MUCH has been written about the need for change in nursing practice as a response to the need for clinical change within the context of contemporary health reform. The need for change is far-reaching and represents the intensity of transformation that will be necessary for the profession to adapt and thrive in this postdigital age of health transformation. Indeed, the very foundations of nursing practice must shift considerably if the practice of nursing is to remain relevant in this unfolding digital health landscape.1
NURSING IN THE MEDICAL MODEL
The history of the profession in the past 100 years has witnessed a profession predominantly bounded within the framework of medicine and institutional health service, reflective of a model that has been highly interventional and represents a strong tertiary care core.2 While nursing practice has clearly demonstrated its roots in the community, by far the largest component of service has historically occurred in institutions and in care models fundamentally influenced by the dominance of late-stage, high-intensity, interventional medical practice (tertiary care) in the United States. In fact, much of the content of the preparation for basic levels of nursing practice has been heavily oriented to medical model foundations and has served to prepare nurses with a facility for practicing in such settings (notably, hospitals).3 For most of the 20th century, the preparation and orientation of almost all nurses has required a stint in the hospital with a heavy orientation of patient care to the institutional practice of medicine. This well-entrenched medical model approach to the delivery of health service has been the primary driver of health service for the entire 20th century in the United States.
The costs, social and economic, of this tertiary care approach to delivering illness care in America have become astounding.4 Almost 18% of the American gross domestic product is directed to paying for the extremely high costs associated with taking care of the sick. The terrible indictment of this is that only 6% of the American population drives the expenditure of 50% of health care dollars.5 In critical care services, 43% of patients there are within 60 days of death.6 Indeed, there is overwhelming evidence of the distribution of health dollars in ways that do not advance the health of individuals or groups but are extensively available to those who can pay for them through a wide variety of means. Evidence suggests, however, that high intervention, late stage, late engagement, high-cost health service has only limited impact and marginal positive outcomes with regard to the net aggregate health of the nation.7 Indeed, most of what health status the citizens of the United States can claim has more to do with the excellence of public health practices (clean water, effective sewage management, immunizations, etc) than any other single factor.
NEW MODEL OF HEALTH
The noisy transition to a new model of health-based services is inexorable even as it is fraught with political rhetoric and polarizing ideology. However, regardless of particular political position or ideology, everyone can agree that health care must change radically if it is to be both economically viable and service effective. While the United States is the number 1 nation in the world in terms of cost of health service, it is number 30 in terms of the net aggregate health of its citizens.8 This is a reality that simply cannot be sustained and will need reformation regardless of the level of agreement around approach.
THE PATIENT PROTECTION AND AFFORDABLE CARE ACT AND A NEW AGE FOR HEALTH
We are now well into the fourth year of implementation of the Patient Protection and Affordable Care Act (PPACA) with the majority of regulations and operations of the PPACA in place January 1, 2014. While there will continue to be political give and take with regard to some elements of the law, the PPACA will likely continue to unfold pretty much in its current form for the next 2 to 3 years by which time many of the new processes will be well on their way to full implementation. That is not to suggest that there will not be modification and adjustments throughout the implementation of PPACA, as there should be as the Act continues to move from policy to reality. Providers will ultimately design and implement the service and payment models necessary to make health reform work over the next decade. For nursing, there will be enormous practice changes ahead that will be essential if nurses are to remain relevant over the next 2 decades. There are a number of arenas where practice reconfiguration will be essential:
1. The move to provide a strong primary care infrastructure as the centerpiece for early engagement health-based service will require increasing retraining and realigning nursing resources away from late-engagement tertiary care service structures.
2. Care delivery will be organized around populations, episodes, and continua of care rather than late-stage compartmentalized tertiary services to better prevent, avoid, or manage high-intensity, high-cost, illness-based intervention.
3. Nurses will be primarily responsible for the effectiveness of the health team around episodes of care and navigating the interaction between patient and provider along the continuum of care in a way that makes good use of resources and achieves the value for which care will be organized and delivered.
4. Hospitals, where the majority of nurses currently work, will experience the most significant change in service and infrastructure where there will be a continuous reduction in the number of bed-based services and an acceleration of home-based, clinic-based, and community-based services.
5. User-driven ownership of health care will mean increasing engagement of the individual and a growing drive for providers to play a supportive role in developing, educating, informing, and providing access to information and health services.
6. Increased influence and use of digital mediums and vehicles for assessing, managing, following, and evaluating users of health services will require the nurse to engage portable digital tools more robustly in ways that increase clinical availability, portability, mobility, and utility in a wider variety of health service approaches.
PRIMARY CARE INFRASTRUCTURE
Health reform simply cannot be sustained if there is not a strong primary care foundation. The ability to reduce cost and care intensity assumes that there will be a reduction in high-cost, high-intensity, late-stage illness care services. Since 50% of the of hospital care costs are driven by 6% of the population,8 there are huge economies of scale implications for reducing those costs and providing a different and better route for health consumers to avoid both high-intensity services and the serious illnesses that they represent.
In addition, it is important to note that the poor and uninsured who wait until very late in their cycle of illness, or until it is reflected in more traumatic conditions or circumstances, add huge costs to the service system by entering the system through the emergency department, the highest cost portal into health care services.9 Those costs are simply redistributed and contribute to the high per unit of service costs and prices everyone pays. Restructuring care delivery and insuring the poor and historically underserved will go a long way toward reducing and appropriately redistributing these costs and will create an incentive to serve this population in a manner that better fits their cultural and personal health needs.
This move to a stronger primary care infrastructure is both timely and beneficial to nurses. Going forward, the physician education community has made it clear that it cannot sufficiently gear up to meet the growing resources demanded for the provision of primary care services.10 At the same time, the growing cohort of primary prepared advanced practice nurses can easily and effectively meet the growing demand for primary care services over the next 6 to 8 years. At a time when more than 90 000 new primary care providers will be needed to meet both the growing population of insured people and the growing demand for early engagement intervention models, the capacity of nursing to address these demands with high-quality, well-prepared practitioners is providential.11 The lingering concern over medically controlled or limiting scopes of practice for advanced practice nurses at the state level will ultimately be mitigated by the growing inability to adequately serve whole populations effectively without removing such barriers. Years of hard-fought efforts for practice equity for advanced nursing practice will be more quickly ameliorated by an untenable demand that cannot be met effectively and timely in any other way. Indeed, there is much to suggest that further future federal funding to states to support local and regional primary service programs should come with the requirement that restrictions on scope of practice be removed. States with medically controlled limitations on scope of practice for nurses should comply with federal standards related to constraint of trade laws and reflect the application of the National Council of State Boards of Nursing Consensus Model across the United States.12
DIGITALIZATION AND THE MOVE FROM FIXED TO MOBILITY-BASED PRACTICE
The digital technology boom of the past 20 years has steadily, yet inexorably, altered human life in fundamental ways. From communication to utility, digital technology has created a contextual framework for human life that could only be the product of dream and mythology. As this digital reality has become more strongly interfaced with human behavior, it has created a symbiosis at a level that humans can increasingly no longer live without. From multifunctional cellular technology to every convenience of modern life, “chip-based” technology now drives the script of human experience and creates the context within which that experience unfolds.
The quantum leap in data production and management now forms the foundation for building evidence that informs our experience and our service trajectory. These machines of technology can now manage data at a quantum level and sort through it in ways that our human minds cannot. These technology devices can now make sense of the data they manage and make decisions about what they imply and how to respond. At every level of human experience, from handheld multipurpose digital assistants to complex potable diagnostic instrumentation, the mobilization of digital mechanics now creates a highly portable social and functional infrastructure for human action and interaction.13 It also challenges our behaviors and practices. Many of the foundations of health reform are grounded in the digital architecture out of which the clinical expectations for practice changes emerge. The ability to handle and use huge aggregates of data, and to apply that data “just-in-time” to significant problems and their associated process solutions, is unparalleled.14 It is vital that the availability and utility of these digital tools become an increasingly acceptable part of nursing practice. Indeed, their presence now defines the vagaries of emerging nursing practice grounded in a digital infrastructure.
The ability to collect, aggregate, and compare clinical data now establishes a ground for evidence-based practice. As evidence can be discerned through evaluation of just-in-time data, the relevant information can now be immediately applied to contemporary practices and decisions. Changes in the content of practice can be made immediately and the clinician can quickly adjust practice behaviors to reflect the latest available information. This belies the long-held tradition of policy and procedure approval processes in nursing, with a turnaround time of 9 to 18 months. Such industrial age practices are simply no longer relevant in our digital age. Nurses need to change clinical practices as quickly as the data suggest. The need for immediate change in this more mobile culture requires an effective prevailing infrastructure that enables a “just-in-time” change in clinical behavior and service.
This expanding digital age also extinguishes the rationale for standardizing nursing action as a way of codifying what is appropriate behavior for practice. In place of standardization is an accelerating demand and ability to customize care as the technology makes it more possible for practitioners to align service tightly to the unique conditions and circumstance of the individuals who use it. Already, the use of genetic profiles informs the treatment of a wide variety of cancers and a growing number of other conditions. The ability to precisely “fit” clinical practices and treatment to the unique needs of the patient changes the script for service and care and the structural and contextual foundations that support it.15 As a result, the language, routines, and rituals of nursing practice garnered from a century of practice habits and patterns must now give way to a new foundation for clinical practice that more strongly represents the digital culture. Some key arenas of practice change that must now undergo critical assessment are as follows:
1. Removing emphasis on nursing process as a vehicle for critical thinking in the digital age of nursing practice. The development and refinement of nursing synthesis as the prevailing model of critical thinking and acting is more relevant to the emerging requisites of contemporary, digitally managed, customized nursing practice.
2. A user-driven, portable, and aggregating health record that moves with the patient (residing in the “cloud”) and can be accessed in real time wherever the patient intersects with the health system across any clinical service or information platform is essential to any value-grounded health system. No economies of scale can ever be achieved without an accessible and effective information and data value chain. As competition becomes more intense on the parameters of achieved health value, it will be virtually impossible to be adaptive and responsive without an information infrastructure that is receptive to immediate changes in demand and practice. Nursing practice must be increasingly intentional. Process and impact must be more rationally and directly related and achievable, with outcomes that are consistently validated and replicated. Providers need to have the capacity to both obtain and interact with the latest patient-based data. They must link and intersect individual clinical contribution with the partnered contribution of other essential members of the patient's clinical team using just-in-time approaches. This seamless integration of the clinical data system is central to any effective clinical relationship and successful model of value-based care.
3. There must be a more effective management of patients in the health system in a way that treats them as members of that system. The notion of “exit and entry” into the system by its users through mechanisms of admission and discharge from the health system creates an interruptive, compartmental, and late-stage notion of the individual's relationship to his or her own health, and to the system that ostensibly supports that health. Subscribers (members) must always be “in” the system and the health system should follow them at all times. Digital “pushes” should provide health support and clinical information access to every subscriber on his or her mobile device. The health system must be so connected to the user that it acts as one with the person and is so customized that it intersects in ways that advise and guide individual health and life choices.
4. Handoffs become increasingly important in value-based health reform. “Seamless and well-linked handoffs all along the continuum of services” implies that the information and clinical system have a high level of interoperability. These interacting systems gather and aggregate knowledge, judgments, resources, and actions that demonstrate a goodness of fit between each component of service in the patient's journey and are both service-effective and value-evident. Wide variations in service and care resulting from inadequate handoff systems are now becoming increasingly untenable as lowered payment becomes the price paid for failing to tightly coordinate and integrate care.
5. Mechanisms for reducing variance within populations, episodes, or processes of patient service will be critical to success in any system of accountable care. Services will be competing on value and will be compared for effectiveness against each other as a mechanism for determining value, and as a part of the process of determining value-based payment for comparable care. Those services with the best price-quality indices and lowest level of costly service variance will experience the greatest advantage in the value payment algorithm. Nursing has the greatest potential for making a difference through the management of variance at any point in the care delivery continuum through good care management within the team and along the patient's health journey.
6. Both the supply chain and service value chain have huge potential for addressing the range of costs that represent the greatest arena of waste within the health system. Choices related to supplies, tools, inventory, utility, and efficacy of use will be important factors in cost control, especially since services will be offered in a wider variety of settings in a multitude of user-driven service models. Good resource management and transparent pricing practices will increasingly be a part of regulating the point-of-service clinical management process. Clinical providers will play a larger role in carefully managing and moderating resource choices as a part of clinical decision-making.
7. Leaders will need to change mechanisms for assigning, scheduling, and staffing nursing resources as models of service change to address delivery of care in a host of new ways that meet patient needs, without predominantly using hospital-based service designs. Newer approaches to employing nurses must emerge, including collateral engagement (transdisciplinary teams), partnering nurses in care systems that reflect broad clinical partnerships, scheduling in the continuum (collateral scheduling vs fixed site or positional scheduling), contracting for deliverables, payment for results rather than process, just-in-time care approaches, and customized care that adapts to unique population and patient characteristics within a bundled pricing framework.
THE CHANGES ARE REAL AND PERMANENT
The implications of health reform are just now unfolding. This is especially true as they inform the choices leaders must make related to organizing the delivery of care services and the best management of resources. However, a template is now emerging with regard to the essential adjustments leaders are contemplating in order to best configure response to the emerging demands of health reform.7 The significant move to creating value for users of health services is central to the role of recalibrating how nurses are used and services are provided. Nurse leaders must now ask a different set of questions regarding the emerging character of the nurse's role in the coordination, integration, and facilitation of value-based care in an accountable care system.
Clearly, nurses will accelerate in importance in a health scripted value-driven health system. As critical navigators of service along the continuum of care, nurses will add considerable value in managing both the partnerships necessary to render truly accountable care, and for ensuring value-defined measures of quality and sustainable health outcomes. Nurse leaders must see this centrality of the nursing role and demonstrate a capacity to act outside of the industrially structured illness care “box.” The time has come for nursing leaders to innovate both the structure and practice of nursing in a way that demonstrates its centrality to the future of health reform and its capacity to lead the emerging transdisciplinary care team into new dynamics and processes of service. This will result in real reform, better access, and higher levels of sustainable health for every American.
The foundations of health reform now call for nursing to pull more of what it does out of the medical model of the past century. It is time to reaffirm the profession in the health script that originates in individual accountability and a community of care and healing. This “refreshed” healing community must now be founded on fundamental definitions of health and the emergent practices that sustain them. Much of the content of health reform is directed to achieving the value of health and creating a healthy society through the efforts of an increasingly complex, digitally based, user-specific delivery system. Changes in delivery and payment models that move from volume drivers to value determinants now reflect the priority of advancing health rather than simply treating illness. The growing emphasis in health reform on rewarding health value says much about the shift in form and substance regarding health policy and practices and affirms the very foundations of the nursing profession. It calls for nurses to write a different script for service and interaction so that the triple aim of good service, high quality, and right price will be obtained, and truly healthy communities will thrive throughout the United States. This is now the charge of the future for nursing practice.
1. Pinakiewicz D, Smetzer J, Thompson P, Navarra M, Lambert M. Fourth annual nursing leadership Congress: driving patient safety through transformation conference proceedings. J Patient Saf. 2009;5(2):109–113.
2. Kitson A, Marshall A, Bassett K, Zeitz K. What are the core elements of patient-centered care? A narrative review and synthesis of the literature from health policy, medicine, nursing. J Adv Nurs. 2013;69(1):4–15.
3. Valiga T. Nursing education trends: future implications and predictions. Clin North Am. 2012;47(4):423–434.
4. Ginzberg P. Fee-four-service will remain a feature of major payment reforms requiring more changes in Medicare physician payment. Health Aff. 2012;31(4):1977–1983.
5. Allood N, Higgins A. Posing a framework to guide government's role in payment and delivery system reform. Health Aff. 2012;31(4):2043–2050.
6. Halpern N, Pastores S. Critical care medicine United States 2000-2005: an analysis of bed number occupancy rates payer mix and costs. Crit Care Med. 2010;37(1):38–43.
7. DeVore S, Champion W. Driving population health through accountable care organizations. Health Aff. 2012;30(1):41–50.
8. Commonwealth Fund. National Scorecard on Health System Performance, 2011. New York: Commonwealth Fund; 2011.
9. Litvak E, Biscognano M. More patients, less payment: increasing hospital efficiency in the aftermath of health reform. Health Affairs. 2011;30(1):76–80.
10. Petterson S, Liaw W, Phillips R, Rabin D, Meyers D, Bazemore A. Projecting US primary care physician workforce needs: 2010-2025. Ann Fam Med. 2012;10(6):503–509.
11. Agency for Healthcare Research and Quality. Primary Care Workforce Facts and Stats #2. Washington, DC: Agency for Healthcare Research and Quality; 2012.
12. Spetz J, Parente S, Town R, Bazarko D. Scope-of-practice laws for nurse practitioners limit cost savings that can be achieved in retail clinics. Health Aff. 2013;32(11):1977–1984.
13. Scott GW. 50 years of physical growth and impressive technological advances unmatched by health human resources reform and cultural change. Healthc Pap. 2012;12(3):30–34.
14. Miranda M, Ferranti J, Straus B, Neelon B, Califf R. Geographical health information systems: a platform to support the “triple aim.” Health Aff. 2013;32(4):1608–1615.
15. Berwick D. What's patient-centered should mean: confessions of an extremist. Health Aff. 2009;28(7):555–565.
digital infrastructure; health reform; nursing navigation; nursing transformation; PPACA; value-based service