Future of Nursing


A landmark report on the FUTURE OF NURSING was issued last fall by the Institute of Medicine and the Robert Wood Johnson (RWJ) Foundation.  There are four major recommendations:

  • Nurses should practice to the full extent of their education and training.
  • Nurses should achieve higher levels of education and training through anNurse Symbol improved education system that promotes seamless academic progression.
  • Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States.
  • Effective workforce planning and policy making require better data collection and information infrastructure.
Each of these recommendations are framed in language that is well suited to public policy-making, but if we read these recommendations from a “Nurse Manifest” lens, they take on even greater importance!  Take, for example, the idea of “full extent of [our] education and training.”  If nursing education reaches the ideals that we have set forth in the “Manifesto” where education is concerned, all of health care could be radically re-invented!  

I believe that more nurses than we imagine have ideals about nursing that are very similar to the values that we described on the initial NurseManifest.com web site.  Let’s brainstorm ways we can better connect with the “Future of Nursing” initiatives going on all around the U.S., and keep these values in the forefront!

20 thoughts on “Future of Nursing

  1. Initially, upon first read of this landmark and timely report, I noticed it was from the Institute of Medicine (IOM), and wondered if we might have an Institute of Nursing with equal clout as the IOM in the future. As I read deeper into the document, I was impressed by the Future of Nursing (FON) work team, the data, analysis and goals to move the profession forward.

    In relation to the Manifesto, I envision a time when NP’s are all completely independant of medicine (we are up to 18 states, with VT being the most recent to abolish mandatory collaboration), and when economic parady exists (NP’s are still restricted from being paid fully, or at all for their services (we are forced to bill under the MD by some private insurers) by outdated health insurance reimbursement structures and health policy laws).

    The FON report coincides with the Affordable Care Act (ACA) and one has to critically evaluate the system that might be saying NP’s can be indepenndant primary care providers, but for the underserved and poor populations, who will now have the healthcare they deserve. As my colleagues point out, from a critical, emancipatory perspective, we have to be careful what we are saying yes to; is it more of the same? Are we still being told what we can get and told what to do by medicine and others in economic power? What is the message within the message?

    In regards to all nurses, we are holistic health experts, and could be paid privately to educate, counsel, advocate for and guide patients-persons in achieving optimal health and/or comfort. The navigator role is a good example, why are other professions taking this from nursing? Are we letting them? Do we continue to let others lead healthcare by staying passive or apathetic? What are we doing about it?

    We have to be educated to even know what the issues are and have the political clout to get things done. We have to stop our own in-fighting as a professionn over the issues, support eah other, value our differences, and realize this is our time to achieve the Nightingale dream for our profession. I have heard generalizations like “NP’s are medical model” (I argue, not if the NP’s practice is holistic and nursing theoretically based); and nurse leaders and academics are the “elite in their ivory towers” and don’t know what bedside nurses do…these types of ruminations are outdated and a waste of our time. We need all types of nurses and must value our diversity in educational preparation and work venue. Most agree that articulation agreements for continuing education and loan forgiveness for advanced education is needed in nursing for us to survive.

    From a Manifesto perspective, can we pool our resources and garner the sociopolitical and policy support needed to achieve the goals and ideals in this IOM FON report?

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  3. Ever the critically minded ursine I think we need to consider the source and the content of these recommendations, to wit:

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

    What would be the alternative policy decision? That nurses should practice ineffectively and inefficiently? “Shoulds” do not change anything, nor do they provide a guidebook, for policy. No nurse should ever practice beneath their capabilities – but beyond that, I think the path to change is dark, twisted, and filled with potholes because the reasons nurses do not practice efficiently and effectively are unclear. Some, no doubt, feel they are thwarted by barriers, others simply do not care to take the responsibility for such active participation, and some may not do it because of institutionalized policies, laws, and regulations. How one might fix this is by no means clear.

    * Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.

    Again, what is the alternative? Should nurses be uneducated, should the educational system for nurses be chaotic and without focus? Obviously not. But how one designs this new educational regimen strikes me as an inordinately large obstacle. I would argue that most of the work in American higher education over the last 50 years has produced more and more college, and graduate school alumni, without critical thinking skills, who are quantitatively innumerate and qualitatively illiterate. We have more graduates, in all fields, but it is not at all clear that we have “better educated” graduates than 50 years ago.

    When I did my nursing pre-requisites 30+ years after my original college days, I was appalled at what passed for academic standards.

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

    Most of the worst features of our current health care (finance) systems are bad not because of who designed them, but because of the design characteristics. Replacing who does the design work without establishing meaningful and objectively superior design standards is unlikely to improve anything. I wouldn’t ask an expert on the ecology of Mars to plan the trajectory of a rocket launch – I’d want an aeronautical or space engineer to do that.

    Putting MDs and nurses, without the requisite design skills, in the position to design our health care (finance) systems is a prescription for disaster. All one needs to look at to convince oneself that this is unsound is nursing documentation.

    There are people with expertise in organizational design, efficient production methodologies, work flow analysis, etc who are far better prepared to do the design work than most physicians and nurses – the problems tend to be the meta-assumptions about goals and objectives, not the credentials/professions of the participants.

    The advantage the finance department has when establishing their policies and procedures is that they tend to have very concrete goals and objectives – profit maximization. They aren’t bothered by extraneous details such professional turf wars over who should do assessments and prescribe and deliver treatments, what documentation systems should guide patient care, where drugs, equipment, and supplies ought to be stored. If the organization will earn higher profits because of a design change, the finance department succeeds. The more participants there are in organizational policymaking and design the more the sleek racehorse looks like an elephant. Physicians want thicker legs to carry their “weight”, nurses want bigger ears to better listen to patient’s needs, dietitians want large trunks to better deliver food to patients and physical therapists want to train elephants to stand on their hind legs.

    To highlight the problem of design skills versus participation consider health care finance mechanisms. It makes no difference whether a finance system is created by actuaries, nurses, or physicians if the critical element – how the inter-personal variation in health care needs and costs (The insurance risks) are managed – is ignored.

    Actuaries are perfectly happy answering questions about how to design managed care and health insurance systems on the same day and for two totally different purposes and clients with totally contradictory goals and objectives. Large insurers are more efficient “risk managers” than small insurers. Get that core assumption wrong, as we have over the last 40 years and there is little sign of change on the horizon, and it doesn’t matter whether a health care finance system is designed by an actuaries, statisticians, physicians, nurses, politicians, or Al Bundy during a break at the shoe store. Its a mathematical and statistical problem not a professional perspective or turf problem.

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

    Again, what is the alternative? Should we endorse a concerted effort to remain ignorant of what is happening in health care organizations, ignoring data and analysis? But again, the danger lies in collecting the wrong data and doing excessively fine tuned analyses of it. So, it isn’t at all that we ought to have better data collection and information infrastructure – that is a given – but what the goals and objectives of the better data collection and information infrastructure ought to be because those are the things that will determine whether the resulting systems are better, or worse, than the ones we have now.

    To be honest, most of the stuff I see come out of RWJF isn’t worth the trees killed to produce and promote it because the meta-theoretical considerations are so seriously flawed and the impact the Foundation has is so ineffective.

    Whether one sees such reports as steering our health care (finance) systems in the direction of improvement (Whatever that might mean) or failing (or encouraging) their fall to mediocrity is once again, a matter of goals, objectives, and perspectives – but with more than 50,000,000 Americans uninsured, millions more receiving inadequate care for other reasons, and our infrastructure more and more apparently a bi-modal system of high tech, high intervention care for the wealthy and low tech, low intervention, or outright negligent care, for the poorest and most vulnerable, I don’t think RWJF ought to be slapping itself on the back quite yet for its activities for the last 40 years. On the one thing I absolutely know really matters – developing a single payer, national health insurer, I think the track record of RWJF is spotty at best.

    On just one major “Success” – curtailment of smoking – we might ask whether this has been a boon or bane. Smoking contributed to early mortality and modest health care costs for senior citizens. Now seniors live longer, consumer more health care services, over longer periods of time, and we are finding ourselves in a financial predicament. The same will happen by eliminating childhood obesity.

    But with over $7,000,000,000 in assets and $400,000,000 in grants per year, for a 5.7% distribution rate per year, one might ask if better asset management at the Foundation might be in order.

    As well, considering that the Foundation began in 1972 – and the last 40 years have seen some of the worst health care finance policy decisions possible, its ability to influence national debate seems questionable.

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  4. Peggy, you have started a great conversation here. I know when this report first came out I was quite angered that the IOM was “detailing” how nurses and the profession should be in the future. Now it doesn’t really take much to get me “angry” about our current professional state (LOL, just read my articles on the nursing shortage), and I have to agree with Thomas that these are sort of “of course statements”.

    Wendy and I also had the pleasure of discussing many of her ideas here over lunch at the AHNA conference.

    Perhaps if there had been more specifics, such as a call to move toward BSN or even MSN as the educational entry, this would have been a more powerful document. It might have been helpful to have an outsider or “partner” recognize some of our deeper professional issues as well.

    I am also concerned that a document issued by the IOM/ RWJF seems to hold so much more weight in the world then say a document issued by the NLN or even our own document of the Manifesto. I just have not been able to figure out why our professional organizations were so excited about this; are we looking for somebody to rescue us as a profession?

    For my part I am striving to educate nurses around holistic practices, self-care, and creating change in the workplace. Most of my RN- BSN students take a class I teach on healthcare policy and politics, and they begin to see that nursing can be a different profession and they can make a difference themselves, right in their own workplace.

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  5. @Carey Right on as regards ANA – I have been monumentally disappointed by the ANA!
    Given the numbers of nurses, mere profession size should have resulted in more influence. While that is largely the result of a lack of aggregate individual action, the ANA is a lot like riding a ferrari with your foot on the brake.

    I certainly believe in the holistic model of nursing care – it was why I decided to be a nurse after all. But I am increasingly pessimistic about the role it will play if nurses can’t figure out how to both increase throughput and high quality care because those are the two things I think are most important..

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  6. What terrific discussion!! Every single point here deserves due consideration. For me, the bottom line is that our “world” (of nursing, of health care, of politics and policy-making) sorely needs this kind of critical examination, and challenge. How about some ideas to move the conversation to action? Clearly, the traditional organizations, as they have existed in the past and still persist, are not functioning at the level of this conversation. But some kind of “organization,” or unified effort, is needed. At the same time, let us know forget the huge huge obstacles that nurses and women have faced, and still face, in every single effort to achieve things like an ION. Very persistent nurses did achieve getting the National Institute of Nursing Research (NINR) established at the NIH (a remarkable and significant achievement, despite the persistent underfunding). So an ION is not at all out of the question. Achieving this requires nurses who are well positioned to take action in a highly political stage, as well as lots of support from those of us “on the ground.” But it is a huge challenge, particularly when we have a clear focus on many of the really disturbing facts and issues that this discussion brings to the forefront — so how do we resist the status quo, change the status quo, and at the same time work within the structure of the status quo to make changes that are sorely needed … is this possible??

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  7. I think one of the things that makes it very difficult is the worldview of nursing.

    I think it has been a long time since the interests of the medical community were focused on patients. That made it easy for the AMA to accomplish its goals because they were focused on the needs of doctors for a long time. Still, they completely missed the implications of managed care and insurance risk assumption which led to the most radical changes in physician practices in centuries, destroying the solo-practitioner model in a few short years.

    If nurses continue a scattershot approach, much like the Democratic Congress between 2008-2010, we will continue to be marginalized because we cannot achieve agreement on the most fundamental goals, objectives, strategies, and priorities. We will continue to spend our time and energy in internecine conflicts. Where Democrats couldn’t manage to govern effectively while controlling the House, Senate, and White House, Republicans have been remarkably effective at dismantling government while controlling only the House.

    Even on so fundamental an issue as how health care is financed, there is little agreement between working nurses, on the rights of undocumented people, the poor, racial and ethnic minorities, and gendered communities, etc. Some nurses are incredibly conservative, some incredibly radical, but most fall right there in the middle with a disturbingly large number thinking that Sarah Palin would make a great President.

    One could, well I would, argue that the most earth shaking changes in the health care delivery system were not planned, in a design sense, at all. They were consequences of an extremely focused, self-serving, and profit maximizing intervention developed by economists, business people, and politicians with little thought devoted to the consequences by many, and no doubt a few people who understood exactly what the consequences would be.

    Most of the problems that nurses face today: working conditions, equipment and supply shortages, inadequate patient care, high throughput, limited interaction with patients, a general feeling that their patients’ needs are not being met, concern about the quality and quantity of care, the legal consequences of professional practice, declining educational standards, the appropriate level of educational preparation (ASN v BSN v MSN v DSN) are all simple consequences of belt-tightening that accompany the manner in which insurance risks are managed, the managed care revolution.

    Physicians have made their deal with the devil and many have prospered, some are unhappy, but in general the physicians have made sure their needs are met. Not so clear that nursing has done the same. As we face a period of declining health care spending, huge cuts that are coming in funding health care services for the elderly, the poor and the differently abled – regardless of which major political party wins the day on the legislative campaign, radical shifts in how Medicare/Medicaid, Managed Care Organizations, and Insurers pay for health care services, the writing on the wall is REALLY, REALLY clear. Fewer people will be able to cover the costs of technologically and clinically feasible care.

    This means that there will be fewer diagnoses of treatable conditions as individuals defer approaching health care providers, fewer diagnoses by health care providers who seek to avoid high cost, high risk patients to maximize net revenues, and fewer jobs for health care providers. Facing the abyss – what is the response of nursing? More and more ASN and BSN programs, more nursing students, more nurses… All of this based on an entirely bone-headed approach focused on perceived social needs for nursing services and ignoring the 2,000 pound gorillas in the room – Who is going to pay the salaries of all these nurses, where are the resources for all this nursing care going to come from, and what other societal goods and services must be traded off to continue these practices.

    For obvious reasons I think the central focus of any effort to bring nurses together ought to be focused on something that is achievable, will have a dramatic impact on the quality and quantity of health care services, will address the central questions of cost and sustainability, and will have intended/unintended consequences that will reshape the health care system in exactly the opposite manner in which the managed care revolution reshaped the health care system over the last 38 years.

    How to accomplish that is also absolutely clear to me – the most radical thing that nurses can do is understand the financial basis of modern health care. The problem is that large numbers of nurses balk at calculating proper doses, IV drip rates, and PCA flow rates and embrace and glorify their lack of quantitative and financial skills.

    So, do people really want to create a nurse led REVOLUTION in health care? Promote quantitative and financial literacy among nurses. Set up study groups to learn how insurance works, examine contracting between hospitals, nursing homes, home health agencies, physicians, and nurses and managed care organizations, Medicare/Medicaid, and insurers. Set up statistical and financial study groups and journal clubs with the same passion that we have invested in promoting TT, HT, and holism. Learn what we really must from experiences like Hurricane Katrina and how the public health is being affected by how health care is financed. Apply the same holistic approach to understanding the complex tapestry of financial interconnectedness that one would apply while doing a Therapeutic Touch intervention and you will lead a quiet, momentum building revolution in nursing.

    It is exactly what Nightingale would be doing, solo, if she was here today, but imagine the impact if just a few hundred quantitatively and financially adept nurses were actively focusing on such activities, setting up quantitative and financial literacy study groups, untangling the web of flawed financial relationships from bedside to boardroom, bringing other nurses, physicians, allied health professionals, patients, and the public along with them, taking the opportunity to challenge nursing budgets, contracting methods, and state and federal health care policies not on the basis of ethics, but on the basis of their abundant quantitative flaws. Focus on building the capacity of nurses to actively participate in assessing the financial and clinical consequences of contracts and Medicare/Medicaid policies before they are signed/implemented rather than trying to put Humpty Dumpty together again after contracts are signed and policies changed?

    But, of course, we all have our favorite thing that we think everyone else should do to create a modern revolution in nursing, and none of us really want to give that up to join with others. Me no less, perhaps even me not at all. But, if we fail to coalesce around an issue that we can win on, that will influence every aspect of nurse-patient interactions, every aspect of relationships between nurses and other health professionals, and the relationships between nurses and their employers and communities, that will demonstrate that the unique worldview of nursing can deliver both a broad, conceptual vision, and a pragmatic, hands on, quantitatively justifiable and implementable solution for how to finance health care services that is radically different, better, more efficient, and more effective than what we have now, and will have in the future, if we fail to act, then nursing will continue to be a marginalized, demeaned, and maligned profession, and when the really radical changes politicians have in store for us manifest, we will see a lot of unemployed and unemployable nurses shaking their heads and asking what happened? And that will be our fault and no other profession’s because we failed to come together and act on something that we could, and should, have done.

    While nurses spent decades debating the appropriate entry level qualifications for nursing, other actors/actresses acted. We are seeing the results of their actions as we watch the development of more ASN programs and I have little doubt, that we will soon be seeing more and more hospital based nursing programs, potentially loosely affiliated with online programs, down the road. Physicians, physical therapists, and pharmacists haven’t done anything like this – Social workers on the other hand, have. Nursing and social work are very much alike in how they have approached education and professional advocacy, so it is not a gender issue at all – there is far greater gender balance in social work than in nursing.

    We aren’t seeing dramatically more medical schools, decreased educational preparation levels, and dramatically increased numbers of physicians. Medical schools aren’t producing physicians to meet patients perceived needs – they are producing quantities of physicians that they believe can be sustained by the amount of funding that will be available to pay physicians’ salaries in the future.

    🙂

    Actionable knowledge will continue to be the most radical thing anyone can ever acquire or promote.

    bear

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  8. This discussion makes my head spin!! I appreciate all the thoughts shared above, and like Peggy, I wonder what (small, achievable, effective) actions can be taken by regular old nurses like myself – to make change happen once and for all. Like Wendy and Carey I really struggled with having the “future of nursing” lined out by the Institute of Medicine. I’m so grateful to read your thoughts, since I started to think I was crazy for thinking these things (when so many others were so excited about the document).
    I, too, have struggled with why nursing can’t seem to implement an entry level of practice (degree) and what Bear writes is frightening – more and more Associate level programs. I understand the Associate level programs for people who already have a Bachelors – I’m all for non-traditional ways of becoming a nurse. However, I had a really hard time when the DNP was added without our ever finding an answer to the entry level of practice question.
    So, what can we do? How can we get more nurses on board? Where are the nurses who feel strongly about these issues as we do and how can we reach them?

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  9. Been thinking a lot about the issues raised and stumbled on a quote from Einstein that bore on it, for me anyway, than found another quote that expanded on that insight.

    1. “Everything should be made as simple as possible, but not simpler.”

    2. “The most beautiful thing we can experience is the mysterious. It is the source of all true art and all science. He to whom this emotion is a stranger, who can no longer pause to wonder and stand rapt in awe, is as good as dead: his eyes are closed.”

    The beauty of Einstein’s work is that he pursued #1 with an appreciation for #2, but he was able to clearly focus on simplicity in the pursuit of his goal of understanding the universe.

    When I say that the worldview of nursing stands in the way it is because we tend to try to accomplish #2, abandoning any possibility of #1 in the process. In fact, some nurses actually reject any effort at achieving #1, preferring to think that the mere effort is somehow anathema. So, for example, a topic near and dear to my heart, Therapeutic Touch.

    Many nurses who practice, or do research on, Therapeutic Touch reject well designed research as either unnecessary or antithetical to the principles of TT. They don’t stop practicing TT, nor do they stop doing research on TT. They just reject the only ways available to improve the quality of their practice and/or research.

    The problems that co-occur with a rejection of simplicity is that there are so many different ways, for example, to appreciate wholeness and complexity, none of which is universally accepted by all, or even a significant minority of nurses.

    Lacking any central focus, that would lead to a situation where even 100 nurses would actually agree, in great detail, to pursue nearly identical objectives, it becomes practically, though not theoretically impossible, for concerted action. In many cases our fellow nurses cannot even agree to follow the patient care plans for an individual patient during a single shift.

    Even on something so simple as the notion of “healing” or “caring” there is a lack of agreement significant enough to warrant action.

    But, the other actors/actresses participating in the design and delivery of health care services are very precisely focused on the objectives they wish to achieve. They have simple requirements such as: Profit maximization; Reduced costs for staff, equipment, and supplies; Increased efficiency (i.e. patient to nurse ratios), Improved throughput of patients; Higher revenues than the year before… They do not trouble themselves with the consequences of meeting these objectives, they just doggedly pursue them…

    When all of this plays out in actual settings, it is not the numbers of nurses that is important, because on that score alone nurses ought to have an overwhelming impact on the policies and procedures of health providers, but the focus, and drive to attain their objectives, of the participants.

    Unfortunately, until someone figures out something that really, really resonates with large numbers of nurses, and that can actually be achieved, I fear that nurses will continue to have relatively little impact on health care delivery. Worse still for nursing, there are many nursing leaders who are working in direct opposition to the very things that most nurses really care about, so their influence doesn’t entail people following them, They can advise Presidents, Congresses, the Senate, but they do not really speak for nurses.

    So, one area in which this is happening is the notion that a nursing crisis exists when many nurses actually like the overtime pay they are able to earn, their ability to switch jobs and regions. As well, technological evolution and workplace innovation, better logistical control and coordination will eventually dramatically reduce the non-existent nursing shortage, and eventually these things will happen, potentially leading to a glut of unemployed and unemployable nurses as has happened many times in the past.

    In the 1970s many clerks and bookkeepers thought they would have lifelong job security because nobody, and no thing, could replace their tedious and exacting work. In a few short years, in the early 1980s, personal computers, Lotus 123, Excel, and other easy to use computer programs eliminated 99% of the work they used to do. Accuracy in data entry and calculation was replaced by accuracy in data entry – the simplest of the two tasks. The demand for people with data entry and calculation skills plummeted.

    I certainly want more caring, compassionate, and healing patient experiences, better working conditions and job opportunities for nurses, but the way I would go about implementing that has attracted as few committed followers as any other nurse’s approaches. 🙂

    Nightingale did not, as far as I have been able to tell, seek to achieve consensus to achieve her goals, she decided what she thought ought to be and doggedly pursued the fulfillment of her objectives despite opposition from generals, doctors, managers, nurses, bankers, business people, and politicians. Nurses, as well as the others, often begrudgingly complied with what she wanted simply because of her single-minded pursuit of her visions.

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  10. Wow!! What wonderful responses … each and every one! I just want to add a couple of thoughts to this discussion, but also encourage new posts to start a focus on ideas for action given what we have now! Suggestion .. folks who post an idea keep your post to one idea per post, and let’s brainstorm how to make the idea come about … keeping to some realistic goals for overly busy folks like we all are. If you are following this blog and want to post but are not yet a contributor or author, let me know and i will get you set up!

    So the thoughts. All of the frustrations are totally valid. Yes, this report came by way of the IOM, and that is very frustrating, and it also signifies the ongoing control of nursing by medicine … even though in this case there were significant nurses who fashioned the report (unlike many many times past when the docs try to control our destiny — and they still do in many blatant ways). But like the goldmark report in the last century, even though this report’s recommendation are pretty lame in many ways, they are mostly unrealized … and getting some energy behind getting them unrealized is a huge goal.

    I think that it is very important to acknowledge all the “reasons” we have not achieved a single level of entry nursing, and to remain open at the same time to the potential for the yet-another DNP entry (after all, it is here, and it is a huge bandwagon that I think it is futile to resist). First of all, the splintering of the various levels of entry is one of the most effective ways to keep nurses alienated from one another, and that circumstance is not of our own making (although often we blame ourselves for it, which perpetuates the myth and feeds into the reality). Keeping nursing education fractured is a major tool for continuing the oppression of nurses. But that being recognized, it is now quite clear from the history of our struggle around this that the solution may not be to directly aim to legislate one level of entry. I personally think that is our ideal and ultimate goal, and I do suspect that in fact the DNP program phenomenon might eventually help with that. But in the meantime, the best solution that I have seen emerge to address this problem is the initiative that Chris Tanner has made reality in Oregon, and that many states are now adopting (which is fabulous) — this is a coordinated statewide curriculum that provides a seamless transition from AD through BS preparation in nursing, making access to BS preparation much much more accessible, and most important, brings AD and BS faculty to the table together to start talking to one another with a single goal, and with the “mandate” to understand one another’s points of view. This is absolutely key to making ultimately achieving the kind of world we seek.

    I won’t go on here .. but the underlying principle that I personally seek is to see the problems and the frustrations through as broad a lens as possible, but not get bogged down by them in a morass of despair. Then to use insight and analysis about the frustration to re-envision the actions that could make a difference, given the realities of the world we live in, and the ideal future we seek. The actions will not be ideal … the Tanner model is a great example … it is grounded in the ideals we seek but also in the realities we live with. So it is not of necessity the world of our ideal, but it is informed by that ideal, which keeps the ideal alive for the next phase of action.

    So thanks to everyone — keep this discussion open of course, but also, get some of the more day-to-day kinds of actions posted on this blog!!

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  11. OK, a focus on one topic. hard for me.

    But, is it really a question of a medicine-nursing divide anymore? If it is important to seek common understandings between ADN, BSN, MSN, and DSN/PhD educated nurses, is there really a significant difference, other than what department MDs are educated in, between MDs and nurses with various degrees?

    The old hallmark of medicine was independent, solo, professional practice. 50 years ago the overwhelming number of MDs in this country were white males in private practices. Look at any medical school nowadays and what you see are multi-ethnics and women in far greater numbers than traditional white males. Nursing, on the other hand, continues to be one of the most gender disparate professions, with little indication that this is likely to change any time soon.

    But, I think the really important thing is that, much like nurses, most medical school graduates will be wage earners, not independent practitioners. Not at all unlike nurses, they will go to work for hospitals, nursing homes, and health clinics. They may get better sign on bonuses, higher compensation, and better profit sharing deals, but the divide between nursing and medicine, in terms of influence over the health care system, is clearly shrinking.

    While MDs may still have more say in patient care decisions, they are also bearing the brunt of the efforts at cost containment, being held directly accountable for the costs of patient care in far more exacting detail than most nurses have yet experienced. While it may seem desirable for nurses to have more influence, it may also be very undesirable when we consider the consequences: More individual responsibility for the costs of patient care at the level of individual nursing units and individual nurses.

    I think the broader influences on IOM reports, that should be our real concern, are not MDs, but corporate and governmental interests, mediated through professional organizations, and with the acquiescence of MDs in much the same way that when new ADN nursing programs are started, the teachers and administrators are nurses who are willing to direct and teach in such programs. An Institute of Nursing could have delivered the same exact report if the interests being served in producing the report are unchanged . Can we legitimately blame those who desire proliferating nursing programs, which will ultimately achieve their goals: reductions in staffing costs and nurses’ salaries, when these goals are achieved with the acquiescence of those who choose to teach in them? If nurses, at every level, refused the inducements to create and expand fragmented nursing education, they would be more difficult to begin and maintain. We nurses enable these corporate interests in lo less degree than the complicity of those serving on the IOM.

    While some MDs, merely because they have been in the system for longer periods of time, wield greater influence than new MDs or nurses, much of that influence derives not from their medical background but by virtue of their allegiance to corporate goals. Patient focused MDs who do not tow the corporate line on cost control have little or no influence on health facility policies and procedures. Much like nurses, they are replaceable with others willing to conform to corporate expectations..

    CNAs would like to wrest some of the turf of nurses away from nurses

    Nurses at various levels would like to wrest some of the turf of nurses at higher levels and MDs away from nurses at higher levels and MDs

    MDs would like to wrest some of the turf they have lost to Administrators and Financial departments away from Administrators and Financial departments.

    Throughout, third party payers are increasingly dictating the working conditions, pay, and professional satisfactions of all clinicians, the level and types of benefits available to patients, and the quality and quantity of care being provided.

    If we focus too much on the diminishing differences between MDs and nurses, which were far more relevant 30 years ago, but which are mere artifacts at the moment, we will not have our eyes on the real problems: consolidation of health facilities, consolidation of third party payers, excessive profiteering, decreasing influence of clinicians over clinical services, corporate belt tightening, system wide reductions in capacity, increasing threats to the public health, and inadequate care for patients.

    If we nurses do not focus on these things we will not be terribly effective. If we continue to focus our attention on presumed differences between MDs and nurses as though MDs still wielded significant influence over nurses and nursing, we will be focused on things that will not yield much change. To effect change we need to understand corporate health care and acknowledge that the real divide is between corporate nurses and corporate MDs and non-corporate nurses and MDs because the gaps between non-corporate nurses and non-corporate MDs are far greater than the gaps between corporate nurses and corporate MDs..

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  12. According to the Mirriam Webster Dictionary:
    The Origin of ACTION is from the Middle English accioun, from Anglo-French accion, from Latin action-, actio, from agere to do — more at agent
    First Known Use: 14th century
    Synonyms: act, deed, doing, exploit, feat, thing
    Definition of ACTION:
    to initiate a proceeding in which one enforces one’s rights; an act of will; a deed or thing done; movement in the direction of ones goals; a manner of performing…
    reference http://www.merriam-webster.com/dictionary/action?show=0&t=1310091487

    The future of nursing is for us to decide by our actions:
    How are we proceeding to enforce our rights to voice, free trade and emancipatory practice?
    In what manner do we perform our caring-healing deeds towards ourselves, each other and humanity?
    Who are the stakeholders and policy makers that we need to engage to create the change we want to see?

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  15. I can feel the passion for our wonderful profession jumping through these comments…it seems for the largest profession in the world we are the most unorganized…and certainly not taken seriously most often…you are all right~ why is the advice of the institute of medicine taken more seriously than our organizations? Maybe because we have given away our power…An example…we hospital based nurses provide highly skilled, caring and evidenced based care and enter into tough interpersonal relations with grace and proficiency only to be unable to bill for one thing we have done!! The hospitals get to bill for services, the doctor and the xray dept….BUT there is no nurse charge at all…not one. We, the nurse, the largest workforce in the world ~~ get lumped into the room rate for the hospital. There is no value placed on our skills…our education…our devotion to great patient care…
    I would propose that building holistic care centers that are run by nurses would draw people in and they would receive better overall care. The patient could come in for a Reiki treatment, or nutritional counseling, an NP appointment, get a massage or take a yoga class…aromatherapy…all provided to them by nurses who taylor a program around the patient’s disease state, mental health or journey to wellness issues…the billing would be for services provided by the nurse…at first most of this would be private pay…we could start tracking the interventions and then demonstrate the increase in improved patient outcomes (and it would!!)~~ insurance companies would take notice and then pay for these centers….because the wave of the future is for payment to be based on better patient outcomes, and a more satisfied patient…then we the nurse would be able to fulfill our roles, have a voice and get paid for it! Just a thought.

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  16. It is more than sobering to consider this topic with the benefit of another year of hindsight.

    I understand that Linda Aiken, one of the champions of producing more nurses to meet a nursing shortage that never existed, is beginning to see the inevitable signs of a glut of nurses.

    The glut has been obvious to me, as I mentioned in several earlier posts, even as nurse’s salaries rose because the market for nurses is much like the market for finance MBAs, and there was never real demand for thousands of finance MBAs. All the finance MBAs were doing was building sand castles in the air, on top of the sand castles in the air being built by by other finance MBAs. Sort of like the profits at ENRON.

    Yes, I would love to see nurse owned, managed, run and staffed holistic centers. I am a little more circumspect than some about how one gets from a dream to a reality. Yes, it would be great to have patients come in for reiki classes, massage sessions, be listened to, be cared for and I am not at all opposed to the idea of billing for those services….

    But, unlike most nurses, I actually spent a decade of my life working in insurance companies, doing insurance and reinsurance rate making, reserving and expense accounting.

    Insurance does not work at all the way many in nursing imagine. Getting the right to bill an insurer is not the same thing as finding a Leprecaun’s pot of gold. Insurers don’t look at what people want, they look at what people need. Nobody, not the US, Germany or any of the emerging economies can afford to give the bulk of their population the kinds of services people would happily consume and it certainly is not viable through insurance mechanisms. Insurers that spend all their money on routine care have no money left for high cost services. They aren’t even called insurers – they are called managed care organizations.

    Insurers would want some simple answers: How many massage sessions is someone eligible for every year? How many yoga classes can they attend? How many reiki sessions do you want covered under the benefits of the Holistic Nurses Insurance Company? When you tell an insurer how many services you want to provide and how much you want to be paid for providing those services they come right back atcha – they tell you how much it will cost to cover such benefits. Then they tell you how much more than that cost they are going to have to add for administrative expenses, their risk margines, and the profit margins they will need to encourage investors to gamble that the insurance company will be able to deliver those benefits, and make a profit sufficient to reward them for the risk they took in supplying the capital necessary to run the operation.

    In the end, insurers will come up with one very simple number – the amount they will charge policyholders for the insurance policies that will pay for your services.

    That premium, I can assure you, will be high enough that there will be very few people covered by those policies. I’d be thinking a minimum premium of 5-10K a year for every man, woman and child in the country and that assumes that there are fairly tight limits on what services are covered, how many instances of service provision will be permitted, and why the services will be offered and paid for.

    This holistic health insurance policy also will not cover acute illness, treatment for cancer, heart disease, bypass operations, physical therapy, or myriad other medically necessary and appropriate care.

    That policy will not cover your patient who comes in looking pale, feeling clammy, experiencing shortness of breath and the obvious signs of severe illness. Reiki sessions are not going to resolve clogged artieries in time to save your patient’s life.

    Yes, you might achieve some noticeable improvements in health and well-being in the patients you serve, after 10 years of very expensive care. But the downside is that those patients are going to live longer than they would have. They will eventually develop all sorts of diseases associated with advanced age. Their arteries will clog, their lungs will fill with pollutants, their knees, hips, ankles will give way, and they will WANT the kinds of services you do not provide. Where do they go for their hip replacement when the only insurance policy they have is for holistic health care?

    As a simple rule of thumb, figure that an insurance policy is going to cost one-third more than the amount that you want to bill it for. If you want to be able to bill your patient’s insurer for $3,000 per year for massage, reiki, yoga classes, aromatherapy, crystals and magnets, their insurance policy is going to cost $4,000 per year (75% benefits to premium dollars is fairly standardard for a large and efficient insurer).

    If you want to be even more lavish, being able to bill for $9,000 per year, the policy will cost about $12,000. Just follow the relationship wherever you want to take it. Perhaps you will go the other way, The Fast Food Holistic Center – People can come in for a 5 minute massage, 5 minutes of reiki. They will wait for a long time to see their massage or reiki therapist, and the therapist will be paid a pittance for their work, and see 40-50 patients a day. So you will only bill for $300 per patient per year, and their policiues will only cost $400.

    In the end, there really are numbers for these things. The heyday of medicine and nursing of the 1960s-2000s is coming to a close. There will be less and less money for health care as more and more baby boomers enter the Medicare and Medicaid programs. The powers that be are not sitting around thinking about how to expand opportunities for nurses to be paid on a fee for service basis, they are actively working to make sure that the costs for doctors, nurses and all the other professional and para-professional staff are incorporated into the fee that will be paid for the bed.

    Doctors have very little influence over hospital policies and very few doctors are being paid on a fee for service basis. The old images of doctors as captains of ships has given way to doctors as members of crewds who are floating out to sea on a rudderless ship with a full load of patients, limited staff, equipment and supplies, and no supply routes to replenish them when they are gone.

    Think post-Katrina New Orleans if you want a glimpse of the future of health care. Does it have to be this way. No. But getting nurses to focus on costs, risk, insurance, finance, economics is nearly impossible. Yet it is these things nurses need to know if they want to lead. They don’t need to become accountants, financial analysts, insurance experts, or economists – but they damned well need to understand these disciplines if they want to influence the direction in which the health care system goes.

    I love insurance – I think insurance is one of the greatest accomplishments of human civilization – but it isn’t what most people think it is – it is a lot more complicated.

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