United States Has the Most

¶ … United States "has the most expensive healthcare system in the world, [yet] 47 million Americans have no health insurance. Healthcare is the country's largest economic sector…. Four times larger than national defense… yet millions cannot afford to take care of their health needs" (Farrell, 2009, 1). Despite being an international leader in science and technology, what has happened to the entire healthcare system in America? Fifteen years ago the subject was at the forefront of the new Clinton Administrator, but now, despite technological advances and increased modernization, America finds hospital emergency rooms stretched far beyond any reasonable capacity, the inability for many doctors to afford adequate malpractice insurance, costs for procedures escalating, and even those with insurance unable to afford the basic standards of healthcare. Indeed, even with the nation spending 20% of the total budget on healthcare, there seems no end in sight ("What's Wrong With America's Healthcare? 2006; Newman, 2008). Scholars, pundits, politicians, and business executives, as well as consumers all agree that there is something wrong with America's healthcare system. Of course, everyone has a different view of causes and solutions, but two major themes arise when discussing the ills of healthcare in modern America. First, costs are skyrocketing without the response of either governmental or private insurance. Second, the demographics and needs of the population have dramatically changed which causes greater pressure placed upon both the private and public sectors of healthcare, as well as companies who do offer insurance to their workforce (Klein, 2007). Although everyone agrees there is something very wrong with American's healthcare, there are polarized views about the solution. Many look to the European system of socialized medicine -- perhaps not always as modern in every case, but certainly available to everyone. However, putting government in charge of a broken program in a relatively litigious society may not be the answer either (Saad, 2007).

Costs seem to be one of the predominant issues, yet one asks if costs are far out of line in America and not in the rest of the developed world? In much of Europe, for instance, socialized medicine seems to provide adequate care (debated, yes), but does have a waiting list for certain non-emergency procedures. Costs in the United States are tied with rising costs of technology and prescription drugs, as well as the unbelievable amount of money that is spent on the administration of both the HMO, Medicare, and Medicaid system -- fully 1/3 of all healthcare dollars not even on care, but on paperwork! Add to this the additional 10% of costs called "defensive medicine" -- tests and costs done so that a doctor or clinic protects itself from malpractice, and we see almost 1/2 of the average healthcare dollar not even being utilized for the purpose of real healthcare (Farrell, 2009; Fineout-Overholt, E., et.al. 2011).

As America changed, healthcare has not necessarily followed. Individuals are living longer, and as they age, require different healthcare solutions. In the 1940s, when the average age of death was far lower, many of the cancers and other illnesses of modernity and age had not yet become epidemic (Saad, 2007). So too, with the advances in technology that can discover disease and cure prior to it becoming debilitating have increased as well. Instead, the system has built layer upon layer of bureaucracy that, instead of streamlining the system, causes more bureaucracy and backlog. So, instead of simply establishing a set of universal care that is part of an even bigger bureaucracy, perhaps it is time to set into practice money spent on preventative care and education at the earliest levels, so that as the population continues to age, at least some of the issues might be mitigated. Providing greater access to medical care, too, with the appropriate economic impetus, should reduce costs and increase the ability of the individual to find appropriate levels of care -- that being the key -- appropriate levels of care (e.g. It is relatively unnecessary to order a full panel of x-rays or scans "just to be sure" if there is a lack of symptoms necessitating said procedures) (Orient, 2007). The changes in the population, then, coupled with the changes in methods of delivery and underlying social transformations have also significantly contributed to both a challenge and a potential for solution within the system (Kovner, et.al., 2008).

In the United States, medical care is provided by not just one institution, but by a number of entities and programs typically both owned and operated by the private sector. Health insurance is also provided by the private sector, the larger entities called Health Maintenance Organizations (HMO's) increasing their market hold over the last several years. There are exceptions to this are national programs such as Medicare, Medicaid, Children's Health Insurance Program and Veteran's Health Administration, all of which are part of the governmental bureaucracy ("Americans at Risk," 2009).

Healthcare in the U.S. is in a critical state, with each successive administration working with a new plan to try to patch the dike.. Currently, between 15 and 20% of the total population has either no insurance or is underinsured for their level of risk -- the highest in the developed world. This is concerning, since more government dollars are also spent per capita than in any global nation. Also, a larger percentage of total income is directed towards healthcare in the United States than in any other U.N. member. Finally, healthcare issues for the single largest cause for personal bankruptcy in the nation ("Underinsured in America," 2002; DeNavas-Walt, et.al., 2008).

Case Study -- the American Emergency Room

One particularly egregious example of costs accelerating and affecting care is that of the whole paradigm of Emergency Medicine. Research shows that the number one reason for Emergency Room overcrowding in the United States is the healthcare system as a whole -- lack of insurance for so much of the population, inadequate insurance for others, and lack of accessibility to healthcare for much of the population. This is particularly true when one analyzes that many older adults, despite Medicare, are often the predominant population in the Emergency Room (Cutugno, 2011). There are segments of the scholarly arena that disagree about the statistics presented regarding the insured vs. The uninsured in the United States. One claim is that the portion of the population that is totally uninsured means that they are not eligible for any government plan, which, according to the census figures, would mean roughly 16% of U.S. citizens. However, one might conclude that with the economic crisis, more individuals have lost their benefits, or assigned reduced benefits, are not eligible for any government plan, and thus there are likely over 50 million Americans without any form of insurance. What do these individuals do when they are sick or have an emergency? They are forced to go to the Emergency Rooms of their closest hospital, wait hours for care that, because of the very nature, costs 3-4 times more than it would in a clinic or office setting (Santoro, 2009).

Particularly in the past two decades, critical care constitutes a significant proportion of many organization's emergency healthcare components. Emergency room overcrowding represents a serious threat to both patient safety and an impact on those individuals who require critical care. The overcrowding seen in most emergency areas is associated with exceeding nurse/patient ratios, providing quick turnaround in medical care, overuse of makeshift patient care areas (triage and hallways) and needing to divert ambulances to other institutions. Overcrowding typically results in extremely long wait times, particularly for those patients who are not critically ill. This leads to patient dissatisfaction, compromised medical care, and the healthcare institution needing to divert care from the extremely critical to other patients during peak use times. This escalating strain on emergency resources is felt throughout the system -- managed care has reduced bed capacity, many more people are without insurance, and budget cuts often result in inadequate staff even in major healthcare emergency rooms (Cowan & Trzeciak, 2004).

How do patients perceive the Emergency Room? The modern healthcare consumer believes they will see a doctor when they come to the ER and are often (about 80 per cent of the time) resistant to nurses or nurse PR actioners even for such things as minor cuts, bruises, and sprains. While this study was rather narrow in its demographic scope, it does point to additional issues that patient's tend to have when going to the ER -- they are usually quite ill and uncomfortable, and lengthy wait times becomes even more frustrating for them. Often, then the consumer frustration becomes more focused at the nurse than the system -- more of a convenience (Patient Perceptions, 2010). This is in contrast too with the Nurses' perception of the workforce and how they are continually being placed into a situation in which they are expected to be effective in both he healthcare/clinical role, and the medical/managerial role. Staffing and lack of control over procedures seem to be the largest issue for nurses, and clear massages are sent through the research indicating necessary changes (Hu, et.al., 2010).

Nursing and the ER

The Emergency Room is often one of the most visible parts of healthcare for political debate. It is also one of the most difficult environments for a modern nurse. It is interesting that one of the founders of modern nursing had emergency experience prior to developing her overall theories. Nightingale also looked at negatives and positives that are the conditions, which could help make people recover and reach their actual potential, as also noted by Maslow hierarchy of needs. She did not look or speak directly of the disease per se, but rather, looked at air, clean water, environment, and sanitation. She published her book in1860 with the title a "Notes on Nursing: What it Is and What it Is Not," connecting human beings and quality of human life, and comparing the stagnant sewage she saw in Scutari, as well as in London. She wrote, "I have met a strong stream of sewer coming up the back staircase of a grand London house from the sink as I have ever met in Scutari."? This is probably still true to date. She talked about the negative influences such as apprehension, uncertainty, waiting and expectation, and fear of surprise can have on patient. This could be compared to the current waiting in an emergency room not knowing how serious the injury was, or even having any information. The prominent example is that of the patient who died in the Emergency Room at Bellevue Hospital earlier this year while waiting to be seen by a doctor. Her most negative health determinants were stagnant water, second hand smoke, air pollution, isolation, and impoverished conditions. The positive determinants were caring and compassion, healthy literacy, sense of family, nurtured infancy, clean water, and excellent nursing care. (Beck, 2005, 142).

Further, emergency room nurses have varying degrees of experiences when at work, most of them highly stressful. One example is of vulnerable populations, those with some form of intellectual disability for instance; including the poor, homeless, or those disenfranchised individuals who are vulnerable. In a study of 23 emergency rooms, for instance, nurses perceived care for the ID patient to be difficult at best, primarily due to communication difficulties. Nurses felt that they had little time to be dealing with outside issues when their own task were so rigidly controlled. However, life expectancy and number of ID patients using ER services is increasing, pointing to a need for increased levels of training in communication with alternative populations (Fisher, et.al., 2009).

Nurses report that one of the biggest issues for them in an ER setting is the issue of patient centered care. Certainly, the modern healthcare professional's role is not limited to only assisting the doctor in procedures, however. Instead, the contemporary professional takes on a partnership role with both the doctor and patient as advocate caregiver, teacher, researcher, counselor, and case manager. The caregiver role includes those activities that assist the client physically, mentally, and emotionally, while still preserving the client's dignity. In order for one to be an effective caregiver, the patient must be treated in a holistic manner. Proper communication and advocacy is another role that the modern caregiver assumes when providing quality care. For the purposes of our essay, the two terms, advocacy and communication, are often interchangeable, since one is the result of the other, and vice versa (Kozier, Erb, & Blais, 1997).

At the heart of healthcare as an institution is, of course, the need to care for the sick and the injured. However, in the contemporary model of healthcare, effective communication during a crisis is not only important, but also vital. Communication by healthcare professionals takes the concern and worry out of the situation; offers a quicker resolution, makes better control of information possible, earns the trust of the public and individual families; and keeps the flow of information consistent and accurate, thus averting potential external problems. Technology has increased the ease and ability for adequate communication -- there are more translators, access to databases, etc. within the field, and certainly there is more information about healthcare available for the layperson. However, the manner in which modern medicine works -- the reality that it is the nurse as opposed to the doctor who tends to follow the patient throughout their care, lends greater credibility to the use of the modern nurse as a paradigm for successful communication and patient advocacy (Nemeth, 2008).

It is a given that the modern nurse will have a far greater exposure to new medical methods, pharmaceutical interactions, and techniques than many nurses of the past. In fact, "the use of clinical judgment in the provision of care to enable people to improve, maintain, or recover health, to cope with health problems, and to achieve the best possible quality of life, whatever their disease or disability, until death" is one of the definitions of modern nursing (Royal College of Nursing, 2003). In fact, with such a vast amount of clinical information needed, combined with the stress of a busy hospital, and the various insurance and legalities to be considered, many contemporary nurse managers find that it is helpful for the modern nurse to utilize a "medical checklist" to improve patient care (Hales, 2008).

In the contemporary world, it is important to note that a more holistic approach is preferable, seeing the patient as more than their disease, and advocating for that patient's proper care and assistance when they are unable (Kozier, Erb, & Blais, 1997). One of the more critical approaches to the rubric of patient care and advocacy is the Theory of Human Caring, by Jean Watson. This book represents a needed, but dramatic, shift in the modeling of patient care, and remains controversial still. Watson's theory formed the basis of modern nursing theory and some of the ideas she epitomizes have become part of other theories, among them Marilyn Ray's "Theory of Bureaucratic Caring for the Nursing Practice." Some of Watson's material came from a previous theoretical maxim, that of the "Self-Scare Deficit" based on the book Nursing: Concepts of Practice (Orem, 1971, 2001). Over the past three-four decades the very idea of patient centered nursing practice has evolved to be the standard in care -- advocacy, concern, communication, and the ability to treat patients with appropriate ethical standards. These same nurses see that a contemporary Emergency Department simply cannot function without the use of a model that addresses all needs -- patient, nurse, physician, healthcare institution, and societal model.

This model, the Health Psychology Model, has three key objectives: 1) to provide adequate and holistic care for the patient, 2) to provide communication and advocate solutions for the patient, and 3) to balance the necessary structure of cost control and ethics when dealing with modern issues in healthcare. It is this conglomeration of the tactical/strategic and holistic/advocate role that is the most ethical manner in which decisions can be made under the system of managed care, as well as the need to balance healthcare decisions with finite fiscal objectives. The nursing literature, particularly that on nursing in emergency and stressful units, about the way patient advocacy balances out the paradigm of nursing while still supporting cost-based care (Schroeter, 2000). Not everyone agrees that it can be quantified in the ER scenario though, since there are varying degrees of advocacy based on certain presumptions (Bennett, 1999). The nurse's role as a patient advocate is to "inform patients of their rights in a particular situation, to support patients in the decision they make, and to intercede when there is a need to protect the patient's rights" (AORN, 2003).

Client communication/advocacy is the application of skills, information, resources and action to speak out in favor of causes, ideas, or decisions to preserve and improve the quality of life for those who cannot effectively speak for themselves. Tyson (1999, p 64) defines patient advocacy as "the act of educating and supporting clients so they can make the best decisions possible for themselves. Nurses frequently encounter patients that feel emotionally powerless, vulnerable to the system, and unable to assert themselves. Thus, the role of the nurse as a client advocate is there to protect the rights of patients. Advocacy has become a concept in nursing practice that is misunderstood and often overlooked by nurses practicing in the role of the caregiver. Professional registered nurses have a duty to protect their patients and have an ethical obligation to act in any instance in which patients may be in danger. The aim of this analysis is to explore operational definitions of the theoretical concept of advocacy in the hospital setting, while retaining the ethical nature of the profession (Butts, et.al., 2007). Advocacy in communication combines two-way or three-way dialog for information dissemination and the proper manner of advocacy necessary.

Within contemporary nursing, particularly in Emergency Medicine, the realities of budgets and staffing may seem overwhelming. Nevertheless the primary goal of the ER nurse is to act as an advocate for the patient -- often because they are in the ER they need even more advocacy because they are unable to understand procedures or act in a cogent manner. The ER Nurse's role, then, is to facilitate and encourage patients to remain involved in their ER experience, and when they cannot, act for them in the best way possible (Burkhard, et.al., 2007).

Advocacy is not as some people suspect: it is not about making decisions for patients or acting 'in loco parentis'. It is about ensuring that no one overrides the needs, rights and humanity of patients. It is about communicating the accurate situation to the patient or patient's family, and allowing decisions to be made based on professional facts. In fact, many nursing and medical practice issues involve the ethics of combining advocacy and communication. Advocacy is very applicable to the medical practice environment because it is during the surgical experience that the sedated or anesthetized patient is most vulnerable. Nurses develop relationships with patients that put them in a position of trust and they are often the first to identify a patient's ethical concerns. Individually, each of the attributes is a helping strategy used in nursing: only when all three attributes are present can advocacy be appreciated by the patient and the nurse. Without adequate communication, many studies show the quality of the healthcare system suffers immeasurably, the patient does not recover as quickly, remains terrified, and is often unable to comprehend treatment (Grace, 2008).

The question, then, of a nurse's responsibility to their employer, to the fiscal needs of the clinic or hospital, or even the constraints that modern medicine has placed on them also form a very real conundrum within the paradigm of philosophical ethics. This question is, as well, one of balance -- balancing the human need with the need to stay solvent. Without the clinic or hospital, the patient suffers; similarly, without enough patients, there is no clinic. Instead of decisions based on monetary though, the central decision should be focused on, "what is the best for the patient within a reasonable time frame, budget constraint, and medical opinion." This of course, assumes that there will not be over-testing done to protect a physician from a malpractice suit, but that simply in the best judgment of the medical professional involved, what is needed for that patient that will allow them to retain the specifics of their Hippocratic Oath. Acting both ethically and responsibly enjoys public trust and confidence, and allows a patient to put their faith in the profession. This very idea of beneficence -- to balance the benefits of treatment against the risk and costs, and to find the appropriate level of care, is really the central notion of modern medical philosophy, and therefore, modern nursing care (Cherry & Jacob, 2007).

However, it is possible, and frankly more appropriate, to move the very central philosophy of nursing into a model that incorporates advocacy, ethics, beneficence, and fiscal responsibility into the umbrella of holism. That model, the Health Psychology Model of Care (HPM), is an integrated, multidisciplinary approach that moves far from the "germ theory" of patient care and management, into the realization that there is a link between the overall health and mental/emotional state of the patient, the physical symptomatology, the need for ethical judgment, and the responsibility to act as an advocate (Penny, 1994). The responsibility of the illness is also a key difference between the models: in the Biomedical Model, since the illness is external, the patient has no responsibility and illness is seen as confined to a specific organ or group of organs. Frankly, it is this holistic continuum that truly defines the new model -- the new model focuses on interaction, focuses on holism, and focuses less on simply the cause of disease, but ways to improve the quality of life to prevent disease (Curtis, 2000).

Scholars have shown us that using the HPM will improve many things, particularly in the Emergency Room. Many modifiers can change the way healthcare is delivered, preventative medicine and advice addressed, and even reduction of stress and surrounding symptoms (Adler, 1994). With ER visits, some depression, distress and exhaustion might occur in both healthcare workers and patients, which can be mitigated with the model. Clearly, use of this is a top priority (Kovner and Knickman, eds.).

One of the fundamental ways upon which this model will works as an overall advocate for the patient is the objective of mitigating negativity from the entire patient model. This cannot be stressed enough -- especially when dealing with the patient directly, as well as with a multidisciplinary approach. Sometimes it is a matter of phrasing, "It looks bad, the blood count is only X," -- but saying instead, "While the blood count is X, I believe we can improve it with Y." Telling a patient bad news can be factual, but still presented in a positive manner. Also, interaction between health-professionals (e.g. doctors, nurses, lab techs, assistants, front office staff, etc.) should remain negative free. Research has clearly demonstrated that this is a basic requirement and has a true and profound effect upon the entire HPM (see: Watson, 2008, inclusive).

Consistent integration of the HPM, then, would expand and use what is known as "The Transtheoretical Model" to institute intentional and individualized change. The profession would need to integrate this model so that the external approach to changing behavior or assisting with illness moves a bit more from the influence of society and outside help to a model of change that approaches health problems in the decision making process of the patient (Velicer, 1998, 216-19). Of course, we are not suggesting that every problem can be solved in that manner, but the HPM requires the individual responsibility and buy-in for the treatment options, changes in behavior to elicit the treatment responses needed (e.g. giving up smoking, losing weight, changing dietary or exercise habits, etc.). This is an active model, one which requires that the patient self-monitor, be truthful, and above all, participatory in their own health program -- indeed, the model requires that the individual invest themselves in their own health (Velicer, 228-31). Patients with chronic or life-threatening illness would also be required to be participatory within our model -- this is the power of the holistic and multidisciplinary approach. The literature tells us that using the HPM on serious illnesses causes a "response shift" within the patient, that changes their view of their treatment, quality of life, health status, and what it is that both the medical profession, their support group, and themselves, can do to accentuate health -- even if that means simply improving the quality of life for a time (Sprangers, 1999, inclusive). In fact, use of the HPM is a dynamic way to provide greater feedback -- both to the patient and to the medical staff assigned to the case. Because the patient's view of themselves and their inner power has changed, so too has their view of the medical profession, and, typically, their willingness to participate in their own recovery. The synergistic approach to modern healthcare, then -- utilizing the patient's own resources, the nurse as an advocate and balance between fiscal and human needs, and the overall case management of multidisciplinary departments will, in the long-term, save the hospital time, resources, and money. Because of the nurses more dynamic role, and varying external roles that function to provide education, training, and support, the hospital visit will be shorter. Instead of rewriting the entire system, the view of simply integrating models that already have sound, empirical research seems far more beneficial for all parties.

Potential Solutions

Certainly there are macro and micro solutions to emergency room overcrowding. In the macro area we must look to the larger picture of healthcare reform and a change in the way we approach and perceive the right to healthcare. Healthcare reform in the United States is incredibly complex and divisive. Besides the costs of care, the American legislative system is set up so that non-medical personnel (e.g. Representatives and Senators) can debate the appropriateness of care in moral and ethical issues (e.g. abortion) and attach conditions to certain types of healthcare. However, in contemporary times, there has not been a single more debated issue since the Clinton years that matches the intensity of polarized opinion on governmental health insurance plans in the United States. These "public options" would compete with private insurance companies, expand the rate of the insured, but put some of the fiscal burden back onto the government. There have been two major options in the debate; the first patterned off Medicare, and funded in a similar manner (which is substantially less expensive than private insurance); the second a negotiated and graduated payment plan based on insurance rates, pharmaceutical costs, health care statistics and demographics. As might be expected, the large insurance companies and providers oppose the former -- costs would be so low, they say, that they cannot fairly compete. This option, then, has been called the "robust" option, and is certainly one favored by the current administration (Ginsburg, 2009). The proposed plan, having gone through a number of changes and committees, is not particularly robust, but does offer a semblance of protection not currently offered, as well as the ability for some negotiation on price. Most economists think that allowing more people to negotiate their health care costs would, at a minimum, provide them with more spendable income on a monthly basis, and, through attrition, and help stimulate sales in other areas of the economy (Health Care Reform, 2011).

In the micro area, however, hospitals and healthcare organizations might have a better chance of mitigating, or at least slowing the problem down to management levels by adopting some tactical considerations:

Limit triage -- Many ER departments have a triage protocol that applies to all patients, regardless of illness or severity. As a result, lines form at triage. By limiting triage to clearly crucial cases, faster turnaround will result.

Develop a fast track -- Fast tracking simple fractures, lacerations, sore throats, headaches, etc. And be moved to a non-critical department and moved through quicker. This will increase patient satisfaction, and create less volume in the waiting room of the ER.

Reevaluate staffing needs. Move from "How few resources can I possibly get by with," to "How can this organization best meet patient's needs."

Use scribes or electronic means for documentation. The average ER physician spends 90-120 minutes during an 8-hour shift just on documentation.