New Roles and Shifting Priorities for Nurses

Abstract

In my CO M M E NT ARY, I cite few studies from the literature. Linda Burnes Bolton, DrPH, RN, FAAN, and Donna E. Shalala, PhD, provide thorough citations and supportive material in the content of their feature articles. Instead, my commentary elaborates on expanding nursing roles in the hospital beyond the bedside. I also delve into the role of the advanced practice nurse across the continuum of care in the United States.I am continually amazed that even though healthcare professionals are trying to speak the new language of population health and coordination of care that reflects the changes occurring through healthcare reform, we always seem to return to hospital-centric ideas. The feature authors are helping us expand our horizons across the continuum while grounding us in the Institute of Medicine (IOM 2011) report on which this issue of Frontiers centers, and why and how to operationalize the report's recommendations.New Roles and Shifting PrioritiesThere is no going back to the expensive illness care system we have had in place for decades. The nation's entitlementdriven system promotes a lack of individual accountability for one's health, enabling some users of the system to lead an unhealthy lifestyle. Significant dollars are paid to the providers who care for the ill, and very few dollars are spent for primary care providers to coach and partner with their patients toward wellness. The incentives for both provider and patient are misaligned in our old system. In this new system of wellness, providers will be financially motivated to serve as care partners with their consumers to help them attain the right level of care for the most appropriate amount of time.The transformation to a health system from an illness system will take a long time, in part because the new system is shifting accountability to individuals for maintaining health and managing their chronic illnesses as effectively as possible-a shift that will no doubt encounter resistance.Nursing Changes in the HospitalThe major tenets and principles of the Affordable Care Act (ACA) mandate reimbursement to hospitals for moving from volume to value, decreasing or eliminating all hospital-acquired conditions, and decreasing or eliminating hospital readmissions. New incentives-pay for performance, not for volume-have been developed as part of the new payment plan.In her interview for this issue of Frontiers, Burnes Bolton articulates the value of bachelor of science in nursing (BSN)prepared nurses in her organization's operations. The studies that she and Shalala cite in their features support the fact that BSN-prepared nurses experience better hospital outcomes than do those nurses without a BSN degree. I agree, and I support the authors in their comments and conclusions on this front.One area that was not discussed by either Burnes Bolton or Shalala is the role of the patient in value-based care. The participation of the patient and his family or significant other is essential to exceptional outcomes. Nursing does have significant control over the number of falls, infections, or skin breakdown occurrences that take place, and nurses are responsible for including the patient and family as part of the care and wellness continuum. However, if the nurse does not engage the patient and significant other, neither the patients' satisfaction nor their clinical outcomes may reflect substantial improvement. Furthermore, under the value-based purchasing model, the hospital's reimbursement is negatively affected by poor outcomes, such that 70 percent of the weighted formula in pay for performance is attributed to the clinical metrics and 30 percent to patient satisfaction outcomes (CMS 2013).To develop a culture in hospitals of nurses as partners with patients and families, the curriculum for, and the faculty teaching, our BSN students should emphasize the following:* Helping the patient become fully informed about her disease* Effectively coordinating care with the patient's entire care and wellness team* Selecting the most cost-effective care path, equipment, and supplies for the patient* Respecting the patient's right to decide her treatment* Honoring, respecting, and incorporating the patient's cultural beliefs about illness, health, and death into her careAdditional Hospital Nursing RolesOther nursing roles are emerging in the hospital as the new models of care are designed or evolve, which were not discussed in the feature articles. …