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2 Study Context This chapter presents essential context for the remainder of the report, ad- dressing in turn the evolving challenges faced by the health care system, which drive the need for a reformed system and the concomitant transformation of the nursing profession; the three primary concerns targeted by health care reform— quality, access, and value; and the principles the committee determined must guide any reform efforts. The final section summarizes the committee’s conclu- sions about the implications of this discussion for the role of nurses in transform- ing the health care system. EVOLVING HEALTH CARE CHALLENGES For decades, the major focus of the U.S. health care system has been on treating acute illnesses and injuries, the predominant health challenges of the early 20th century. In the 21st century, the health challenges facing the nation have shifted dramatically: • Chronic conditions—While acute injuries and illnesses will never dis- appear, most health care today relates to chronic conditions, such as dia- betes, hypertension, arthritis, cardiovascular disease, and mental health conditions, which in 2005 affected nearly one of every two Americans (CDC, 2010). This shift can be traced in part to the increased capabili- ties of the health care system to treat these conditions and in part to the 4

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4 THE FUTURE OF NURSING health challenges of an aging population, as the prevalence1 of chronic conditions increases with age. Dramatic increases in the prevalence of many of these conditions since 1970 are expected to continue (DeVol et al., 2007). Increasing obesity levels in the United States have com- pounded the problem, as obesity is related to many chronic conditions. • An aging population—According to the most recent census projections, the proportion of the U.S. population aged 65 or older is expected to rise from 12.7 percent in 2008 to 19.3 percent in 2030 (U.S. Census Bureau, 2008), in part as a result of increases in life expectancy and the aging of the Baby Boom generation. As the population continues to age, a dramatic growth in demand for health care services will be seen (IOM, 2008). • A more diverse population—Minority groups, which currently make up about a third of the U.S. population, are projected to become the majority by 2042 and 54 percent of the total population by 2050 (U.S. Census Bureau, 2008). Diversity exists not only among but also within various ethnic and racial groups with respect to country of origin, pri- mary language, immigrant status and generation, socioeconomic status, history, and other cultural features. • Health disparities—Health disparities are inequities in the burden of disease, injury, or death experienced by socially disadvantaged groups relative to either whites or the general population. Such groups may be categorized by race, ethnicity, gender, sexual orientation, and/or income. Health disparities among these groups are driven in part by deleterious socioenvironmental conditions and behavioral risk factors, and in part by systematic biases that often result in unequal, inferior treatment (IOM, 2003b). • Limited English proficiency—The number of people living in the United States with limited English proficiency is increasing (U.S. Cen- sus Bureau, 2003). To be effective, care and health information must be accessible and offered in a manner that is understandable, as well as culturally relevant (IOM, 2004a; Joint Commission, 2007). While there are national standards for linguistically and culturally relevant health care services, the rapid growth of diverse populations with limited Eng- lish proficiency and varying cultural and health practices is emerging as an increasingly complex challenge that few health care providers and organizations are currently prepared to handle (HHS Office of Minority Health, 2007). 1 Prevalence defines the total number of individuals with a condition, and incidence refers to the number of new cases reported in a given year.

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4 STUDY CONTEXT PRIMARY CONCERNS IN HEALTH CARE REFORM: QUALITY, ACCESS, AND VALUE In the search for solutions to improve the health care system, experts target three primary concerns: quality, access, and cost or value (Goldman and Mc- Glynn, 2005). Substantial reforms designed to reshape and realign the major features of the entire health care system are needed to redress deficiencies in these three areas. Quality Despite unsustainable growth in health care spending in the United States (discussed below), the care received by individuals can often be too much, too little, too late, or too haphazard. Moreover, substantial geographic variations exist in the intensity of care provided across the nation, with attendant differences in quality, as well as cost (Fisher et al., 2009). The quality improvement movement in health care has grown significantly since the publication of two IOM reports: To Err Is Human: Building a Safer Health System and Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2000, 2001). These re- ports helped shift discussions about quality away from assigning all responsibility and accountability to individual health professionals. They showed that improv- ing quality requires an understanding of how such elements as systems and pro- cesses of care, equipment design, and organizational structure can fundamentally enhance or detract from the quality of care. Researchers also have emphasized the importance of building interprofessional teams and establishing collaborative cultures to identify and sustain continuous improvements in the quality of care (Kim et al., 2010; Knaus et al., 1986; Pronovost et al., 2008). Access Although the Affordable Care Act (ACA) provides insurance coverage for an additional 32 million Americans, millions of Americans will still lack coverage in 2019 (CBO, 2010). Even for those with insurance, out-of-pocket expenses, such as deductibles and copays, as well as limited coverage for necessary services and medications, create financial burdens that can limit access to care (Doty et al., 2005; Himmelstein et al., 2009). Other significant barriers to access include a lack of providers who are accepting new patients, especially those covered by Medicaid; a lack of providers who offer appointments outside of typical busi- ness hours; and for some a lack of transportation to and from appointments. Also hindering access is the above-discussed rapid growth of populations with limited English proficiency (U.S. Census Bureau, 2010), as well as limited health literacy among fluent English speakers.

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0 THE FUTURE OF NURSING Value The term “value” has different meanings in different contexts. For the pur- poses of this report, the committee uses the following definition: “value in health care is expressed as the physical health and sense of well-being achieved relative to the cost” (IOM Roundtable on Evidence-Based Medicine, 2008). As one of the major components of value—quality—is discussed above, this section focuses on cost. The United States spends more than any other nation—16.2 percent of gross domestic product in 2008—on health care (CMS, 2010a). Yet this investment is not matched by superlative health care outcomes (OECD, 2010), indicating deficiencies in the value of some aspects of the health care system. Moreover, while the United States spends too much on certain aspects of health care, such as hospital services and diagnostic tests, spending on other aspects is dispropor- tionately low. For example, public health represents less than 3 percent of health care spending (CMS, 2010b). Health care spending is responsible for large, and ultimately unsustainable, structural deficits in the federal budget (Dodaro, 2008), and many economists be- lieve that rising health care costs are a principal reason why wages have increased so little in recent years (Emanuel and Fuchs, 2008). However, establishing and sustaining legislated cost controls and health care savings has proven elusive. Challenges with regard to costs and spending make achieving value within the health care system difficult. Throughout its deliberations, the committee found it useful to focus on ensur- ing that the health care system delivers good value rather than focusing solely on cost. Accordingly, the committee paid particular attention to high-value innova- tions in nursing care that provide quality, patient-centered care at a lower price. Three specific examples are featured as case studies later in this chapter. PRINCIPLES FOR CHANGE The challenges faced by the U.S. health care system have been described and documented in recent years by many government agencies, researchers, policy analysts, and health professionals. From this work, a consensus has begun to emerge regarding some of the fundamental principles that should guide changes to meet these challenges. Broadly, the consensus is that care in the United States must become more patient centered; primary care and prevention must play a greater role relative to specialty care; care must be delivered more often within the community setting and even in people’s homes; and care needs to be coordi- nated and provided seamlessly across health conditions, settings, and providers. It is also important that all providers practice to the fullest extent allowed by their education, training, and competencies and collaborate so that improvements can be achieved in both their own and each other’s performance. This section pro-

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1 STUDY CONTEXT vides an overview of these shifts in thinking and practice that a growing number of health care experts believe should be at the core of any proposed health care solutions. The Need for Patient-Centered Care Health care research is demonstrating the benefits of reorganizing the de- livery of health care services around what makes the most sense for patients (Delbanco et al., 2001; Hibbard, 2004; Sepucha et al., 2004). As outlined in Crossing the Quality Chasm, patient-centered care is built on the principle that individuals should be the final arbiters in deciding what type of treatment and care they receive (IOM, 2001). Yet practice still is usually organized around what is most convenient for the provider, the payer, or the health care organi- zation and not for the patient. Patients are repeatedly asked, for example, to change their expectations and schedules to fit the needs of the system. They are required to provide the same information to multiple caregivers or in sequential visits to the same provider. Primary care appointments typically are not available outside of work hours. The counseling, education, and coaching needed to help patients make informed decisions have historically been given insufficient atten- tion (Hibbard, 2004). Additionally, patients’ insurance policies often limit their choice of provider, especially if the provider is not a physician (Craven and Ober, 2009). Box 2-1 presents an example of how one health system, the University of Pittsburgh Medical Center, has implemented a truly patient-centered program. How Patient-Centered Care Improves Quality, Access, and Value A number of studies have linked patient-centered and quality care (Sepucha et al., 2004). For example, studies that compared surgery with watchful waiting for patients with benign prostatic hyperplasia showed how strong a role patient preference played in determining quality of life (Barry et al., 1988; Fowler et al., 1988; Wennberg et al., 1988). Likewise, involving patients more directly in the management of their own condition was found to result in significant improve- ments in health outcomes for individuals with insulin-dependent diabetes mellitus (Diabetes Control and Complications Trial Research Group, 1993). By 2001, so many different studies had found similar results that Crossing the Quality Chasm identified patient-centered care as one of six pillars on which a 21st-century health care system should be built (the others being safety, effectiveness, timeli- ness, efficiency, and equity) (IOM, 2001). One of the hallmarks of patient-centered care is improving access to care, a key component of which is access to information. For example, a growing num- ber of patients have greater access to their own laboratory results and diagnostic writeups about their procedures through such electronic forums as personal health records and patient portals. Many people participate in online communities to

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2 THE FUTURE OF NURSING BOX 2-1 Case Study: When Patients and Families Call a Code The University of Pittsburgh Medical Center Is Transforming Care at the Bedside I n 2001, 18-month-old Josie King (UPMC) at Shadyside, “I told my was hospitalized at Johns Hopkins chief medical officer, ‘We’re going to Children’s Center with burns let patients and families call a rapid- she had sustained in a bathtub response team’—a group of staff accident. Josie responded well to who are designated by the hospital treatment at first, but her condi- to respond immediately to other tion quickly deteriorated. When her staff’s requests for help with critical mother, Sorrel King, expressed con- or emergency patient situations. He cern, the staff nurses and physicians thought I was insane.” repeatedly dismissed them, and 2 days before her scheduled discharge As we’ve always known, when you give Josie died. The cause was dehydra- power and authority to patients, they tion and a wrongly administered treat it with great respect. opioid—the result of a series of errors the hospital acknowledged. —Tami Minnier, MSN, RN, FACHE, Ms. King has since devoted herself chief quality officer, University of Pitts- to the elimination of medical errors, burgh Medical Center founding the Josie King Foundation (www.josieking.org) and address- Shadyside had been one of the ing clinicians, policy makers, and first three hospitals to participate in consumers on the importance of Transforming Care at the Bedside creating a “culture of safety.” And (TCAB), an initiative of the Institute the need is pressing. According to a for Healthcare Improvement (IHI) and 2000 Institute of Medicine report, up the Robert Wood Johnson Founda- to 98,000 people die from medical tion, enabling front-line nurses to test errors each year (IOM, 2000); nearly their ideas for improving the safety 10 years after that report’s publica- and quality of care. Ms. Minnier tion, despite improved patient-safety called on Sorrel King to work with systems, a 2009 report gave a grade the nurses in Shadyside’s TCAB unit of C+ to efforts to empower patients in creating what they called Condi- to prevent errors (Wachter, 2009). tion H (or Condition Help). They Tami Minnier, MSN, RN, FACHE, interviewed patients and families heard Ms. King speak in 2005, and about when and why they might call the message was clear: if the staff for a rapid-response team, consisting had listened to her mother’s con- of a nurse administrator, a physician, cerns, Josie would have lived. “When a staff nurse, and a patient advocate I came back to work the following who would convene immediately in Monday,” said Ms. Minnier, at the response to a patient’s or visitor’s call. time chief nursing officer at the Uni- versity of Pittsburgh Medical Center They held drills with staff, and within

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3 STUDY CONTEXT for calls, and more than 60 percent 6 months, Condition H went live in of the calls led to interventions that the hospital’s TCAB unit. were deemed instrumental in pre- While some staff feared that venting a patient-safety event. patients would abuse the hotline, Condition H is spreading and that concern was not borne out. serves as one example of the changes Today, patients and families through- hospitals have adopted using TCAB out UPMC’s 13 acute care hospitals methods. Reports on TCAB have can use Condition H. They receive shown that it generates improved information on how to make the call outcomes, greater patient and family (dial 3131 and say, “Condition H”) satisfaction, and reduced turnover of during admission and through post- nurses (Hassmiller and Bolton, 2009). ers, a video, and stickers placed on Sorrel King addressed medical and patients’ phones. nursing students at an IHI-sponsored Ms. Minnier is now chief quality event in 2009 and spoke strongly in officer at UPMC and monitors the use favor of Condition H. “Had I been of Condition H. At Shadyside, a 500- able to push a button for a rapid-re- bed hospital, two or three calls are sponse team, that team would have made each month, and only a few come, they would have assessed Josie patients have called twice during the and . . . said one thing: the child is same admission. An analysis of the thirsty,” Ms. King said. “They would 45 calls made in the first 17 months have given her a drink, and she never showed that inadequately managed would have died” (Matthews, 2009). pain was the most frequent impetus UPMC Media Services Information about Condition H is clearly posted throughout UPMC at Shadyside, on patients’ televisions, bulletin boards, and telephones.

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4 THE FUTURE OF NURSING learn more about or even how to manage their own conditions. Improving access also requires delivering care in a culturally relevant and appropriate manner so that patients can contribute positively to their own care. Fewer studies have examined the economic value of patient-centered care. One such study found that offering a nurse advice phone number and a pediatric after-hours clinic resulted in a 17 percent decrease in emergency department visits (Wilson, 2005). Yet there is no reason to believe that enhancing patient- centered care will or even should always lead to lower costs. For example, truly patient-centered approaches to care may require new programs or additional services that go beyond current standards of practice. Nurses and Patient-Centered Care Nurses have long emphasized patient-centered care. The case study in Box 2-2 provides but one example—the patient-centered approach of midwifery care at the Family Health and Birth Center (FHBC) in Washington, DC. Through the FHBC, mothers-to-be who often have little control over their own lives de- velop a sense of control over one very important part of their lives. From such modest beginnings, many more hopeful futures have been launched. The Need for Stronger Primary Care Services Consensus is also strong on the need to make primary (rather than specialty) care a greater part of the health care system. Despite steps taken by the ACA to support the provision of primary care, however, the shortage of primary care providers is projected to worsen in the United States in the coming years (Boden- heimer and Pham, 2010; Doherty, 2010). Primary care has been described in many ways. The IOM has defined it as “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community” (IOM, 1996). Starfield and colleagues identify the functions of primary care as “first-contact access for each new need; long-term person- (not disease) focused care; comprehensive care for most health needs; and coordinated care when it must be sought elsewhere” (Starfield et al., 2005). Similarly, the Government Accountability Office (GAO) has cited the following hallmarks of primary care: preventive care, care coordination for chronic ill- nesses, and continuity of care (Steinwald, 2008). Thus primary care is closely tied to two of the principles for change discussed below—the need to deliver more care in the community and the need for seamless, coordinated care.

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 STUDY CONTEXT How Primary Care Improves Quality, Access, and Value Countries that build their health care systems on the cornerstone of primary care have better health outcomes and more equitable access to care than those that do not (Starfield et al., 2005). However, primary care plays a less central role in the U.S. health care system than many health policy experts believe it should (Bodenheimer, 2006; Cronenwett and Dzau, 2010; IOM, 1996; Starfield et al., 2005; Steinwald, 2008). Geographic variations nationwide illustrate the importance of primary care. Regions of the United States with a higher ratio of generalists to specialists provide more effective care at lower cost (Baicker and Chandra, 2004), and studies have shown that those states with a greater ratio of primary care providers to the general population experience lower mortality rates for all causes of death (Shi, 1992, 1994). The positive effect is more pronounced among African Americans who have access to primary care than among whites, thus indicating that this is a promising approach to decreasing health disparities (Starfield et al., 2005). Yet primary care services have been so difficult to access in parts of the United States that one in five adults has sought nonurgent care at an emergency department (IOM, 2009). Nurses and Primary Care Nurses with varying levels of education and preparation play important roles in primary care. Health promotion, education, and assessment are essential components of primary care that are also traditional strengths of the nursing profession; these services may be provided by either registered nurses (RNs) or advanced practice registered nurses (APRNs). RNs provide primary care services across the spectrum of health care settings—from acute care to home care to public health and community care. As visiting or home health nurses, RNs are positioned to identify new health problems or needs, such as medication education, prevention services, or nutrition counseling. In public health clinics, they may provide community assessments, developmental screenings, or disease surveillance. RNs in acute care settings may identify new health care problems and needs as they care for patients and their families. The range of possibilities for RNs providing primary care is significant, and their capacity for filling these roles is not always recognized. APRNs, especially nurse practitioners (NPs), also provide primary care ser- vices across all levels of the health care system. In many situations, NPs provide care that is comparable in scope to that provided by primary care physicians. As discussed in Chapter 3, in many situations, APRNs are qualified to diagnose potential and actual health problems, develop treatment plans, in some case

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 THE FUTURE OF NURSING BOX 2-2 Case Study: Nurse Midwives and Birth Centers The Midwifery Model of Maternity Care Gives Mothers Control and Improves Outcomes W (www.yourfhbc.org), where certified hen Wendy Pugh de- livered her first child at nurse midwives provide pre- and age 30 in a Washington, postnatal care and assist with labor DC, hospital in 1999, her and delivery with little technological labor was induced—not out of medi- intervention. Delivery takes place at a cal necessity, she said, but because homelike freestanding birth center or “there was a scheduling issue with at a nearby hospital, depending on the doctor.” She didn’t question the the woman’s choice, her health, and obstetrician’s decision at the time, such factors as whether she is home- but when she got pregnant again, less. The FHBC accepts Medicaid and she polled her friends and discovered private insurance and offers a slid- that many had had cesarean sections. ing-scale fee for those ineligible for When she asked why, few gave medi- Medicaid. No one is turned away. cal reasons. She decided she wanted Ruth Watson Lubic, EdD, CNM, “a more organic process.” opened the FHBC in 2000 in re- sponse to the disproportionately high rates of infant and maternal death, Midwifery teaches you that the woman cesarean section, and premature birth is the most important person in the among poor and minority women in relationship and that’s why you should listen to her and try to give her what Washington, DC. In 2009 the infant she wants and what she needs. mortality rate in the city was 12.22 per 1,000 live births, far exceeding —Ruth Watson Lubic, EdD, CNM, that of any state in the nation (Heron FAAN, founder, Family Health and et al., 2007). Nationwide, nearly four Birth Center times as many black as white infants die as a result of premature birth or low birth weight (HRSA, 2006). Dr. Seven months into her second Lubic had already founded the first pregnancy, Ms. Pugh arrived at freestanding birth center in the coun- the Family Health and Birth Center (FHBC) in northeast Washington, DC try (in 1975 in New York City) and

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 STUDY CONTEXT day. In contrast, during the deliv- has dedicated her career to reducing disparities in birth outcomes. “We’re ery of her third child—her second hoping to serve as a model for the delivery at the FHBC—she received whole country,” Dr. Lubic said. There assistance during labor from a doula, are now 195 such centers in the a trained volunteer who provided United States. coaching and massage; her newborn was placed on her chest immediately after the birth; mother and child went home within hours of delivery; and when the infant showed difficul- ties with breastfeeding, a peer lacta- tion counselor went to their home. Two systematic reviews have found that women given midwifery care are more likely to have shorter labors, spontaneous vaginal births without hospitalization, less perineal trauma, higher breastfeeding rates, and greater satisfaction with their births (Hatem et al., 2008; Hodnett et al., 2007). Unpublished FHBC data show that, compared with all African American women giving birth in Washington, DC, women giving Sam Kittner/kittner.com birth at the center have almost half A pregnant woman receives prenatal care at the Family Health and Birth Center. the rate of cesarean sections, one- third the rate of births at less than 37 weeks’ gestation, and half the rate Ms. Pugh’s case highlights the of low-birth-weight newborns. The differences between the midwifery lower rates of complications added model of care, which promotes up to an estimated $1,231,000 in maternal and infant health, and the savings in 2005—more than the cost obstetrics model, which anticipates of operating the center that year. The complications. During the hospital FHBC reports a 100 percent breast- delivery of her first child, Ms. Pugh feeding rate among women giving received pitocin to induce labor, saw her newborn for just a few moments birth at the center. before the child was taken away, and Obstacles to widespread use of did not breastfeed until the second the FHBC model include the fact that continued

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2 THE FUTURE OF NURSING Recurrent patterns of success included actively engaged nurses supported in standardizing their own processes of care according to the IHI bundles and empowered and supported in monitoring and enforcing those standards across disciplines, including with their physician colleagues (Berwick et al., 2006). Encouraged to innovate locally to adapt changes to local contexts, nurses proved the ideal leaders for changing care systems and raising the bar on results. One new role for nurses that taps their potential as innovators is the clinical nurse leader (CNL), an advanced generalist clinician role designed to improve clinical and cost outcomes for specific groups of patients. Responsible for coordi- nating care and in some cases actively providing direct care in complex situations, the CNL has the responsibility for translating and applying research findings to design, implement, and evaluate care plans for patients (AACN, 2007). This new role has been adopted by the VA system. The Need for Interprofessional Collaboration The need for greater interprofessional collaboration has been emphasized since the 1970s. Studies have documented, for example, the extent to which poor communication and lack of respect between physicians and nurses lead to harmful outcomes for patients (Rosenstein and O’Daniel, 2005; Zwarenstein et al., 2009). Conversely, a growing body of evidence links effective teams to better patient outcomes and more efficient use of resources (Bosch et al., 2009; Lemieux-Charles and McGuire, 2006; Zwarenstein et al., 2009), while good working relationships between physicians and nurses have been cited as a factor in improving the retention of nurses in hospitals (Kovner et al., 2007). As the delivery of care becomes more complex across a wide range of settings, and the need to coordinate care among multiple providers becomes ever more important, developing well-functioning teams becomes a crucial objective throughout the health care system. Differing professional perspectives—with attendant differences in training and philosophy—can be beneficial. Nurses are taught to treat the patient not only from a disease management perspective but also from psychosocial, spiritual, and family and community perspectives. Physicians are experts in physiology, disease pathways, and treatment. Social workers are trained in family dynamics. Occupa- tional and physical therapists focus on improving the patient’s functional capacity. Licensed practical nurses provide a deeply ground-level perspective, given their routine of measuring vital signs and assisting patients in feeding, bathing, and movement. All these perspectives can enhance patients’ well-being—provided the various professionals keep the patient and family at the center of their attention. Finding the right balance of skills and professional expertise is important under the best of circumstances; in a time of increasing financial constraints, per- sonnel shortages, and the growing need to provide care across multiple settings, it is crucial. Care teams need to make the best use of each member’s education,

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3 STUDY CONTEXT BOX 2-7 Case Study: The Nurse–Family Partnership Nurses Visit the Homes of First-Time At-Risk Mothers, and the Results Are Wide-Ranging I n 2007 Crystalon Rodrigue, a It was a quiet, almost offhand recent high school graduate living remark, but it represents the kind in St. James, Louisiana, had an of shift in attitude that the NFP has adverse reaction to an injectable helped foster among young women contraceptive. She discontinued it for more than 30 years. Now active and soon got pregnant. She was 19 in 375 counties in 29 states, the NFP years old and unemployed and living sends registered nurses (RNs), usually with her mother, and her relationship with baccalaureate degrees, into the with her boyfriend was faltering. She homes of at-risk, low-income, first- turned to the state department of time mothers for 64 planned visits health; was referred to the Nurse– over the course of a pregnancy and Family Partnership (NFP); and met the child’s first 2 years. “Miss Tina,” a nurse who visited her at home. When [the Nurse–Family Partnership “In the beginning of my preg- nurse] came along, I was really down nancy, and maybe all throughout, and out. I wouldn’t get out of the house at all. She’s helped me to be strong, I was a little stressed out,” the 21- to know that I can actually make it by year-old Ms. Rodrigue said recently. myself and be a very good mom. “I was depressed because I was having relationship problems with —Crystalon Rodrigue, 21-year-old my child’s father. Miss Tina helped Louisiana client of the Nurse–Family me….” Ms. Rodrigue was interrupted Partnership by the chatter of her 19-month-old daughter, Nalayia, who was learning to read, her mother said with pride. Improving the lives of children Then she continued, “Miss Tina is the chief aim of the NFP, yet the helped me to think about myself.” interventions target mothers. The continued

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4 THE FUTURE OF NURSING BOX 2-7 continued ning. The nurse does this by engag- nurse discusses options for the ing the mother in a relationship that mother’s continued education and provides a model for interactions economic self-sufficiency; supports with others. The child’s father and her in reducing or quitting smoking other family members are encour- or drinking; teaches her about child aged to participate. development, nonviolent discipline, “We don’t look for the great big and breastfeeding; and helps her change,” said Luwana Marts, BSN, make decisions about family plan- © 2010 Marc Pagani Photography, marcpagani.com Tina Becnel, a nurse who provides home visits, helped Crystalon Rodrigue during her pregnancy and continued through her daughter Nalayia’s second birthday.

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 STUDY CONTEXT RN, regional nurse consultant for “Low-income, minority people who the NFP in Louisiana. “A part of the have not had a lot of trust in the model is that only a small change is health care system might be willing necessary. So if a client never quits to let a nurse in the door.” smoking but she doesn’t smoke in the Barriers to implementation include presence of her child, that’s a plus.” the fact that states use various In case-controlled, longitudinal sources to fund the NFP, and in some trials conducted among racially and the funding is limited. The Affordable ethnically diverse populations—be- Care Act mandates that $1.5 billion ginning in 1977 in Elmira, New York, be spent over 5 years on home visita- and continuing in Memphis, Tennes- tion programs for at-risk mothers and see, and Denver, Colorado—the NFP infants*—substantially less than the has shown reductions in unintended $8.5 billion over 10 years that Presi- second pregnancies and increases dent Obama requested in his 2010 in mothers’ employment. Children budget (OMB, 2010). While the act of mothers visited by nurses are less establishes a federal agency to over- likely to be abused and by age 15 to see such home visitation programs, it be arrested. (For links to these and does not specify that nurses provide other studies of the NFP, visit www. the care. Also, some municipalities nursefamilypartnership.org/proven- increase the nurse’s caseload beyond results/published-research.) The the recommended 25, diminishing per-child cost is $9,118; for the high- the intensity and effectiveness of the est-risk children, a return of $5.70 interventions. per dollar spent is realized (Karoly et For her part, Ms. Rodrigue is look- al., 2005). ing ahead. She had completed a cer- Several models of home visita- tified nursing assistant program while tion are in use, but the NFP relies pregnant and will soon start nursing on trained RNs for its interventions. school, in which she had enrolled A 2002 study compared home visits but quit shortly after high school. “I by untrained “paraprofessionals” wasn’t ready for it,” she said. “But and nurses. On almost all measures, now I have a child and I know what the nurses produced far stronger to expect. I feel like I’m ready. I want outcomes (Olds et al., 2002). “People to better myself.” trust nurses,” said Ruth A. O’Brien, PhD, RN, FAAN, professor of nurs- ing at the University of Colorado in *Patient Protection and Affordable Care Act, Denver and an author of the study. HR 3590 § 2951, 111th Congress.

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 THE FUTURE OF NURSING skill, and expertise, and all health professionals need to practice to the full extent of their license and education. Where the competency and skills of doctors and nurses safely overlap, it makes sense to rely on nurses to provide many of those services. Similarly, where the competency and skills of RNs and licensed practi- cal or vocational nurses safely overlap, it makes sense to rely on the latter—or as the case may be, nurses’ aides—to provide many of those services. In this way, more specialized skills and competencies are appropriately reserved for the most complex needs. This type of skill balancing should not, however, be used as a means of cutting costs by indiscriminately replacing more skilled with less skilled clinicians. CONCLUSION Nurses are well positioned to help meet the evolving needs of the health care system. They have vital roles to play in achieving patient-centered care; strength- ening primary care services; delivering more care in the community; and provid- ing seamless, coordinated care. They also can take on reconceptualized roles as health care coaches and system innovators. In all of these ways, nurses can contribute to a reformed health care system that provides safe, patient-centered, accessible, affordable care. Their ability to make these contributions, however, will depend on a transformation of nursing practice, education, and leadership, as discussed in Chapters 3, 4, and 5, respectively. Nurses must remodel the way they practice and make clinical decisions. They must rethink the ways in which they teach nurses how to care for people. They must rise to the challenge of providing leadership in rapidly changing care settings and in an evolving health care system. In short, nurses must expand their vision of what it means to be a nursing professional. At the same time, society must amend outdated regulations, attitudes, policies, and habits that unnecessarily restrict the innovative contribu- tions the nursing profession can bring to health care. REFERENCES AACN (American Association of Colleges of Nursing). 2007. White paper on the education and role of the clinical nurse leader. Washington, DC: AACN. Asch, S. M., E. A. McGlynn, M. M. Hogan, R. A. Hayward, P. Shekelle, L. Rubenstein, J. Keesey, J. Adams, and E. A. Kerr. 2004. Comparison of quality of care for patients in the Veter- ans Health Administration and patients in a national sample. Annals of Internal Medicine 141(12):938-945. ASPH (Association of Schools of Public Health). 2008. Confronting the public health workforce crisis. Washington, DC: ASPH. ASTHO (Association of State and Territorial Health Officials). 2004. State public health employee worker shortage report: A civil service recruitment and retention crisis. Washington, DC: ASTHO. Baicker, K., and A. Chandra. 2004. Medicare spending, the physician workforce, and beneficiaries’ quality of care. Health Affairs Suppl Web Exclusives:W184-197.

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