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Rethinking Nursing

The IOM has convened a nursing initiative to draft a blueprint for nursing, but some say 'corporate elites' will only provide toothless recommendations


By Joe Carlson
Posted: July 20, 2009 - 12:01 am ET
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As a wave of reform legislation threatens to upend many certainties in healthcare, the industry's largest single workforce—nursing—already finds itself at the cusp of significant change.

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Today's nurses sit in an uneasy state of tension on critical issues, such as: when to expand their scope of practice to meet primary-care needs, whether technology is actually freeing up more time for patient care, and how to train enough new nurses at appropriate educational levels.

Experts say those are some of the key issues that are likely to emerge when an Institute of Medicine commission begins an inquiry that organizers are billing as a ground-breaking study of the profession.

The Initiative on the Future of Nursing, funded by a $4 million grant from the Robert Wood Johnson Foundation, is intended as a critical examination that could shatter existing conceptions of the field and lay out a blueprint for 21st century nursing. “They consider this a transformational opportunity, and they'd like a report that is transformational,” said study commission Chairwoman Donna Shalala, who was an HHS secretary in the Clinton administration and today is president of the University of Miami. “It could be like a torpedo, and cut right through the trees, and the forest, and give us a clear pathway if it's successful.”

The commission held its inaugural meeting in Washington on July 14, two days before nursing took the national stage as President Barack Obama announced in a pro-reform news conference in the White House Rose Garden, “I should disclose right off the bat, I have a long-standing bias towards nurses."

Due in fall 2010

Although the IOM commission's official announcement was swathed in language referencing the ongoing reform efforts in Congress, organizers say that their report is not due out until fall 2010—well after the self-imposed deadlines for reform legislation. Organizers say they want the report to have its impact when providers and payers start scrambling toward the goals enshrined in whatever reform legislation becomes law. “We hope we will get legislation this year for health reform, but I think it's inconceivable that that will be the last word for health reform,” IOM President Harvey Fineberg said.

Committee members include: Linda Burnes Bolton, chief nursing officer with 914-bed Cedars-Sinai Medical Center, Los Angeles; Jennie Chin Hansen, president of the AARP; C. Martin Harris, chief information officer of the 1,080-bed Cleveland Clinic; Robert Reischauer, president of the Urban Institute; and John Rowe, professor of health policy at Columbia University and former chairman and CEO of Aetna.

The effort already is not without critics. Vanderbilt University School of Nursing Dean Colleen Conway-Welch said nurses already know the answers to most of the questions posed by the group, but those solutions will never become reality until the other fractured healthcare constituencies, like physicians and specialty practitioners, also agree to changes. Labor leaders noted that the 16-member committee lacks a union representative or, for that matter, any member who is an active staff nurse besides a nurse-midwife who graduated with her degree in 2008 (See related editorial, p. 20).

Suzanne Gordon, author of more than half a dozen nursing books, including co-authorship of Safety in Numbers: Nurse-to-Patient Ratios and the Future of Health Care, said she expected no greater impact from this latest IOM commission than what happened after the institute's 1996 report from its committee called the Adequacy of Nurse Staffing in Hospitals and Nursing Homes. “Like the other IOM report, the 1996 report on staffing, this one suffers from the same problem, which is that you have corporate elites doing the study, and you end up with a series of recommendations that are all voluntary,” Gordon said.

Not so, organizers say. “The work of this committee will not simply sit on a shelf,” Fineberg said. “It is both distinctive and different from what was done in the past.”

When the committee begins its formal inquiry—which will analyze past reports, new data sets and public dialogue from three town hall-style meetings—experts say one of the key subject areas they will discover is the tension between nurses and their fellow healthcare workers in defining the scope of work.

The Robert Wood Johnson Foundation specifically charged the committee with investigating whether advance practice nurses should perform more primary-care services, but resistance to that concept could prove strong down the road. “The reality is there is a great tension between physicians' organizations and nurses' organizations in terms of what should be the scope of practices,” SEIU Healthcare Chairman Dennis Rivera said. The physicians' perspective has been that an increase in nurses' responsibilities would invade the space of the physicians, he said. Conway-Welch, the nursing dean at Vanderbilt in Nashville, said she hoped that the committee could bring together all stakeholder groups to resolve scope-of-care issues because progress in the past has been stymied by the silo mentality of the various interest groups and their associations. Nurses, physicians, public health officials—those and more—will have to figure out how to come to the table and broker common solutions and concessions in order to achieve the ultimate goal of reform, which she summarized as: “The right provider giving the right care at the right time to the right patient for the right reasons at the right cost in the right setting, for the right reimbursement. If we can do that, we'll solve an enormous amount of problems,” Conway-Welch said.

Technological advances

Nurses of the future will also have to deal with technological advances. Observers say advanced and ever-changing electronic health-record systems are leading to rapid improvements in nursing informatics, whose practitioners are building vast databases that help define new care models for nurses.

The new information technology doesn't necessarily lead to time-savings—hospital officials say tasks like bar-code scanning of medications is more time-consuming than drug administration from hand-written orders—but it will become more common as the drive toward quality means eliminating preventable errors.

Discussions of any length on the challenges facing staff nurses eventually all lead back to the classroom. Observers ask why, for example, are the latest advances in healthcare technology still not being taught in many schools if that technology is expected to remain a permanent fixture of the profession?

Observers note that the system of educating new nurses is essentially the same as it has been for decades—which is to say, fragmented from the other healthcare professions and regulated under different standards in the 50 states. Rebecca Patton, president of the American Nurses Association, said it makes no sense that so many different levels of education were available to nurses, including two-year associate degrees, three-year nursing diplomas and four-year baccalaureate programs. Patton favors a single educational standard based on the available scientific evidence, although that has been a difficult argument to make in light of the nursing shortage.

“It's been a difficult conversation for our industry to have,” Patton said. “To individuals who are uninformed, they don't understand why you can't be a nurse in two years. … But the data is showing that patient outcomes are impacted by the educational preparations … and it's the four-year degree that's needed.”

Even in the well-trod subject matter of the nursing shortage, the IOM committee may find new solutions. Nancy Korom, the vice president of patient-care services at 236-bed Children's Hospital of Wisconsin, Milwaukee, said her hospital and others in the area have worked hand-in-hand with nursing schools to enable them to expand student enrollment without adding staff.

Children's Hospital has agreed to have some of its master's-educated nurse practitioners teach semesterlong courses at nursing schools, for example. Hospital officials also sponsor students entering nursing programs who make commitments to the facility, and the hospital has agreed to expand its clinical rotation programs for students when the demand is there, Korom said.

The organizations that set up the initiative want the study commission and their eventual readers to remain open to innovative solutions to problems that have been widely discussed in the past. “The issue is how do we really shift the paradigm so that we can rid ourselves of this waxing and waning of shortages, and at the same time prepare them for the 21st century needs that patients have?” Robert Wood Johnson Foundation President and CEO Risa Lavizzo-Mourey said.


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