Challenges, Trends, and Opportunities

To accomplish this move from acute illness care to a wellness and prevention model, a shift to increased delivery of primary

care is required. Nurses can and should play a fundamental role in this transformation of the healthcare system. The In- stitute of Medicine (IOM) 2010 report The Future of Nursing noted that the nursing profession is the largest segment of the healthcare workforce and can play a vital role in accomplish- ing the outcomes envisioned in the 2010 Affordable Care Act.

To this end, the IOM has identified barriers limiting nursing’s ability to respond effectively to the coming changes and rec- ommends the following:

• Nurses should practice to the full extent of their education and training.

• Nurses should achieve higher levels of education and train- ing through an improved education system that promotes seamless academic progression.

• Nurses should be full partners, with physicians and other health professionals, in redesigning healthcare in the United States.

• Effective workforce planning and policy making require better data collection and information infrastructure.

Strong clinical leadership will be required in order to take risks and innovate to improve the care provided and achieve the shift to a wellness focus. After a decade of re- search, Peter Buerhaus et al (2012) report that the latest survey results create a picture of nursing’s capacity to prac- tice successfully in a care delivery environment that is ex- pected to emphasize teams, care coordination, and become driven by payment incentives that reward quality, safety, and efficiency.

New roles for nurses are being created and tested

throughout the country. For example, at Massachusetts

General Hospital the concept of the “Attending Nurse” has

been introduced for the purpose of coordinating the work

of the interdisciplinary team, which addresses overuse, un-

deruse, and misuse of services to improve clinical out-

comes, enhance client and staff satisfaction, reduce length

of stay for inpatients, and lower costs. The Attending

Nurse serves as a consistent contact for client/family and

the healthcare team in support of the staff nurse and facil-

itates consistent use of a comprehensive client plan of care

by all members of the healthcare team. The Attending

Nurse also works to promote seamless communication

between the healthcare team members to identify the next

steps to ensure progression of the client’s plan of care

(Erickson, 2012).

Another role first introduced in oncology care 20 years ago is now expanding to other specialties—Nurse Navigator.

The role, title, and description of Nurse Navigator (or Patient Navigator) vary with disease, practice setting, and gaps in care (Desimini, 2011). Various healthcare organizations are now utilizing Nurse Navigators to proactively address clients’

and families’ psychosocial, information, and care coordina- tion needs (Horner, 2013). Nurse Navigators guide the client and family through healthcare experiences—answering healthcare questions, providing education, helping individu- als understand their diagnoses and treatment options, com- municating with insurance carriers, and facilitating timely access to appropriate healthcare resources, including appoint- ments and diagnostic testing and support for follow-up care.

Nurse Navigators also work in elder care with the goal of maintaining independence and quality of life for their aging clients.

In addition to new roles, nursing is developing innova- tive care models, such as nurse-managed health clinics, home visitation programs for low-income mothers, and the Transi- tional Care Model (TCM). By emphasizing the use of mas- ter’s-prepared nurses to oversee care from the hospital to within the home, this model has reduced readmissions for elderly clients with multiple chronic conditions. In support of these new models and the IOM recommendations, ad- vanced practice nurses (APNs) must be allowed to practice to the full extent of their education and licensure. Working independently or with physicians, they can provide cost- effective care and help address the growing primary care shortage (Hassmiller, 2010).

In the community setting, nurses working in collabo- ration with physicians can create a patient-centered medical home (PCMH), which is a model of care where individuals have a direct relationship with a provider who coordinates a cooperative team of healthcare professionals, takes collective responsibility for the care provided, and arranges for appro- priate care from other qualified providers when needed. This model encourages self-management support, electronic pre- scribing, test and referral tracking, and advanced electronic communication, resulting in a model that is dependent on in- formation technology and exchange of health data (HIMS &

NCQA, no date).

In this new era, nurses must not only embrace technol- ogy but become super users. To date, nurses have not neces- sarily welcomed information technology for a number of reasons, such as complexity of user interface or difficulty of program navigation. More importantly, programs have often been developed for other departments, such as billing, or to promote physician order entry. As a result, nursing’s contri- bution to healthcare is often virtually invisible.

In truth, nursing is a costly yet essential resource whose value is not adequately captured in the healthcare record.

There have been no well-received and few successful soft- ware programs developed that accurately collect and generate data reflecting the true value of nursing, which is critical to assure adequate investment in the nursing profession (Ruther- ford, 2012). In fact, with a few exceptions, current billing practices subsume nursing in the room rate much like a hotel

includes housekeeping and maintenance services in their room rates. This practice essentially makes nursing invisible and implies that nursing care is static with all clients receiving the same level of care regardless of their diagnosis or indi- vidual needs. Harris (2007) further notes “the use of the DRG as the basis for payment suggests that nursing care is wholly linked to the medical diagnosis.” The growth of nursing in- formatics is leading the way in developing and implementing software programs using standardized nursing languages to demonstrate nursing’s contribution and provide data to sup- port evidence-based practice.

The rapid growth in information technology has al- ready had a radical impact on healthcare. Advances in digital technology have increased the applications of telehealth and telemedicine, bringing together client and provider without physical proximity (Heller, 2011). Technological advances in the treatment of disease have led to the increased need for ethical, informed decision making by clients and families.

The enhanced power of the consumer in the client-provider relationship has created a heightened demand for more so- phisticated health education techniques for both the client and the provider. For example, “informational” sites have ex- ploded on the Internet, providing the consumer with both fac- tual resources and misinformation. For the nurse, distance learning modalities link students and faculty from different locales and expand the potential for continuing professional education. And technically sophisticated clinical simulation laboratories have been developed to sharpen critical thinking and client care skills in a safe and user-friendly environment (Hibbard, 2008).

In 2011, an estimated 101.1million Americans were aged 50 years or over, representing more than 32% of the population. This number is predicted to rise to 111.3 million by 2016. Increased U.S. life expectancy has shifted the lead- ing causes of death from infectious diseases and acute ill- nesses to chronic diseases and degenerative illnesses. Some 80% of older Americans live with at least one chronic condi- tion (Economist Intelligence Unit, 2011). These statistics make two things clear to healthcare providers: (1) More peo- ple will receive their health and preventive care in community settings, and (2) people in need of hospital and other facility care will be sicker and in need of a higher level of care. Heller noted that the standard ratio of critical care/specialty beds to general-use beds in hospitals today is close to 1:1, up sub- stantially from a decade ago. Furthermore, expanded life ex- pectancy has led to increases in the number, severity, and duration of chronic conditions, thereby increasing the com- plexity of the care provided and managed by clinicians (Heller, 2011). Because of this escalating need for healthcare, there is legitimate concern in the healthcare world regarding the impact of potential mass retirements on the supply of nurses available to the workforce.

The discussion of issues and challenges would be in-

complete without consideration of the building and retention

of the nurse workforce. Literature review confirms the ever-

present issues of actual and perceived nursing shortages, fi-

nancial constraints, and the promotion and funding of

nursing education. But there is another issue that feels like

CHAPTER 1ISSUES AND TRENDS IN NURSING AND HEALTHCARE DELIVERY

the proverbial elephant in the room . . . aging. The average

age of nurses today is 46 years. Baby boomers now in their 50s comprise approximately 25% of today’s workforce (AACN, 2012). Research does support that, while young people are entering the field of nursing, aging is affecting the current workforce as a whole. Aging nurses are reported to have higher workload demands than other professions, as they struggle with the high demands of caring for an aging population with high-acuity needs. This increases the risk of stress reactions, including fatigue, poor health, injury, and chronic pain (Gabrielle, 2008). The Aging Nurse Project (2007) concluded that older nurses were most concerned about their physical health, particularly their backs, espe- cially since many older nurses are working longer than they expected, reportedly because of changes in their retirement plans or other economic downturns (Restuccia, 2007).

Numerous authors have recently discussed multigenera- tional conflict in the nursing workforce as one of the challenges nurses face (Kupperschmidt, 2006; Lancaster, 2002). When people born in the year 2000 begin working, the workforce will be composed of four generations, each bringing to the work set- ting the unique characteristics of their parentage, work ethic, and worldview.

As might be expected, the oldest of the older nurses (so-called Traditionalists) have fewer technology skills, but a strong work ethic (almost a calling), and are dismayed by what they consider unprofessionalism in younger nurses.

Baby boomers, who often rejected the conformity of their parents’ generation, are considered independent, critical thinkers who view their work as a career. These nurses have

not necessarily welcomed information technology into their practice, but have been forced to learn and use technology.

The next-generation nurses (often called Gen Xers) entered the workforce in a time of national recession and witnessed their parents losing pensions and job security. They experi- ence more portability and options for the use of their practice skills and have little patience for hierarchical reverence in the workplace. The youngest nurses (and those who will be en- tering practice in the next few years) grew up enmeshed in digital technology, are not deeply invested in who does the work as long as the work gets done, and may view nursing more as an occupation than a profession.

Finally, the patient population and the nursing work- force are becoming increasingly multicultural. Exactly how this is affecting (and will affect) healthcare in general is not known. What is clear is that there will be change and nursing needs to be an active participant in shaping this change.

In closing, we take an optimistic view. Nursing is a rich and diverse profession practiced by people from many cultural and educational backgrounds and in varied set- tings, which creates a rich source for innovative thinking.

Nurses are in a position—and have the opportunity and the challenge—to return to their earlier roots in community- focused nursing as front-line advocates and supporters for improving the health and well-being of clients, families, or populations through cost-effective, culturally appropriate, evidence-based practice.

The future of the profession is in our hands. It’s time

to step up and demonstrate the real power, creativity, and car-

ing of nursing.