Rebalancing our health care systems paradigm

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• Joan L. Shaver, PhD, RN, FAAN, AAN President

In presenting a paper recently, I once again reviewed some of the issues related to the relentless nursing workforce shortage. As well, at a recent invitational meeting, I had the privilege of debating the models, standardization, and fundamental quality issues related to instigating a clinical practice doctorate. These events rekindled some thinking about 3 elements related to our care systems paradigm and nursing issues. First, the nursing shortage related to acute care dominates the workforce dialogue but remains skewed and not fully comprehensive. Secondly, staring us in the face is a huge potential opportunity to create care systems better matched to a progressively aging population with “at risk” lifestyles contributing to obesity, chronic illness and functionality (mental and physical) declines. Thirdly, we would do well to link this need for care systems better matched to population health needs to the growing movement within nursing to embrace clinical practice doctorates.

Public discourse related to the nursing shortage most often target hospital care. The reasons are obvious given our history, how many RNs practice there, and our current biomedical-dominated health care system that is highly focused on acute care. Fellow Linda Aiken and her team have done much to provide strong evidence linking well-educated nurses to high quality care and patient safety. While well-warranted, most activities and policies have been oriented toward those of recruitment, retention, and reinstatement of nurses in acute care. Through the United States Health Resources and Services Administration (HRSA), federal monies were and are being made available to develop and test incentives for recruiting new and retaining already-practicing hospital nurses. Hospitals have instituted strategies including sign-on and recruitment bonuses, increased governance participation, tuition access, flexible hours and other innovations. Controversial are the emerging strategies for recruitment and rapid readying of foreign-educated nurses for hospital practice, along with relaxation of policies governing eligibility. We have seen high profile advertising promote new interest in nursing as a career choice and some growth in available scholarship monies. Consequently, nursing schools have seen large increases in applications. Largely funded through state and private funding, nursing schools and colleges have received little increased monies to expand educational capacity. Some schools have increased capacity but generally with little in the way of extra resources and, not uncommonly, at the expense of the current faculty workloads. Sources often outside of nursing are advocating for growth of the nursing programs that educate in the shortest amount of time, spurring more investment in community college and even diploma programs. Yet, this dynamic runs counter to what we know to assure care quality and patient safety in acute care settings. Even though projections indicate that the supply of nurses, no matter how well-maximized, is not likely to be sufficient over time for existing care systems, initiatives to modulate the utilization of nursing expertise in acute care settings (ie, demand) remain under-emphasized. Not to ignore 2 examples in this realm, our American Academy of Nursing (AAN) Commission on Nursing Workforce, having done exemplary fieldwork, continues to seek corporate partners for creating technology supportive of maximizing nursing practice in acute care settings. As well, the Robert Wood Johnson Foundation Transforming Care at the Bedside initiative has led to design and testing of efficiencies that make nursing practice more effective and compelling.

While the focus on acute care is dominant, there is a huge opportunity for us to have a different but major influence on the health care of our nation. Possibly, we should be arguing another form of nurse shortage. Setting the delivery care system and its financing aside, the aging of the population and the increasing prevalence of chronic disease (eg, diabetes), not to mention functional (eg, fibromyalgia), socially-derived (eg, substance abuse) or mental (eg, major depression) disorders, is revealing the mismatch of our health system to the needs of our population. Chronic disease management and prevention or functionality restoration and preservation are looming large. Effective interventions are bound to encompass competence in comprehensive assessment/screening, monitoring, and the shaping of healthy behaviors through patient/population education and coaching/guiding toward self-monitoring self care—the essence of advanced nursing practice. Comprehensive care means that much more of our attention should be paid to this domain of health care and nursing practice. With over 200,000 (and growing) advanced practice nurses, we are well-positioned to create innovative models of care and systems of practice integrated with acute care. We would do well to have much more of our dialogue, policies and resources oriented to this domain.

Perhaps the growing movement towards establishing clinical practice doctorates is a key to shifting the paradigm toward more continuous or comprehensive care. Some debate the need for such a degree. I take the stand that through our nursing and health care science development, we have earned the right to teach its application in the form of advanced clinical practice competencies at a level for which awarding of a doctorate is warranted; not to ignore that it will advance how we play our part in interdisciplinary health care transformation. Another debated issue is whether and how much a clinical practice doctorate should go beyond the study already within our specialty practice master’s degree. Many believe that we have leveraged our master’s study to what, in other disciplines, would earn a doctorate. When people have looked at lengths of study and science exposure within doctoral programs, study within many of our nursing specialty practice master’s programs is comparable. If a doctorate warrants more competency-building, debated is what those competencies entail. Various thought leaders have argued that we have been remiss in teaching the competencies of systems level leadership and influence. If we are to add to the competencies expected for a practice doctorate, it will likely include (at least) direct clinical practice and population health practice management, health informatics, as well as practice, program, and systems evaluation.

Relative to a clinical practice doctoral degree, Fellow Mary Mundinger, Dean at Columbia University School of Nursing, has called for an emphasis on direct clinical practice and has pleaded for standardizing the nature of the competencies to be mastered. Nursing practice is broad since we practice across a variety of the current delivery system venues, including primary care, public and occupational health, acute, long-term and home care. We practice at the grassroots level but also as administrative leaders and teachers within the systems. Often our approach is to be “all-encompassing” when we define degree requirements, seen by some to be shortchanging the direct practice dimensions of study. On the other hand, being knowledgeable only in the ways of the “guild” and its historical practice patterns, to the exclusion of being knowledgeable in navigating systems, perhaps retards our abilities to transform health and care systems. Much work is needed by us to envision care systems better matched to contemporary demographics. We would do well to make the competencies for the practice doctoral degree highly aligned with that vision and a strong blend of direct patient care along with systems navigation, evaluation and transformational skills.

In summary, there are several policy implications and points of intersect in these ideas. It is imperative that we address how to solve the growing hospital nurse shortage in a comprehensive manner. Policies and resources to maximize faculty and new graduate capacity and to design practice models that modulate demands for nursing are especially warranted. Given today’s demographics, and in collaboration with other disciplines, we in nursing are well-positioned to promote the creation of care systems for preventing or managing chronic disease or illness integrated with acute care, helping individuals maintain high functionality in the context of aging or illness through the strengthening of self- and family-care. We are in need of policies and resource allocations that promote novel care systems encompassing this care and “care continuity” through a rebalance of hospital-based rehabilitative care with community/home-based pro-habilitative care. From innovations for smooth transitioning across acute, long-term, community or home care, novel collaboratives between acute care and primary care nurses should emerge. Leadership will come from having clinicians highly skilled in delivering comprehensive direct and systems-savvy care and with credentials at parity with collaborators in complementary health disciplines.