The changing role of nurses
Research Activities, December 2012, No. 388
The health care workforce doesn't get any bigger than nurses. Three million strong, they're the largest group of clinicians in the country. Research Activities spoke with AHRQ's senior advisor for nursing Beth Collins Sharp, Ph.D., M.S.N., about her perspective on trends in nursing, why nurses are important in research, and the role of nurses at AHRQ.
What role do you see nurses playing in health care research?
Nurses affect so many aspects of health care in addition to direct clinical care—quality measurement and improvement, case management, data collection for clinical trials, insurance coverage review, health and insurance hot lines, patient education classes, and many others. In many of these roles, we hold certification or additional training.
This isn't new. In fact, modern nursing was founded by an epidemiologist and health services researcher. Florence Nightingale was a renowned statistician who was famous for her statistical documentation of mortality during the Crimean War. She collected data proving that more soldiers died from infection than from battle and she championed for improved hygiene procedures to reduce the mortality rates.
If Florence Nightingale were alive today, AHRQ investigators would be clamoring to have her as a consultant on their grants for quality measurement, healthcare-associated infections, and training in patient-centered services.
Why are nurse researchers so critical in developing health services research?
We bring an on-the-ground perspective—a reality check—to studies. Ideally, nurses are involved from the beginning as questions are developed through to the end when the research gets put into practice. We're often the clinicians collecting data and documenting care or implementing the intervention. We can identify problems during pilot studies or run-in periods in the research protocols. After all, we are experienced with clinical protocols. And, of course, when the study is complete, we're often doing much of the patient education.
Nurse practitioners and certified nurse midwives continue providing the patient's view in advanced practice with patients in a variety of settings, including a strong presence in primary care and underserved areas. Even when nurse researchers are not currently in clinical practice, I believe "thinking like a nurse" remains. I was recently in a very busy ER with a family member for a minor issue so we spent a lot of time waiting. During the visit, I constantly interpreted what I was seeing: "Oh, that woman needs an ice pack", "that man will get his test done before that one", "that's the nurse manager, the one who's calling impromptu meetings because the computers just went down." Nurses are able to identify aspects of health care that would be important to include in a study or data that may be missed without that clinical perspective.
As the health care system undergoes transformation, how will the role of nurses change?
Well, everyone's role is changing—including the patient's. But the piece that cuts across everything is interdisciplinary collaboration with patient-centeredness, which is a long-standing nursing value and well ingrained in nursing practice. As the number of advanced practice and doctorally-prepared nurses grows, the interest in designing studies and being principal investigators grows. Nursing research used to focus mostly on nursing education studies and then on psychosocial questions. So there's a lot of methodological expertise in qualitative methods and evaluation.
I remember when the first physiologic and genetics test questions were being posed by nurses—some people questioned whether it was really "nursing" research. But nursing has always had a holistic view of the patient, so it makes sense that the science should reflect all paradigms. I see nurses having an increasing presence on multidisciplinary teams in co-investigator and principal investigator roles. The multidisciplinary approach is such a positive way to go—especially for the patient. But probably the biggest stimulus of transformation is the Institute of Medicine's (IOM) 2011 report, The Future of Nursing: Leading Change, Advancing Health.
What's changed since the IOM report on the future of nursing was published?
There was so much buzz in the nursing community when the report was released, you'd have thought the report was only by and for nurses. But it was sponsored by the Robert Wood Johnson Foundation (RWJ) and the IOM and the chair was Donna Shalala (former secretary of HHS and current president of the University of Miami), who is not a nurse. She said, "The report is really about the future of health care in our country. It points out that nurses are going to have a critical role in that future, especially in producing safe, quality care and coverage for all patients in our health care system." The report was rolled out to stakeholders beyond the nursing community.
The report resonated with several sectors of the health care industry and they recognize that the report is actionable. The RWJ Foundation and AARP collaborated to create an initiative called the Future of Nursing Campaign for Action. So far, over 80 organizations have become involved in this initiative.
Another change has been the passage of the Affordable Care Act (ACA). There are provisions that speak about both registered nurses and nurse practitioners. For example, a National Healthcare Workforce Commission was established to address workforce issues in multiple disciplines. It is chaired by Peter Buerhaus, Ph.D., R.N., who is also an AHRQ grantee. We've had progress in other areas. Medicare now pays the same reimbursement to certified nurse midwives for a service if the same service was otherwise delivered by a physician. The nurse practitioner role is spelled out in several points of the ACA—most often in primary care and the patient-centered medical home, as well as advanced practice education loans and training grants such as geriatric nursing career incentives.
Do you think the Affordable Care Act will help advance nursing practice?
Calling out nurse practitioners in legislation helps the health care industry take note and look at policies that incorporate advanced nursing practice. Sometimes the policies need tweaking during implementation. I recently learned of an issue with incentives for electronic health records (EHR) to encourage e-prescribing. Nurse practitioners may need extra documentation fields if their State regulations for scope of practice require physician collaboration or additional documentation. This documentation has downstream effects in EHR incentives and penalties. This is an over-simplification of the issue, but is a good example of some of the scope of practice challenges for nurse practitioners.
The issues about scope of practice continue to be "spirited." Currently, there's a lot of posturing around over who should be in charge of medical homes, for example. There are some misperceptions about nurse practitioners—like they're trying to replace physicians or silly things like they're "physician extenders" or "mid-level" providers [chuckles]. Be warned—don't use those phrases with your nurse colleagues! All kidding aside, my personal view is that in the current environment where health care demands and deserves a team approach, there's plenty of work for everyone.
Since patient-centered care is a shared value, things settle into collegial practice as long as the open dialogue continues. That may sound Pollyanna, especially being so close to Beltway politics, but I think that patients want quality care, will demand it, and one way they'll receive it is from advanced practice nurses.
How are the views of nurses reflected in the work at AHRQ?
I've always loved that AHRQ has a multidisciplinary atmosphere where teamwork is more than talk. It's real. When I think about AHRQ's portfolios, they reflect important areas of transformation and there's a place for nursing in all of them. I can't even begin to tell you how much nurses are involved in at AHRQ, but I can give you a few examples. We have nurses working with HHS on the National Quality Strategy called for by the ACA, coordinating site visits to assess Patient Safety Organization performances, analyzing utilization data, and promoting our materials. One of our nurses recently managed a challenge for nurse practitioners and physician assistants who work in retail environments to translate existing AHRQ research reports into innovative resources.
Almost all of our nurses have advanced degrees. At least one of our nurse practitioners still sees patients. We're nurses and "once a nurse, always a nurse." I don't know the origins of that expression, but it captures the essence of the strong nurse identity that many of us hold.
What are your goals for integrating nurses' expertise at AHRQ?
As senior advisor for nursing, I look for intersections with AHRQ where the nursing perspective can be helpful and areas to promote AHRQ to nursing stakeholders. I'm sort of the concierge for nursing. I have two big goals. They're pretty huge, actually. One is to have nurses on every technical expert and peer review panel and similar groups where the business of that group involves nursing stakeholders. I think that's a reasonable expectation, and for my purposes I assume that is just about everything we do here at AHRQ. I want to have ready resources for my colleagues who think nurses are important stakeholders for their work.
Second, I want to promote the use of AHRQ products by nurses. Nurses are not only the largest segment of health services, we are integrated throughout the system, most especially with patients. Our unique perspective can have real impact. I don't think we have consistently engaged the nursing perspective or leveraged the opportunities that are available by partnering with nurse stakeholders. As I go to meetings and chat with my nurse colleagues, I hear two clear messages: They love the work of the Agency and think it's so important to patient care. On the other hand, they express concern that most materials don't resonate with them because they perceive that the target audience is mainly physicians. I'm hoping we can make our materials more multi-disciplinary in general and routinely target materials to nurses.
There will be a lot of work involved to accomplish those goals, but they're actionable and have real potential to improve health care. Plus, it will be fun. I'm excited by the possibilities.
Editor's note: This interview is part of an occasional series that looks at trends in health care. For more information about nursing research at AHRQ, Email Beth.CollinsSharp@ahrq.hhs.gov