment plan, unless the patient is seen and examined by a supervising physician within a specified period of time; • et a simple fracture or suture a laceration; s • erform: p − osmetic laser treatments or Botox injections, c − rst-term aspiration abortions, fi − igmoidoscopies, or s − dmitting examinations for patients entering skilled nursing facilities; or a • rovide anesthesia services unless supervised by a physician, even if she p has been trained as a certified registered nurse anesthetist.
|
From page 102... ...
. Similarly, the roles of NPs in nurse-managed health centers and patientcentered medical homes can be hindered by dated state practice acts.
|
From page 103... ...
Equally important, however, is the federal government's responsibility to all American taxpayers who fund the care provided under these and other programs to ensure that their tax dollars are spent efficiently and effectively. Federal actors already play a central role in a number of areas that would be essential to effective reform of nursing practice, especially that of APRNs.
|
From page 104... ...
or clinic using MD's provider ID Certified nurse 65% of physician 100% if billed Usually accounted Own ID possible, CNM or employer midwife (CNM) feeb "incident to" in a for in surgeon's but not required may be reimbursed physician office or global fee directly clinic using MD's provider ID Physician assistant Lesser of the actual Lesser of the actual 100% if billed Use assistant Own ID required Only employer can be (PA)
|
From page 105... ...
CMS therefore should ensure that its rules and polices reflect the evolving practice abilities of licensed providers, rather than relying on dated definitions drafted at a time when physicians were the only authorized providers of a wide array of health care services.
|
From page 106... ...
In March 2010, the board of directors of AARP concluded that statutory and regulatory barriers at the state and federal levels "are short-changing consumers." Acknowledging that nurses, particularly APRNs, can provide much of the care that Americans need and that barriers to their doing so must be lifted, the organization updated its policy on scope of practice. AARP states that "the policy change allows us to work together to ensure that our members and all health care consumers, especially in underserved settings such as urban and rural communities, have increased access to high quality care." The amended policy reads as follows: Current state nurse practice acts and accompanying rules should be interpreted and/or amended where necessary to allow APRNs to fully and independently practice as defined by their education and certification.
|
From page 107... ...
, there has been "no formal examination of the impact of RN role expansion on care cost or on physician and RN workload." The authors describe the expansion as a shifting of skills and activities, which in the long run, given the physician shortage, could free up physician resources, especially in long-term care, community health, and school-based health. On the other hand, given the projected nursing shortage, task shifting to overworked nurses could create unsafe patient care environments, especially in acute care hospitals.
|
From page 108... ...
The United States in their specialty; meet state require has a shortage of primary care physi- ments for continuing education; cians, especially in rural areas, but provide evidence of their education; Alison Mitchell, president of Texas and collaborate with a physician on Nurse Practitioners, told the Dal- "medically delegated tasks," such las Morning News in April 2010 that as circumcision and hospital admis nurse practitioners (NPs) are ready to sion.
|
From page 109... ...
secretary of Association to announce "a number agriculture) , the first governor to of investments to expand the primary opt out of Medicare's require care workforce." These included ment that the state's CRNAs be increased funding for NP students supervised by physicians.
|
From page 110... ...
Res. H-160.947, Physician Assistants and Nurse Practitioners." 18 AMA.
|
From page 111... ...
There are also new guidelines on how to supervise CNMs, NPs, and physician assistants. The AAFP notes that its new proposed legislation, the Health Care Truth and Transparency Act of 2010, "ensures that patients receive accurate health care information by prohibiting misleading and deceptive advertising or representation of health care professionals' credentials and training." The legislation is also endorsed by 13 other physician groups.
|
From page 112... ...
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.21 According to a survey of U.S.
|
From page 113... ...
Fig 3-4.eps 100 90 80 70 Percentage 60 50 40 30 20 10 0 Quality of care Cost Convenience Having qualified staff to provide care Not at all satisfied Not very satisfied Somewhat satisfied Very satisfied FIGURE 3-5 Patient satisfaction with retail-based health clinics. NOTES: Question asked: Overall, Fig 3-5.eps how satisfied were you with your or your family member's experience using an onsite health clinic in a pharmacy or retail chain on the following items?
|
From page 114... ...
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. Fragmentation of the Health Care System The U.S.
|
From page 115... ...
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.
|
From page 116... ...
, and the Massachusetts Medicaid program formally named NPs as PCPs. Despite the shortage of PCPs that occurred after the Massachusetts legislature enacted health care reform in 2006, no private insurance companies listed NPs as PCPs in Massachusetts.
|
From page 117... ...
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.23 High Turnover Rates 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.
|
From page 118... ...
NOTES: Percents do not add to 100 because registered nurses may have provided more than one reason. Includes only RNs who are not working in nursing.
|
From page 119... ...
TABLE 3-4 Changes in Position Setting, by 2007 Setting, for Registered Nurses Who Graduated in 2001−2008 Setting in 2007 Percent Who Left Setting Between 2007 and 2008 Hospital 11.1 Nursing home/extended care 25.8 Home health 21.2 Public/community health 23.2 Ambulatory care 20.8 Other 18.9 NOTES: Public/community health includes school health and occupational health. Other settings include academic education and insurance/benefits/utilization review.
|
From page 120... ...
. In 2002, 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
|
From page 121... ...
. It is essential, however, that residency programs outside of acute care settings be developed and evaluated.
|
From page 122... ...
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.
|
From page 123... ...
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.
|
From page 124... ...
Loan repayment and educational debt should be postponed during residency, especially if a reduced salary is offered. At the committee's December 2009 Forum on the Future of Nursing: Care in the Community, Margaret Flinter, vice president and clinical director, Community Health Center, Inc., spoke about her organization's decision to develop nurse residency programs for APRNs.
|
From page 125... ...
. 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., 2009a)
|
From page 126... ...
. To fill gaps created by retirement and the increasing demand for nursing services, resulting in part from an aging population and increased rates of insur ance coverage, the nursing workforce will need to expand by attracting younger
|
From page 127... ...
30 20 10 0 LPN RN NP MD RN faculty MD faculty FIGURE 3-8 Average age of nurses at various levels of education and of MDs. NOTE: LPN = licensed practical nurse; MD = doctor of medicine; NP = nurse practitioner; RN = registered nurse.
|
From page 128... ...
. The 2008 National Sample Survey of Registered Nurses (NSSRN)
|
From page 129... ...
the cultural competence of nursing students and faculty.29 Strategies to increase diversity in nursing include • providing supervised clinical experiences for nursing and other health professional students at HNC; • offering group educational programs to community members and per sons working in community agencies and one-to-one mentoring of com munity residents who are interested in a nursing career (which includes providing clinical experiences, taking participants to planning meetings, having them talk directly to student advisers at the School of Nursing, arranging experiences at the hospital or nursing home, and holding con versations with interested persons) ; • creating structured opportunities for nursing students and faculty to be engaged in service to the community so they can begin to comprehend the life experiences of the residents and be more sensitive to their needs when advising and creating recruitment programs; 29 This section draws on a September 8, 2010, personal communication with Kay T
|
From page 130... ...
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 under graduate students participate in a Back to School event each fall where Harambee offers school physicals and immunizations for underserved middle school students.
|
From page 131... ...
This section offers a brief look at four of the current initiatives -- the accountable care organization (ACO) , the medical/health home, the community health center (CHC)
|
From page 132... ...
The ACA indicates that medical/health homes should be supported by community-based interprofessional teams or "health teams" that include physicians, nurses, and other health professionals.31 The medical/health home concept has been adopted and adapted in several ways. The latest phase of the broader nursing strategy at the VA, for example, 31 Patient Protection and Affordable Care Act, HR 3590 § 3502, 111th Congress.
|
From page 133... ...
"This is not your typical staff nurse role in primary care settings," said Catherine Rick, chief nursing officer of the VA.32 What the staff nurse brings to primary care that has not been there before is the provision of chronic care management, care coordination, health risk appraisal, health promotion, and disease prevention. Work on rolling out the VA's medical home model began in August 2009, and the program was officially launched in April 2010.
|
From page 134... ...
"We decided to cently, she said, she would not have have a full-time RN [registered nurse] had the time to make those follow- care manager for every full-time pri up calls; her caseload would have mary care provider," said Catherine been too high.
|
From page 135... ...
At the Under the old model, when a veteran VA, the clinical nurse leader oversees was hospitalized, the primary care the care provided by more than one providers would wait to see the team, while the RN care manager patient. Now, she said, they visit a focuses on the care provided by just veteran in the hospital.
|
From page 136... ...
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. 33 Patient Protection and Affordable Care Act, H.R.
|
From page 137... ...
ARRA provided grants to help state and local governments as well as health care providers in their efforts to adopt and use HIT. CMS also provided incentives, under ARRA to encourage eligible hospitals and health professionals to become "meaningful users" of certified EHRs.
|
From page 138... ...
"And it residents are African American, have showed that we were making a long low incomes, and are medically un term commitment." derserved. Nurse practitioners (NPs)
|
From page 139... ...
A fitness center with a full the designation because it is led by time personal trainer is on site, full nurses rather than physicians -- an dental care is available, and chronic issue for the 250 nurse-managed illness management groups provide health centers across the nation. peer support.
|
From page 140... ...
Implications for Nursing Practice 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.
|
From page 141... ...
institutionspecific workflow." 34 This paragraph draws on a paper commissioned by the committee on "Health Care System Reform and the Nursing Workforce: Matching Nursing Practice and Skills to Future Needs, Note Past Demands," prepared by Julie Sochalski, University of Pennsylvania School of Nursing, and Jonathan Weiner, Johns Hopkins University Bloomberg School of Public Health (see Appendix F on CD-ROM)
|
From page 142... ...
Furthermore, the performance of these fundamentally restructured teams will be monitored through the use of biometric, psychometric, and other types of process and outcome "e-indicators" extracted from the HIT infrastructure. 35 This and the next paragraph draw on a paper commissioned by the committee on "Health Care System Reform and the Nursing Workforce: Matching Nursing Practice and Skills to Future Needs, Note Past Demands," prepared by Julie Sochalski, University of Pennsylvania School of Nursing, and Jonathan Weiner, Johns Hopkins University Bloomberg School of Public Health (see Appendix F on CD-ROM)
|
From page 143... ...
. As leaders from the TIGER Initiative told the committee, "Regardless of the setting or environment of care, the best, most up to date information is required to support safe, effective care and promote optimal outcomes." And yet, they pointed out, "Today, health information is not shared across the various providers and stakeholder groups who provide, fund and research care." The members of the TIGER Initiative hope to help change that situation by developing the capacity of nursing students and members of the nursing workforce "to use electronic health records to improve the delivery of health care" and "engage more nurses in leading both the development of a national health care information technology (NHIT)
|
From page 144... ...
Despite the evidence demonstrating that APRNs are educated, trained, and competent to provide safe, high-quality care without the need for physician supervision, states' legislative decisions regarding legal scopes of practice range from restrictive to permissive. 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.
|
From page 145... ...
Nurses therefore represent a large and unexploited opportunity to achieve greater value in health care. 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.
|
From page 146... ...
. The out-of-reach water pitcher to cardiac problem has been shown to pose arrest, getting "the right message to a danger to patient safety (Graham the right person at the right time" and Cvach, 2010)
|
From page 147... ...
The 30-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.
|
From page 148... ...
In the field of health care, expansion of scopes of practice to reflect the full extent of one's education and training should occur for all health professionals to maximize the contributions of each to patient care. For example, one impact of enhancing nurses' scopes of practice may be to allow the currently inadequate numbers of physicians to better use their time and skills on the most complex and challenging cases and tasks, as well as broaden the array of services they can offer as part of a collaborative team of providers (e.g., within new models of care -- ACOs, medical homes, transitional care -- that are part of the ACA, as well as in groups of specialty providers)
|
From page 149... ...
2010a. AARP 2010 policy supplement: Scope of practice for advanced practice registered nurses.
|
From page 150... ...
2007. New directions for nurse practitioners and physician assistants in the era of physician shortages.
|
From page 151... ...
In Nurse practitioners: Evolution and future of advanced practice. 5th ed., edited by E
|
From page 152... ...
2002. Trends in the supply of physician assistants and nurse practitioners in the United States.
|
From page 153... ...
In Nurse practitioners: The evolution and future of advanced practice, edited by E
|
From page 154... ...
1986. Health technology case study 3: Nurse practitioners, physician assistants, and certified nurse-midwives: A policy analysis.
|
From page 155... ...
2010c. Nurse practitioners and physician assistants in the United States: Current patterns of distribution and recent trends.
|
From page 156... ...
2010. The importance of community health centers: Engines of economic activity and job creation.
|
From page 157... ...
total outcomes of 120 hours/week Alaska None None No N/A Arizona None None No N/A Arkansas MD Collaboration None No None stated Required California MD Supervision None No 4 prescribing NPs Required - 1 MD Colorado None (although None No 5 NPs - 1 MD; preceptor and board may waive mentoring restriction period required for prescribing during the first 3,600 hours of prescriptive practice) Connecticut MD Collaboration None No None stated Required Delaware MD Collaboration None No None stated Required Florida MD Supervision None No 1 MD - no more Required than 4 offices in addition to MD's primary practice location (If MD provides primary health care services)
|
From page 158... ...
Idaho None None No N/A Illinois MD Delegation At least once per Yes, periodic None stated Required month (no duration review required for specified) Rx orders Indiana MD Collaboration None Yes, at least 5% None stated Required random sample of charts and medications prescribed for patients Iowa None None No N/A Kansas MD Collaboration None No None stated Required Kentucky MD Collaboration None No None stated Required Louisiana MD Collaboration None No None stated Required Maine None (although None No N/A supervision by a physician or nurse practitioner is required for first 24 months of NP practice)
|
From page 159... ...
Michigan MD Delegation None No None stated Required Minnesota MD Delegation None No None stated Required Mississippi MD Collaboration At least once every Yes - a None stated Required 3 months representative sample of either 10% or 20 charts, whichever is less, every month Missouri MD Delegation NP must first Yes - once every 2 3 FTE NPs - 1 Required practice for at weeks MD least one month at same location of collaborating MD, after which time MD must be on-site once every 2 weeks Montana None None 15 or 5% of charts, None stated whichever is less, reviewed quarterly (may be reviewed by MD or NP peer) Nebraska MD Collaboration None No None stated Required Nevada MD Collaboration Part of a day, once Yes (percentage 3 NPs - 1 MD Required a month left to MD & NP discretion)
|
From page 160... ...
Rhode Island MD Collaboration None No None stated Required South MD Delegation None No 3 NPs - 1 MD Carolina Required South Dakota MD Collaboration No less than one Yes (percentage 4 NPs - 1 MD Required half day a week or left to MD & NP 10% of the time discretion) Tennessee MD Supervision Once every 30 20% of all charts None stated Required days (no duration every 30 days specified)
|
From page 161... ...
Wisconsin MD Collaboration None No None stated Required Wyoming None None No None stated NOTES: For the purposes of this chart, "collaboration" includes all collaboration-like requirements (such as "collegial relationship," etc.)
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.