Veterans Administration takes steps to ensure quality care
Innovation comes at a cost—whether the expense is in time, money or dealing with the inconvenience of change. Although the latter isn't always bad, if change affects a powerful subculture, country or a prominent profession, innovation may not come easily—unless there's a benefit to the majority.
The current environment in health care is struggling with the expense of change. Today, there's a physician shortage that's projected to grow through 2020, according to a new Association of American Medical Colleges work force projection (Krupa, 2010). Their prediction is that in 2015, there will be 62,900 fewer doctors than are needed, which will grow to a shortage of 91,500 doctors by the year 2020.
With more patients insured due to health care reform and a growing aged population who will be tapping into Medicare, there will be a greater burden on primary care services moving forward. It's clear that change is needed.
Expanding nurses roles
Filling the impending gap with new physicians may be problematic as expenses and time commitments are extremely high to educate doctors. Despite a call from the American Association of Medical Colleges for the current administration to increase funding for new doctors, the projected graduates are expected to fall short of the estimated need (Reuters, 2010).
In addition to graduating more doctors, the current medical community is debating whether nurses can be developed to take on more primary care responsibilities. They are already trained in providing patient care—proponents say that it wouldn't take much for nurses to be trained to take on expanded duties that would free doctors to shoulder more challenging treatments.
VA promotes Clinical Nurse Leaders
The U.S. Department of Veterans Affairs (VA) has taken the lead in expanding nurses' roles by committing to have one or more Clinical Nurse Leaders (CNL) in its medical centers by 2016 (Hendren, 2010).
CNL is an emerging nursing role developed by the American Association of Colleges of Nursing (AACN) to improve the quality of patient care. Educated at the master's degree level, CNLs also pursue additional training as specialists in a defined area of practice.
According to the VA, CNLs act as clinical leaders who manage in health care delivery environments. Their role may include having the decision-making authority to recommend care plans based on examinations—currently, only physicians can prescribe care plans. In the VA environment, CNLs could function as part of a team by communicating, planning and implementing care with other health care professionals, including doctors and other nurses.
To meet the growing need for education, the Department of Health and Human Services is offering $31 million in grants to nursing schools to increase full-time enrollment of primary care nurse practitioner and nurse midwife students; and $14.8 million for nurse-managed health clinics.
Specialized education needed
Many in the health care field believe that a higher level of educational development for nurses is a necessity. In addition to AACN, reports released by the Institute of Medicine, the Robert Wood Johnson Foundation and the American Hospital Association have identified a need for additional training for health care providers to improve patient standard of care (Stanley, 2010).
The Institute of Medicine recommends a residency training program for nurses in addition to an increase in the number of nurses who earn bachelor's and Ph.D. degrees (Page, 2010).
One of the more vocal opponents to expanding nurses' responsibilities is the American Medical Association. Rebecca Patchin, MD, RN and AMA board member said, "Increasing the responsibility of nurses is not the answer to the physician shortage." Patchin recommends that health care facilities adopt a "physician-led team approach" (Page, 2010) and also states that any care provided in an operating room or office is best done under physician guidance (Carey and Villegas, 2010).
However, a JAMA study published in 2000 indicates that the care patients received under doctors and nurses in some settings were equal in quality:
"In an ambulatory care situation in which patients were randomly assigned to either nurse practitioners or physicians, and where nurse practitioners had the same authority, responsibilities, productivity and administrative requirements, and patient population as primary care physicians, patients' outcomes were comparable." (Mundinger et al., 2000)
Is it time for nurses' roles to expand?
The argument can be made that all primary care responsibilities do not need to be overseen by a doctor. And, according to the JAMA report, patient outcomes are similar in some care situations whether they were seen by a doctor or a nurse—as long as the nurse had the same freedom and authority as the doctor to act.
Donna Shalala, former Health and Human Services Secretary and current Institute of Medicine chair of the committee on the future of nursing, says nurses are an important component to advance health care quality.
"We cannot get significant improvements in the quality of health care or coverage unless nurses are front and center in the health care system—in leadership, in education and training, and in design of the new health care system," she said. "We can't be fighting each other if we really are going to have a high quality system that we can afford."
And, the VA has taken an important first step to advance nurses' roles to address gaps in health care delivery by utilizing nurses with master's level education and specialized training in clinical management roles.
There is little doubt that education will serve as the platform for effective change in health care. Yet, we're still uncertain what innovations the worsening doctor shortage will create in the near future. As we hope for a health care system that is able to support a growing burden, we must also hope that the public will not have to carry the heavy expense of whatever change is in store.
Resources
Hendren, R. (2010, July 13). Nursing's growing role. HealthLeaders Media.
Reuters. (2010, September 30). Health reform to worsen doctor shortage: group. Thomson Reuters.
