Evolving Practice of Nursing and Patient Care Delivery Models

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The Institute of Medicine (IOM) in its Future of Nursing report stated that there is a need for nurses to be able to practice to the full extent and scope of their education and training (IOM, 2010). In doing so, the belief was that this would increase access to care and provide nurses with the opportunity to practice as they were trained. O’Brien (2003) notes, after all, that the whole reason APRNs began being trained in the latter half of the 20th century was to fill the gap being left behind by primary care physicians as they left their primary care practice to go work for specialized medicine. Today, however, nurses are still bound by regulations that require them in many states to work under the supervision of physicians even though the nurses have the training to treat patients independently of doctors.
Still, the recommendations of the IOM are being used in states like Oklahoma to push for new legislation that would allow nurses to be nurses as they were intended to be. If this indeed comes about in Oklahoma and in other states across the country, the practice of nursing will grow and change. Continuity of care, accountable care organizations (ACOs), medical homes and nurse-managed health clinics—all of these will be impacted.
By growing the field of nursing, continuity of care will be improved as it will ensure that nurses are more coordinated less over-burdened: they will be able to engage in patient-centered care, communicate with one another effectively, and coordinate so that when a patient is handed off to the incoming nurse there is no lapse in quality of care delivered to the patient. ACOs will also be impacted, since they focus on delivering collaborative, holistic care to patients and rely on a range of medical specialists and health care professionals. Nurses will be able to play an instrumental role as ACO professionals, providing assistance with health literacy education, preventive care and so on (Korda & Eldridge, 2011). Medical homes, like ACOs, also focus on providing patient-centered holistic care for the whole patient and here nurses can also play a critical part in collaborating with other health care professionals to maintain a high degree of quality care for the patient. For marginalized and vulnerable populations, Nurse-managed health clinics can be started, and if nurses can practice independently of physicians they can manage these in order to increase access to care for those populations that hitherto have not be adequately served by the health care industry. As the American Nurses Association (2010) notes, “nurses, especially nurse practitioners, have the skills and opportunity to reframe how primary care is delivered” via nurse-managed health clinics (p. 7). With these innovative health care models to use, nurses will be able to reshape the health care industry as they work to gain independence in a health care system that they have been educated to lead. As a result there will be a need for more nurses in the future as they are the ones who are willing to be on the front lines, leading the transformation of the industry and of communities to promote a greater health for all.
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The first nurse colleague with whom I shared these ideas noted that she did not view any of these models as entirely practical except maybe the nurse-managed health clinic and only then if nurses could truly operate independently of physicians and all external supervision. She also felt that APRNs have be trained to provide primary care and yet in the industry there is regulation against this as though the APRNs somehow were not prepared to do so. She argued that until something changes at the federal level in terms of how this issue is regulated she does not see much hope for the industry in general. With respect to the ACO idea, she said that in reality there is a lot of red tape and bureaucratic issues that make it a headache to deal with. For instance, she told how ACOs are responsible for overseeing how reimbursements are paid out and for making sure quality care is delivered by all participants, which means extra-duty work for them. ACOs have monitor the quality of care that integrated and collaborating health care professionals provide to patients, and that includes EMS employees. EMS employees are burdened with making home-visits patients after discharge for up to three days in order to ensure that quality care standards are being met. It all adds up and becomes quite costly just in terms of human capital expenditure and in reality it is simply impractical, according to my colleague. In truth, she said that she did not see how there was much hope for the nursing industry: everything was just going to become increasingly bureaucratic and over-regulated, which in her view would lead to more unnecessary burnout among nurses and higher turnover rates. The nursing shortage would continue and there would be no real expansion of access to care—if anything access to quality care would diminish. Her view overall was particularly negative, especially when she talked about the red tape involved in the industry today and the need to abide by so much unnecessary (in her view) regulation that seemed to stifle care in many respects and keep the industry from operating efficiently.
The second colleague was very supportive about the ideas presented in this paper and said that she would love to see more nurses coming into the health care industry because it would mean the possibility of more collaborative care, greater quality care, and so on. She was hopeful that nurses training today would be able to practice to the full scope of their training and education and she thought that just being allowed to do that would really be a great and significant step in the right direction of helping communities, raising health literacy, and improving community health. Her only concern was that there might not be enough nurses to meet the demand for care. She also stated that she was not sure how the cost of care issue would be addressed, as it seemed that the ACA was not working out as intended and that the health care industry was in a state of uncertainty for the present. Overall, that was her big concern—dealing with the cost of care, especially when it comes to vulnerable and underserved populations, as they are the ones who tend to receive the least amount of care because they have no coverage and are not enrolled in any program. She said that there should be something done to cut down on the cost of care in general and that if nurses could somehow open up a clinic that reduced the cost of care for the poor and underprivileged that it would be a good step forward. She said that if costs could not be brought down it would not matter what nurses attempted to do for the marginalized and underserved populations, because they would not come for care believing the costs to be high and coverage to be for others but not for them.
The third nurse colleague of mine stated that she was surprised there were so many options as she was not really clued in to any of them. She wanted to know a bit more about what was going on in the nursing industry and had more questions about the medical homes as she thought those sounded like something she would like to be in. However, she was also interested in the idea of nurse-managed health clinics. She said she did not know why nurses were not permitted to practice independently in some states and that she thought it was kind of an injustice that nurses had to practice under supervision of physicians if they have been trained to be on their own. She did not understand why that was the case and she thought it should be addressed especially if it could help to improve access to care. Overall, she thought that the nursing industry was heading in the right direction and she was appreciative for my sharing these thoughts with her.
References
American Nurses Association. (2010). New care delivery models in health system reform: Opportunities for nurses and their patients. Kansas City, MO: Author.
IOM. (2010). The future of nursing. Retrieved from http://nacns.org/wp-content/uploads/2016/11/5-IOM-Report.pdf
Korda, H., & Eldridge, G. N. (2011). ACOs, PCMHs, and health care reform: nursing’s next frontier?. Policy, Politics, & Nursing Practice, 12(2), 100-103.
O’Brien, J. (2003). How nurse practitioners obtained provider status: Lessons for pharmacists. American Journal of Health-System Pharmacy, 60(22), 2301-2307.