Walmart changed the pharmaceutical retail industry forever by creating the $4 Prescription Program. In one fell swoop, a gargantuan company disrupted part of the health care ecosystem. Today it looks like they are taking a new angle on how to manage in store health clinics. In the past, Walmart utilized a separate company that ran health clinics within the store but these closed in 2008 after about 3 years in operation. By partnering with St. Dominic in Mississippi, Walmart has made a deliberate choice to support local health care professionals ability to provide care to their community.

This type of movement directly ties with Hope Street Group’s belief that using new places to deliver primary care can achieve greater capacity at lower cost.

You can read more about this here: Walmart to open clinics in stores , The Clinic at Walmart and Recommendation 3: Use new people, places, and tools to achieve greater capacity at lower cost.

Nursing  Modernizes to Reflect Modern Times

As health care evolves, so has the nursing profession.  Advanced Practice Registered Nursing (APRN),  an umbrella term to include the 4 roles of advanced practice nurses, have been expanding at a rapid rate.    There are over 250,500 APRNs in the country, according to the recently released HRSA report on the nation’s nursing workforce, in 2008, there were:

1) 174,300 Nurse Practitioners

2) 18,500 Nurse Midwives

3) 35,000 Nurse Anesthetists

4) 59,000 Clinical Nurse Specialists.

Landmark reports including the IOM’s Crossing the Quality Chasm and it’s follow up, Health Professions Education: A Bridge to Quality, emphatically recommended that a modern well-functioning health care workforce must be prepared to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement innovation, outcomes results and informatics.

Advanced Practice Nurses Evolve to the Doctoral Level

The American Association of Colleges of Nursing developed a consensus process to address the nursing profession’s current practice of preparing advanced practice nurses in master’s degree programs as no longer adequate to meet modern complexity and demands.   A roadmap to adopt the position that all advanced practice nursing programs will move  to the doctorate of nursing practice (DNP) by 2015.  This curriculum is intended to propel nursing practice forward and keep it grounded in the practice domain.  Historically, nurses were often earning PhDs with a focus on generating new knowledge.  What was missing was an expert clinician to provide leadership and could translate and infuse evidence into care delivery systems.    A clinical doctorate would address the growing complexity of health care,  compounded by an escalating demand for services, burgeoning growth in scientific knowledge, and the increasing sophistication in technology. The nursing profession recognizes that in order to transform health care delivery, we must recognize the critical need for clinicians to lead, design, evaluate, and continually improve the context within which care is delivered.   Picture an expert nurse practitioner who can also lead quality improvement efforts,  build programs to help all providers practicing within the context of an evidence-base,  effect cultural change, and engage in executive level decision-making in large, complex health care institutions.  A DNP will create a highly qualified APRN to meet evolving models of care delivery that focus on outcomes, a nurse practitioner on steroids, if you will.

National  APRN Standards are Established. 

The National Council of State Boards of Nursing has internally modernized their standards across a range of issues by creating an advanced practice nursing regulatory model.  It requires all APRN programs follow clear, consistent curriculum guidelines with rigorous accreditation standards, that state licensing boards develop standard requirements for APRN licensure, and that educational programs are standard across the 4 APRN roles.  It boldly states that the hodge-podge of nurse practice  acts across  the nation, over half of which are restrictive, must be removed.  It recommends that solely boards of  nursing regulate advanced practice nurses – which is not the norm in some states.   For example, some states require boards of medicine to regulate or co-regulate advanced nursing practice.   The profession has set new standards and many states are not in compliance with them.  Some states, such as Virginia, have a restrictive practice act, which had not been modernized since the 1970s,  creating unnecessary practice restrictions in a time of dire need and workforce shortages.   [The report, APRN Consensus, is found below]

IOM Focuses on Nursing’s Future

Last fall the IOM released, The Future of Nursing, which makes several bold recommendations.  The report is based on 4 key principles: 1) Nurses should practice to the full extent of their education and training; 2) Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression. 3) Nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States; and 4) Effective workforce planning and policy making require better data collection and an improved information infrastructure.  The report recommends that the number of nurses with a doctorate be doubled by 2020 so that nurses are prepared to lead and improve collaborative health care improvement efforts. In order to do this, the report strongly urges all levels of government to remove regulatory barriers to practice.   One strategy  the IOM recommends is to have Congress limit federal funding for nursing education to states that have not adopted the model rules and regulations described above.

All to say, the times they are a changing.  Modern nursing practice has adapted to the surge in chronicity,  the broad mandate to make threshold improvements in patient safety, care transitions and quality of care.  Advanced practice nurses with doctorates in nursing practice are prepared to lead the way.   In this time of transformation, if the health  professions stay fixed, immutable, and non-adaptive to the changing landscape, we can expect more of the same bleak health care outcomes, unsafe practices, and out of control health care inflation.  

Dr. Eileen O’Grady is a Certified Nurse Practitioner and Wellness Coach and teaches health policy at Pace University’s DNP program.   She earned a PhD and wishes she had a DNP degree.    www.eileenogrady.net

Sources:

American Association of Colleges of Nursing. DNP Roadmap Taskforce Report.  http://www.aacn.nche.edu/dnp/pdf/DNProadmapreport.pd

The National Council of State Boards of Nursing: Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education  http://www.nonpf.com/associations/10789/files/APRNConsensusModelFinal09.pdf

IOM: The Future Of Nursing Report    http://thefutureofnursing.org/recommendations

The National Sample Survey of Registered Nurses (2008)   http://bhpr.hrsa.gov/healthworkforce/rnsurvey/2008/nssrn2008.pdf

Could? How about, almost definitely.  Even before legislation passed, many Americans were unable to obtain a timely appointment due a shortage of primary care physicians in their local communities.  An estimated 60 million Americans, or one in five,  were reported to lack adequate access to primary care. This results in patients increasingly turning to costly emergency room visits to obtain the routine care they should be receiving from their primary care provider, and reduced availability to emergency services for those who need it most. Since proposing legislation that would expand access to our nation's uninsured, many experts have warned that the need for primary care will also grow dramatically once an individual mandate to carry health coverage is implemented. Even without the mandate, our increasing aging population and spiraling levels of chronic condition prevalence will further stress the current primary care shortage and potentially threaten the long-term fiscal sustainability of our national health care system.

But don't take my word for it, check out what the Shots blog, from National Public Radio has to say.