Nursing — A New Paradigm

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By Donna Cardillo, RN, MA, CSP, FAAN

Long before the Affordable Care Act became law, major changes were brewing in the U.S. healthcare system. The aging population, advances in technology and research, escalating healthcare costs and an epidemic of chronic illness have forced all of us in healthcare to step back and reevaluate virtually everything we have been doing. Examining our healthcare practices will help us find better and more cost-effective ways of delivering quality care and improving the health of the nation. As a nurse and career columnist on the nursing profession, I believe the ACA is accelerating that needed reinvention and implementation — and other career experts agree.

This is nursing’s time,” said Tine Hansen-Turton, MGA, JD, FAAN, FCPP, CEO of the National Nursing Centers Consortium and executive director of the Convenient Care Association. “Most healthcare models coming forward heavily rely on nurses to make that success happen and in some cases drive that success.”

Nurses were named the most trusted profession in the nation in 2012, according to a Gallup poll. Since Gallup started to include nurses in its poll in 1999, nurses have scored at the top or close to it in terms of trust every year. And yet, nurses who possess a broad knowledge and skill base in the planning, management and delivery of care have been largely underutilized in the past. Let’s look at how and where RNs and advanced practice nurses are working in emerging and evolving healthcare models by care setting.

Hospital care
While hospitals have been the foundation of our healthcare delivery system for decades, care is shifting out of the acute care arena into alternate inpatient settings, ambulatory settings, the home and the community. David Houle, a futurist, and Jonathan Fleece, a healthcare attorney, authors of “The New Health Age: The Future of Health Care in America,” predict one-third of all hospitals will close by 2020 because of this trend. Only the sickest, most acutely ill patients will occupy hospital beds in the future, according to the authors’ review of hospital care expense, medical errors and hospital-acquired infections and extensive ED wait times.

So while nurses still will be needed in this setting, their role will evolve into one that is less about performing patient care tasks and more about providing care management and coordination. “This is where the biggest role shift needs to occur,” said Cynthia Nowicki Hnatiuk, RN, EdD, CAE, FAAN, executive director of the American Academy of Ambulatory Care Nurses and the Academy of Medical Surgical Nurses. “Many nurses are unfortunately still very task-oriented. In order to work to the full extent of their license, they must move into a clinical leadership role and focus on care coordination.”

Alternate inpatient settings
As acute care beds shrink, facilities offering services such as rehabilitation (acute and long-term), subacute and acute long-term care, assisted living, hospice and others are expanding. Charlotte Eliopoulos, RN, MPH, PhD, executive director of the American Association of Long Term Care Nurses said there is a rise in acuity and complexity in the LTC environment. Therefore, the role of the RN in those settings is evolving into one of a clinical consultant. AALTCN advocates increasing the presence of RNs and APNs in the LTC environment. More nurses also are becoming licensed nursing home and assisted living administrators, which according to Eliopoulos, “puts nurses in a strategic position to bring about the changes that need to happen.”

Medical homes
The patient-centered medical home, simply put, is a multidisciplinary team approach to care in an office setting that views the patient/consumer as a partner in that care. PCMHs are led, to date, primarily by physicians who employ APNs, RNs, social workers and various therapists and specialists, many of whom make home visits to clients. The RN plays a vital role on the team, engaging patients in their own care and coordinating that care. The National Nursing Centers Consortium is advocating to have the federal government designate more APN-led clinics as PCMHs to officially recognize and sanction them as well as increase reimbursement to them, according to Hansen-Turton.

Ambulatory care
Services of all types — surgi-centers, wellness centers, hemodialysis, medi-spas, clinics and nurse advice lines — will be responsible for an increased rate of care. Sg2, a future-focused healthcare information systems company, forecasts that outpatient volumes may grow 17% over the next five years, according to a June 2013 article in Becker’s Hospital Review. These ambulatory care services are being provided by managed care companies, government agencies, privately owned entities including those run by nurse entrepreneurs, PCMHs, school health and faith-based community programs, and the public health sector.

Nurse-managed health centers
These are typically APN-led practices that offer a patient-centric, team approach to care. According to the NNNC, most of these clinics are in underserved and rural areas providing care to the most vulnerable in the population, but will be expanding in response to the shortage of primary care physicians and the projected increase in demand for primary care services under the ACA. Hansen-Turton said there are four major categories of these clinics: wellness, school health, primary care and birthing centers. These centers also are led by certified nurse midwives, clinical nurse specialists and RNs.

Retail clinics
Retail clinics, such as those found in pharmacy chains such as CVS or Walgreens and large retailers, such as Target or Walmart, that house a pharmacy are 95% staffed by nurse practitioners and offer care that is fast, accessible, affordable, efficient and of high quality, said Hansen-Turton. Some of the higher volume clinics also utilize RNs for flu shots and health screenings.

Home health
Traditional home care services continue to flourish as greater efforts are made to keep disabled individuals in their homes even for routine care, such as disease management and mother-baby services, and to provide care for aging individuals and avoid nursing home and assisted living care when possible. In addition to RNs, more physicians, NPs and even dentists now are making house calls.

This is an exciting and challenging time for nurses as we take on new, expanded roles that play to our strengths. It’s a new dawn in healthcare and a new day for nursing. We have to shed our preconceived notions about what we are capable of doing and where and how care will be delivered, as we swim with the tide of change, reinvention and evolution. It’s time for all nurses to come out of the background of healthcare and lead the way to more compassionate care, improved outcomes and better health for all.

Career planning TIPS by Donna

It is imperative that every nurse – new and experienced – realize the healthcare landscape has completely changed. There will be plenty of opportunities for RNs and APNs who stay current with trends in education, technology, care and personal and professional development. Nurses must be willing to step outside their comfort zone and learn new ways — and places — of working and thinking about their profession. The AAACN’s Hnatiuk stresses that, to stay competitive, nurses also will have to be able to articulate the value that they bring to outcomes, beyond tasks, in any setting. So what does every nurse need to do? Here are four key areas:

1| Skill building
Clinical skills alone won’t see us through in this new paradigm. Self-marketing, computer skills, oral and written communication, conflict management, negotiation, leadership and networking skills must be learned and practiced. Hnatiuk said nurses also need to be more business savvy, with an understanding of finances, staffing, acuity and productivity.

2| Education
Higher education is no longer optional. It is a foundation for practice in any setting and fundamental to professional and personal growth and development. Hnatiuk advises that formal and continuing education, along with clinical certification, will help nurses take their practice and careers to the next level.

For those considering advanced practice, particularly becoming nurse practitioners, the NNCC’s Hansen-Turton advises: “Don’t think too long; jump in. Opportunities will be increasing for NPs over the next 5-10 years. NPs are and will continue to be a hot commodity.” Certified nurse midwives, clinical nurse specialists and certified registered nurse anesthetists also will see expanded opportunities.

3| Professional association involvement
Our professional associations are where we connect with one another, form communities, share best practices (local and national), stay current with trends and issues, and find support. Hnatiuk added that through association involvement, you learn more than you could by yourself and progressively learn leadership skills.

4| Mentoring
Hnatiuk encourages nurses to take advantage of opportunities to be mentored and to mentor others. “We have so much to share. Mentoring will allow us to achieve all we’re capable of doing.”

Donna’s top picks for hot roles in nursing

Staff nurses in critical care (all types including NICU), emergency, OR, oncology, labor and delivery, telemetry, med/surg, peds and psych will remain in high demand for those with advanced degrees and clinical certifications.

Clinical nurse leaders take clinical practice to the next level without becoming advanced practice nurses. According to the Clinical Nurse Leader Association website, CNLs are master’s prepared advanced generalists who work at point of service and focus on coordinating, facilitating and overseeing evidence-based practice, safety, quality, risk reduction and cost containment.

Telehealth nurses use phones and computers for virtual home visits, assessments, remote monitoring, education, counseling and triage. The use of telehealth services is a big growth area, according to both Hansen-Turton and Hnatiuk, especially in rural areas, home health and in other care coordination settings.

Nursing informatics specialists manage implementation and maintenance of electronic medical records and other uses of information technology in the delivery of healthcare. They facilitate interface between clinicians and IT in many ways including education, research and practice such as supporting virtual services in inpatient and outpatient settings.

Care managers (not to be confused with case managers) work one-on-one with people with chronic illnesses or disabilities and their loved ones, usually in their homes. They function as liaisons with insurance companies and healthcare providers, help manage medications, create plans of care, research treatment options and more. They also are known as geriatric care managers, nurse concierges, professional patient advocates and nurse navigators.

Care coordinators (aka population care or transitional care coordinators and nurse navigators) work with patients in hospital, home or office settings. “I not only work one-on-one with a patient with diabetes, but I also look at our entire diabetic population and use aggregate data,” said Sandra Siegel, RN, MS, care coordinator at Hunterdon Healthcare Partners based in New Jersey.“In so doing, I’m working smarter and improving care for all.”

According to the National Coalition of Oncology Nurse Navigators, “The ONN [a type of care coordinator] serves as a single point of contact for patients and their families throughout their entire cancer care experience — and most importantly is an advocate and personal care coach on the patient’s behalf.”

Holistic nurses promote health, wellness and healing from a whole-person perspective. They assess, teach, coach and counsel individuals (consumers and staff) and in some cases incorporate modalities/practices, such as Reiki, meditation, yoga and essential oils. These nurses may work in any practice setting incorporating a holistic approach to care.

Nurse case managers focus on care coordination, financial management and resource utilization to yield cost-effective outcomes that are patient-centric, safe and provided in the least restrictive setting, according to the fourth edition of the “Nursing Case Management Review and Resource Manual.” The role will expand and become even more important as nurses strive to meet health outcome and cost containment goals of the ACA, according to Catherine M. Mullahy, RN, BS, CRRN, CCM, president of Mullahy & Associates, LLC, author of “The Case Manager’s Handbook” (fifth edition).

Wellness coaches work with individuals and groups to set and achieve health goals. This service is being offered by hospitals, managed care companies, medical homes, nurse entrepreneurs, private health promotion companies and nurse-led clinics.

Home health nurses provide a broad range of services including care coordination, care management, disease management (management of an individual chronic illness), hospice and palliative care, mother-baby services, wellness and prevention, education, coaching and more — all key components of the new healthcare paradigm.

Other nursing specialties to watch include: gerontology, bariatrics, genetics, plastic surgery/dermatology/medical esthetics, clinical documentation improvement specialist, women’s health and nephrology/dialysis.

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