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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

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Death squads have re-entered the health care reform discussion. For those of us in the trenches of making Health Care quality and efficiency a reality, the strong emotional response to “End of Life” planning is somewhat incomprehensible. To us, the futility, unwarranted expense,and assaultive nature of invasive procedures during a person’s final decline are stark and real. Many nurse friends of mine are so passionate on the subject that they say, only half in jest, that their first tattoo will be “Do Not Resuscitate!” boldly inked on their chests. So why do many people react negatively to the notion of “End of Life Planning”; fearing that it is a screen for a covert agenda to force euthanasia on the elderly, ill and disabled? Should we simply ignore the reaction as the voice of an ideological fringe element, or is it worth exploring what lies behind the political rhetoric to understand the phenomena better?

My belief is that ignoring this, and other consumer based responses to the health care debate, is something done in arrogance and at the reform movement’s great peril. We should be actively reaching out to understand what is involved in the feelings and thoughts of those who voice these opinions, and perhaps the place to begin to understand such a reaction is with our selves.

Do you have an up-to-date, properly executed Advanced Directive on file with your health care providers and institutions, and thoroughly discussed with your family members? If not, what are the barriers preventing you from doing so? Are you somewhat in denial about the possibility that you could be in need of such a document at any moment, even if you are healthy at this time, in other words that you could actually die? Is it hard to think of who you would ask to execute your desires if the need would arise, or is it simply a daunting idea to obtain the correct document and get it to all the right locations? What if you didn't even really understand what “resuscitation” or “ventilator” means, and are embarrassed to ask and fearful to take a provider’s precious time when you have multiple other more pressing issues to discuss in your precious ten minute appointment?

Deeper and more complex issues may underlie the criticism about the desirability of end of life planning. A large proportion of our population retains the belief in the powerful and effective nature of medical technology. This cultural bias is reinforced by TV shows like “House”, where the sixth hi-tech procedure finally saves the patient’s life; given that belief system it only makes sense to keep all intervention options open. One often hears, in quality improvement and healthcare redesign circles, the issue of poorly aligned financial incentives driving unproductive, and even harmful, medical system behavior. Average consumers, while not as articulate as insiders, share some of the same concerns. When they hear “End of Life” planning discussed in the same sentence as “cost savings”, their, not unintelligent response is, “Who benefits from saving costs on my Grandma’s life?”

So, what I suggest that we do to address these issues? First, start with yourself and your family. Get, review and discuss Advanced Directive documents and experience the emotions evoked and face the complexity of the issues that need answers in order to complete the documents. Then move to the next level and gather focus groups of real consumers and ask them what their concerns are about the documents and how your local community, medical group and health plan can support them in making their “Future Plans for Health Care”. The change in language is not accidental as it is important for the focus of such a conversation to be on what health care options, ranging from full intervention to none at all, that an individual would choose, rather than using the already loaded term “End of Life”, which suggests that options are ending.

Then, we need to carry what we learn in these personal and individual explorations into the larger, political, arena. It is important to ensure that all discussions about End of Life planning are respectful of all points of view. We need to shift the focus from cost savings to how to support individual consumers in making decisions that are compatible with their belief and value systems. Having real answers about who benefits and where do any savings go; do they increase specialist salaries, or lower premiums for the average purchaser? Including real people sharing their stories about the difficult and complex decision making that went into their end of life decisions for themselves and their loved ones should change the tone to one of concern and caring. Invite religious and spiritual perspectives as legitimate and necessary parts of decision making. Let go of the polemical and realize that these issues are ultimately personal and made by individuals and families. The fact that most people choose lower intensity services when they are lovingly offered an unbiased discussion of the benefits and liabilities of intensivist end of life procedures should not be the motivating force behind the conversations. The focus should be that such an approach is harmful to the patients and families, and that our responsibility, as health care providers, is to “First Do No Harm”.

All these suggestions are based on the concept that for real change to successfully occur it has to be understood by, and meet the needs of, those who are being served and that it is our responsibility to find ways to engage consumers. Attempting to impose well meaning, and from an insider point of view, clearly beneficial changes, without that engagement, will lead to the virulent resistance to change that so much of the reform effort has encountered.