Future Forces in Healthcare: New Roles for Nurses
A recent study by PricewaterhouseCoopers' Health Research Institute provides information regarding current workforce challenges in healthcare.
The federal government predicts that nurse and physician retirements will contribute to a shortage of nearly 1 million nurse and 24,000 doctors by 2020 (PwC, 2007). Presently, nurses and physicians are not dispersed or utilized effectively in the United States. Unfortunately, future shortage statistics are based on the current malfunctioning healthcare system. As advanced practice nurses know, the delivery of care is best accomplished using a multidisciplinary team approach. This coordination of care has become more intricate and complex over the past decade. Nursing leaders in today's healthcare arena must weigh in on the types of care providers needed in their specialty area, the roles these providers are trained to deliver, and how other levels of providers (e.g., downsubstitution) and technological advances (e.g., information systems) can be employed to provide a more efficient healthcare delivery model (PwC, 2007).
Several key findings in the report were that the (1) use of temporary nurses is no longer a stopgap measure but has become a way of life for many hospitals, (2) process of educating and retaining new nurses is broken, (3) failure to retain nurses is costly and wasteful, (4) hospital leaders are in a state of denial about nurse dissatisfaction, (5) new wave of medical schools could repair the inequity of physicians in underserved areas and specialties, (6) nursing education is stifled by perverse financial incentives, and (7) workforce is too often a second thought for executives who are distracted by numerous payment and regulatory issues (PwC, 2007).
Two of the "future forces" discussed in the report were the blurring of nurse and physician roles in primary care and a prediction that rainmaker roles may change for hospitals.
Nurse and physician roles are blurring in primary care. According to PwC researchers, hospitals in the United States now rely more heavily on physician extenders, such as nurse practitioners and physician assistants. Competition for these clinicians is increasing, particularly with the advent of retail health clinics, which heavily employ physician extenders (PwC, 2007). The National Sample Survey of Registered Nurses by the Health Resources Services Administration (HRSA) stated that there were more than 141,209 nurse practitioners with credentials as NPs in the United States, an estimated increase of 38,560 from 2000 (HRSA, 2005). It is difficult to estimate the number but more and more NPs are now working in emergency departments, urgent care areas, and other emergency care settings (HRSA, 2005).
Rainmaker roles may change for hospitals. The PwC report says hospital nurses will be elevated from "overhead" to "rainmaker." Arainmaker is someone who brings in significant revenue for a business; physicians have traditionally been the rainmakers for hospitals. Nurses have always been considered overhead. In fact, nursing care is not even billed separately but rather as part of the "room charge." PwC predicts that new pay-for-performance programs, which emphasize clinical quality and patient satisfaction, will give nurses significant ability to influence revenue. Some of us have felt for a long time that this paradigm shift was in order. Instead of thinking of nurses as the largest "expense" in the hospital's budget, we should identify nurses as the largest potential "revenue" producer. "For too long, administrators have viewed nursing as an expense rather than valuing nursing care as a critical investment in quality, cost-effective care. The study by the American Nurses Association (ANA) demonstrated the economic value of RNs and speaks to the societal benefit of providing better nurse staffing, which ANA believes should be the driver in policy decisions" (ANA, 2006).
After all, if you need medical care, you can have almost anything done (including surgery) as an outpatient. The reason patients are admitted to hospitals in today's healthcare environment is that they need nursing care. Patients and their physicians should prefer hospitals with better outcomes and fewer adverse events, and both are strongly linked to nursing care.
It comes as no surprise to us that a central issue in the future of healthcare is nurses in both adequate numbers and adequacy of training. The ANA recently reported that excellent nursing contributes to better patient outcomes. The report stated that if nursing staffing numbers and nursing hours per patient were increased for all patients, there would be reduced morbidity for thousands of patients and mortality would be decreased by more than 6,700 patients annually in the United States. In addition, the report noted that approximately 4 million hospital care days could be avoided each year in the United States with appropriate RN staffing. The areas of adverse outcomes reported by the ANA included (1) hospital length of stay, (2) hospitalacquired pneumonias, (3) hospital-acquired urinary tract infections, (4) postoperation infections, and (5) decubitus ulcers. According to the PwC, it appears that the tide may finally be turning in understanding just how important nursing is to the hospital's bottom line.
What can we, as individual nurses, do to promote this change in thinking? First and foremost, we need to step up to the plate and not to be shy about touting the importance of
nursing care to achieve positive patient outcomes. Subservience to medicine should be a thing of the past as we present ourselves, and our profession, to individual patients and the public at large. Taking credit for the contributions of nursing is important at all levels, from grocery store conversations to legislative arenas where we speak to healthcare issues. In addition, we must preserve the moral high ground. Internationally, nurses already enjoy extremely high rankings in public opinion polls about trustworthy occupations. This is because we are seen as altruistic, not selfserving. Maintaining this trust is essential and patient advocacy plays an important role. This means never forgetting why we do what we do because patient care is the real bottom line. We must continue to act in our patients' best interest at all levels, from the bedside to the halls of Congress.
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