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Running head: HEALTH CARE REFORM AND NURSING
In What Ways does Health Care Reform Impact the Nursing Profession?
Kelly Pasch
Ferris State University
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Health Care Reform and Nursing
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Abstract
This paper analyzed the question “In what ways does health care reform impact the nursing
profession?” An introduction to health care reform and its importance to the nursing profession
were revealed by examining the historical and theoretical basis to nursing practice. An
assessment of the healthcare environment was used by assessing public health and incorporating
the different types of healthcare models. It revealed these models shared the same goals and
visions for patient care and health care expenditures. Next, the positive and negative inferences
and implications of how health care reform will impact the nursing profession were considered.
In addition, the nurse’s role in health care reform was explored as well. Lastly, strategies that
would improve quality and safety were discussed using the American Nurses Association (ANA)
Standards of Practice in leadership, collaboration, resource utilization, and communication. Also,
recommendations and interventions using Quality and Safety Education for Nurses (QSEN) were
given in the areas of Patient-centered Care, teamwork, and collaboration. From this analysis, it
was determined that health care reform does impact the nursing profession and is relevant to
professional nursing practice as well as quality of care.
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In what ways does health care reform impact the nursing profession?
The Patient and Affordable Care Act (PPACA) passed on March 23, 2010, focuses on
primary care, wellness optimization and prevention of disease and will affect both the quality
and cost of care. According to Mason (2010) it is estimated an additional 32 million Americans
will receive health insurance coverage because of the PPACA. With new emphasis on nursing’s
strengths there will be a demand for more nurses in acute inpatient and outpatient care, chronic
and transitional care, primary care and preventative care.
Health Care Reform has created the opportunity to showcase the value and strengths of
nursing. Advanced practice Registered Nurses (APRNs) and Registered Nurses (RNs) will be in
greater demand as the health care system moves from a paradigm of acute care and disease
treatment to one of health promotion and disease prevention (Mason, 2010). The purpose of this
paper is to discuss the relevance of health care reform to nursing and what changes are in store
for nursing due to the PPACA.
Theory Base
In order to understand how health care reform impacts the nursing profession, it is
imperative to look at the theoretical basis of nursing practice. Health care reform is shifting the
focus of care from one model to another that promotes disease prevention, primary care, chronic
care management, and care coordination, all services nurses provide (Mason, 2010). Betty
Neuman, a nursing theorist believed that nursing is concerned with the whole person and
considered her work a wellness model. She viewed health on a continuum from wellness to
illness, which was “dynamic in nature and constantly changing” (Tomey & Alligood, 2010, p.
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314). According to Tomey & Alligood (2010), Neuman uses prevention as interventions to
improve quality of care to help the client who may be an individual, family, group, or
community maintain system stability. Neuman’s model suggests three levels for nursing
interventions. These include primary prevention, secondary prevention, and tertiary prevention.
The first intervention which is primary prevention is applied to patient assessment and
identification to decrease possible risk factors (Nursing Theories, 2012). Secondary prevention
involves the treatment related to signs and symptoms following a reaction to illness. Lastly,
tertiary prevention takes place after active treatment or the secondary prevention phase. It
focuses on modification of behavior toward optimal client system stability. The goal of tertiary
prevention is to lead the client back towards primary prevention in a circular manner (Tomey &
Alligood, 2010).
Additional Theories and Concepts
The theoretical contributions of interdisciplinary perspectives are evident when
discussing health care reform and its impact on the nursing profession. The chaos theory
developed by Edward Lorenz in 1961 demonstrates a new science perspective and provides new
ways to examine the world (Lett, 2001). The chaos theory is often thought to refer to
randomness and lack of order, but it is more accurate to think of it as an apparent randomness
that results from complex systems and interactions among systems (Lett, 2001). Small changes
can result in larges differences and multifaceted systems must follow simple rules. This can be
seen within the nursing profession. Nursing knowledge is made up of many systems, such as the
health care system and the human system. Chaos theory explains how apparently random events
seem to have some pattern of involvement or association (Lett, 2001).
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According to Lowenstein (2003) chaos theory discusses the ending of old patterns and
the development of new. With the passage of the Affordable Care Act (ACA), the nursing
profession will begin to recognize new trends and models emerging into health care. Nurses will
recognize health care needs for society and cost effective services such as Nurse-managed health
clinics. In addition, with identifying patient and community needs, nurses will generate new
ideas for quality care and communicate those needs in a political arena with healthcare reform.
Nurses will learn finance and business models to generate new ideas to lower the costs of
healthcare (Lowenstein, 2003).
Relevant to the discussion of health care reform and its impact on the nursing profession
is the Change theory. This theory developed by Kurt Lewin is based on a three step process that
provides the change agent a framework to implement a change effort (Morrison, 2010). The first
phase, the “unfreeze” phase reassessed the current process or practice that is in place. It is
relevant that our health care system has been assessed and reassessed with the passage of the
health care reform act. Nurses will be in a position to lead rather than follow (Lowenstein,
2003). The second phase or “implementation” phase is when people start to open their mind,
look at other views or perspectives and take on new responsibilities. This is evident with health
care reform and its impact on the nursing profession because Advanced practice RNs will be
required to take on more of a primary care role within our health care system. The third phase or
“refreeze” involves making the change stick. Change will only be effective if it is made
permanent. There will further changes in the future and will give people the opportunity to
thrive and take full advantage of the change (Morrison, 2010). Health care and nursing is
changing all the time and it is simply in the patient’s best interest that every nurse needs to be
aware of it to promote quality care and improve patient outcomes.
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Assessment of the Healthcare Environment
An assessment of the health care environment will help identify the models and factors of
health care reform and the ways it will impact the nursing profession. First, and foremost, health
care reform not only impacts the nursing profession, but also focuses on improving the health of
those within communities. It emphasizes on public health through health promotion and disease
prevention. This can be done through interventions that target not only society as a whole, but
organizations and the communities from within.
Accountable Care Organizations and Patient-Centered Medical Homes
The Affordable Care Act (ACA) guided many changes to the ways health care is
organized, financed and delivered. Furthermore, it changed the conditions on the ways to
address distribution, education, and the training of heath care providers. In the midst of these
changes, is a clear trend toward an integrated service method (Korda & Eldridge, 2010). The
first models, Accountable Care Organizations (ACOs), are made up of groups of health care
providers such as nurses, physicians, hospitals, and specialists. These health care professionals
work together to coordinate care for their patients and have a shared responsibility for quality of
care and costs. ACOs also share in savings for reducing healthcare costs and meeting Medicare
cost targets. If the ACO meets or exceed quality performance standards established by Health
and Human services, they are eligible to receive payments for the “shared savings” or cost
targets (Korda & Eldridge, 2010). The second model, Patient-Centered Medical Homes
(PCMHs) include patients to be active in their own health and well-being. PCMHs provide each
patient with a primary care provider such as a physician (MD), nurse practitioner (NP), or
physician assistant (PA). According Haney (2010), PCMHs provide patients with a primary care
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practice or provider who coordinates their healthcare across diverse heath settings. This may be
done through the promotion of capitated payments or financial incentives to health care
providers to promote preventative care and management of chronic illnesses. The goal of this
type of care is to decrease the dependence on emergency room and specialist care (Haney, 2010).
The PCMH model is similar to that of the ACO in that it must meet requirements that highlight
care and services within the nurse’s scope of practice. Korda & Eldridge (2010) point out that
both these models of care focus on nursing theory and also promote the expansion of the nurse’s
roles and responsibilities. “Patient-centered” or “family-centered” care is not new to the nursing
profession and with this area of expertise from nurses; they can serve as leaders and educators to
their interdisciplinary health care team (Haney, 2010).
Nurse-managed health clinics
Health care reform establishes a grant money program to aid in funding of NurseManaged Health Clinics (NMHCs). This is for the purpose of providing complete primary care
and wellness services to those who are underserved, underinsured, or living in poverty (Haney,
2010). There are more than 250 NMHCs nationwide who serve more than 2.5 million patients
annually and with the new health care reform law, they have the capability of serving more
(Hansen-Turton, Bailey, & Torres, & Ritter, 2010). According to Hansen-Turton et al. (2010)
NMHCs model of care promotes wellness promotion, disease prevention, and chronic illness
management. Not only do they provide these services, but may provide dental and mental health
services as well. Furthermore Hansen-Turton et al. (2010) found that nurse-led models of care
provide health care to patients at a lower cost than that of a physician office. In addition,
NMHCs have a reputation for providing high quality of care, cost-effective care, and high patient
satisfaction scores among patients (Hansen-Turton et al., 2010).
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Another NMHC that will benefit the children of the United States are School-Based
Health Clinics (SBCHs). There are more than 1,900 SBHCs in the United States and nearly
1,100 of those provide primary care services to children in their communities. Many of these are
staffed by nurse practitioners (NP) or physician assistants who are supervised by a physician. In
addition, not only do SBHCs offer primary care services but mental health services and
education too (Hansen-Turton et al., 2010). Also SBHCs serve many children from other
schools within their community as well as teachers and others. “SBHCs reduce the need for
parental work leave, limit the amount of classroom time missed for health care appointments,
promote health, and the use of preventative strategies, improve follow-up and compliance with
treatment plans, and provide care regardless of the ability to pay for it” (Hansen-Turton et al.,
2010 p.26). NMHCs expand the scope of nursing practice allowing Advanced practice nurses
(APRNs) to work to their full extent of their education. Nurses know to how to expand quality
care throughout communities while being cost effective and improving patient outcomes
(Hassmiller, 2010).
Nursing Shortage
The passage of health care reform will also impact the nursing profession by increasing
the growing problem of the nursing shortage. Some contributing factors include the newly 32
million Americans who will have access to health care services. In addition, nursing school
enrollment is not growing fast enough to meet the projected demand of registered nurses and
advanced practice nurses (American Association of Colleges of Nursing, 2012). According to
Rother & Lavizzo-Mourey (2009) without sufficient numbers of nurses entering the workforce,
the United States health care system will not be able to meet the public’s demands for health
care. Another contributing factor to the nursing shortage is the aging population. The average
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age of the nurse is forty-four years old and it is climbing. In addition, with the Baby Boomers
aging, the need for health care continues to grow (American Association of Colleges of Nursing,
2012). Research by the Institute of Medicine (IOM) found that nurses are most likely to catch
medication errors and prevent nosocomial infections. Furthermore, the lack of nurses in the
health care field affects quality of care as well as positive patient outcomes (Rother & LavizzoMourey, 2009).
Inferences and Implications
The inferences and implications of how health care reform affects the nursing profession
can be seen by analyzing what health care reform means for nurses, the nurse’s role in health
care reform, and solutions to the nursing shortage.
To begin we can look at what health care reform means or addresses for nurses. First and
foremost, health care reform will focus on primary care and prevention. There will be an
emphasis on preventative care, thus increasing the demand for Advance practice nurses (APRNs)
and RNs (Mason, 2010). Also health care reform will deliver integrated health care models such
as ACOs and PCMHs to the nation’s health care system. This will promote primary care,
prevention, and chronic disease management, all care services that registered nurses coordinated
and provide (Mason, 2010). The expansion of NMHCs will help train more nurses in primary
and preventative care and offer high quality, cost effective care to people regardless of their
ability to pay. Also NMHCs will help fill the primary physician shortage gap (Webb &
Marshall, 2010). Not only will health care reform help train more nurses, it contributes greatly
to nursing education. According to Webb & Marshal (2010) under the PPACA, changes make it
possible for nurses to go back to school for their bachelor’s, masters, or even higher degrees.
Health Care Reform and Nursing
The expansion of the Loan Repayment and Scholarship program and the elimination of the 10%
doctoral cap can make this possible for nurses.
Nurses can play a vital role and demonstrate leadership in health care reform. As the
single largest group of health care providers with nearly 3.1 million, nurses have a front-row seat
to delivery of care. From this perspective nurses are valuable to policy implementation and
policy makers (Kurtzman, Dawson, Johnson, & Sheingold, 2010). Nurses offer patient-oriented
perspectives to discussions of benefit packages and this brings a holistic view point as well as a
wellness model for the population being served (Kuznar, 2011). Some ways that nurses can
demonstrate leadership is by knowing what is happening in the “political arena” and taking a
stand on it. Furthermore, nurses should become a part of their state nursing association and
know the stance of the American Nurses Association (ANA) on political issues (Kuznar, 2011).
One way nursing has overcome the barriers to policy making is by creating the Nursing Alliance
for Quality Care (NAQC). This was created by leaders of national nursing organizations whose
aim is to “establish national health care quality and safety goals by supporting the adoption of
evidence-based nursing practice and strengthen the visibility of nursing in performance
measuring and public reporting” (Kurtzman et al., 2010, p.11).
With the growing issue of the nursing shortage due to the passage of health care reform,
some nursing shortage solutions were addressed. Research from Lynn & Redman (2006)
showed that among staff nurses education and enhanced communication with administration
were the most important, followed by better pay, compensation, and improved benefits. Nurses
followed these solutions with changes in patient workload, increased the number of nurses as
well as value nurse retention. Some other answers proposed by nurses to improve the nursing
shortage include providing mentoring programs for new nurses and support networks for nurses
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experiencing emotional distress to prevent nurse burnout. MacKusick & Minick (2010) found
that nurses who embrace diversity and provide support networks increase the retention of nurses
in clinical practice. Moreover, some implications for practice that may help an organization
understand the reasons why nurses leave may be research. Also performing exit interviews may
discover why nurses plan to leave the profession (Flinkman, Leino-Kilpi, & Salantera, 2010).
In summary, by analyzing what health care reform means for nurses, the nurse’s role in
health care reform, and solutions to the nursing shortage, one can see the ways health care reform
impacts the nursing profession. Many changes have already taken place due to the passage of
the Affordable Care Act, but many more are going to occur. Nurses will play an important role
in affecting the health care system and patients of the United States. Not only will they provide
quality care at a fraction of the cost, there will be a shift from a sick care model to a focus on
disease prevention and health promotion.
Recommendations for Quality and Safety Improvements
With quality and safety benchmarks at the frontline of health care, it is imperative to
discuss s nursing interventions when analyzing the impact of health care reform on the nursing
profession. The American Nurses Association (ANA) standards of professional practice are used
as references for improvement recommendations. The standards of leadership, collaboration,
resource utilization, and communication will be addressed as well at featuring Quality and Safety
Education for Nurses (QSEN) competencies.
Leadership
The standard of Leadership states “The Registered nurse demonstrates leadership in the
professional profession” (ANA, 2010, p. 55). As health care reform changes our country’s
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health care system, nurses can play a vital role in being a leader amongst the changes. Nursing
interventions that may help the nurse’s transition to a leadership role may include the nurse to
bring patient-perspective viewpoints to policy tables when discussing policies and benefit
packages. In addition, by participating in professional nursing organizations, nurses demonstrate
leadership by making a commitment to their goals and visions. Furthermore, nurses need to
advocate for health care equality and safety for all patients and emphasize preventative care.
Also, the nurse should encourage a commitment to continue nurse education to advance the
nursing scope of practice.
Collaboration
Collaboration and teamwork are important aspects to nursing practice. The ANA (2010)
states a professional registered nurse “collaborates with healthcare consumer, family, and others
in the conduct of nursing practice” (p. 57). These standards fall in place with the QSEN
competency of teamwork and collaboration where the nurse “functions effectively within nursing
and interprofessional teams, fostering open communication, mutual respect, and shared decisionmaking to achieve quality patient care (QSEN, 2012).
My recommendations for healthcare reform and the ways it impacts the nursing
profession include encouraging teamwork within the health care setting such ACOs, PCMHs,
and NMHCs. Nurses should team up with patients, families, and physicians to acquire and
exchange information about patient issues and concern. Moreover, nurses need to work
effectively within their own scope of practice and know their own views in issues about health
care reform. By engaging in policy change and initiatives, nurses will improve team work and
collaboration among the health care team.
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Resource Utilization
Nurses are called to “utilize appropriate resources to plan and provide nursing services
that are safe, effective, and financially responsible” (ANA, 2010, p. 60). One criterion calls for
the registered nurse to “assist the health care consumer and family in factoring costs, risks and
benefits in decisions about treatment and care” ( ANA, 2010, p.60). One nursing intervention
includes acknowledging all the education and leadership skills for nurses to support and develop
NMHCs. As noted earlier, NMHCs provide quality primary and preventative care at a lower
cost. The registered nurses should advocate for NMHCs in addition to resources which may
advance nursing practice.
Communication
Finally, the last standard of professional practice the nurse should display is that of
communication. The ANA (2010) states “The registered nurse communicates effectively in a
variety of formats in all areas of practice” (p.54). The QSEN competency of Patient-Centered
Care also demonstrates the importance of communication as a standard of practice.
By communicating effectively and empathetically, the nurse will provide compassionate
and coordinated care for their patients. In regards to health care reform and policy, the nurse
needs to focus on the patient’s preferences and questions and be able to communicate those
efficiently to all members of the health care team to ensure positive patient outcomes. Nurses
are patient advocates and must communicate and be proactive for patients regarding needed
changes in health care reform policy. Lastly, by nurses being active through the involvement
and care of patients and families, they can examine the cost effectiveness of healthcare, quality
and safety (QSEN, 2010).
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Conclusion
In the ever changing health care system, it is important for nurses to act upon those
changes to advance the nursing profession as well improve quality care and patient outcomes. It
is inevitable that health care reform will impact the nursing profession. This paper set out to
analyze the question “In what ways does health care reform impact the nursing profession?’ A
review of the Affordable Care Act and theoretical basis to nursing practice, an assessment of the
health environment, the inferences/implications revealed the pros and cons to the ways health
care reform impacts the nursing profession. However, the discussion of quality safety and
improvements showed nurses ways to incorporate health care reform into their daily nursing
practice. The analysis discovered not only some ways health care reform impacts the nursing
profession, but the nurse can be a leader and ever changing force to improve the health and
quality care within their scope of nursing practice.
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