Left out of debate
Nurses’ voices not being heard on reform: study
Many nurses consider themselves the only workers in the healthcare system who really understand how to coordinate a patient’s care across the dizzying array of care settings, a process that is fraught with opportunities for errors and satisfaction problems.
Many also say they’re the only ones who can appreciate a person’s health holistically, instead of seeing a patient through the lens of niche medicine. And they’re often the only observers with enough real-world knowledge to deliver a cold splash of practicality to administrators’ high-minded innovations.
Yet a new survey has found that nurses are widely seen as having the least amount of influence on policy of all the groups in healthcare, even though past surveys of Americans report that the public considers nurses more honest and ethical than other healthcare professionals.
“At a time when trust is eroding for other professions, it remains very high for nurses. And among health professions, it remains very high. That is an asset that we as health professionals need to build on—the fact that trust is high and has remained high over a long period of time,” said Risa LavizzoMourey, president and CEO of the Robert Wood Johnson Foundation.
The Princeton, N.J.-based foundation last week released the results of an opinion survey of about 1,500 participants who were drawn in equal measure from academia, insurance companies, providers, corporate healthcare offices, government and a category labeled “industry thought leaders.” The survey, conducted by polling firm Gallup, found that nurses’ voices were regarded as the least influential at a time when they are seen as being needed the most to accomplish the goals of reform.
For example, 90% of the respondents said that they would like nurses to have more influence in the development of policies to reduce medical errors and improve patient safety, and 89% said that nurses ought to have a more influential voice in developing policy to increase quality of care.
As the nation debates ways to improve quality while slowing cost growth, both in Washington and in the individual boardrooms, where are all the nurses? They’re still at the bedside, observers say, and they might be working a double.
“They’ve always been seen as kind of more the worker bees of the profession, and perhaps not big-picture thinking enough to have meaningful input in the healthcare reform debate,” said Marjorie Maurer, vice president of operations and chief nursing executive at 325-bed Advocate Good Samaritan Hospital, Downers Grove, Ill. “It’s been relegated to a subordinate profession to medicine, and therefore not able to be seen as having the intellectual capital in what needs to happen in redesigning healthcare.”
One key issue cited by numerous nurse executives in interviews was the contentious effort to expand nurses’ scope of practice. Physicians’ groups often argue that advance practice nurses lack the training to safely per- form primary-care tasks like prescribing medications, while nurses argue that health systems rely too heavily on doctors who are expensive and often in short supply for primary care.
Another area of doctor-nurse rivalry cited in the study was the perception that doctors have more influence in the policymaking world because they generate revenue. “It’s a very archaic culture that would defer their (nurses’) input based on the fact that they do not bill for their services. And it’s unfortunate. A more contemporary model would have them at the table,” said Peggy Naleppa, who began her healthcare career as a diploma nurse and this month became president and CEO of Peninsula Regional Health System, Salisbury, Md. “They know the realities of providing care. They know the implementation.”
For example, doctors can prescribe medications to heart-failure patients to prevent fluid retention, and hospital pharmacists can make the drugs available, and insurers can limit payment of claims based on whether there’s proof that patients are following the protocols for taking the lifesaving medications.
Yet it’s the nurse who can point out that the patient may not have access to a car to pick up the drugs, or may be too poor to afford a decent scale at home to monitor weight to prove if the patient is taking the drugs, Naleppa said.
The nurse, if invited into the boardroom or the policy forum, will talk about how the relentless piling on of innovations in healthcare delivery eventually becomes counterproductive because the complexity of the healthcare system itself creates problems in quality, payment and patient satisfaction.
“We have built, over the years, with good intentions, one of the most complex systems to navigate,” said Mary Ann Osborn, vice president and chief clinical officer at 381-bed St. Luke’s Hospital, Cedar Rapids, Iowa. “We have to ask, ‘Is this going to add value for the patient? Or is going to add more complexity?’ ”
That sentiment applies particularly to healthcare information technology. Your typical hospital patient, for instance, has to tell half a dozen people about his or her medication allergies for the various record-keeping systems, when one recitation of that information ought to be enough.
“Any time there is a meeting or testimony, and people are talking about patient care, that is a real missed opportunity if the nurse is not there providing the patient perspective,” said Susan Hassmiller, senior adviser for nursing at the Robert Wood Johnson Foundation. “I think you’d see some real differences in our system if more nurses were at the table.”