Potentially upsetting the balance of power between doctors and nurses, the Institute of Medicine has delivered a phone-book-sized report that argues giving nurses more leadership roles and caregiving authority could save time and money on the path to healthcare reform.
Fueling the turf battle
Institute of Medicine report pushes expanded scope for nurses; docs say study draws illogical conclusions
The changes recommended by the IOM would require difficult departures from the status quo. Advocates for nurses, however, point to no less an institutional organization than the Veterans Affairs Department as an example of how experimenting with nurse labor can produce better results.
Congress passed the Veterans' Healthcare Eligibility Reform Act in 1996, nearly doubling the number of eligible enrollees in military healthcare programs within eight years. In response, the VA moved away from a system of hospital-based acute care and toward community-based delivery emphasizing primary care and chronic-disease management—roles filled by registered nurses and skilled nurse practitioners, the IOM said.
The result? Studies showed that higher proportions of veterans received appropriate care relative to comparable Medicare enrollees, and spending per beneficiary rose more slowly—30% cost growth for VA patients between 1999 and 2007, compared with 80% for Medicare beneficiaries over the same period, according to the Congressional Budget Office.
The VA anecdote is offered in a sprawling new report released last week, The Future of Nursing: Leading Change, Advancing Health, through a $10 million collaboration between the Robert Wood Johnson Foundation and the IOM.
The report presented the VA's solution as an example of how the U.S. healthcare system can better use nurses to quickly and cheaply meet the demands of the tidal wave of newly insured Americans in this year's Patient Protection and Affordable Care Act. But long-standing barriers threaten such an approach, including not only the spectrum of legal limitations on nurse practice, but also serious shortcomings in educational attainment of nurses themselves.
Critics—and there are many—say the report's supposed evidence-based approach employs questionable data sets to draw illogical conclusions, such as the suggestion that nurses with less training can cause fewer negative health outcomes than more thoroughly trained physicians.
Physicians' groups say that if healthcare reform is pushing doctors' jobs into nurses' hands, it will only fuel resentment toward the federal mandates. “The idea that physician oversight of healthcare will be compromised plays into the worst of the public's fears about healthcare reform,” said Alexander Hannenberg, a practicing anesthesiologist at Newton-Wellesley Hospital, Newton, Mass., and president of the American Society of Anesthesiologists. “Everyone is concerned about what compromises will have to be made to expand coverage and reduce cost.”
Proponents of nurse empowerment say that in many cases, nurses are only fighting for a seat at the boardroom table or a position of leadership in a healthcare delivery team, particularly in the emerging medical home model of care.
“On the face of it, you may think this is a report about nursing, but don't be misled. This is a report about one of the key missing pieces in the struggle to improve healthcare in America,” said Risa Lavizzo-Mourey, a physician and the president and CEO of the Robert Wood Johnson Foundation. “This is what Americans want and deserve from their healthcare system.”
“Some of the conclusions are likely to be controversial, but that is because they are consequential,” she said.
In addition to oft-repeated suggestions such as increasing nurse-faculty salaries, the IOM is recommending that at least 80% of nurses in the U.S. receive bachelor's degrees within the next 10 years—a recommendation sure to rankle associate-degree nursing schools that would become entry points into nursing, rather than full pathways to R.N. careers.
The IOM wants nurses to gain more autonomy in practice and to take leadership roles on healthcare teams for roles such as prescribing drugs and diagnosing disease with limited or no physician oversight, urging top-down federal regulation to help achieve the goal.
The report notes that the Federal Trade Commission has a history of challenging anti-competitive policies and laws promulgated by the American Medical Association and state lawmakers on issues such as physician-supervision requirements and restrictions on nurse-run clinic locations. The IOM also urges the CMS and other federal agencies to design payment policies that encourage states to adopt up-to-date rules on nurses' practice.
Given the sheer number of researchers who have produced peer-reviewed scholarship on nursing, observers could perhaps be forgiven for rolling their eyes when they hear a Washington-based blue-ribbon commission has produced a compendium of research and recommendations on the future direction of nursing that runs to 586 pages.
But for skeptics and apathetic readers, the IOM presents this urgent picture: In a time when 32 million more Americans are about to get health insurance, skilled nurses are cheaper than physicians, they are easier to produce in large numbers, and they can prevent costly mistakes and perform with essentially the same rate of errors as doctors once they are established in the workforce. Polls find that nurses are the most trusted professionals in America, and advocates say privately that the political arguments against their wider adoption may have more to do with protecting physician income than delivering quality healthcare.
While it might be hard to argue with the notion that nurses are cheaper and quicker to produce than doctors, physicians' groups take strong exception to the quality and income arguments. The AMA notes that most Americans will willingly wait hours to see an emergency physician at an ER, and that nurses have nowhere near the clinical training and expertise to handle complex conditions and diagnoses.
“We feel there is no substitute for the education and training that is the difference between the physician and the nurse,” said Rebecca Patchin, the former chairwoman of the AMA board of trustees, whose resume includes seven years of lobbying the California Legislature on physician issues.
The IOM report cites data showing that primary-care doctors and nurses tend to see cases of low or moderate complexity, and that none of the numerous academic studies have shown that states with more-restrictive laws on what advanced practice nurses can do produce better quality outcomes for patients than less-restrictive states.
That includes the power to prescribe drugs, which nurse advocates say has been an area of particular concern by physicians in scope-of-practice battles. “When nurses are trained and educated in the advanced practice role, their prescriptive practices are on par with safety for physicians,” said Karen Daley, president of the American Nurses Association. “It's unfortunate that they don't want to see the evidence and acknowledge the veracity of the evidence.”
Despite claims by nurse advocates that the IOM report's conclusions are evidence-based, physicians' groups say the data are questionable. “The problem is that the current state of healthcare outcomes data is so limited that one has to be very careful about drawing unfounded conclusions,” said Hannenberg, the Massachusetts anesthesiologist. “Most of the clinical outcomes data today has to rely on administrative or billing data. It is a data set that was never designed for outcomes studies, and it is exceedingly limited in its power to draw conclusions about outcomes.”
The quality debate is hardly new (April 5, 2010, p. 28). Nursing groups hope the imprimatur of a body such as the Institute of Medicine can finally start to overcome the gravitas of the AMA and the related constellation of influential medical societies and associations.
Observers say lawmakers have been hesitant to make changes in the past.
But imagine the scene: a state legislator listening to lobbyist arguments on whether to grant clinicians with less training the legal right to prescribe drugs or diagnose diseases. Are they more likely to take the word of the highly organized physicians' groups that have long dominated American medicine, or that of the more fractured nurses' groups that in 40 years have not been able to even agree on whether registered nurses should have bachelor's degrees?
The IOM report says that after passage of the healthcare reform laws, 28 states began considering changes to their scope-of-practice laws, particularly those in rural and frontier areas, which contain 25% of the population but only 10% of the physicians.
“Despite opposition from some physicians and specialty groups, the strong trend over the past 20 years has been a growing receptivity on the part of state legislatures to expanded scopes of practice for nurses,” according to the IOM report. “There simply are not enough primary-care physicians to care for an aging population now, and their patient load will dramatically increase as more people gain access to care.”
Patchin, a practicing anesthesiologist and pain management specialist in Loma Linda, Calif., in addition to her duties with the AMA, said the argument for rural access to care runs headlong into ZIP code studies that have found that the unequal distribution of advanced practice nurses mirrors that of primary-care physicians.
“Overwhelmingly, they practice in the same geographic areas. That's why we feel the best approach is a team approach to healthcare,” Patchin said. “Nurses are a very vital part of that team. … Each team member has a role, and the role within the team would be defined by the state's scope-of-practice” laws.
Regardless of whether Americans come to see the IOM report as a “milestone in America's long and sometimes troubled journey to improve healthcare,” as the IOM president called it, or just another reason to despise healthcare reform, leaders from the various nursing groups already are planning to meet in November to discuss implementation strategies.
In the meantime, the National Health Care Workforce Commission—which was created by the reform law and run by the Government Accountability Office—will continue to gather national and regional data on healthcare staffing trends, along with the separate and pre-existing National Center for Health Workforce Analysis, which is run out of HHS’ Health Resources and Services Administration and conducts detailed nursing-workforce surveys every four years.
That information will help guide industry leaders and government officials who continue to apportion workforce development grants in the reform law, such as the $253 million in grants HHS announced on Sept. 28 to build the primary-care workforce of physicians, advanced practice nurses and physician assistants alike.
Jacalyn Golden, a certified registered nurse practitioner with the Cleveland Clinic, said the long-running battle over which professions can perform what tasks is obscuring the greater needs of the public—and it needs to end.
“It's been a long time, and attitudes need to change, and we need to stop seeing this as a turf battle between medicine and nursing,” Golden said. “We need to talk about the patient concerns, not turf concerns. We need a moratorium on turf battles.”
Send us a letter
Have an opinion about this story? Click here to submit a Letter to the Editor, and we may publish it in print.