Research Briefs

The Transformational Role of Nursing in Health Care Reform Cindy Sickora, DNP, RN; and Sabrina Marie Chase, PhD

ABSTRACT Successful health care reform will require more than insuring 32 million additional Americans. It will demand that our expensive, hospital and provider–driven model of care adopt a community-driven wellness model that emphasizes disease prevention. Nursing is perfectly situated to lead this transformation. By educating students in ways that build on nursing’s legacy of health promotion and disease prevention, nurse educators can prepare nursing students to partner with underserved communities to offer low-cost, prevention-based services that meet local needs. This article uses preliminary data from the Jordan & Harris Community Health Center in Newark, New Jersey, to demonstrate how nurses can serve as role models in microsystem health care, while still following the Institute of Medicine’s recommendations for health care reform. [J Nurs Educ. 2014;53(5):277-280.]

Received: March 11, 2013 Accepted: November 27, 2013 Posted Online: March 21, 2014 Dr. Sickora is Associate Professor and Dr. Chase is Assistant Professor, School of Nursing, Rutgers, the State University of New Jersey, Newark, New Jersey. Dr. Sickora is also Director, New Jersey Children’s Health Project and Director, Jordan & Harris Community Health Center, Rutgers, the State University of New Jersey; and Dr. Chase is also Director of Community Programs, Joint Urban Systems PhD Program in Urban Health, School of Nursing, Rutgers, the State University of New Jersey. The authors wish to thank the U.S. Department of Health and Human Services, the Health Resources Services Administration, and the Healthcare Foundation of New Jersey for generously funding this project. Finally, they would like to thank the Urban Health Writing Group for ongoing encouragement. The authors have disclosed no potential conflicts of interest, financial or otherwise. Address correspondence to Cindy Sickora, DNP, RN, Associate Professor, School of Nursing, Rutgers, the State University of New Jersey, 65 Bergen Street, Newark, NJ 07101; e-mail: [email protected]. doi:10.3928/0148434-20140321-02

Journal of Nursing Education • Vol. 53, No. 5, 2014


n 2010, the Institute of Medicine (IOM) published its report on the future of nursing, articulating the critical role of nursing in the United States health care system and its place in the future implementation of the Affordable Care Act. Reforming the health care system will require much more than simply providing health insurance to an additional 32 million uninsured Americans (Hassmiller, 2010; IOM, 2010). True reform will not only require changes in our framework for providing care, but it will also demand that nurses operate more efficiently, more cost effectively, and to the full scope of their professional practice (American Academy of Nursing [AAN], 2010; Nandiwada & Dang-Vu, 2010). These changes will support the autonomous role of the RN in community-based health care. Adding millions of newly-insured Americans to the health care system will also burden primary care in new ways (IOM, 2010), suggesting that instead of focusing on individual disease treatment, the focus must now shift to maintaining wellness and population health (AAN, 2010). Although daunting, this challenge presents an opportunity to transform our nation’s health care paradigm—a transformation that is critical to not only improve health indices but also to ensure the wise use of health care dollars. Under the current system in the United States, health care is provider-driven, with hospitals and physicians at the helm (Nelson, 2002), and illness is the primary source of financial reward, incentivizing the use of complex treatments and expensive procedures (Gawande, 2009). Alternatively, a population-focused model would promote wellness and shift the hierarchical balance back to the patient and the community (Nelson, 2002). The IOM’s Crossing the Quality Chasm: A New Health System for the 21st Century report (2001) recommended that we move toward the creation of such community-guided health care microsystems. Microsystems are “places where patients, families and care teams meet” (Godfrey, Nelson, & Batalden, 2005, p. 2). These places offer individuals the opportunity to identify their own needs and to work with providers to establish culturally relevant and culturally competent care that is delivered on the patients’ terms (Doherty & Mendenhall, 2006). This empowerment model asserts that providers do not serve patients well by assuming a dominant role (Nelson, 2002). Instead, it posits that individuals and communities can, with support and education, articulate their own needs and teach providers how best to address them (Ruddy & Rhee, 2005). In this model, active community participation would shift the locus of power from the provider 277


to the individual and the community, creating the groundwork for true partnerships between caregivers and recipients of care (Ruddy & Rhee, 2005). These health care partnerships, in turn, would foster mutual respect, create learning opportunities, and offer much to both providers and patients. Nursing is uniquely situated in this health care transformation (IOM, 2010). As the source of the largest body of health care providers in the nation, and as the profession that most clearly prepares providers for multiple levels of practice, nursing is in the best position to assume leadership in the current transition to population-focused, community-based, microsystem-level health care. As its reputation as the “most trusted healthcare profession” (Larson, 2012) indicates, nursing is already positioned to develop the community-based relationships necessary to implement this new model of care.

Fostering a Nurse-Managed Microsystem: An Example In its preplanning stage, the Jordan & Harris Community Health Center (The Center) was initially conceptualized when a faculty member from the prelicensure Accelerated Baccalaureate of Science in Nursing program at the University of Medicine and Dentistry School of Nursing (UMDNJ; now the Rutgers School of Nursing) performed a community needs assessment and Strengths, Weaknesses, Opportunities, and Threats analysis of the community in the Ironbound neighborhood of Newark, New Jersey, and identified the parallel needs of the community residents and the UMDNJ nursing students. Health services in the community were limited; the city had experienced multiple hospital closures, losing ambulatory services, in addition to beds. Wait time for clinic appointments was more than 3 weeks, and residents were using emergency services for their primary care. These findings were submitted to the Health Resources Services Administration (HRSA) in response to a call for Nurse Education Practice Quality and Retention proposals, which was an opportunity to educate nurses and students of the health sciences in microsystem health care. HRSA funding established The Center, which serves three public housing developments in the city of Newark, with a collective population of approximately 3,000 residents. Its central location is the Hyatt Court Housing Complex, a geographically isolated public housing facility managed by the Newark Housing Authority. The Center focuses on a nursing approach of enhancing wellness while also addressing the community’s high burden of chronic disease. An important additional goal is the education of nurses and other health care professionals in health promotion, disease prevention, and the treatment of acute and chronic illness at the community level. The founding faculty member and project director (C.S.) provides program oversight, direction, and supervision of students. Many of The Center’s clients experience poor health. Obesity, hypertension, diabetes, and asthma are the most common chronic health problems. Many of Newark’s residents are uninsured and depend on the urban safety net, which provides limited access to both primary and specialty health care. Less than 40% of the state’s physicians accept Medicaid, which is the lowest acceptance rate in the nation (Barnett, 2012). 278

In alignment with the IOM recommendations, the Jordan & Harris Community Health Center is community driven. Its community advisory board is predominantly composed of local residents who direct its activities. The Center also relies heavily on partnerships between nurse leaders and individuals, families, and the community at large. Operating on the premise that communities can identify their own health care needs, the community advisory board works closely with the project director and the RN coordinator to identify the community’s most pressing health issues. Students training at The Center experience firsthand the day-to-day complex issues faced by vulnerable populations (i.e., impoverished and marginalized individuals with limited access to health care). They also have the opportunity to partner with residents in finding solutions to these challenges through community-directed action. From the start, The Center’s onsite clinical coordinator, who is an RN, established the individual, family, and community relationships necessary to improve health outcomes in this marginalized community. On site 5 days per week, the RN provides health care access by supporting residents, identifying their health issues, and addressing their unique needs by performing ongoing assessments and screenings. Unlike the hierarchy at other services in the city, the RN coordinator of The Center is the first-line health care provider, referring patients as needed to the program’s advanced practice nurses (APNs), to the city’s health department clinics, or to the patient’s primary care provider (PCP) if one is identified. The RN communicates directly with the PCPs and staff from other community clinics as part of the care coordination continuum, and in so doing, the RN prevents the duplication of services. For example, in one case involving a 72-year-old woman with chronic congestive heart failure, the RN sent written reports to the cardiologist who sees the patient. The cardiologist, in turn, spoke directly to the RN after all office visits. This level of collaboration has been established with multiple PCPs, specialists, and providers in the past 2 years. Each nursing encounter is recorded on an electronic health record, which can be accessed by all team members (i.e., community health workers, APNs, students). As another example, before a public housing resident calls an ambulance, the nurse is often called to perform an initial assessment; this intervention has successfully prevented unnecessary emergency room visits on multiple occasions. This onsite nurse provides quality, access, and value—the IOM’s three criteria for evaluating transformed health care in this millennium. In this microsystem, the RN’s role demands sharp assessment, critical thinking skills, and the ability to foster relationships with the community. The RN must recognize the difference between conditions that can be managed at The Center and those that require further intervention. The RN must also help residents to identify the community’s health education needs, while still providing this level of care with cultural competence and respect. The role requires a sound understanding of access to local resources, such as pharmaceuticals, transportation, mental health counseling services and facilities, food banks, and other community assets that can be used to meet patients’ needs. The RN must build relationships not only with residents Copyright © SLACK Incorporated


but also with organizations that can support the mission of local community-based care. The RN also serves as a role model to students of multiple disciplines who work at The Center, exposing them to cost-effective, accessible, high-quality communitybased health care that meets the needs of the neighborhood’s vulnerable and underserved residents. Indeed, this system is a powerful example of microsystem-based care.

additional funding opportunities are explored. The Rutgers School of Nursing is currently exploring innovative payment models, which include the bundling of services for billing to Medicare, Medicaid, and private insurance carriers. Perhaps more importantly, the Rutgers School of Nursing is investigating the possibility of billing for services proffered by this autonomous RN role. These billing options are a first step in sustaining nurse-managed health care.

Preliminary Resident Outcomes The project is in its preliminary phases of measuring both quantitative and qualitative health outcomes. In the first year of full-time operation, great strides had been made in community education and participation. For example, in Year I, distribution of the influenza vaccination was largely a symbolic gesture—only 50 vaccinations were administered to a population of approximately 3,000 people. Within 2 weeks of receiving the influenza vaccination in Year II, more than 150 vaccinations had been administered; at the time of writing this article, more than 400 vaccinations had been administered. Approximately 25% of the population has requested RN services in 18 months, emphasizing the power of word of mouth. The Center is demonstrating how onsite nursing care from baccalaureate-prepared nurses and APNs working within a community-driven, microsystem model can reduce health care costs and improve outcomes. For example, in a recent review of 142 of The Center’s health records, it was found that more frequent nursing encounters led to better control of hypertension. Twenty-five percent of all patients treated for hypertension are now experiencing blood pressure readings that are within normal limits. Not only has onsite nursing care resulted in improved blood pressure management among residents, but it has also been linked to better diabetic management and early detection of acute illness.

Preliminary Student Outcomes Less than 10% of students from the Rutgers School of Nursing (formerly UMDNJ) have experienced life in the projects. Prior to this experience, public housing was a foreign domain for the majority of students. Bringing them to community sites housed in neighborhoods that often elicit fear is an eye-opening experience. They found that their presence and their services are welcomed and that the community values their knowledge and expertise. They have the opportunity to see firsthand the many barriers to good health in marginalized communities. They learn that limited access to resources, such as the Internet, limits knowledge and understanding of health-related issues. They find that it is much easier to develop a successful care plan when they are familiar with—and truly understand—local social determinants of health. Students have begun partnering with residents to develop more realistic care plans based on this new knowledge. Their experiences allow them to go back into the hospital setting, where many health decisions are made, and apply this new knowledge when working with hospitalized patients and their families to develop realistic treatment plans as true health care partners.

Sustainability As HRSA funding has expired, the Rutgers School of Nursing has made a commitment to continue this project while Journal of Nursing Education • Vol. 53, No. 5, 2014

Nursing and Health Care Reform As graduates of a community-intensive training model such as this, baccalaureate nursing students can develop the relationships necessary to assume the community-based role of health promoter, care coordinator, and case manager (Tanner, 2010), thus expanding the role of the RN in community settings and increasing access to care for underserved populations. APNs are well-positioned to assume the primary health care provider role (Holt, 2011), filling the provider gaps soon to be created by the need for a much larger primary health care workforce (IOM, 2010). All nurses, from baccalaureate to APNs, must be prepared to assume these expanded roles in health care reform by providing quality, access, and value. The Jordan & Harris Community Health Center represents the future of health care in underserved populations by pioneering the long-term vision provided by the IOM for both microsystem health care and the role of nursing in a reformed health care system. The program demonstrates how building relationships and allowing communities to direct their own care can change health outcomes in vulnerable communities that experience the greatest insult: health disparities. Empowering people to take an active role in their health care shifts the traditional health care hierarchy to the recipient of care, making individuals, families, and communities the drivers of this reformed health care paradigm. The program model further demonstrates that communities can identify their own health care needs and are more likely to actively participate in planning, implementing, and evaluating services when such services are culturally relevant at the local level. Professional nursing is the linchpin. The nurse-managed microsystem health care model described in the current article demands an innovative role for the RN. Working to the full scope of training and education, the RN is the first-line provider, continuously assessing individuals, families, and the community. The RN identifies health care needs and, in partnership with care recipients, plans how best to meet those needs. The APN provides primary care, demonstrating the efficiency and effectiveness of nursing in a system that will soon be inundated with individuals seeking PCPs. Finally, educating nursing students within this framework prepares them to assume a leadership role in the transforming health care environment.

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engaging patients, families and communities as coproducers of health. Families, Systems, & Health, 24, 251-263. Gawande, A. (2009, June). The cost conundrum: What a Texas town can teach us about health care. The New Yorker. Retrieved from http://www. Godfrey, M.M., Nelson, E.C., & Batalden, P.B. (2005). Clinical microsystems: “The place where patients, families and clinical teams meet”: Assessing, diagnosing and treating your outpatient primary care practice. Retrieved from workbooks/outpatient_primary_care.doc Hassmiller, S. (2010) Nursing’s role in healthcare reform. American Nurse Today, 5(9). Retrieved from article.aspx?id=7086&fid=6850 Holt, M. (2011). Public health and nursing practice: Seizing the receptive moment. Nurse Education in Practice, 11, 224-227. Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academies Press.


Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press. Larson, J. (2012, January 5). Why nursing is still the most trusted profession [Web log post]. Retrieved from Nandiwada, D.R., & Dang-Vu, C. (2010). Transdisciplinary health care education: Training team players. Journal of Health Care for the Poor and Underserved, 21, 26-34. Nelson, A. (2002). Unequal treatment: Confronting racial and ethnic disparities in health care. Journal of the National Medical Association, 94, 666-668. Ruddy, G., & Rhee, K. (2005). Transdisciplinary teams in primary care for the underserved: A literature review. Journal of Health Care for the Poor and Underserved, 16, 248-256. Tanner, C.A. (2010). Transforming prelicensure nursing education: Preparing the new nurse to meet emerging health care needs. Nursing Education Perspectives, 31, 347-353.

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The transformational role of nursing in health care reform.

Successful health care reform will require more than insuring 32 million additional Americans. It will demand that our expensive, hospital and provide...
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