Chapter 16: Nursing in the Modern World PDF

As a new graduate nurse, you are about to enter a proud profession that ranks high in the public's trust and fills an essential societal need. Although most of your attention will be focused on learning your new role and caring for your patients in the first year or two of practice, we encourage you...

As a new graduate nurse, you are about to enter a proud profession that ranks high in the public's trust and fills an essential societal need. Although most of your attention will be focused on learning your new role and caring for your patients in the first year or two of practice, we encourage you to join your professional organization and at least become aware of the many political and economic issues that affect nurses, the nursing profession, and, ultimately, the health of our patients. You will be introduced to them in this chapter. Most nurses, most of the time, see their patients and the health-care system up close. In fact, most nurses work within the health-care system, experiencing its effects both personally and through their patients. Sometimes this leads to acceptance of current practices even when they could hurt patients. Other times, however, alert nurses draw attention to solvable problems. Here is an example of an alert nurse's action during the flu epidemic of 2017 to 2018: Katherine Lockler, a Florida nurse, posted a 6-minute video after a 12-hour shift during which she saw multiple instances of failure to take action to protect people from the spread of the flu virus during a flu season when the flu shot was only about 35% effective. In the video, she demonstrates how to sneeze into your arm, calling it a "magic trick" to keep others well. She also scolded a softball coach for bringing the whole team to visit a teammate in the emergency department (ED). At the time the article about her video was printed in a Florida paper, it had already been viewed 4.8 million times (Bever, 2018). Since then, we have encountered many instances of heroic nurses, particularly during the COVID-19 pandemic, where nurses worked to the point of mental and physical exhaustion to provide care to many very sick patients. What has the COVID-19 pandemic shown us? For all its devastating effects, the COVID-19 pandemic also stimulated nimbleness and agility uncharacteristic of the health-care industry. Suddenly health-care facilities were locked down and totally reliant on themselves to address the challenges of this novel and life-threatening virus. The triaging and prioritizing of our work pushed all non-essential activity out. For example, we were challenged to keep as much of the testing and diagnosing of COVID-19 away from our facilities as possible. Once welcoming of visitors and family, hospitals and nursing homes found themselves cutting their patients off from their loved ones. Patients died with no family present, saying goodbye on cell phones or tablets. Among the saving graces during this time were our nation's nurses. They kept coming to work, consoling their colleagues and patients, and letting their own safety take a backseat to the needs of the patients and communities who needed them. Nurses have demonstrated their ingenuity and agility by being proactive across a variety of settings. Some of the inventions in acute care hospitals were really revisited "old school" nursing interventions that date back to years gone by... back to a time when we didn't have technology or automated equipment to treat our patients. An example of this is the practice of proning (turning patients onto their stomachs) patients with COVID to ease their breathing and keep their airways open. This method of positioning improved patient comfort and, in many cases, reduced the morbidity and mortality of COVID-19 for these patients. Nurses also quickly repurposed technology to provide better care. An example is the use of tablet technology for both families and nurses to stay in constant communication with COVID-19 patients, which was a comfort to patients and enhanced nursing surveillance of these patients while reducing the use of personal protective equipment (PPE). In addition, many nurses shared their ideas to improve protection of staff and partnered in biodesign initiatives to confront the challenges of dwindling PPE supplies. Academic medical centers with access to engineers, scientists, and nurses combined their talents to build what they were having trouble purchasing. Items such as face shields were designed and produced using 3D printers. Workflows were redesigned to accommodate better care and management of PPE. Moving patient equipment such as IV pumps outside the isolation rooms allowed nurses to easily adjust medication doses and troubleshoot equipment without unnecessary exposure. This list of simple fixes and inventions could be endless, but one thing that is constant has been the contribution and creativity of practicing nurses. Each of us can act individually when we see situations that concern us. We can also work collectively through our nursing organizations on behalf of the nursing profession and the people we care for. Innovation Defined as "the design, invention, development, and/or implementation of new or altered products, services, systems, organizational structures, or system models" (Cianelli et al., 2016, p. 4), innovation is a natural part of providing the highest quality nursing care, yet it receives far too little attention in most leadership and management textbooks. As you just read, the examples of Katherine Lockler and many nurses during the pandemic showed some of the best innovative ideas that arose from challenges encountered in clinical practice. Generally speaking, health-care organizations are risk-averse in order to protect their patients and the people caring for them. Within this cautionary environment, however, nurse leaders and managers are still able to introduce what Cianelli and colleagues (Cianelli et al., 2016, p. 5) call the "spirit and practice of innovation." To do this, leaders need to promote thinking "outside the box" (i.e., considering new ways to solve problems and to improve care). They also need to be able to tolerate taking some risk as many new ideas or solutions may not succeed the first time they are tried. Along with these important characteristics, they also need to exercise flexibility, as opposed to rigidity, and autonomy, thinking for oneself instead of thinking the same way as everyone around you. Health Care Today Health Concerns This section on the many health problems today in the United States begins with a remarkably long list of current concerns. Despite its length, it only highlights some of our current concerns and is not by any means exhaustive. It will, however, give you an idea of the number and scope of these issues. The opioid crisis has been responsible for many potentially preventable deaths across the country. Life expectancy in the United States declined for the second year in a row in 2016 because of the increase in fatal opioid overdoses, whereas the decline in deaths because of heart disease seemed to have leveled off (Stein, 2017). Drug overdose deaths exceeded 100,000 annually as of April 2021 (CDC, 2021). Health-care--associated (i.e., nosocomial) infections have "escaped" from hospitals and now can be found occurring in nursing homes and in the community. Adverse drug events, including prescribing errors, medication administration errors, and serious side effects, have harmed many patients. Health-care providers have been forced to cancel surgeries, diagnostic scans, and other procedures because of cyberattacks, making it clear that increased security measures and regulation are called for (hhs.gov, 2022). More Americans died from gun-related violence in 2020 than in any preceding year according to Pew Research (2022). LGBTQ (lesbian, gay, bisexual, transgender, and queer) individuals face a number of mental health issues and distress related to the effects of discrimination (healthypeople.gov, 2022). Demographics and Diversity Increased numbers of older adults, longer life expectancy, a more ethnically and racially diverse population, and recognition of serious inequities in the U.S. health system present challenges that need to be met to improve access to care for all members of society. Older adults and ethnic minorities include many at-risk, vulnerable individuals who suffer disadvantages in access to care, payment for care, and quality of care (Affordable Care Act \[ACA\], 2010; Anderson et al., 2003). Social Determinants of Health (SDOH) Much has been written about health disparities and inequities, with some groups receiving less or poorer quality care and subsequent poorer outcomes, including being ill more often, having more chronic illnesses, and experiencing shorter life expectancies. SDOH are those conditions or situations in a person's environment that affect health, function, and quality of life (see Figure 16-1). The many social determinants are grouped into the following categories: Education (access and quality) Health care (access and quality) Neighborhood and home environment Social and community climate The current Healthy People 2030 goals include many SDOH-related goals. Many conditions included in the SDOH, such as high levels of pollution, living in a food desert where fruits and vegetables are expensive or hard to find, and encountering discrimination based on age, race, religion, sexual preference, or other factors, are called "upstream" factors that affect a person's health and well-being (Health.gov, 2022). Addressing SDOH Most of the programs and policies designed to address SDOH are community-based, addressing a wide range of these upstream factors. Here are a few examples: The Centers for Disease Control and Prevention (CDC) has several programs addressing SDOH. These include prevention of lead poisoning in children, culturally tailored interventions, and the prevention of youth violence. Green Cart in New York City brings fresh fruits and vegetables to underserved communities using mobile carts. Boston Center for Independent Living negotiated greater access to medical equipment for people with disabilities. Figure 16-1 Social Determinants of Health. Retrieved from https://health.gov/healthypeople/objectives-and-data/social-determinants-health Current Trends in Care The following are trends in the provision of health care that present some challenges but have the potential to improve care: Increased use of electronic health-care records, which eliminates paper and allows remote access to patient information but requires increased attention to cybersecurity. Health-care providers have been forced to cancel surgeries, radiology examinations, and other services because of cyberattacks, making it clear that increased regulations are called for (hhs.gov, 2022). Reduction of unnecessary hospital admissions Increase in surgical procedures done on an outpatient basis Attention to providing patient-centered care, reducing the ineffectiveness of fragmented, uncoordinated, unresponsive, and inaccessible care (Alkema, 2016) Using "big data" from many sources, including patient data from large health-care systems, to identify trends that otherwise would not have been noted Integrated health-care systems that provide community-based primary care and home health care as well as acute care and long-term care within a single coordinated system Keeping the caring in nursing in a highly technological setting Continuing the efforts to reduce health disparities in people who are poor or members of minority groups Continuing increase in the use of alternative and complementary modalities such as meditation, massage, and nutraceuticals U.S. Health-Care System Challenges Victor Fuchs (2018) remarked that the United States "already spends so much so badly" that we could use these misspent funds to catch up with or even outdo everyone else in creating a system of universal health care (p. 15). The United States has technologically advanced, highly sophisticated health care but has been spending more per capita (per person) on health care than most countries without achieving the highest quality outcomes. Among the industrialized countries of the world, the United States is the only one that does not provide basic health insurance coverage to every citizen. Before the ACA, 81 million Americans ages 19 to 64 were underinsured or uninsured (Schoen et al., 2011). Many reported going without care, skipping doses of medication, or not filling a prescription because they could not afford it. One-third reported using credit card debt or a loan to pay health-care bills. Sixty-two percent of personal bankruptcies in the United States (2007 figures) were because of individuals' health problems, even though 78% of these individuals had health insurance (ANA, 2009). To address this, the ACA provides subsidies to lower the costs of health insurance for people whose incomes are 400% or less than the federal poverty level (healthcare.gov, 2022). Concerns About the U.S. Health-Care System The diverse interests of consumers, providers, insurance companies, government, and regulators also present challenges to those trying to redesign the current system to make it more cost-effective as well as more responsive to health-care consumers' needs. The three primary problems with the U.S. health-care system are the number of uninsured, high costs, and less-than-ideal outcomes (Fuchs, 2018). If the United States has the most advanced knowledge and equipment and spends a great deal of money on health care, then why the cause for concern? What is wrong? The answer is not simple. For most people, health insurance comes through their place of employment. A serious problem with this is that if one loses their job, health insurance is also lost. If not eligible for Medicaid or Medicare, purchasing health insurance on one's own can be very expensive. Another is that many employers are motivated to keep the cost as low as possible or transfer much of the cost to the employee. But most consumers are relatively satisfied with their job-related insurance and, so long as they have it, are reluctant to trade it for an untested plan (Capretta, 2017). The term universal health care means that every individual has access to affordable, high-quality health care. One model used in Canada employs a single payer, usually a government agency. A second model uses a two-payer system, which also allows people to have private insurance as well as government-supported health care if they can afford it (Redwanski, 2007). Redwanski describes the effect that a universal health-care system would have on prescription drugs: All pharmacies would be reimbursed the same amount and expected to have the same drugs in their formulary. To adjust to the lower prices, however, pharmaceutical manufacturers may reduce their budgets for developing new drugs. Managed care was originally designed to reduce the amount spent on health care by emphasizing prevention. However, some believe that it has become a way to limit care choices and ration care (Mechanic, 2002) rather than prevent illness. As managed care plans grew and spread across the country, these companies became powerful enough to negotiate reduced rates (discounts) from local hospitals (Trinh & O'Connor, 2002). They could, in effect, say, "We can get an appendectomy for \$2,300 at hospital A; why should we pay you \$2,700?" If hospital B does not agree, the hospital may lose all the patients enrolled in that managed care plan. This pressures hospital B to reduce costs and spread staff thinner than before. With the upsurge in for-profit health plans and the purchase of not-for-profit hospitals by for-profit companies, U.S. health care has become increasingly "corporatized." It was thought that this would yield a highly efficient, responsive system ("the customer is always right"). That has not happened, however, because the "customer" who pays for insurance coverage is usually the employer or the government, not the individual. Furthermore, the United States is facing what Buchan called a "demographic double whammy" of an aging population that will need more health care and, at the same time, an aging workforce (Hewison & Wildman, 2008, pp. 1-3). In Canada, a debate regarding privatization versus public funding of health care continues (Villeneuve & MacDonald, 2006). Health care is still illness- and disease-focused there as in the United States. Although there is interest in complementary and alternative treatments, they have not been integrated into general care. Disparities in the care of members of minority groups threaten to increase if not addressed more effectively. Global interconnectedness has brought new concerns about how quickly and easily infectious diseases can cross national borders. Human immunodeficiency virus (HIV), severe acute respiratory syndrome, Ebola, Chikungunya, and the annual waves of influenza that cross the globe are just a few reminders of how vulnerable populations remain. These risks create an increased need for health-care provider surveillance across continents. A broader view of global health encompasses concern for the health of all people (Wilson et al., 2016). Health-Care Reform and the Affordable Care Act After lengthy arguments and despite some strenuous opposition, the Patient Protection and Affordable Care Act, known familiarly as Obamacare after the president who promoted it, was enacted in 2010 (Rosenbaum, 2011). This complex legislation contained provisions for sweeping changes in health care (see Table 16-1). The following are some of the changes of most interest to nurses: Insurance reforms that prohibit cancellation if the person is ill, eliminate preexisting condition clauses, and prohibit lifetime limits Creation of state health insurance exchanges to offer affordable insurance coverage Support for nursing education and nursing students Nurse-managed clinics eligible for federal funding Expansion of school-based health centers Support for transitional care and chronic disease management Creation of accountable care organizations and medical homes that bridge the gap between hospital, nursing home, and home and medical office care (Webb & Marshall, 2010) Free preventive care services for women, including HIV screening, contraception, breastfeeding, and domestic violence services A standardized report of health insurance coverage so that consumers can compare different plans (ANA, 2013) Provisions of the ACA were not universally welcomed. Fewer people than expected applied for coverage of preexisting conditions, and some insurers threatened to drop individual policies for children if they had to cover preexisting conditions (Adamy & Radnofsky, 2012). Several states also resisted setting up the proposed health exchanges (Anonymous, 2013). Some call the ACA socialized medicine and are strongly opposed to it; others think it is a much-needed step in the direction of ensuring that everyone can receive the health care they need. Some even say it did not go far enough. The second opinion seems to be in line with the World Health Assembly resolution supporting universal coverage: \[E\]nsuring that all people have access to needed health services---prevention, promotion, treatment and rehabilitation---without facing financial ruin because of the need to pay for them. (World Health Organization, 2012, p. 38) If the ACA were completely withdrawn, several major benefits would be lost; these are illustrated in Figure 16-2. table 16-1 Major Provisions of the Affordable Care Act 2010 to 2015 2010 Young adults can be covered by parents' health insurance to age 26 instead of 19. Insurers will eventually be prohibited from denying coverage for preexisting conditions. In the meantime, the government will provide coverage. 2011 Insurers are required to spend 80% of their premiums on patient care or reimburse policyholders for the excess. Reimbursement for Medicare Advantage plans (HMOs) is frozen at 2010 rates. 2012 Hospitals with high readmission rates will be penalized by Medicare. States are expected to submit plans for insurance exchanges. 2013 Tax increases on medical devices and for Medicare are applied on high-income wage earners. States will begin enrolling people through their insurance exchanges. 2014 State health exchanges will be up and running. Preexisting condition rule is now effective. Medicaid is expanded to those earning 133% of poverty-level wage. Businesses with more than 50 employees must provide health insurance. Uninsured individuals will pay increased taxes. 2015 Added tax on so-called "Cadillac" insurance plans offered by employers. Source: Adapted from Leonard, D. (2012, October 11). Obamacare is not an epithet. Bloomberg/BusinessWeek. Additional references from www.nursingworld.org/practice-policy/health-policy/health-system-reform Figure 16-2 Benefits of the Affordable Care Act: What Would Happen if It Were Withdrawn? Adapted from http://nursingworld.org/healthcarereform Nursing Issues Issues of high workloads, mandatory overtime, incivility, workplace violence, and lack of professional autonomy contribute to these concerns, along with an aging nurse workforce. On the bright side, there are indications of increasing interest in a nursing career as salaries improve and job opportunities expand. Safe staffing, defined as the appropriate number and mix of nursing staff, is a critical issue for nurses and the people who need their care. A series of research studies has demonstrated the importance of adequate nurse staffing. There is powerful evidence that nurses save lives: for each additional patient assigned to a nurse, there is a 7% increase in the likelihood of a patient dying within 30 days of admission (Aiken et al., 2002; Potter & Mueller, 2007). Nurses cannot gain in-depth understanding of their patients, protect their patients, or catch early warning signs if they are overloaded by the number of patients for whom they are responsible. Adequate numbers of nurses affect patient mortality, length of stay, prevalence of urinary tract infections, fall rates, incidence of hospital-acquired pneumonia, and more. Trends in Nursing and Health Care Change and innovation are constants in health care. The following are trends that are expected to affect the nursing profession and the care nurses provide to their patients in the near future: Efforts to ensure patient safety, especially in acute care, will continue to be emphasized, including reduction of nosocomial infections, medication errors, failure to rescue, and other serious adverse events. The use of a variety of technological innovations (computerized order entry, telehealth, mobile devices, sensors, webcams, etc.) are becoming standard practice in health care. The beneficial effects of alternative and complementary approaches (such as meditation, herbs, use of nutraceuticals, yoga, visual and musical arts, etc.), already widely accepted by many members of the public, will be integrated into standard medical and nursing practice (Fleischer & Grehan, 2016). Increased focus on care transitions (from hospital to home, from the nursing home back to the hospital, etc.) will involve nurses in better preparing patients for these transitions. Whenever and wherever possible, care will move out of the hospital and into the community. Continued use of "physician extenders" (nurse practitioners and physician assistants, etc.), although this may also put additional strain on current nursing staff. What does all this mean for the new nurse? Many opportunities for nurses will open up in community-based care, transitional care, quality improvement efforts, telehealth, and nontraditional roles. However, there will also be challenges ahead as cost cutting increases the demand on individual staff members and the tolerance of errors that threaten patient safety and well-being becomes very limited. Health Care in the Future One of the fundamental reasons why the United States has not achieved successful health-care reform is that there hasn't been agreement on whether access to health care is a privilege or a right. Citizens of the United States are guaranteed access to basic education, fire and police protection, mail, parks, and many other benefits but not health care (Bauchner, 2017). Ideally, a new model of health care is needed that offers the following: Holistic, person-centered care Seamless connections across community, acute-care, and long-term care settings (Pogue, 2007) Elimination of health disparities Guaranteed accessible, affordable care for everyone Safe care that heals and does not harm the patient Equivalent support for prevention, health promotion, and mental health care as for acute and primary care Creation of a healthy environment, from green buildings to the elimination of air, water, soil, and other forms of pollution Attention to global health concerns: climate change, hunger, poverty, and disease at home and in developing countries Although there were provisions in the ACA that addressed some of these concerns, there is still much work to do on health-care reform. Advocating for Nursing's Future Within the nursing profession, there is also much work to do. One issue to address is image-related challenges (Motshedisi et al., 2015). Too often, members of the public and colleagues in other professions think of nurses in only an assistive role, as "perpetual servants of heroic physicians" based on impressions from the media (Bleich, 2012, pp. 180-184; Summers & Summers, 2014). This limited view ignores our unique perspective that encompasses the whole person within that individual's family and community. Nurses think differently from other health-care providers. Michael Bleich (2012, p. 184) says we need to "publicly give voice to the value of this perspective," particularly during this time of debate regarding the shape of our health-care system in the future. If we do not participate in the debate, we "will be left to react to models that may stymie our capacity to influence health" and the future of the nursing profession. Another concern is external appearance. Cohen (2007) quotes Dumont on the question of dress, particularly wearing uniforms covered with cartoon characters: "You're the only thing between the patient and death, and you're covered in cartoons. No wonder you have no authority." The following are some additional suggestions to improve nursing's image: Always introduce yourself as an RN. Define professional appearance appropriate to your workplace and enforce it. Define professional behavior and enforce it. Take every opportunity to speak to the public about nursing. Document what nurses do and how important they are (Cohen, 2007). What else can nurses do? It is important that more members of minority groups be brought into nursing so that nursing better reflects the increasing diversity of the population. Collaboration with colleagues in other health professions is also vital to improving health care. Physicians, therapists, social workers, psychologists, aides, assistants, and technicians are also concerned about the quality of care provided. Patients and their families, too, are concerned and personally affected by the quality of care provided. All these groups together would have a strong voice in health-care reform. Nurses are the largest professional group within health care in terms of numbers. They spend the most time with patients and receive top ranking for having the public's trust according to Gallup polls. These are significant accomplishments. However, a national Gallup poll of 1,500 opinion leaders revealed a serious lack of nursing representation and influence at the highest policy levels. These opinion leaders thought that government and health insurance executives have the most influence on health-care reform. Only 14% of them thought that nurses would be influential. It was also noted that nurses did not have a single, unified voice and seemed disinterested and uninvolved for the most part (Khoury et al., 2011). There was a more positive side to these disturbing survey results. Many of the opinion leaders interviewed thought more nurses should get involved. Given their number and unique position within health care, nurses should be full partners in health-care reform (Hassmiller & Reinhard, 2015). Issues on which nurses should have a say include patient safety, quality of care, reducing medical errors, health promotion, and prevention (Hassmiller, 2011). The urgency of making our voices heard is undisputable. Hassmiller (2011) wrote that "right now is the right time to tackle the difficult and essential work of bringing nursing perspectives, knowledge, and voices into health policy decision making" (p. 308). This is still true today. An example of political activism in support of improving health care and making it more accessible from Canada follows: The Canadian Federation of Nurses Unions released the results of a public opinion poll on various health-care issues. One issue was access to prescription drugs: 77% of people responding to the poll supported a universal drug plan so that everyone could obtain the medications they need. It was estimated that in the previous year one in five Canadians did not fill a prescription because they could not afford it (Close-Up Media, 2016). The following are some specific actions you can take to exert leadership in supporting your profession and improving health care: Be sure you are registered to vote if you are eligible. Every county has a supervisor of elections office that you can visit, call, or connect with online to register. Learn more about the health-care system and your role in it. Take advantage of legislative days when your state nurses' organization or your college organizes groups of nurses and nursing students to visit their legislators either locally or at the state capitol building to discuss nursing issues and ask for their support. Another excellent learning experience supported by many community colleges involves service learning programs. In these programs, students commit up to 20 hours a week to engage in community projects of endless variety: urban gardens, autism programs, Special Olympics, health screenings, care kits for hospital patients or nursing home residents, and so forth. You can gain an appreciation of the needs of people in your community, learn how health and social welfare programs do and do not work well, and gain leadership skills. Evangeline Manjares, dean of academic and student service at Nassau Community College in New York, added another benefit of these programs, stating, "Everyone is too involved with looking at our cell phones. It's time to maybe share some of their cell phone time with the community" (Finkel, 2017, p. 29). Here are some ways to get involved: Join both your professional association and specialty association and support their efforts to improve care. Talk about these issues with everyone and anyone who will listen. Write letters to the editor, speak on local radio and television programs, and participate in online discussions. Send e-mail messages to your legislators, sign petitions if you support them, and communicate your position through social media. Speak to your local, state, and national representatives about these concerns. Consider supporting the ANA or your specialty organization's political action committee (PAC) even if you can only afford a small amount. These funds make it possible for the organization's staff to be visible and speak with key legislators on issues important to nursing. In summary, "be visible, be vocal" in your support of nursing and improved health care (Davis, 2015). The ANA Web site features some of the many ways in which the ANA advocates for nurses and patients in the political arena. Just a few examples: Capitol Beat Blog: analysis of national issues Advocacy Toolkit: educational materials for nurse advocates ANA Political Action Committee: supports nursing-friendly candidates for Congress Nurses Vote: encourages political action Issues of practical importance include: Retirement of nurses is occurring faster than the rate of entry into the profession. The median age of nurses nationally is 52 years of age. At the same time, the demand for nurses is increasing as the population ages and the number of individuals with chronic diseases increases. The BLS predicts there will be 195,000 openings annually over the next 5 years. Insufficient support for nurses in the workforce reduces retention. Given these very important issues facing the nursing profession, it is no surprise that the advocacy groups try to: Increase the supply of nurses. Create healthy work environments for nurses. Support the quality of health care. Support regulations and policies that allow nurses to practice "at the fullest extent of their education and licensure"