Nurses, Policy, and President Obama

• Dr Tim
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Nurses form the centerpiece of healthcare service. Professional nurses coordinate, integrate, and facilitate every aspect of the patient’s continuum of care. In hospitals, it is nurses who provide the 24 hour management of patient care services. It is nurses to assure all of the activities directed towards advancing the patient’s health are coordinated and integrated in the best interests of the patient and in ways that advance the patient’s experience. Nurses are located at the intersection of every health process. Indeed, nurses navigate the many challenges and barriers to effective patient care, working around them and even through them, as necessary, to assure patients receive the services they need in support of their health journey. Any decisions related to health reform not only affect nursing practice but will, ultimately, need to be advanced and implemented by nurses whose historic role is directed to making these kinds of initiatives work.

For too long, however, nurses have been marginalized from the policy and decisions made by others (more often than not, non-patient care persons) in a manner uninformed by nurses’ contribution. The untold costs associated with strategic plans, practices, initiatives, and processes which simply don’t and can’t work is incalculable. Yet, these decisions and practices still persist, even in the 21st century. The marginalization and discounting of nurses roles and participation in decisions and planning has a long and well-documented history. Much of it parallels the experiences of the women’s movement and reflects the historic challenges to the power and position of women in the greater society as well as healthcare decision-making. In addition, the accelerated growth of lay leaders (mostly men) in positions of power in healthcare with little understanding of clinical issues and patient care processes has seriously compromised and complicated effective patient care service, quality, and clinical outcomes. It is simply untenable to believe that healthcare transformation can be successful without the inclusion, investment, and engagement of nurses “at the table”.

Those at the decision-making table for future health care reform may not realize the impact of what’s missing at the table if nurses are not included in the dialogue and decision-making. One of the errors of groupthink is evidenced by groups who are unaware of the players they need in the dialogue and the contribution they might make simply because they are not present. In hospitals and healthcare services, nurses comprise 60% of the provider workforce making decisions and taking actions with regard to patient care services. Much of the research coming out of the Magnet experiences of the best hospitals in the country clearly indicate that nurses create the culture of the hospital and/or healthcare organization and have a direct influence on the clinical viability and impact of healthcare services. This vital force essential to the integrity and effectiveness of decisions and actions affecting health service and patient care should not be ignored. Every task force and workgroup related to health care reform should include nurses whose insights can advance the clarity of the dialogue and inform leaders in ways that can help assure practical applicability and both positive and sustainable results.

Furthermore, in many communities across the United States, nurses are the primary providers of healthcare services. In many rural and isolated communities, nurses provide the majority of healthcare services in places where physicians and other providers are simply not present or refuse to go. Decisions which affect policy and application regarding access, service distribution, payment for service, quality of care, etc. simply can’t be adequately addressed and resolved without nurses full participation. As primary care becomes an increasing concern in the political and healthcare community, it is advanced practice nurses who will ultimately provide the majority of primary and preventive services as physicians continue to fail to meet the increasing demand for these services. Research related to preparation and performance has clearly enumerated comparable if not higher levels of effectiveness of patient care and services from these advanced practice nurses when compared to physicians and physician assistants. These data also frighten leaders in healthcare services simply because they do not support traditional beliefs and approaches to delivering services, creating challenges to existing paradigm for patient care. These emerging realities create a real need to expand the dialogue and shift our untenable policy positions affecting autonomy, authority, competence, as well as address issues of power and patient care decision-making and clinical processes.

This is a critical time in our nation on so many levels. As we confront the economic crisis, it becomes ever more clear how intricately tied into the crisis our past policies are related to excess, entitlement, and public decisions. The time is now right to critically confront and address many of the root causes of the issues that have historically been addressed only symptomatically. Gathering the right stakeholders to the policy table is a critical first step in assuring the decisions made there are adequate, accurate, and can be successfully implemented. A seat at the table must include nurses and nurses must be willing to engage the challenge and opportunity to write a script for healthcare. Every player at the table will be affected and called to change past beliefs, practices, and rituals and routines; nurses no less than any other provider. If we are to negotiate at an even table and if we are to actually assure impact on outcome that makes a difference and is sustainable, nurses must be present. Let the nursing community and all those who advocate for it work to remind President Obama, his leadership team, and healthcare leaders of the essential contribution of nurses to this dialogue and of the necessity to include them at all the tables where it will be held. The healthcare system simply cannot meet the demand of sustainable change without them. Dr. Tim

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