Expanding Nurse Roles to Solve Healthcare Access Problems

Introduction

Healthcare is one of those industries where the promotion of innovation and change management is essential. It is also a field where managing that change through tried-and-true practices — such as evidence-based practice — is a necessity. One change that is significantly affecting nursing, especially at the advanced levels, is the flattening of the hierarchy that has traditionally governed what nurses are allowed to do, what they are expected to do, and what they must do. Whether driven by the aging of the population, shortages of certain types of physicians, or general access challenges for patients, there is often a clear reason for the need for innovation and proper change management in the nursing field. While physicians should indeed retain a higher level of responsibility and a broader scope of duties than nurses, there is also a compelling need to raise the profile and responsibility level of nurses. The shifts occurring in the healthcare industry and in society as a whole are among the major reasons why.

Central Issue and Contributing Factors

As indicated in the introduction, a number of societal and industry factors are emerging that are creating pain points within the healthcare industry and for the patients it serves. These factors are producing situations in which the number of doctors and specialists is entirely out of proportion to the number of people who need their services.

One reason for this imbalance is the surging older population in the United States, particularly relative to younger demographics. This was brought on by a massive surge in the birth rate in the late 1940s, the 1950s, and much of the 1960s, when the Baby Boomers entered the world following World War II and its aftermath. That surge was followed by a sharp decline in the late 1960s and beyond, as the birth rate fell by nearly half. The result is that this large cohort is now reaching retirement age, and it is considerably larger than the generations that follow it. This imbalance will eventually resolve itself, for better or worse, as the next few decades unfold. In the meantime, however, the disproportionate size of the older population is causing wide-ranging problems, including concerns about the financial solvency of Social Security and Medicare, as well as access to healthcare for all who need it. People in older generations are, of course, also the people who require the most healthcare (Henry, 2009).

Another factor driving the need to innovate in nurse training and utilization is a general shortage of physicians. Whether related to the Baby Boomer demographic surge or other causes, there are many situations in which the doctor-to-patient ratio for a given specialty is skewed to the significant disadvantage of patients. If someone needs an endocrinologist or an allergy consultation, they should not be waiting two or three months — or more — for an appointment. Yet this is frequently happening for Medicare and Medicaid patients and privately insured patients alike (Hoyler, Finlayson, McClain, Meara, & Hagander, 2014).

A further contributor is the plight of Medicare and Medicaid patients specifically. Whether related to the Patient Protection and Affordable Care Act — often referred to as the ACA or ObamaCare — or to other policy changes preceding or following it, there has been considerable revision to reimbursement schedules and program administration. These changes have generated frustration for physicians operating under a profit-based model. For many, the outcome has been a decision to stop accepting government-insured patients altogether, citing the administrative burden and net financial loss of participating in these programs. There are those who decry this as a failure of professional responsibility, viewing healthcare as a right, while others point out that healthcare businesses that cannot sustain themselves financially will not survive — and that the government is not subsidizing their losses (Bassett, 2010).

Taken together, these factors create a confluence of circumstances leading to diminished access to physicians, both general practitioners and specialists. In some areas, population growth has outpaced the available physician supply. In others, doctors have left the market through retirement, exit from government healthcare programs, or other reasons. When multiple such factors occur simultaneously in the same region, the result is serious difficulty for patients seeking quality, timely care (Fitzpatrick & Duley, 2012).

Target Population and Thesis

While certain groups are more affected than others, the target population for this issue is, broadly speaking, the entire United States population, including visitors who require medical care. The groups most acutely affected include people living in poverty who rely primarily or entirely on Medicaid, uninsured individuals, and the elderly — particularly those on Medicare alone. Some of these affected groups will shift over time as population dynamics, legislation, and healthcare policy evolve. However, some of the structural factors described above will persist even under the most favorable demographic and societal conditions (Stephens & Ledlow, 2010).

The proposed innovation and solution is to further integrate and expand the responsibilities and participation of nurses in improving healthcare access for the general public. For example, one major consequence of physician shortages is that doctors are often the only professionals authorized to prescribe medication. However, several classifications of advanced nurses can assist with this function, provided they have attained the required level of competence and training. Two prominent examples are Physician Assistants (PAs) and Advanced Practice Registered Nurses (APRNs). A real-world illustration is APRNs providing medication management services for psychiatric patients under the supervision of a board-licensed psychiatrist. A psychiatrist working alongside two or three APRNs is able to serve far more patients than the psychiatrist could competently treat alone.

The scope of this issue is considerable but is not uniformly present across all areas of healthcare. Primary care physicians treating everyday conditions such as infections can often see patients with little advance notice, and urgent care centers are specifically designed for such needs. The more serious and consistent problems arise with access to specialists such as endocrinologists, allergists, and psychiatrists. Patients with diabetes who need endocrinologists, or individuals with mental illness who need psychiatrists, encounter real barriers when those specialists are unavailable. Compounding the problem is the fact that many people with mental health conditions, diabetes, and other chronic illnesses are not currently seeking treatment at all. If those individuals were to recognize the urgency of their conditions and attempt to seek specialist care simultaneously, already-strained areas would face even greater shortfalls, and new geographic pain points would emerge (Paterick & Paterick, 2013).

While the problem does not exist everywhere, it is widespread enough that its presence in multiple regions simultaneously leads to measurably worse health outcomes. The additional burden represented by undertreated populations who should be receiving care further amplifies the scope and severity of the problem (Paterick & Paterick, 2013; Viola, 2012).

Though access to healthcare is not explicitly guaranteed by the Constitution, many advocates argue it is a fundamental right, and even those who do not subscribe to that view can recognize that too many patients face restricted access to care, resulting in health outcomes far below what they could and should be. For example, a patient with type II diabetes might alleviate much of their condition through lifestyle changes, but for as long as pharmacological interventions are required, they should have access to a physician who can prescribe Metformin, insulin, or other necessary medications. The same principle applies to cardiac care, respiratory conditions, and general family practice. Even routine illnesses require a trained clinician to rule out more serious conditions — bronchitis, pneumonia, or emerging epidemics — and advanced nurses are well positioned to serve this function (Paterick & Paterick, 2013).

Key Concepts and Theoretical Framework

To understand the solution, it is important to define the nursing designations best positioned to address access-to-care gaps.

APRN — Short for Advanced Practice Registered Nurse. These are registered nurses who hold a master's degree or higher in nursing. In many, though not all, states, they can prescribe medication provided they operate under the supervision of a licensed physician.

Nurse Practitioner (NP) — NPs are nurses who are able to diagnose and treat certain medical conditions. Unlike APRNs in some states, NPs do not always require direct physician supervision — this varies by state law. They may also prescribe medication independently or under collaborative agreements.

Physician Assistant (PA) — PAs are nationally and/or state-certified professionals who can prescribe medications and act on behalf of a supervising physician. The specific scope of their practice depends on the specialty and the setting in which they work.

The overall theoretical framework for this solution involves striking a balance between having qualified advanced healthcare professionals deliver care to those in need, while not diluting the qualification standards of the clinical workforce in ways that endanger patients. Physicians hold their credentials and rank for good reason. At the same time, this should not prevent appropriately trained nurses from providing comprehensive care within their scope of competence. When an advanced nurse encounters a situation that concerns or confuses them, they can consult with the supervising physician. The physician can personally intervene and conduct a higher-level assessment when the situation demands it, and can also review reports, charts, and notes to maintain oversight. If care quality deteriorates as measured by aggregate outcomes, the supervising physician must take corrective action.

The danger to be avoided is excessive reliance on advanced nurses without adequate physician supervision, which could produce new and potentially serious problems. However, the majority of patients can be effectively and optimally cared for by an advanced nurse, with outcomes that are comparable to those achieved under direct physician care (Robeznieks, 2013).

Conclusion

The intervention described above is not the only solution under consideration. Remote physician consultations conducted via mobile applications, for example, are showing a good amount of promise as a complementary approach. However, the environment involving direct care by an in-person healthcare professional remains the most important arena of care at this time. With that in mind, advanced nurses will play an integral role in improving both healthcare access and quality — at least until physician shortages diminish. Even if physician supply does eventually improve, having a well-trained advanced nursing workforce capable of functioning independently in the appropriate contexts will remain a valuable asset, particularly in disaster situations and mass-casualty events where additional clinical personnel are urgently needed.

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