Left out of de­bate

Nurses’ voices not be­ing heard on re­form: study

Modern Healthcare - - The Week In Healthcare - Joe Carl­son

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.”

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