Diana J. Mason

Interprofessional collaboration and education.

The Institute of Medicine (IOM) report, The Future of Nursing: Leading Change, Advancing Health, identifies interprofessional collaboration among health care providers as an essential part of improving the accessibility, quality, and value of health care in the United States. The report highlights four key messages, one of which emphasizes nurses’ role as “full partners, with physicians and other health professionals, in redesigning health care.” Another underscores that nurses “must be accountable for their own contributions to delivering high-quality care while working collaboratively with leaders from other health professions.” This message emphasizes the importance of nurse leadership in advancing interprofessional collaboration in all settings, including in the boardrooms of organizations that have an impact on health and health care delivery. The same year that the IOM report was published, the World Health Organization (WHO) released a blueprint for implementing interprofessional education and collaborative practice to meet demand in the face of a global health care workforce shortage. In the WHO framework, collaborative practice “happens when multiple health workers from different professional backgrounds work together with patients, families, carers and communities to deliver the highest quality of care.” It makes sense that the best care would be delivered by a team of “carers” or providers with diverse experience, education, and training—all of whom exchange information with one another and are dedicated to patient health and well-being. Interprofessional collaboration is based on the premise that when providers and patients communicate and consider each other’s unique perspective, they can better address the multiple factors that influence the health of individuals, families, and communities. No one provider can do all of this alone. However, shifting the culture of health care away from the “silo” system, in which clinicians operate independently of one another, and toward collaboration has been attempted before without enduring success. For nearly five decades a commitment to interprofessional learning has waxed and waned in health professions training programs. During this time, health care leaders have shown intermittent interest in interprofessional collaboration in the delivery of health care. Strong and convincing outcome data demonstrating the value of team-based care have been lacking, but changes in our health care system now require that we explore how we can make interprofessional collaboration the norm instead of the exception. The Future of Nursing: Campaign for Action is a collaboration of the Robert Wood Johnson Foundation (RWJF) and AARP that was established in late 2010 to implement the IOM’s recommendations at the national and state levels. To date, 51 action coalitions and dozens of national organizations are committed to carrying out this important work. In this article, we highlight the imperative to shift professional cultures toward collaboration, current state initiatives designed to foster interprofessional collaboration, opportunities and resources for incorporating interdisciplinary efforts into daily practice, and the challenges that remain. By Mary Sullivan, PhD, RN, FAAN, Richard D. Kiovsky, MD, FAAFP, Diana J. Mason, PhD, RN, FAAN, Cordelia D. Hill, LMSW, and Carissa Dukes, BGS

Health care reform: what's in it for nursing?

On March 23 President Barack Obama signed the Patient Protection and Affordable Care Act into law (PL 111-148). A subsequent reconciliation bill, the Health Care and Education Reconciliation Act (PL 111-152), was also signed by the president to modify elements of the health care reform act that had fiscal implications (http://bit. ly/6vPCxh). As the final form of the new health care reform law continues to be interpreted by those who will be implementing it, analyses by the American Nurses Association (www.nursingworld. org/healthcarereform) and AARP’s Center to Champion Nursing in America (http://bit.ly/cj0jNa) have highlighted how it will affect nurses and nursing and the myriad opportunities to advance nurses’ contributions to care.

Commonalities of nurse-designed models of health care

The American Academy of Nursing has identified examples of care redesign developed by nurses who address the health needs of diverse populations. These models show important clinical and financial outcomes as summarized in the Select Edge Runner Models of Care table included in this article. A study team appointed by the Academy explored the commonalities across these models. Four commonalities emerged: health holistically defined; individual-, family-, and community-centric approaches to care; relationship-based care that enables partnerships and builds patient engagement and activation; and a shift from episodic individual care to continuous group and public health approaches. The policy implications include examining measures of an expanded definition of health, paying for visionary care, and transparency and rewards for community-level engagement.

Professionalism in Health Care Organizations

Health care organizations have been under enormous pressure for the past 8 years, and it might get worse. The Affordable Care Act (ACA) sought to alter the course of a huge ship. Soon the ship may be turning in another direction into uncertain waters. How should these organizations navigate the turbulence while maintaining the “quadruple aim” of improving people’s experience with care, improving the health of the population, reducing health care cost, and fostering job satisfaction among health care workers? A new Charter on Professionalism for Health Care Organizations may provide a touchstone.

Resolved: the AMA is out of touch.

Recent resolutions reinforce turf battles. But theres some cause for hope.

Rethinking Rural Hospitals.

Mackay’s article suggested that people could get a similar benefit from eating more fruits and vegetables, he called that notion “a bit simplistic.” Natural foods don’t contain acetate and butyrate in amounts as large as those in the modif ied high-amylose maize starch, Mackay said. Nevertheless, the experimental benefits of the modified starch “speak to the fact that many of these diseases might have as their basis our poor diet.” Clarke echoed Mackay. “With particular conditions, perhaps we can’t get enough of these [short-chain fatty] acids with a healthy diet.” Still, the modified starch likely can’t replace all of the nutrients found in, say, the Mediterranean diet, with its good fats, lean proteins, and plenty of fruits and vegetables, Clarke said. “We shouldn’t take our foot off the accelerator in terms of getting people to have a healthy diet and lifestyle,” she said. “But I think that these products [acetylated or butyrylated starch] can add to that in specific situations.”

A New Charter on Professionalism and Health Care Organizations

Nurses should embrace and share this ethical framework.

Partnering With Nurses to Transform Primary Care.

Thomas Sinsky, MD, a primary care internist in Iowa, was burning out. The complexity and intensity of work required for each patient seemed to grow exponentially over the years. The demands of managing prevention, acute and chronic illnesses, phone calls, emails, faxes, prescriptions, forms, and quality measures left him exhausted and unsatisfied. Fortunately, working along with his wife, a fellow internist, and their nurses, they were able to transform their practice into a teambased care model. He now works with 3 registered nurses who manage all preventive care, conduct initial assessments that include psychosocial aspects of patients’ lives, share the findings with him during his visits with patients, follow up with treatment plans, coordinate care for complex patients, and provide health teaching and counseling to engage patients in better managing their chronic conditions. “I love my work now. I’m able to actually see more patients and spend more time with them on issues that matter and require my expertise,” noted Sinsky at a June 2016 Josiah Macy Jr. Foundation invitational conference, which served as the basis for a new report, Registered Nurses: Partners in Transforming Primary Care (I was cochair of the conference planning committee). “I provide the medical decision making and the therapeutic plan and the [registered nurse] is the leader of the team when it comes to operationalizing the plan and managing the patients’ care.” This theme was repeated throughout the conference, held in partnership with the American Academy of Nursing. An interprofessional group of participants discussed the challenges to more widespread use of registered nurses in primary care. (The focus was not on advanced practice registered nurses, such as nurse practitioners, except as primary care practitioners who need to redesign their own practices.) The executive summary was published in September and includes the group’s recommendations. A full report that includes commissioned papers will be published at the end of 2016. Challenges and Opportunities The imperative to transform primary care is increasingly obvious, given the aging population and increasing rates of obesity and chronic illnesses. The Affordable Care Act (ACA) has boosted the demand for primary care by providing coverage for 20 million previously uninsured people in the United States. In addition, in an effort to contain the rate of health care expenditures, the ACA includes financial mechanisms to support health promotion and enhance chronic care management. But a shortage of primary care practitioners, including physicians, complicates successfully addressing these challenges. Some primary care practices already make use of registered nurses, but often only for triaging and managing prescription renewals and emails. Instead, the Macy report calls for registered nurses in primary care to help patients better manage their chronic illnesses through teaching and coaching patients for behavior change, managing complex care teams to improve clinical and financial outcomes, and coordinating care for patients requiring complex care, including those with behavioral health problems. Thomas Bodenheimer, MD, and Laurie Bauer, RN, MSPH, of the University of California, San Francisco, have argued that well-prepared registered nurses could partner with physicians to manage a panel of patients with chronic illnesses, including adjusting medications through standing orders as permitted by state law. The participants at the Macy conference concurred. But using registered nurses in the transformation of primary care is challenging for a number of reasons. First, only about 4% of schools of nursing are preparing registered nurses for primary care. One of the Macy conference’s commissioned papers by Danuta Wojnar, PhD, MN, MED, of Seattle University in Washington, and Ellen-Marie Whelan, PhD, RN, of the Centers for Medicare & Medicaid Services, reported on a survey of schools of nursing and found that, of the 529 responses, 77% understand the need to teach primary care but admit doing so to a limited degree. Others intentionally omit primary care content because they believe that undergraduate programs should focus on acute care. Furthermore, there is a lack of good role models for clinical practicums in primary care. The Macy report calls for schools of nursing to increase the breadth and depth of their curricula and practicums in primary care. This will require retooling faculty who have been teaching in other clinical areas, identifying and partnering with exemplary primary care practices, and working with health systems to retrain practicing registered nurses to move to primary care or enhance the roles they already play in this setting. Second, if schools of nursing increase their focus on primary care, will the jobs be there? Primary care practices must reevaluate their skill mix and rethink team roles in ways that can incorporate registered nurses beyond simply triaging or managing prescription refills and emails. This would require that all team members practice to the top of their education, training, and scope of practice. This may in turn require changes to scope-of-practice laws and regulations to permit nurses to practice by protocols and standing orders. Diana J. Mason, PhD, RN

Commentary on: Molding the future of advanced practice nursing

27. National Council of State Boards of Nursing. Position paper on the licensure of advanced nursing practice. Chicago: National Council of State Boards of Nursing; 1992. 28. American Association of Colleges of Nursing. 1994-95. Enrollment and graduations in baccalaureate and graduate programs in nursing. Washington: American Association of Colleges of Nursing; 1995. 29. Montemuro MA. The evolution of the clinical nurse specialist: response to the challenge of professional nursing practice. Clin Nurse Spec 1987;1:106-10. 30. McCormick KA, Lang N, Zielstorff R, Milholland K, Saba V, Jacox A. Toward standard classification schemes for nursing language: recommendations of the American Nurses Association Steering Committee on Databases to Support Clinical Nursing Practice. JAMIA 1994;1:421-7.

Where does the waste go

A 1 During Fiscal Year 2010 the amount of waste sent to Georgia landfills continued a 3-year decline, primarily due to the faltering economy, and perhaps in part to increased recycling efforts. (The possible reasons for this change are explored in the Executive Summary of this report.) Permitted capacity in 2010 is estimated to be approximately 37 years of remaining MSW landfill space and 43 years of remaining permitted C&D landfill space.