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ROLE OF NURSES IN HEALTH CARE.
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Examines contemporary nursing care and makes suggestions for improvements in the nursing profession in the 21st Century.... More...
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Paper Abstract:
Examaines contemporary nursing care and makes suggestions for improvements in the nursing profession in the 21st Century. Brief history of health care. Major changes in the Ameican health care system. Attempts to reform, standardize, lower costs and have better access to health care. How changes will effect future role for nurses.
Paper Introduction:
The Advancement of Nursing into the 21st Century
I. Introduction - Brief History of Health Care
A. How and what it was
There have always been healers, shamans, and others involved in caring for others well-being. However, in terms of organized systems in Europe, by 999 these existed only in monasteries and palaces. However, during the next two centuries it spread into cities and towns as they were built, with physicians, surgeons, apothecaries, barbers, and midwives all involved. While physicians used to be at the top of the hierarchy, surgeons are now. Pharmacists have remained lower in the hierarchy, while nurses developed as a new profession, separate from midwifery. Medieval medicine often also dealt with prevention, including diet measures and exercise programs. There was information available in regimi
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Medievalmedicine often also dealt with prevention, including diet measures andexercise programs. (1999) provided several case studies illustratingthese advantages and concluded that case management is a viable, andimportant, extension of the role of the professional nursing staff. Inaddition, the effects of cost-sharing seem to negatively affect the use ofpreventive counseling by both HMOs and PPOs (Solanki et al., 2 ),nullifying some of their supposed advantage. They benefit financially by offering preventiveservices and limiting the need for acute and chronic care services. Crumbley, D.R., Ice, R.C. and Thomas, M. Managed Care 1. B. (1999) noted that nurses express themselves asactually having difficulty with patient teaching, even though this is suchan important part of their role. (2 ). They need to develop allies who recognize the need forcooperative efforts in order to address the health care crisis incontemporary America, and the worsening problems of an aging populationwith chronic diseases and long-term care issues. D. References A dose of history. (1999). Too few nurses start a new shortage cycle.OR Manager, 15(1 ), 1, 9. There is an interesting article about nursing case management thatfocuses on the impact on the nurse, rather than the efficacy of thepractice or the impact on the client. (1998). Theinterest in this is driven by business which was struggling with providingbenefits to employees that were constantly increasing as insuranceproviders sought to cover their increasing costs from the health carerevolution. They recommended that Medicareencourage the new direction of supporting education, reimbursement forprevention efforts, and monitoring cost and quality outcomes. How do they work? It became an independent agency in 1995, headed byan appointed commission. Instead,labor, business, and some Democratic leaders stuck to a policy course basedon an employer-mandate system, rather than Clinton's reforms. Nurses feel like they are able to help their client become empowered andthey take great satisfaction in connecting clients to communities ofresources. For example, Crumbley et al.(1999) described the Wound Care Clinic at Naval Hospital Charleston whichis a nurse-managed ambulatory clinic using nursing case management fordealing with patients with both chronic and complicated wounds. Healthcare FinancialManagement, 53(8), 31-34. Kazmers, A., Jacobs, L.A., and Perkins, A.J. Thus, the Prospective Payment Systemmay shift the burden of health care toward the nursing profession in orderfor clinics and other institutions to survive. Policy Law, 24(3), 489-529. Managed care: Where do we go from here? F. Neal (1999) concluded that the Prospective Payment System willabsolutely require home health administrators and clinicians to find a morecost-effective framework to provide care that is still quality care. Theseprojects involved seven different model types, including the free clinic,and at least two-thirds of the projects seemed likely to continue withlocal support after funding ended. Capitation, however, is an entirelydifferent system. Poor, mothers and children, chronically ill, disabled This decreased access to health care differentially impactspopulations, with the underinsured and uninsured falling in the lowerincome categories. Nursing CaseManagement, 4(4), 196-197. Advocating healthy publicpolicy: Implications for baccalaureate nursing education. Solanki, G., Schauffler, H.H., and Miller, L.S. G. Oneof the focuses is on facilitating the growth of nursing staff casemanagement, because obviously nurse's services are less costly than thoseof physicians and other specialists. Averagemonthly premiums for HMOs began to increase at the end of 1997 to anaverage of $46 for family coverage in 1999 (Cauchi, 1999). and Wheeler, K. (1999). Matson, T. This seems to beeven more mythical, however, than the current model of depending uponfamilies. 3. Increasing cost of pharmaceuticals The advancement in technology, along with the improvement of medicalinterventions pharmacologically have led to improved health in thepopulation and a longer life-span, but at increasing financial cost.Advanced technologies are part of the impetus for managed care, as more andmore people make use of bypasses and organ transplants. Applying disease management strategies to Medicare.Milbank Quarterly, 77(4), 461-484, i-ii. Essentially, managed care organizations, like HMOs, receive amonthly premium from subscribers which does not guarantee them any healthcare services that they wish, but only access to the managed care system(Makover, 1999). They did not come to any conclusions about which was the mostlikely problem, but did indicate that nurses may need to learn more aboutthe principles of teaching and learning, or focus more on using thoseprinciples in their practice. Introduction - Brief History of Health Care A. (1999). Reutter, L. People are living longer with chronic, andacute, conditions, and utilizing medical resources literally for decades.This leads to steadily increasing costs of providing quality health care tothe entire population. For others, it is the lack of study of publichealth policy-making and advocacy. K. This leaves apopulation of underinsured, or completely uninsured, adults and childrenwho are often also underserved because they do not seek medical care untilthe last moment. Fifteen of the top 25 HMO plans are non-profits, butthere are a total of 757 licensed HMOs and 1, 35 PPOs in the United States. These work by focusing on preventive services, such as mammographyscreening, cancer screening, blood pressure screening, and preventivecounseling. Webster, J.H. Instead, there isthe uneasy recognition that there will be an increasing strain on analready-burdened health care system until some solutions are developed. Decreased access to health care 1. Health Care Strategic Management,17(11), 1 -13. Fee for service vs. Nursing involvement 1. deSales, T., Wellard, S. They may likewise be unwilling to support legislation, orprograms, which provide a larger role for nurses in case management,seemingly usurping their authority. and Georgoulakis, J. In California alone, Coffman and Spetz (1999) have estimated thatthere is a need for an additional 43, RNS by the year 2 1 and anadditional 74, by the year 2 2 . What's wrong with managed care and how to fixit. Provisions of the Balanced Budget Actchallenges IDS care coordination patterns. They described a quasi-experimentalpilot study that explored the need for this kind of program for seniorstudents in a baccalaureate nursing program. (1999). Conclusion 1. Case management can also be a very effective tool for providingquality and cost-effective patient services. For example, Medicare's outpatientProspective Payment System is scheduled for implementation on July 1, 2 ,and the expectation is that providers will experience a further reductionin revenues as a result (Matson and Georgoulakis, 1999). Journal ofHealth Poli. Social Security Bulletin, AnnualStatistical Supplement, 29-79. C. Casemanagement methods were advocated. Neal, L.J. H. Capitation and insurance protection: How toprotect against unpredictability. Rovinsky, M. 3. However, in terms of organized systems inEurope, by 999 these existed only in monasteries and palaces. Although there have been suggestions aboutrationing care, or prioritizing care, these have not been adopted on anational basis and most states have not emphasized this. Sch., 31(4), 389-393. Major changes in the American health care system A. A case study in success. There is also increased emphasis on productivity under managedhealth care systems and with the focus on reducing health care costs.Nursing in the year 2 is not the same as nursing even 2 years ago.II. The author noted that involvement in shapinghealthcare policy is actually an outcome listed for the leadership standardof advanced nursing practice by the American Nurses Association. B. For example, the Robert Wood Johnson Foundation funded39 Reach Out projects to care for the uninsured and underserved, using agreat deal of physician volunteerism to stretch available funding. Nurse activism/advocacy As mentioned above, nurse activism is one direction that theprofession can take and this can be bolstered by changes in nursing schooleducation. HIV Prevention In the meantime, during the 198 s and 199 s, HIV prevention effortsbecame a more important element of federal and state policies, requiringboth financial and other medical resources. Medicare/Medicaid The program that eventually became Medicare/Medicaid began slightlylater, with the Health Insurance program of 1965, later called Medicare.It is administered by the Health Care Financing Administration, not theSocial Security Administration. HMOs/PPOs 1. What is it? Maynard, C.A. Prevention efforts firstfocused on the gay male community, next extending to the community ofintravenous drug users, and finally reaching out to minorities and women.The lack of educational efforts in some communities mean that individualsstill adopt ineffectual strategies to prevent HIV infection, as in a studyby Crosby et al. Preventionstrategies other than male condoms employed by low-income women to preventHIV infection. E. Theyalso described learning activities, or experiences, that they recommendedas practical additions to the learning process, including analyzingpopulation health issues, developing position papers of resolutions, andworking with lobbyists and policy makers. Coffman, J. Public Health Nursing, 17(1), 53-6 . The DRGs representcategories of patients who are provided with services established throughstandardized protocols which cover issues like length of hospitalizationand appropriate treatments. Physicians and surgeons stillpossess the power and they may be unwilling to share that sufficiently toallow nursing educators to make the needed changes in programs to meet newdemands. (1999) indicated that Medicare has to reflect the long-term publicperspective and should take a leadership role in dealing with the costs ofmedical care for an aging population. Caring, 18(1 ), 46-48, 5 -52. Nursing education 1. They concluded that outcomes for patientsdiffered by type of arterial reconstruction, urgency, indication, and sub-population, which DRG-based reimbursement was not sufficiently sensitiveto. In this system, the patient pays a subscriber fee to theinsurance company or organization. The authors noted that there is an ongoing need fornurses to learn better self-care, not only to serve as models for theirpatients, but to counteract the tendency of nurses to be codependent,ignoring their own needs and health. J. These include additionsof new skills and models, including critical thinking, communicationskills, community health nursing, management skills, budgeting,understanding managed care, nursing ethics, problem-solving skills, andothers. For example, Reutter and Williamson (2 ) noted that one of the newroles for nurses is advocating for public policies that promote health.This is a larger focus, looking at the needs of the whole population,rather than just ameliorating the problems of an individual after the fact. Inother words, a patient is not actually directly linked to the doctor, butto his or her managed care organization. At least one reportindicated that drug costs surpassed the spending on physicians' services(Buske, 2 ). How does it work? Social security administration In the United States, we have developed more extensive systems ofhealth care provision and administration, striving to cover more and moreof the citizens. Webster (1999) described theexperience as powerful, noting that nursing case management brings nursescloser to the lives of their patients, sharing many of their struggles inways similar to old-fashioned family doctors. Yet, there seem to be cycles of abundance and shortagethat create an unstable health care situation. D. 2. This isstill not a solution to the problem, however, but a hope that somethingwill happen to change the situation for the better by developing apopulation of healthier, more prevention-oriented individuals whopresumably would not need as many costly services. There was also a focus in this article on the theme of caring, andhow public health nursing, like case management nursing, provides theopportunity for nurses to express their caring for clients in a unique way. In some locales, there is a lack of available nursing staff. Nursing profession is in ideal position to make changes The nursing profession is in an ideal position to make change at thistime, but there are a number of obstacles. E. (1999). Nursing Case Management, 4(4), 168-177. JAMA, 283(1), 99-1 4. Outcomes afterlower-extremity reconstruction in DRGs 478 and 479. Why is it happening? Part I. Nonetheless, the author seems to believe that this shiftwould lead to more viable and equitable long-term care which would providehigh quality services while meeting the expanding demand. The babyboomers, who represent the bulk of the nurse population, are in mid-life atthis time. Case management Fundamentally nursing case management is outcomes-based. (1999). Public Health Nursing, 17(1), 3-1 . Aging of the population 1. Journal ofNursing Education, 39(1), 21-26. What are some of the problems with thecurrent model and how should those problems be addressed in a new model ofnursing education? (1999). In addition, mothers and children are receiving less inthe way of prenatal and maternal health care because of budget cuts, andthe chronically ill and disabled have also been affected by this. and Cassidy, R. (1999). Makover, M.E. Nurses also have theopportunity of following cases and seeing exactly how they have made adifference, which is very rewarding and empowering. (1999). The results were exceptional. (1999). If,for example, the patient goes for an office visit and a lab test isrequired, along with an x-ray, the patient is responsible for paying thefees for those services rendered. Thus, nurses need to find and use theteachable moment in working with health promotion and the prevention ofdestructive habits. An experience of community. What are they HMOs are health care management organizations which are focused onpreventive health care. Cauchi, R. The nurseis the decision-maker, handling each case from inception to conclusion in acoordinating fashion (Crumbley et al., 1999). Res., 34(6), 1331-135 . Tompkins, C.P., Bhalotra, S., Trisolini, M., Wallack, S.S., Rasgon, S.and Yeoh, H. I. Montgomery (1999) proposed an alternative model placing primaryresponsibility for long-term care needs on the individual, rather than thefamily, which seems to create even more problems, given the insurancesituation today. L. In order to change this, Maynard proposed a model for developingskills in this kind of leadership in graduate nursing education, focusingon four elements: information, commitment, initiative, and involvement. the missing millions: Organized labor,business, and the defeat of Clinton's Health Security Act. (2 ). C. (1999). (1999). (1999). Gottschalk, M. Purpose of paper The purpose of this paper is to look at the context of contemporarynursing care and make some suggestions about how to improve the nursingprofession in the 21st century. For deSales et al. The focus was onconnecting local communities, communities created by individuals andfamilies, and communities of resources. Managed care companies essentially are hiring doctors and hospitalsto provide health care services to the subscribers of the companies. Tefra, Balanced Budget Act (1997) The Balanced Budget Act, although pushed by Republicans, was embracedby the president. (1999). Montgomery, R.J. H. (1999). Drug costs surpass spending on physicians. In other words, nurses need to be able to move from a position ofrelative weakness and low status politically and in the health care fieldto one of higher status and influence in order to accomplish the necessarychanges. In essence, the provisions create financialincentives to change patient-flow patterns in the actue and postactepatient populations. Thiswould be particularly problematic since there seems to be such a shift incare toward the nursing profession. Nurs. (2 ). Buske, L. Insurance companies are withdrawing theircoverage from the self-employed and moving out of areas in which theycannot seem to succeed financially, such as rural locations. According toGottschalk (1999), this is at least partially attributable to the failureof organized labor to develop a cohesive coalition in support of thepresident's proposal. Montgomery (1999) noted that the health care system is stillpredicated on the assumption that the family is and should be the primarycare provider and primary source of responsibility for older adults.However, the author asserted that this assumption has led to policies thatdo not serve either families or the elderly in need of care. There seems to be increased public support forthis option, which is a threat both to the aging and disability communitieswho require intensive use of health care resources. There are a number of opinions about managed care, but basically itis a response to escalating health care costs. They call upon educators, employers,and state policymakers to implement efforts to avoid such a shortage. This may change its list ofpreferred providers which means that the patient must find a new doctor onthe preferred list in order to have services covered by the managed careorganization (Makover, 1999). In addition, a bipartisan Social Security Boardwas established to make recommendations about OASDI and SSI programs(Social Security, 1999). The insurance company then is the payer for the doctoror other health care provider. (2 ). Registered nurses'perceptions of teaching: Constraints to the teaching moment.International Journal of Nursing Practice, 5(1), 14-2 . Integrating multidimensionalstress management into a baccalaureate nursing curriculum. On the other hand, the Prospective Payment System is another attemptto control costs by expecting health care providers, particularlyfacilities such as nursing homes and hospitals, to maximize both researchand technology to minimize costs, because they are not going to bereimbursed for their actual costs. 2. (2 ) looked at patients inDRGs 478 ad 479 involving vascular procedures involving lower-extremityarterial reconstruction. Advancement in technology 1. The world and I, 15(2), 299-315. Finding ways to create connections amongcommunities: Partial results of an ethography of urban public healthnurses. One of the first efforts in that direction was the SocialSecurity Administration which developed a program called the Old-Age,Survivors and Disability Insurance (OASDI) program which was financed byworkers and used to provide monthly stipends to the individuals named inits title. Tompkinset al. Crumbley et al. Maintaining an adequate supply ofRNs in California. Coleman (1999) noted that the reality is that there is increasingpressure to control health care expenditures and deal with some of theproblems of an aging population with chronic disabilities through assistedsuicide and euthanasia. Political influence: A model for advancednursing education. Enrollment, costs By 1997, enrollment in HMOs was at 83.7 million, with enrollment inPPOs at 89.1 million. 2. They concluded that there were important factors ignored in the DRGsystem which had a major impact both on outcomes and the need for resourceutilization. Schulte (2 ) indicated that the study had implications fornursing practice, education, and research, noting that public healthnursing is a unique specialty that is not always properly appreciated,understood, or effectively taught in the schools. capitation The fee for service system is exactly what it sounds like. They concluded that it wouldbe helpful, and suggested a number of strategies for incorporating thesetechniques into the whole process of nursing education. and Bethune, E. While physicians used to be at the top of the hierarchy,surgeons are now. Outpatient PPS will createhospitals' greatest challenge. (2 ). There is more emphasis on paperwork,for example, with the need to provide documentation for programs likeMedicare. Managed care represents a major revolution in health care coverage,and one that many people are complaining about. Prospective payment System/DRGs DRGs are yet another idea designed to standardize health care withthe hope of providing quality services at lower costs. It has beenbuilt on gender, income, and ethnic inequities and has led to a situationin which our health care service system is completely inadequate to meeteither current or future needs. The authorconducted an ethnographic study to explore the culture of public healthnurses and learned that the connection of communities was the primary themeamong nurses, clients, supervisors, and administrators. Grossman, S. At a very different level, another interesting proposal for changingnursing education is that the baccalaureate nursing curriculum shouldintegrate multidimensional stress management into its programs (Grossmanand Wheeler, 1999). Social security. C. It uses the nurseas the hub, or like the gatekeeper in managed care situations. Mathias, J.M. CMAJ,162(3), 4 5. Migration from acute care to public health 1. Managed care enrolled 46.7 percent of the Medicaid population by the endof 1997, while HMOs enrolled 14.9 percent of that population. Prevention efforts arenot just advantageous for business, but for the individuals who benefit bynot developing acute and chronic illnesses that impact both the quality andquantity of their lives.III. The Economist, 353(8151), 1 4-1 5. Home services or euthanasia: At the heart ofthe debate. Crosby, R.A., Yarberg, W.L., and Meyerson, B. Many of them have the opportunity for early retirement,increasing the potential for nurse shortages by the year 2 2 . Provisions of this act had important impacts onintegrated delivery systems for health care because of changes in paymentrates for such services. Facilitating the growth of nursing staff casemanagement in PPS. Community nursing/public health Community nursing or public health nursing is also a coordinating-type of endeavor. Kazmers et al. Although the focus inmanaged care is often directed to providing standardized, quality services,the real impetus for managed care is cost-cutting or cost containment. It was during the Renaissance that actual scientific understandingdeveloped about the location and operation of the internal parts of thehuman body. and Williamson, D.L. Physicianshelping the underserved: the Reach Out program. At least at Naval HospitalCharleston, the results were decreased costs, improved quality of care,reduced complications, faster wound healing times, and better coordinationof care management between the different disciplines involved in woundcare. Caring, 18(7), 16-18, 2 -21. Living longer, higher costs There are problems attendant upon the aging of the population coupledwith improved health care. Nurse-managedwound clinic. Current model inadequate As is obvious from the preceding sections, most of the authors foundthe current model of nursing education inadequate in some way. In general, there seems to be a focuson modifying traditional content in several ways. Challenges 1. Content that should be included Almost every article I read advocated for changes in nursingeducation. The changes that have occurred alreadyhave altered the nursing profession. The result is likely to be improved professional stature andincreased respect, but also increased resistance and some sort of backlash. This is supposedly a prepayment fornecessary services. (2 ). Mathias (1999) noted thatthe end of the 199 s saw the beginning of a new shortage cycle, and thatthis is partly attributable to movements within the health care field,status of nurses, and demand levels. There was information available in regimina sanitatis,which were essentially self-help guides to healthy living (A dose ofhistory, 1999). Scott, H.D., Bell, J., Geller, S. The federal government generally enters the picture when individualshave already developed one or more chronic diseases and Medicare often paysfor the last and most expensive phases of the disease processes. They suggested specifics that needed to be added to baccalaureate nursingeducation for public health nursing including coursework on determinants ofhealth and their interrelationship, the policy process, and theoreticalframeworks dealing with a socio-environmental approach to health. The directand indirect effects of cost-sharing on the use of preventive services.Health Serv. Their study explored the possibility thatnurses are not adequately prepared to deal with patient teaching and healthpromotion, either because of contextual factors or because of inadequatepreparation. The Social Security Act of 1935 provided retirement benefits,while benefits for dependents and survivors were added in 1939, benefitsfor the disabled in 1956, and benefits for the dependents of the disabledby amendments in 1958. Image J. However, these types of programsrequire strong physician leadership, a funded administrative core,community support, and the will to serve those who are in need to extraassistance (Scott et al., 2 ). PPOs,or Preferred Provider Organizations, are another form of managed care planwhich essentially indemnifies its members. (2 ). They only provide a center amount of moneyeach month per patient to provide all necessary services to that patient.If the patient requires more services than is covered by capitation, thenthe doctor operates at a loss with that patient. Patient teaching/health promotion/prevention De Sales et al. Journal of SurgicalResearch, 88(1), 18-22. The family role in the context of long-termcare. In the meantime, drug costs have increased to the point that somepatients have been forced to choose between the drugs that they have beenprescribed because they cannot afford them all. However, with managed care, the situation isdifferent. (2 ). Maynard (1999), too, focused on expanding the influence of nursesinto the political arena. Essentially, before 199 ,health care was covered by indemnity insurance which reimbursed patientsfor medical expenses. Inother regions, however, there is a superfluity of nurses, or nurses withadvanced degrees. Capitation was designedto control costs by emphasizing prevention so that patient's would not needso many services, but it has a major downside for doctors with a clienteleweighted toward the capitation system. Clinical Nurse Specialist, 13(4), 191-195. Public health nurses thought that nursing schools had beeninadequate in teaching public health/community nursing practices. However,during the next two centuries it spread into cities and towns as they werebuilt, with physicians, surgeons, apothecaries, barbers, and midwives allinvolved. Move toward wellness model Along with all of this, there has been some movement toward awellness model that is not solely market-driven. D. Journal of Aging and Health, 11(3), 383-416. Schulte, J. and Spetz, J. There are attempts to address this through various programs, bothpublic and private. Underinsured/Uninsured Exacerbating the problem is an increase in the uninsured andunderinsured population. (1999) in which low-income women used such totallyineffectual strategies as using oral contraceptives, asking the partner ifhe has HIV, and douching. Coleman, D. However,Maynard (1999) indicated that personal experience teaching beginninggraduate students has shown her that they are primarily in an apoliticalstate, reluctant to participate in political activity, and non-reflectivein terms of the implications of inertia or withdrawal for health carepolicy. Schulte (2 ) indicated that the basic culture ofpublic health nursing was connecting and coordinating. Patients,or insurance companies, pay fees for the particular service rendered. (1999). Journal of Medical Practice Management,14(2), 65-68. Theoretically, they are supposed to save costs, but in mostinstances they do not operate in a financially effective manner. Along with this increased need is a decreased enrollment in nursingschools, fewer faculty members, and an aging nurse workforce. Pharmacists have remained lower in the hierarchy, whilenurses developed as a new profession, separate from midwifery. The Advancement of Nursing into the 21st CenturyI. The focus on prospective payment systems for skillednursing services, limits imposed for acute rehabilitation providers, andTEFRA limits for long-term acute care all have a major impact on healthcare delivery (Rovsinky, 1999). The hierarchy of members of thehealth care profession has not changed. How all these changes will affect the future roles, skills, andneeded knowledge for nurses generalists A. NursingConnections, 12(2), 23-29. How and what it was There have always been healers, shamans, and others involved incaring for others well-being. Health care reform (Clinton's failure) Surprisingly enough, Clinton has been unable to sell his health carereform efforts to either the public or the Congress. It is asystem of assessment, planning, provision of nursing services, education,coordination of interdisciplinary teams, and referral. (1999). Divisions developed between labor and publicinterest groups, and parts of organized labor actually had interestsaligned with those of large employers and commercial insurers. What has resulted is insurancepolicies for health care providers to cover their losses under this system(Hamilton, 1998). (1999), the problem is nurses' lack of knowledge of teachingand learning principles. B. The discovery of the microscope led to the discovery ofbacteria and other organisms, while the discovery of x-rays led to theability to find out what was happening inside the body without cutting itopen (A dose of history, 1999). G. Hamilton, F. Nursing shortage There seems to be some ambiguity about the reality of a nursingshortage.
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