Department of Veterans Affairs⁵

In 1996, Congress greatly expanded the number of veterans eligible to receive VA services, which created a need for the system to operate more efficiently and effectively (VHA, 2003). Caring for the wounded from the wars in Afghanistan and Iraq has further increased demand on the VA system, particularly with respect to brain injuries and posttraumatic stress disorder. Moreover, the large cohort of World War II veterans means that almost 40 percent of veterans are aged 65 or older, compared with 13 percent of the general population (U.S. Census Bureau, 2010; VA, 2010).

Anticipating the challenges it would face, the VA began transforming itself in the 1990s from a hospital-based system into a health care system that is focused on primary care, and it also placed emphasis on providing more services, as appropriate, closer to the veteran’s home or community (VHA, 2003, 2009). This strategy required better coordination of care and chronic disease management—a role that was filled by experienced front-line RNs. More NPs were hired as primary care providers, and the VA actively promoted a more collaborative professional culture by organizing primary care providers into health teams. It also developed a well-integrated information technology system to link its health professionals and its services.

The VA uses NPs as primary care providers to care for patients across all settings, including inpatient and outpatient settings. In addition to their role as primary care providers, NPs serve as health care researchers who apply their findings to the variety of settings in which they practice. They also serve as educators, some as university faculty, providing clinical experiences for 25 percent of all nursing students in the country. As health care leaders, VA NPs shape policy, facilitate access to VA health care, and impact resource management (VA, 2007).

The results of the VA’s initiatives using both front-line RNs and APRNs are impressive. Quality and outcome data consistently demonstrate superior results for the VA’s approach (Asch et al., 2004; Jha et al., 2003; Kerr et al., 2004). One study found that VA patients received significantly better health care—based on various quality-of-care indicators⁶—than patients enrolled in Medicare’s fee-for-service program. In some cases, the study showed, between 93 and 98 percent of VA patients received appropriate care in 2000; the highest score for comparable Medicare patients was 84 percent (Jha et al., 2003). In addition, the VA’s spending per enrollee rose much more slowly than Medicare’s, despite the 1996 expansion of the number of veterans who could access VA services. 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 System⁷

The Geisinger Health System employs 800 physicians; 1,900 nurses; and more than 1,000 NPs, physician assistants, and pharmacists. Over the past 18 years, Geisinger has transformed itself from a high-cost medical facility to one that provides high value—all while improving quality. It has borrowed several restructuring concepts from the manufacturing world with an eye to redesigning care by focusing on what it sees as the most critical determinant of quality and cost—actual caregiving. “What we’re trying to do is to have [our staff] work up to the limit of their license and … see if redistributing caregiving work can increase quality and decrease cost,” Glenn Steele, Geisinger’s president and CEO, said in a June 2010 interview (Dentzer, 2010).

Numerous improvements in the quality of care, as well as effective innovations proposed by employees, have resulted. For example, the nurses who used to coordinate care and provide advice through the telephone center under Geisinger’s health plan suspected that they would be more effective if they could build relationships with patients and meet them at least a few times face to face. Accordingly, some highly experienced general-practice nurses moved from the call centers to primary care sites to meet with patients and their families. The nurses used a predictive model to identify who might need to go to the hospital and worked with patients and their families on creating a care plan. Later, when patients or families received a call from a nurse, they knew who that person was. The program has worked so well that nurse coordinators are now being used in both Geisinger’s Medicare plan and its commercial plan.⁸ Some of the nation’s largest for-profit insurance companies, including WellPoint and Cigna, are now trying out the approach of employing more nurses to better coordinate their patients’ care (Abelson, 2010). As a result, an innovation that emerged when a few nurses at Geisinger took the initiative and changed an already well-established program to deliver more truly patient-centered care may now spread well beyond Pennsylvania. Geisinger was also one of the very first health systems in the country to create its own NP-staffed convenient care clinics⁹—another innovation that reflects the organization’s commitment to providing integrated, patient-centered care throughout its community.

Kaiser Permanente^10,11

As one of the largest not-for-profit health plans, Kaiser Permanente provides health care services for more than 8.6 million members, with an employee base of approximately 165,000. Kaiser Permanente has facilities in nine states and the District of Columbia, and has 35 medical centers and 454 medical offices. The system provides prepaid health plans that emphasize prevention and consolidated services designed to keep as many services as possible in one location (KP, 2010). Kaiser is also at the forefront of experimenting with reconceptualized roles for nurses that are improving quality, satisfying patients, and making a difference to the organization’s bottom line.

Nurses in San Diego have taken the lead in overseeing the process for patient discharge, making it more streamlined and efficient and much more effective. Discharge nurses now have full authority over the entire discharge process until home health nurses, including those in hospice and palliative care, step in to take over the patient’s care. They have created efficiencies relative to previous processes by using time-sensitive, prioritized lists of only those patients who are being discharged over the next 48 hours (instead of patients who are being discharged weeks into the future). Home health care nurses and discharge planners stay in close contact with one another on a daily basis to make quick decisions about patient needs, including the need for home health care visitation. In just 3 months, the number of patients who saw a home health care provider within 24 hours increased from 44 to 77 percent (Labor Management Partnership, 2010).

In 2003, Riverside Medical Center implemented the Riverside Proactive Health Management Program (RiPHM)™, an integrated, systematic approach to health care management that promotes prevention and wellness and coordinates interventions for patients with chronic conditions. The model strengthens the patient-centered medical home concept and identifies members of the health care team (HCT)—a multidisciplinary group whose staff is centrally directed and physically located in small units within the medical office building. The team serves panel management and comprehensive outreach and inreach functions to support primary care physicians and proactively manage the care of members with chronic conditions such as diabetes, hypertension, cardiovascular disease, asthma, osteoporosis, and depression. The expanded role of nurses as key members of the HCT is a major factor in RiPHM’s success. Primary care management nurse clinic RNs and licensed practical nurses (LPNs) provide health care coaching and education for patients to promote self-management of their chronic conditions through face-to-face education visits and telephone follow-up. Using evidence-based clinical guidelines, such as diabetes and hypertension treat-to-target algorithms, nurses play important roles in the promotion of changes in chronic conditions and lifestyles, coaching and counseling, self-monitoring and goal setting, depression screening, and the use of advanced technology such as interactive voice recognition for patient outreach.

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. RiPHM has provided a strong foundation for the patient-centered medical home. By implementing this program and expanding the role of nurses, Riverside has sustained continuous improvement in key quality indicators for patient care.

Guided care is a new model for chronic care that was recently introduced within the Kaiser system. Guided care is intended to provide, within a primary care setting, quality care to patients with complex needs and multiple chronic conditions. An RN, who assists three to four physicians, receives training in such areas as the use of an electronic health record (EHR), interviewing, and the particulars of health insurance coverage. RNs are also provided skills in managing chronic conditions, providing transitional care, and working with families and community organizations (Boult et al., 2008).

The nurse providing guided care offers eight services: assessment; planning care; monitoring; coaching; chronic disease self-management; educating and supporting caregivers; coordinating transitions between providers and sites of care; and facilitating access to community services, such as Meals-on-Wheels, transportation services, and senior centers. Results of a pilot study comparing surveys of patients who received guided care and those who received usual care revealed improved quality of care and lower health care costs (according to insurance claims) for guided care patients (Boult et al., 2008).

History of the Regulation of the Health Professions

A paper commissioned by the committee¹³ points out that the United States was one of the first countries to regulate health care providers and that this regulation occurred at the state—not the federal—level. Legislatively, physician practice was recognized before that of any other health profession (Rostant and Cady, 1999). For example, legislators in Washington defined the practice of medicine broadly as any action to “diagnose, cure, advise or prescribe for any human disease, ailment, injury, infirmity, deformity, pain or other condition, physical or mental, real or imaginary, by any means or instrumentality” or to administer or prescribe “drugs or medicinal preparations to be used by any other person” or to “[sever or penetrate] 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 rendered the practice of medicine not only comprehensive but also (in medicine’s own view) exclusive,¹⁵ a preemption of the field that was reinforced when physicians obtained statutory authority to control the activities of other health care providers.

Most APRNs are in the opposite situation. Because virtually all states still base their licensure frameworks on the persistent underlying principle that the practice of medicine encompasses both the ability and the legal authority to treat all possible human conditions, the scopes of practice for APRNs (and other health professionals) are exercises in legislative exception making, a “carving out” of small, politically achievable spheres of practice authority from the universal domain of medicine. As a result, APRNs’ scopes of practice are so circumscribed that their competence extends far beyond their authority. At any point in their career, APRNs can do much more than they may legally do. As APRNs acquire new skills, they must seek administrative or statutory revision of their defined scopes of practice (a costly and often difficult enterprise).

As the health care system has grown over the past 40 years, the education and roles of APRNs have continually evolved so that nurses now enter the workplace willing and qualified to provide more services than they previously did. As the services supported by evolving education programs expanded, so did the overlap of practice boundaries of APRNs and physicians. APRNs are more than physician extenders or substitutes. They cover the care continuum from health promotion and disease prevention to early diagnosis to prevent or limit disability. These services are grounded in and shaped by their nursing education, with its particular ideology and professional identity. NPs also learn how to work with teams of providers, which is perhaps one of the most important factors in the successful care of chronically ill patients. Although they use skills traditionally residing in the realm of medicine, APRNs integrate a range of skills from several disciplines, including social work, nutrition, and physical therapy.

Almost 25 years ago, an analysis by the Office of Technology Assessment (OTA) indicated that NPs could safely and effectively provide more than 90 percent of pediatric primary care services and 75 percent of general primary care services, while CRNAs could provide 65 percent of anesthesia services. OTA concluded further that CNMs could be 98 percent as productive as obstetricians in providing maternity services (Office of Technology Assessment, 1986). APRNs also have competencies that include the knowledge to refer patients with complex problems to physicians, just as physicians refer patients who need services they are not trained to provide, such as medication counseling, developmental screening, or case management, to APRNs. 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 psychiatric/mental health. Most NPs train in primary care; however, increasing numbers are being trained in acute care medicine and other specialty disciplines (Cooper, 1998).

The growing use of APRNs and physician assistants has helped ease access bottlenecks, reduce waiting times, increase patient satisfaction, and free physicians to handle more complex cases (Canadian Pediatric Society, 2000; Cunningham, 2010). This is true of APRNs in both primary and specialty care. In orthopedics, the use of APRNs and physician assistants is a long-standing practice. NPs and physician assistants in gastroenterology help meet the growing demand for colon cancer screenings in either outpatient suites or hospital endoscopy centers. 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. In some states, they are very detailed, while in others, they contain vague provisions that are open to interpretation (Cunningham, 2010). Some states have kept pace with the evolution of the health care system by changing their scope-of-practice regulations to allow NPs to see patients and prescribe medications without a physician’s supervision or collaboration. However, the majority of state laws lag behind in this regard. As a result, what NPs are able to do once they graduate varies widely across the country for reasons that are related not to their ability, their education or training, or safety concerns (Lugo et al., 2007) but to the political decisions of the state in which they work. For example, one group of researchers found that 16 states plus the District of Columbia have regulations that allow NPs to see primary care patients without supervision by or required collaboration with a physician (see Figure 3-3). As with any other primary care providers, these NPs refer patients to a specialty provider if the care required extends beyond the scope of their education, training, and skills.

FIGURE 3-3

Requirements for physician–nurse collaboration, by state, as a barrier to access to primary care. NOTE: Collaboration refers to a mutually agreed upon relationship between nurse and physician.

Other legal practice barriers include on-site physician oversight requirements, chart review requirements, and maximum collaboration ratios for physicians who collaborate with more than a single NP. See Safriet (2010, Appendix H on the CD-ROM in the back of this book) for further discussion of inconsistencies in the regulation of NP practice at the state level.

There are fundamental contradictions in this situation. Educational standards—which the states recognize—support broader practice by all types of APRNs. National certification standards—which most states also recognize—likewise support broader practice by APRNs. Moreover, the contention that APRNs are less able than physicians to deliver care that is safe, effective, and efficient is not supported by the decades of research that has examined this question (Brown and Grimes, 1995; Fairman, 2008; Groth et al., 2010; Hatem et al., 2008; Hogan et al., 2010; Horrocks et al., 2002; Hughes et al., 2010; Laurant et al., 2004; Mundinger et al., 2000; Office of Technology Assessment, 1986). No studies suggest that care is better in states that have more restrictive scope-of-practice regulations for APRNs than in those that do not. Yet most states continue to restrict the practice of APRNs beyond what is warranted by either their education or their training.

Depending on the state, restrictions on an APRN’s scope of practice may limit or prohibit the authority to prescribe medications, admit patients to hospitals, assess patient conditions, and order and evaluate tests. Box 3-1 provides an example of the variation in state licensure regulations, detailing examples of the services an APRN would not be permitted to provide if she practiced in a more restrictive state (Safriet, 2010). In addition to variations among states, the scope of practice for APRNs in some cases varies within a state by geographic location of the practice within the state or nature of the practice setting.

BOX 3-1

Variation in State Licensure Regulations. Several states permit APRNs to provide a broad list of services, such as independently examining patients, ordering and interpreting laboratory and other tests, diagnosing and treating illness and injury, prescribing (more...)

Current laws are hampering the ability of APRNs to contribute to innovative health care delivery solutions. Some NPs, for example, have left primary care to work as specialists in hospital settings (Cooper, 2007), although demand in those settings has also played a role in their movement. Others have left NP practice altogether to work as staff RNs. For example, restrictive state scope-of-practice regulations concerning NPs have limited expansion of retail clinics, where NPs provide a limited set of primary care services directly to patients (Rudavsky et al., 2009). Similarly, the roles of NPs in nurse-managed health centers and patient-centered medical homes can be hindered by dated state practice acts.

Credentialing and payment policies often are linked to state practice laws. A 2007 survey of the credentialing and reimbursement policies of 222 managed care organizations revealed that 53 percent credentialed NPs as primary care providers; of these, 56 percent reimbursed primary care NPs at the same rate as primary care providers, and 38 percent reimbursed NPs at a lower rate (Hansen-Turton et al., 2008). Rationales stated by managed care staff for not credentialing NPs as primary care providers included the fact that NPs have to bill under a physician’s provider number, NPs do not practice in physician shortage areas, NPs do not meet company criteria for primary care providers, state law does not require them to credential NPs, and the National Committee for Quality Assurance (NCQA) accreditation process prevents them from recognizing NPs as primary care provider leads in medical homes. As discussed above, some states require NPs to be supervised by physicians in order to prescribe medications, while others do not. In this survey, 71 percent of responding insurers credentialed NPs as primary care providers in states where there was no requirement for physicians to supervise NPs in prescribing medications. In states that required more physician involvement in NP prescribing, insurers were less likely to credential NPs. Of interest, this was the case even though the actual level of involvement by the physician may be the same in states where supervision is required as in states where it is not. Also of note is that Medicaid plans were more likely than any other category of insurer to credential NPs.

Although there is a movement away from a fee-for-service system, Table 3-2 shows the current payment structure for those providing primary care.

TABLE 3-2

Medicare Claims Payment Structure by Provider Type.

The Federal Government and Regulatory Reform¹⁶

Precisely because many of the problems described in this report are the result of a patchwork of state regulatory regimes, the federal government is especially well situated to promote effective reforms by collecting and disseminating best practices from across the country and incentivizing their adoption. The federal government has a compelling interest in the regulatory environment for health care professions because of its responsibility to patients covered by federal programs such as Medicare, Medicaid, the VA, and the Bureau of Indian Affairs. 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. They pay for the majority of health care services delivered today, they pay for research on the safety and effectiveness of existing and innovative practice models and encourage their adoption, and they have a compelling interest in achieving more efficient and value-driven health care services. The federal government also appropriates substantial funds for the education and training of health care providers, and it has an understandable interest in ensuring that the ever-expanding skills and abilities acquired by graduates of these programs are fully utilized for the benefit of the American public.

In particular, the Federal Trade Commission (FTC) has a long history of targeting anticompetitive conduct in health care markets, including restrictions on the business practices of health care providers, as well as policies that could act as a barrier to entry for new competitors in the market. The FTC has responded specifically to potential policies that might be viewed predominantly as guild protection rather than consumer protection, for example, taking antitrust actions against the American Medical Association (AMA) for policies restricting access to clinical psychologists to cases referred by a physician and for ethical prohibitions on collaborating with chiropractors, podiatrists, and osteopathic physicians. In 2008, the FTC evaluated proposed laws in Massachusetts, Illinois, and Kentucky, finding that several provisions could be considered anticompetitive, including limits on advertising, differential cost sharing, more stringent physician supervision requirements, restrictions on clinic locations and physical configurations or proximity to other commercial ventures, and limits on the scope of professional services that can be provided that are not applicable to professionals with similar credentials who practice in similar “limited care settings” (for example, urgent care centers) (DeSanti et al., 2010; Ohlhausen et al., 2007, 2008). Likewise, the FTC initiated an administrative complaint against the North Carolina Board of Dental Examiners in June 2010 (FTC, 2010). The Board had prohibited nondentists from providing teeth-whitening services. The FTC alleged that by doing this the Board had hindered competition and made it more difficult and costly for consumers in the state to obtain this service.

As a payer and administrator of health insurance coverage for federal employees, the Office of Personnel Management (OPM) and the Federal Employees Health Benefits program have a responsibility to promote and ensure employee/subscriber access to the widest choice of competent, cost-effective health care providers. Principles of equity would suggest that this subscriber choice would be promoted by policies ensuring that full, evidence-based practice is permitted for all providers regardless of geographic location.

Finally, the Centers for Medicare and Medicaid Services (CMS) has the responsibility to promulgate rules and policies that promote access of Medicare and Medicaid beneficiaries to appropriate care. 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.

Expanding Scopes of Practice for Nurses

For several decades, the trend in the United States has been toward expansion of scope-of-practice regulations for APRNs, but this shift has been incremental and variable. Most recently, the move to expand the legal authority of all APRNs to provide health care that accords with their education, training, and competencies appears to be gathering momentum. In 2008, after 5 years of study, debate, and negotiation, a group of nursing accreditation, certification, and licensing organizations, along with several APRN groups, developed a consensus model for the education, training, and regulation of APRNs (see Appendix D). The stated goals of the APRN consensus process are to:

• “strive for harmony and common understanding in the APRN regulatory community that would continue to promote quality APRN education and practice;
• develop a vision for APRN regulation, including education, accreditation, certification, and licensure;
• establish a set of standards that protect the public, improve mobility, and improve access to safe, quality APRN care; and
• produce a written statement that reflects consensus on APRN regulatory issues” (see Appendix D).

The consensus document will help schools and programs across the United States standardize the education and preparation of APRNs. It will also help state regulators establish consistent practice acts because of education and certification standardization. And of importance, this document reflects the consensus of nursing organizations and leaders and accreditation and certification boards regarding the need to eliminate variations in scope-of-practice regulations across states and to adopt regulations that more fully recognize the competence of APRNs.

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. (AARP, 2010a)

Meanwhile, after passage of the ACA, 28 states began considering expanding their scope-of-practice regulations for NPs (Johnson, 2010). Expanding the scope of practice for NPs is particularly important for the rural and frontier areas of the country. Twenty-five percent of the U.S. population lives in these areas; however, only 10 percent of physicians practice in these areas (NRHA, 2010). People who live in rural areas are generally poorer and have higher morbidity and mortality rates than their counterparts in suburban and urban settings, and they are in need of a reliable source of primary care providers (NRHA, 2010). The case study in Box 3-2, describing an NP in rural Iowa, demonstrates the benefits of a broad scope of practice with respect to the quality of and access to care.

BOX 3-2

Case Study: Advanced Practice Registered Nurses. Promoting Access to Care in Rural Iowa The passage of the Affordable Care Act will give millions of Americans better access to primary care—if there are enough providers. The United States has a (more...)

Scope of Practice for Non-APRN Nurses

Generalist nurses are expanding their practices across all settings to meet the needs of patients. Expansions include procedure-based skills (involving, for example, IVs and cardiac outputs), as well as clinical judgment skills (e.g., taking health histories and performing physical examinations to develop a plan of nursing care). According to Djukic and Kovner (2010), 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. To avert this situation, nurses need to delegate to others, such as LPNs, nursing assistants, and community health workers, among others. A transformed nursing education system that is able to respond to changes in science and contextual factors, such as population demographics, will be able to incorporate needed new skills and support full scopes of practice for non-APRNs to meet the needs of patients (see Chapter 4).

Physician Challenges to Expanded Scope of Practice

The AMA has consistently issued resolutions, petitions, and position papers supporting opposition to state efforts to expand the scope of practice for professional groups other than physicians.¹⁷ The AMA’s Citizens Petition, submitted to the Health Care Financing Administration in June 2000, and the AMA-sponsored Scope of Practice Partnership (SOPP), announced in January 2006, both focused on opposing scope-of-practice expansion. The SOPP in particular, an alliance of the AMA and six medical specialty organizations, was an effort on the part of organized medicine to oppose boundary expansion and to defeat proposed legislation in several states to expand scope of practice for allied health care providers, including nurses (Croasdale, 2006; Cys, 2000).

The SOPP, with the assistance of a special full-time legislative attorney hired for the purpose, spearheaded several projects designed to obstruct expansion of scopes of practice for nurses and others. These projects included comparisons between the medical profession and specific allied health professions on education standards, certification programs, and disciplinary processes; development of evidence to discredit access-to-care arguments made by various allied health professionals, particularly in rural areas of a state; and identification of the locations of physicians by specialty to counter claims of a lack of physicians in certain areas (Cady, 2006). One of the policies pursued by the SOPP is the AMA’s 2006 resolution H-35.988,¹⁸ Independent Practice of Medicine by “Nurse Practitioners.” This resolution opposes any legislation allowing the independent practice of medicine by individuals who have not completed state requirements to practice medicine.

The AMA has released a set of 10 documents for members of state medical associations to help them explain “to regulators and legislators the limitations in the education and training of non-physician providers” (AMA, 2009). One of these, the AMA Scope of Practice Data Series: Nurse Practitioners, uses the term “limited licensure health care providers.” The document argues that these providers—NPs—seek scope-of practice expansions that may be harmful to the public (AMA, 2009). Other organizations, such as the American Society of Anesthesiologists and the American Association of Family Physicians (AAFP), have also issued statements that do not support nurses practicing to their fullest ability (ASA, 2004), although the AAFP supports nurses and physicians working together in collaborative teams (Phillips et al., 2001). The AAFP recently released a press packet—a “nurse practitioner information kit.”¹⁹ The kit includes a set of five papers and a new piece of legislation “clarifying” why NPs cannot substitute for physicians in primary care, although as Medicare and Medicaid data show, they already are doing so. 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.

Action has been taken at the state level as well. For example, in 2010, the California Medical Association (CMA) and the California Society of Anesthesiologists (CSA) sued the state of California after Governor Schwarzenegger decided to opt out of a Medicare provision requiring physician supervision of CRNAs (Sorbel, 2010). At the time of release of this report, the case had not yet been heard.

Reasons for Physician Resistance

The CMA and CSA both cited patient safety as the reason for protesting the governor’s decision—although evidence shows that CRNAs provide high-quality care to California citizens, there is no evidence of patient harm from their practice, and 14 other states have taken similar opt out actions (Sorbel, 2010). A study by Dulisse and Cromwell (2010) found no increase in inpatient mortality or complications in states that opted out of the CMS requirement that an anesthesiologist or surgeon oversee the administration of anesthesia by a CRNA. As noted earlier in this chapter, the contention that APRNs are less able than physicians to deliver care that is safe, effective, and efficient is not supported by research that has examined this question (Brown and Grimes, 1995; Fairman, 2008; Groth et al., 2010; Hatem et al., 2008; Hogan et al., 2010; Horrocks et al., 2002; Hughes et al., 2010; Laurant et al., 2004; Mundinger et al., 2000; Office of Technology Assessment, 1986).

Some physician organizations argue that nurses should not be allowed to expand their scope of practice, citing medicine’s unique education, clinical knowledge, and cognitive and technical skills. Opposition to this expansion is particularly strong with regard to prescriptive practice. However, evidence does not support an association between a physician’s type and length of preparation and the ability to prescribe correctly and accurately or the quality of care (Fairman, 2008). Similar questions have been raised about the content of nursing education (see the discussion of nursing curricula in Chapter 4).

Support for Expanded Scope of Practice for Nurse Practitioners

Some individual physicians support expanded scope of practice for NPs. The Robert Wood Johnson Foundation Nursing Research Network (described in Appendix A) conducted a survey of 100 physician members of the online physician site Sermo.com²⁰ and found that more than 50 percent of respondents agreed either somewhat or strongly that “allowing NPs to practice independently would increase access to primary care in the U.S.” (RWJF, 2010e). As Figure 3-4 shows, however, physicians were more skeptical that expanding NPs’ scope of practice in this way would decrease costs, and they feared a decrease in average quality of care provided to patients.

FIGURE 3-4

Physician opinions about the impact of allowing nurse practitioners to practice independently. SOURCE: RWJF, 2010d. Reprinted with permission from Lori Melichar, RWJF.

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. adults by the Wall Street Journal.com/Harris Interactive (Harris Interactive, 2008), almost all respondents who had used a retail-based health clinic (313 total) were very or somewhat satisfied with the quality of care, cost, and staff qualifications (see Figure 3-5). Such public support can be backed up with high-quality clinical outcomes (Mehrotra et al., 2008).

FIGURE 3-5

Patient satisfaction with retail-based health clinics. NOTES: Question asked: Overall, 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?

Despite opposition by some physicians and specialty societies, 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. 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. For example, in 2007 Pennsylvania Governor Edward Rendell announced a blueprint for reform, known as Prescription for Pennsylvania (Rx for PA), to promote access to care for the state’s residents and reduce health care expenses (see the case study in Chapter 5). One initiative under Rx for PA was expanding the legal scope of practice for physician assistants, APRNs, CNSs, CNMs, and dental hygienists. This initiative has had an important impact on access to care. Outcome data after the first year of Rx for PA show an increase in the number of people with diabetes receiving eye and foot examinations and a doubling of the number of children with asthma who have a plan in place for controlling exacerbations (Pennsylvania Governor’s Office, 2009).

The experience of states that have led these changes offers important reas surance to physicians who continue to believe that patient care may be adversely affected, or that expanded nursing practice autonomy threatens the professional and economic roles of physicians. States with broader nursing scopes of practice have experienced no deterioration of patient care. In fact, patient satisfaction with the role of APRNs is very high. Nor has expansion of nursing scopes of practice diminished the critical role of physicians in patient care or physician income (Darves, 2007). With regard to the quality of care and the role of physicians, it is difficult to distinguish states with restrictive and more expanded scopes of practice. 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.

Effect of Fragmentation on Realizing the Value of Nurses

Within this system, the contributions of nursing are doubly hidden. 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. A 2007 review of 100 demonstration projects that provided incentives for high-value care to hospitals and physicians found no examples that specifically delineated or rewarded nurses’ contributions (Kurtzman et al., 2008). Yet nurses’ work is estimated to vary by 15 to 40 percent for any given diagnosis-related group (Laport et al., 2008). The effect on the provision of health care is difficult to document, but a closer look at staffing ratios suggests some of the consequences. Generally speaking, as an analysis by the Lewin Group concludes, because health care facilities cannot capture the full economic value of the services nurses provide, they have an economic incentive—whether they decide to heed it or not—to staff their organizations “at levels below where the benefit to society equals the cost to employ an additional nurse” (Dall et al., 2009).

Barriers to measuring and realizing the economic value generated by nurses exist outside the hospital setting as well. In many states, APRNs are not paid directly but must be reimbursed through the physician with whom they have a collaboration agreement. Payments are funneled through the physician provider number, and the nurse is salaried.

For years, professional nursing organizations have sought to counter the inequitable aspects of the fee-for-service payment system by lobbying to increase the types of services for which NPs can independently bill Medicare, Medicaid, and other providers. They have had some success in that regard in the past (Sullivan-Marx, 2008). However, according to Mark McClellan and Gail Wilensky, both former directors of CMS, this approach has become a losing proposition. As McClellan and Wilensky testified to the committee in September 2009, while fee-for-service is not going to disappear any time soon, its future is severely limited in any sustainable health care system.

Proposals to Address Fragmentation

Alternative proposals for financing the health care system have coalesced around the idea of providing “global payments” that are shared among a predetermined group of providers, such as hospitals, physicians, nurses, social workers, nutritionists, and other professionals, and “bundled payments” that are linked to a single episode of care, such as treatment of and recovery from a heart attack. A full exploration of all the benefits and caveats of such alternative payment proposals is beyond the scope of this report. However, as the Medicare Payment Advisory Commission (MedPAC) noted in its June 2008 report to Congress, “[b]undling payment raises a range of implementation issues because under bundled payment the entity accepting the payment—rather than Medicare—has discretion in the amount it pays providers for care provided, whether to pay for services not now covered by Medicare, and how it rewards providers for reducing costs and improving quality” (MedPAC, 2008). It will be up to the entity accepting payment to determine how and indeed whether to valuate nurses’ contributions. Yet the tendency of human nature is to follow the practices and behaviors with which one is most familiar. Without the presence of nurses in decision-making positions in these new entities, the legacy of undervaluing nurses, characteristic of the fee-for-service system, will carry over into whatever new payment schemes are adopted. The services of nurses must be properly and transparently valued so that their contributions can fully benefit the entire system.

Residencies Outside of Acute Care

Residency programs are supported predominantly in hospitals and larger health systems, with a focus on acute care. This has been the area of greatest need since most new graduates gain employment in acute care settings, and the proportion of new hires (and nursing staff) that are new graduates is rapidly increasing (Kovner et al., 2007). It is essential, however, that residency programs outside of acute care settings be developed and evaluated. Chapter 2 documents the demographic changes on the horizon; the shift of care from hospital to community-based settings; and the need for nursing expertise in chronic illness management, care of older adults in home settings, and transitional services. In this context, nurses need to be prepared for new roles outside of the acute care setting. It follows that new types of residency programs appropriate for these types of roles need to be developed.²⁵

Several community care organizations are already acting on their own perceived need for a residency-type program lasting 3 months or longer for new employees. At the Visiting Nurse Services of New York, nurses receive a great deal of education and training on the job. New nurses with a bachelor’s degree participate in an internship that provides hands-on experience and mentoring from experienced staff that prepares them for home-based nursing. “We really have to do a lot of our own education and training to compensate for the fact that most of the nurses don’t come with the experience, the competencies, or the comfort and confidence with technology that we think they need,” said Carol Raphael, the organization’s president and CEO (IOM, 2010a).

There are a few successful transition-to-practice initiatives in the field of public health, although they are commonly called internships, orientations, or mentoring programs. For example, the North Carolina State Health Department has begun a pilot effort with four public health departments in an effort to educate new nurses about population-based health. The 6-month mentoring program is being used as a recruitment and retention tool and has very explicit objectives, including an increase in retention and understanding of population health and a willingness to serve as a mentor as the program goes forward.²⁶ Another successful community-based transition-to-practice program, called LEAP (Linking Education and Practice for Excellence in Public Health Nursing), was recently demonstrated in Milwaukee Wisconsin. Two public health departments and three community health centers not only collaborated to diversify the nurses entering public and community health settings, but also offered them paid traineeships to transition into their settings. 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. Financial support was secured from a variety of sources, including foundations, corporations, and partnership members themselves. The program is new and is currently undergoing an evaluation to deter mine its financial sustainability.²⁷ Such programs are not widespread, however, and need to be.

Evidence in Support of Residencies

Much of the evidence supporting the success of residencies has been produced through self-evaluations by the residency programs themselves. For example, Versant has demonstrated a profound reduction in turnover rates for new graduate RNs—from 35 to 6 percent at 12 months and from 55 to 11 percent at 24 months—compared with new graduate RN control groups hired at a facility prior to implementation of the residency program (Versant, 2010). Other research suggests residencies may be useful to help new graduates transition into practice settings (Goode et al., 2009; Krozek, 2008).

The UHC/AACN nurse residency program described above also reports reduced rates of turnover and cites cost savings to its participants. According to the UHC (2009) and AACN,²⁸ since 2002 the program:

• saved participating organizations over $6 million per year on the costs of turnover for a first-year nurse (the cost to recruit and retain a replacement nurse was estimated at $88,000);
• increased its retention rate from 87 percent in 2004 to 94 percent in 2009;
• increased stability in staffing levels, thereby reducing stress, improving morale, increasing efficiency, and promoting safety;
• achieved a return on investment of up to 14:1; and helped first-year nurses in the program achieve the following:
  • develop their ability in clinical decision making,
  • develop clinical autonomy in providing patient care,
  • incorporate research-based evidence into their practices, and
  • increase commitment to nursing as a career.

The committee focused its attention on residencies for newly licensed RNs because these residencies have been most studied. 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. As a growing number of nurses pursue advanced practice degrees immediately after receiving a bachelor’s degree—with no break between for employment in a clinical setting—the benefit to APRNs of completing a residency is likely to grow as well. The committee believes that regardless of where the residency takes place—whether in the acute care setting or the community—nurses should be paid a salary, although the committee does not take a position on whether this should be a full or reduced salary. 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. The intensity and demands of providing service in the complex setting of a federally qualified health center (FQHC), Flinter testified, often discourage newly graduated NPs from joining an FQHC and the clinics from hiring newly graduated NPs. In 2006, she continued, her organization started the country’s first formal NP residency training program. The goal was to ensure that new NPs would find the training and transition support they needed to be successful as PCPs. The program is a 12-month, full-time, intensive residency that provides extensive precepting, specialty rotations, and additional didactic education in the high-risk/high-burden problems commonly seen in FQHCs. The NP residents are trained in a chronic care/planned care approach that features both prevention and chronic disease management, advance access to eliminate waits and delays, integrated behavioral health and primary care, and expert use of the electronic health record. In Flinter’s view and that of her organization, the initial year of residency training is essential to transitioning a new NP into a fully accountable PCP (Flinter, 2009). And indeed, the ACA allocates $200 million from 2012 to 2015 as part of a demonstration project that will pay hospitals for the costs of clinical training to prepare APRNs with the skills necessary to provide primary and preventive care, transitional care, chronic care management, and other nursing services appropriate for the Medicare population.

Residency provides a continuing opportunity to apply important knowledge for the purpose of remaining a safe and competent provider in a continuous learning environment. Paying for residencies is a challenge, but the committee believes that funds received from Medicare can be used to help with these costs. In 2006, about half of all Medicare nursing funding went to five states that have the most hospital-based diploma nursing programs (Aiken et al., 2009). The diploma programs in these states directly benefit from receiving these funds. Most states, however, and most hospitals do not receive Medicare funding for nursing education. The committee believes it would be more equitable to spread these funds more widely and use it for residency programs that would be valuable for all nurses across the country.

An Aging Workforce

Like the U.S. population, the nurse workforce continues to grow older. Over the past three decades, there has been a profound shift in the age composition of nurses. In 1983, approximately 50 percent (596,000 full-time equivalents [FTEs]) of the workforce was between the ages of 20 and 34, while only 17 percent (202,000 FTEs) was over the age of 50. Since the 1980s, the number of FTEs in the nursing workforce has doubled, and there has been a dramatic increase in the number of middle-aged and older RNs. From 1983 to 2009, the number of nurses over age 50 more than quadrupled, and the number of middle-aged nurses (aged 35–49) doubled to approximately 39 percent (977,000).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). Figure 3-7 shows the age shift in the nursing workforce that has occurred over the past two decades.

FIGURE 3-7

Age distribution of registered nurses, 1980–2008 SOURCE: HRSA, 2010.

The figure shows that since 1980, the nursing workforce has grown older, as reflected by more RNs reporting that they fall within the older age categories with each successive survey. At the same time, the figure indicates that in both 2004 and especially 2008, the number of young RNs in the workforce was growing relative to earlier years. This increase may reflect, in part, the impact of the Johnson & Johnson Campaign for Nursing’s Future, which launched a large national media initiative in 2002 aimed at attracting people into nursing. As other similar recruitment initiatives followed, more, younger people chose to become nurses, reversing a 20-year trend of declining entry into nursing by young people.

The shift in the age composition of the nursing workforce can be attributed in part to the large number of baby boomers who became RNs in the 1970s and 1980s, followed by much smaller cohorts in the later decades (Buerhaus et al., 2009a). These smaller cohorts were a result of not only the decrease in births, but also a decrease in interest in the profession during the 1980s and 1990s when women began entering other professions that had typically been dominated by men (Staiger et al., 2000). The physician workforce has also been aging, but in much smaller numbers. Figure 3-8 compares the average age of nurses with varying levels of education with that of physicians and physician faculty. Between 2001 and 2009, the number of physicians aged 50–64 grew by 77,000 FTEs, while the number of RNs in that same age group grew by almost five times as many (368,000 FTEs) (Staiger et al., 2009). Compared with the size of the nursing workforce, however, the size of the physician workforce is less dependent on interest in profession. The supply of physicians is influenced more by institutional factors that govern the number of available slots in medical schools and residency programs. For example, the supply of physicians was deliberately expanded in the 1960s with the introduction of the Medicare and Medicaid programs but has remained fairly constant since then. This pattern has resulted in large successive cohorts of physicians who are replacing smaller groups of retiring physicians (Staiger et al., 2009).

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.

As the coming decades unfold, nurses and physicians will continue to age. Many of the large numbers of older RNs will retire, and increasing numbers of middle-aged RNs will enter their 50s. Although the number of younger RNs has recently begun to grow, the increase is not expected to be large enough to offset the number of RNs anticipated to retire over the next 15 years (Buerhaus et al., 2009b). To fill gaps created by retirement and the increasing demand for nursing services, resulting in part from an aging population and increased rates of insurance coverage, the nursing workforce will need to expand by attracting younger individuals into the profession—a challenge that has been more difficult for the nursing profession than it has been for medicine (Kimball and O’Neil, 2002).

Gender Diversity

Throughout much of the 20th century, the nursing profession was composed mainly of women. While the absolute number of men who become nurses has grown dramatically in the last two decades, from 45,060 in 1980 to 168,181 in 2004 (HRSA, 2006), men still make up just over 7 percent of all RNs (HRSA, 2010). Overall, male RNs tend to be younger than female RNs, with an average age of 44.6 years. Men are also more likely to begin their careers with slightly more advanced nursing degrees (HRSA, 2006).

Efforts to recruit more men into the civilian nursing profession have had minimal success, and a body of research indicates gender-based reasons for entering the nursing profession. The evidence is generally thin, but men tend to list factors associated with security and professional growth that led them to the nursing profession: salary, ease of obtaining work, job security, and opportunities for leadership. By contrast, women tend to list factors that represent social encouragement from family or friends (Zysberg and Berry, 2005). While more men are being drawn to nursing, especially as a second career, the profession needs to continue efforts to recruit men; their unique perspectives and skills are important to the profession and will help contribute additional diversity to the workforce.

Racial and Ethnic Diversity

To better meet the current and future health needs of the public and to provide more culturally relevant care, the current nursing workforce will need to grow more diverse. Previous IOM reports have found that greater racial and ethnic diversity among providers leads to stronger relationships with patients in nonwhite communities. These reports argue that the benefits of such diversity are likely to be felt across health professions and to grow as the U.S. population becomes increasingly diverse (IOM, 2004, 2006). The IOM’s report Unequal Treatment: Addressing Racial and Ethnic Disparities in Health Care identifies the diversification of the health care workforce as an important step toward responding to racial and ethnic disparities in the health care system (IOM, 2003). Because nurses make up the largest proportion of the health care workforce and work across virtually every health care and community-based setting, changing the demographic composition of nurses has the potential to effect changes in the face of health care in America.

Although nurses need to develop the ability to communicate and interact with people from differing backgrounds, the demographic characteristics of the nursing workforce should be closer to those of the population at large to foster better interaction and communication (AACN, 2010a). The 2008 National Sample Survey of Registered Nurses (NSSRN) documented the lack of diversity in the nursing workforce, with 5.4 percent of nurses describing themselves as Black/African American, 3.6 percent as Hispanic/Latino, 5.8 percent as Asian or Native Hawaiian/Pacific Islander, 0.3 percent as American Indian/Alaska Native, and 1.7 percent as multiracial (HRSA, 2010). Figure 3-9 compares the racial/ethnic diversity of RNs with that of the U.S. population.

FIGURE 3-9

Distribution of registered nurses and the U.S. population by racial/ethnic background. SOURCE: HRSA, 2010.

Numerous programs nationwide are aimed at increasing the number of health professionals from underrepresented ethnic and racial groups. One program that seeks to increase diversity while also responding to the health needs of underserved populations is the Harambee Nursing Center (HNC) in Louisville, Kentucky (AAN, 2010c). The name refers to an African tribal word that means “let’s pull together.” HNC was founded in 2003 by the University of Louisville School of Nursing, in partnership with the University of Louisville hospital and several religious groups, “to improve the health of the approximately 11,000 lowincome, primarily African-American, urban, underserved Smoketown-Shelby Park-Phoenix Hill neighborhood” (Roberts and Hayes, 2005). It is managed by nurses with the help of a volunteer family practice physician. Since its inception, a goal of the program has included attracting greater numbers of minority persons into nursing and other health professions and providing opportunities to enhance 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 persons working in community agencies and one-to-one mentoring of community 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 conversations 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;
• distributing literature and pictures related to the history of African Americans in nursing; and
• collaborating with other community agencies to include nursing education and career options in their educational and jobs programs.

Outcomes cited by Dr. Roberts include the following:

• Nursing careers and educational pathways are now formally included in job-related programs implemented by the Presbyterian Community Center (PCC). For example, over the past 2 years, PCC has selected 50 community residents into the Changemaker program, which targets 19- to 25-year-olds to engage them in self-discovery, goal setting, and progress toward career goals, with the condition of giving back to the community. Each year about four to six Changemakers examine health careers in depth. HNC included nursing and health careers in the proposal that funded this pathway and provides supervised clinical experiences, mentoring, part-time job opportunities where possible, and education about nursing.
• Arrangements have been made to connect interested residents with entry into a medical assistant program that provides articulation to associate’s degree education and then mentoring to advance to the bachelor’s of science in nursing (BSN) and further, in addition to baccalaureate programs.
• The University of Louisville School of Nursing hosts a recruitment booth at the Annual Health Fair at HNC.
• Community health students and faculty now provide education at the community middle school regarding careers in nursing.
• Based on HNC’s feedback to the School of Nursing, criteria for selection of students into the RN–BSN program are under scrutiy. Last year no African American student was accepted. One of HNC’s mentorees missed selection by only a few points. Dialogue with faculty led to an examination of policies that resulted in the omission of minority students.
• Literally hundreds of undergraduate and graduate nursing students (from several academic institutions) have supervised learning experiences in the community. 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 undergraduate students participate in a Back to School event each fall where Harambee offers school physicals and immunizations for underserved middle school students. Each year 2 to 4 graduate nursing students serve as research or program assistants and/or researchers, and nursing students in the PhD program engage in research-related projects.

Conclusion: Demographic Challenges

The nurse workforce is slowly becoming more diverse, and the proportion of racially and ethnically diverse nursing graduates has increased by 10 percent in the last two decades, growing from 12.3 to 22.5 percent (HRSA, 2010). Nonetheless, additional commitments are needed to further increase the diversity of the nurse workforce. Steps should be taken to recruit, retain, and foster the success of diverse individuals. One way to accomplish this is to increase the diversity of the nursing student body, an issue addressed in Chapter 4. The combination of age, gender, race/ethnicity, and life experiences provides individuals with unique perspectives that can contribute to advancing the nursing profession and providing better care to patients.

Impact of Technology on the Design of Health Care Delivery

In 2009, the American Recovery and Reinvestment Act (ARRA) (Public Law 111-5) included provisions to create incentives for the adoption and meaningful use of health information technology (HIT). ARRA strengthened standards for maintaining the privacy and security of health information. 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. A definition of “meaningful use” was developed by the Secretary of HHS by official rulemaking procedures, providing opportunity for public and professional input (HHS, 2009). The meaningful use objectives will likely continue to be refined but outline core requirements that should be included in every EHR. By adopting these recommendations, users will be eligible for federal incentive payments and will be able to report information on the clinical quality of care. States can add or modify additional objectives to this definition for their Medicaid programs (CMS, 2010).

A recent article in the New England Journal of Medicine summarizes the meaningful use criterion as follows: “use by providers to achieve significant improvements in care” (Blumenthal and Tavenner, 2010). Given the nature of patient data collection, nurses will be integral to proper collection of meaningful use data. For example, among the first set of criteria to be measured include patient demographics, vital signs, and lists of patient’s diagnoses, allergies, and active medications. As EHRs become more refined and integrated, nurses will have the opportunity to help define additional meaningful use objectives.

Implications for Time and Place of Care

Care supported by interoperable digital networks will shift in the importance of time and place. The patient/consumer will not always have to be in the same location as the provider, and the provider will not always have to interact with the patient in real time. As EHRs, computerized physician order entry systems, laboratory results, imaging systems, and pharmacies are all linked into the same network, many types of care can be provided without regard to location, as the “care grid” is available anywhere, anytime.

Remote patient monitoring is expanding exponentially. An ever-growing array of biometric devices (e.g., indwelling heart or blood sugar monitors) can collect, monitor, and report information from the patient in real time, in either an institution or the home. Some of these devices can also provide direct digitally mediated care; the automated insulin pump and implantable defibrillators are two examples.

The implications of these developments for nursing will be considerable and as yet are not fully understood (Abbott and Coenen, 2008). It is not clear how much of nursing care might be independent of physical location when HIT is fully implemented, but it will likely be a significant subset of care, possibly in the range of 15–35 percent of what nurses do toda. That is, for this proportion of care, nurses need not be in the same locale (or even the same nation) as their patients. As new technologies impact the hospital and other settings for nursing services, this phenomenon may increase.

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. Moreover, the relative proportion of time RNs spend on various tasks is likely to change appreciably over the coming decades. While HIT arguably will have its greatest influence on how RNs plan and document their care, all facets of care will be mediated increasingly by digital workflow, computerized knowledge management, and decision support.

In the future, virtually every facet of nursing practice in each setting where it is rendered will have a significant digital dimension around a core EHR. Biometric data collection will increasingly be automated, and diagnostic tests, medications, and some therapies will be computer generated and managed and delivered with computer support. Patient histories and examination data will increasingly be collected by devices that interface directly with the patient and automatically stream into the EHR. Examples include automated blood pressure cuffs, personal digital assistant (PDA)–based functional status, and patient history surveys.

In HIT-supported organizations, a broader array and higher proportion of services of all types will be provided within the context of computer templates and workflows. Care and its documentation will less frequently be “free-hand.” As routine aspects of care become digitally mediated and increasingly rote, RNs and other clinicians can be expected to shift and expand their focus to more complex and nuanced “high-touch” tasks that these technologies cannot readily or appropriately accomplish, such as communication with and guidance and support for patients and their families. There will likely be greater opportunities for such interventions as counseling, behavior change, and social and emotional support—interventions that lie squarely within the province of nursing practice.

Impact of Technology on Quality, Efficiency, and Outcomes

Adoption of HIT is expected to increase the efficiency and effectiveness of clinician interactions with each patient and the target population. EHRs and other HIT should lower the cost per unit of service delivered and/or improve the qual ity of care as measured by outcomes or achievement of other end points, such as increased adherence to optimal guidelines. HIT will lead to greater efficiency if it takes less time for a clinician to provide the same unit of service or if a lowercost clinician practicing with extensive HIT support can deliver the same type of care as a higher-cost non-HIT-supported provider. Controlled time and motion studies that have compared clinicians performing the same task with and without HIT support have produced mixed findings on time efficiencies gained across clinicians and settings. One area with emerging evidence is hospital nursing time spent in documentation, with studies showing a 23–24 percent reduction (Poissant et al., 2005). On the other hand, these efficiency gains may be partially offset by the information demands of quality improvement initiatives and similar programs undertaken by a growing number of institutions (DesRoches et al., 2008).³⁴

According to a review of the literature conducted for the committee, although research on the impact of HIT on the quality of nursing care is limited, documentation quality and accessibility generally improve after the implementation of HIT. Medication errors almost always decrease after the implementation of bar code medication administration (Waneka and Spetz, 2009). DesRoches and colleagues (2008) conducted a national survey of more than 3,436 RNs (1,392 responses) and found that hospitals with basic EHR systems were more likely to be recognized for nursing excellence (magnets/magnet-like) and to have quality improvement programs. No differences were found in time spent on patient care activities for nurses in hospitals with and without minimally functioning systems.

Technology is also used to measure patient outcomes, with varying results. While measuring outcomes is critical to the provision of 21st-century health care, complications have developed in ensuring that outcome measures from different institutions and organizations are, in fact, comparable. Even ensuring that outcome measures from different parts of the same organization are comparable can be problematic. Researchers in Colorado conducted a comprehensive review of the use of rescue agents—a Joint Commission–approved quality measure—based on the EHRs at the Children’s Hospital in Aurora. They found that variations in the way information was entered in the EHRs accounted for significant variations within the institution and could be responsible for as much as a 40-fold difference in outcome measures among hospitals (Kahn and Ranade, 2010). The researchers concluded that “more detailed clinical information may result in quality measures that are not comparable across institutions due [to] institution-specific workflow.”

A longitudinal study of 326 hospitals found that those that had implemented more advanced EHR systems over the time period had higher costs and increased nurse staffing levels (Furukawa et al., 2010). Patient complications increased in these hospitals, while mortality for some conditions declined. It should be noted, however, that these results may be difficult to interpret because of the implementation of minimum nurse staffing regulations at the same time that the implementation of EHRs ramped up. During that time, nurse staffing rose, and thus costs per patient rose, and if there is any correlation between implementation of EHRs and increased nurse staffing due to the ratios, the results may confound the two. In addition, the study did not control for hospital ownership (e.g., nonprofit, forprofit) or system affiliation, both of which might be important.

Finally, a systematic review of the literature (fewer than 25 articles) showed that the time spent on documentation of care may increase or decrease with EHRs (Thompson et al., 2009). The increases in time however, may be compensated for by the use of EHRs in other activities, such as giving/receiving reports, reconciling medications, and planning care.

Technology Transforming Roles for Nurses

The new practice milieu—where much of nursing and medical care is mediated and supported within an interoperable “digital commons”—will support and potentially even require much more effective integration of multiple disciplines into a collaborative team focused on the patient’s unique set of needs. Furthermore, interoperable EHRs linked with personal health records and shared support systems will influence how these teams work and share clinical activities. It will increasingly be possible for providers to work on digitally linked teams that will collaborate with patients and their families no longer limited by real-time contact.³⁵

As the knowledge base and decision pathways that previously resided primarily in clinicians’ brains are transferred to clinical decision support and CPOE modules of advanced HIT systems, some types of care most commonly provided by nurses can readily shift to personnel with less training or to patients and their families. Similarly, many types of care previously provided by physicians and other highly trained personnel can be provided effectively by APRNs and other specialty trained RNs. 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.

Increasingly, technology is allowing nurses and other health care providers to offer their services in a wider range of settings. For example, the ability of the Visiting Nurse Service of New York to tap into mobile technology, as described in Chapter 2, allowed that organization to provide ever more complex care in the home setting (IOM, 2010a).

Involving Nurses in Technology Design and Implementation

As the largest segment of the health care workforce with some of the closest, most sustained interactions with patients, nurses are often the greatest users of technology. In many instances, they may know what will work best with regard to technological solutions, but they are asked for their opinions infrequently. According to a survey of nurses at 25 leading acute care facilities across the United States, nurses find “that existing systems are often splintered, unable to interface and require multiple log-on to access or enter data. They call repeatedly for integrated systems to ease their workload and help them reach clinical transformation” (Bolton et al., 2008).

Studies show that involving nurses in the design, planning, and implementation of technology systems leads to fewer problems during implementation (Hunt et al., 2004). The TIGER Initiative (for Technology Informatics Guiding Education Reform) is a collaborative effort of 1,400 nurses from various organizations, government agencies, and vendors whose goal is “to interweave informatics and enabling technologies transparently into nursing practice” (TIGER, 2009). 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) infrastructure and health care reform.” They also see the need to “accelerate adoption of smart, standards based, interoperable technology that will make health care delivery safer, more efficient, timely, accessible, and patient-centered, while also reducing the burden of nurses” (TIGER, 2009).

Nurses have also invented new technology to help them care for their patients. For instance, Barbara Medoff Cooper, professor in pediatric nursing and director of the Center for Biobehavioral Research at the University of Pennsylvania School of Nursing, developed a microchip device that is situated between the nipple and the rest of the baby bottle. It measures the sucking ability of premature neonatal babies, which has been shown to be an accurate indication of the infant’s ability to feed successfully and thus survive discharge. The information thus gathered has helped guide parents and providers in better planning for the care of high-risk neonates at home (Bakewell-Sachs et al., 2009; Medoff-Cooper et al., 2009).

Another effort, called TelEmergency, brings a certified emergency room physician to 12 rural hospitals in Mississippi from the University of Mississippi via a T-1 line, but only when needed. The system is managed by a group of 35 APRNs who provide care in these rural communities, including management of the technology as a referral system. The nurses are able to handle 60 percent of all emergency care, saving the hospital consortium $72,000 per month (AAN, 2010b).

The case study in Box 3-5 shows how nurses at one institution are working to ensure that they spend their time in patient care and not on the technology associated with delivering modern health care.

BOX 3-5

Case Study: Technology at Cedars-Sinai Medical Center. Sending Alerts via Text Message Shortens Nurses’ Response Times to Critical Alarms In January 2010 a California hospital was fined for the death of a man whose cardiac alarm had been set to (more...)