Introduction

Definitions of professions are rooted in history with their evolution shaped by social, economic and political forces. The last two decades of the twentieth century have brought rapid and massive change to the health care system that is redefining ideas about how many and what kinds of health care workers are needed, where they should practice, and how much they should be paid. Prior to World War II, there were two major professional groups in the hospital -- doctors and nurses -- with a high proportion of care delivered in patients' homes. As health care technology became increasingly sophisticated and oriented toward acute care, there was a proliferation of health care workers. At the present time, there are more than 200 different allied health occupations, as well as the traditional professions, with some workers focused on narrow aspects of care and others having broad overlapping roles. This growth has resulted in an inflated acute care system, delivering what is now recognized as large amounts of inappropriate care and costing more than society is willing to pay. Thus, in the 1990's, we are seeing significant redesign of the system and redefinition of health care workers' roles.

These facts have major implications for nursing and it is important that nurses have an understanding of the sociopolitical context within which they function and the complex and interactive factors that determine Who Does What In Health Care. After identifying some of the factors that influence the health care workforce, several key issues for nursing are discussed.

Health Care Workforce Determination

A health care workforce does not consist of a well-defined set of roles, but changes over time in response to many factors. It is influenced by the form of government of the society, definitions of health, social values, costs, the society's expectations for the health care system and the political power of various players.

Influence of Government

In this country, both public and private sectors have major roles in the health care system. With regard to the public sector, all three branches of government -- the legislative, executive and judicial -- influence health care decisions.

The legislative branch determines such things as what services or programs of care the government will pay for and for which members of society. By subsidizing the education of health care workers, it directly influences the number and type of workers. Through state licensing laws, it determines which health care workers may perform what services, and in legislation related to reimbursement it determines who can be paid for performing various services. In laws regulating the use of controlled substances, the approval process for drugs and devices, and many other clinical aspects of care, the legislative branch influences what can be done in health care. These decisions or health policies are made at national, state and local levels, and which level has responsibility for making laws in certain areas is often a matter of debate.

The judicial branch of government is responsible for interpreting laws related to health care. For example, through the interpretation and application of antitrust law, it determines when groups of health care professionals or hospitals are using illegal, anticompetitive practices to protect their delivery of services. The executive or administrative branch of government develops rules and regulations that further interpret the laws and oversees the implementation of various health care programs.

The private sector is expected to operate within policies set by the government but also has a great deal of influence in what public policies are enacted.

There is constant interaction between the public and private sectors throughout our society and this is no different in the health care system. Roles and relationships between the two sectors and across national, state and local levels are not fixed and well specified, but vary over time and in different circumstances. All of this means that health care policy and programs are continuously changing and being redefined, and the constant change influences the composition, size and activities of the health care workforce.

One way in which the relationship between public and private sectors is expressed is in debates regarding whether certain aspects of health care should be determined by law, regulation and other public policy or by the marketplace. An example in recent history is reform of the health care system. Although the Clinton Administration placed high priority on developing a plan for health care reform to address the problems of high cost, limited access for many people and type and quality of care delivered, it was not successful in achieving major reform through public policy. Instead, private sector employers who refused to pay for continuously increasing costs have produced major restructuring of the health care system through promoting managed care and competition. In the process, of course, government at all three levels has continued to set policy for the regulation of health care and health care providers, but the major impetus for reform has come from the private sector.

Definition of Health

Definitions of health are socially determined. While some view health narrowly as the absence of disease, the World Health Organization (1996) defines it broadly as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity." The scope of definitions of health and illness determines in part who is considered qualified to treat health problems. Paul Griner (1995) addresses this definitional issue in describing the increased morbidity and mortality due to physical and mental abuse, addictions and other preventable conditions, which exceed illness and death due to impaired health from non-preventable causes. "This . . . has implications both for the boundaries of medicine and nursing and for the desirable mix of professionals best suited to address these challenges . . . the professions must expand their definition of the boundaries of health care and find ways to interact better with their communities -- more involvement with schools, with neighborhood groups, and with individual families. The desirable mix of professionals best suited to address these challenges is a point for discussion. Social workers, psychologists, teachers, and parent role models, may play more important roles than physicians and nurses. In any case, the implications for both the nature of the work of health care and the mix of team members best suited to that work are significant."

As noted by Griner, how a health problem is conceptualized influences who should provide the care. Health problems perceived as having a physiological or physical basis commonly have been viewed as within the scope of practice of physicians. Problems viewed as psychological or social psychological in character have been viewed as within the scope of practice of those with training in behavioral sciences. Problems that involve mind and body interactions have been more ambiguous, with more disagreement regarding under whose scope of practice they fall.

Social Values

Other sources of influence on Who Does What in Health Care are social values related to gender and work, and expectations regarding professionalism and decision making in health care. Gender exerts a major influence in work roles in all countries. Although it is changing, many occupations have been viewed as primarily for women, for men, or for both. "Female" occupations generally have been those associated with roles of nurturer, teacher, and mother, while "male" occupations have been those that required physical strength or substantial education. In general, women's roles have been less socially valued as reflected in social status and financial rewards. The sociological literature of the 1960s and 1970s, for example, commonly characterized nursing as a female profession and medicine as a male profession.

One sociologist (Etzioni) characterized medicine and law as "full professions" and nursing and teaching as "semi-professions." He noted that one of the reasons that society was less apt to grant professional status and its commensurate authority to make decisions to the "semi-professions" was that they were largely made up of women. Virginia Cleland, in 1971, characterized sexism as nursing's most pervasive problem in attempts to increase nurses' authority and recognition as professionals.

In the 1970s and 1980s theories of comparable worth prompted legal cases in which challenges were made to the common practice of paying women less for doing work essentially comparable to that of men. An example of comparable work challenged was that of nurse practitioners, who generally are women, and physicians assistants, who generally are men. The value that society places upon gender is changing, but is still a major force in determining roles and salaries of health care workers.

A strongly held value in this country relates to capitalism and belief in the right to make a profit, but this value sometimes conflicts with values of professionalism. Earlier in this century when health care costs made up considerably less than 5% of the gross national product of the economy, the health care industry generally was not viewed as a place to achieve great wealth. At the end of World War II, physicians earned approximately twice what nurses did and neither group was highly paid. Most hospitals were not-for-profit, and

technology was fairly limited in the numbers and types of drugs and devices, complexity of surgical procedures, and nursing care. As technologies proliferated and health care became more complex, there were more opportunities for profit making in manufacturing and selling drugs, supplies and devices, in delivering services, and in owning and administering health care organizations. The increased potential for large financial gains in the health care industry increased the conflict between professional ideology and expectations for profit.

In the mid 20th-century physicians had considerable autonomy in deciding how to treat patients, and the sociological literature on professions used the physician to exemplify a full professional. A professional was considered to have an altruistic service orientation in which the needs of the client were placed before the needs of the professional. The professional was given considerable autonomy over how to practice, under the assumption that he or she acted in the best interests of the client. In contrast, the motto for a business person was caveat emptor, or "let the buyer beware," illustrating the different social expectations for the professions and business. As health care became big business, these differences became more blurred. There was a proliferation of administrators seeking increased authority for decision making in all aspects of hospital operations, physicians' and administrators' incomes increased significantly, third party payers began to exercise more control over what services would be reimbursed and the health care system generally placed increasing constraint on physicians' authority to determine what care to give.

Two factors that contributed to increased participation in medical decision making by payers and by those administering insurance plans were the rapidly increasing costs of health care and the acknowledgment of the lack of a science base for much of medical practice. Health care costs increased as a percentage of the gross national (domestic) product (GDP) from less than 6% in 1960 to approximately 15% in 1997. When the percent of GDP consumed by health care approached 10%, there began to be serious concern on the part of consumers and payers regarding the cost of health care. Efforts to reduce costs (and to increase profits) included reducing the numbers and types of physicians, nurses and other health care workers employed, cross training workers to increase their efficiency, substituting lower paid workers for higher paid ones, establishing more restrictive formularies and negotiating for better discounts from pharmaceutical companies, using the leverage gained from buying for groups of hospitals, and other ways that directly or indirectly influence what, how, and by whom care is delivered.

At the same time as costs were increasing, physician researchers were documenting major variations in how care was delivered in different settings across the country. (Wennberg, 1988). Researchers (Chassin, Kosecoff, Soloman and Brook, 1987) also began to identify the extent to which medical variations could be attributed to inappropriate care. Inappropriate care means not giving care when it should be given, giving care when it should not be given or giving the wrong care. The amount of excessive care seems to be 20-25% in terms of diagnostic and therapeutic procedures. It is more difficult to estimate how much needed care has not been delivered or how much wrong care has been given, but in any case, the widespread existence of inappropriate care has been acknowledged. Recognition of this fact has prompted public and private attention to effectiveness research, or learning what interventions produce desirable patient outcomes at the lowest cost. Payers are increasingly monitoring the outcomes of practice and making payment decisions based on what practices are thought to be the most cost effective. For example, if it can be demonstrated that an internist can manage acute low back pain effectively by NSAIDS, watchful waiting and other conservative means, it is likely that the internist will be reimbursed for that care rather than the surgeon for performing a laminectomy. The emerging societal expectation expressed in the desire for evidence-based practice at the lowest cost is a major determinant of much of the change presently occurring.

Political Power of Physicians

Multiple private sector special interest groups interact with various levels and branches of the government to determine policy regarding what can be done in health care, who can do it, who pays for it, and who is paid. In this health care political arena, physicians have long been the dominant and most successful players.

Paul Starr (1982) documented how, following World War II, organized medicine used its considerable power to strengthen the position of medicine and to increase the dominance of physicians over other health care workers and in the health care system generally. He described well how physicians worked in the legislative arena and in hospitals to solidify and extend their power in the health care system.

Barbara Safriet, (1992) in an analysis of the role of advanced practice nurses, noted that physicians were the first health care practitioners to achieve legislative recognition of their practice. She observed that the broad definition of medical practice "combined with the usual provision making it illegal for anyone not licensed as a physician to carry out any acts included in the definition, resulted in a preemptive strike by the medical profession to totally occupy the health care field, at least for any activity that could be deemed diagnosing, treating, prescribing, or curing." All other health care providers, including nurses, would have to "carve out tasks or functions from this all-encompassing medical scope of practice in seeking legislative recognition of their own professional roles, no matter how traditional or long-standing their activities."

A related way in which physicians have used their political power to determine who could do what in health care has been to influence reimbursement policy and payment systems. Which clinicians can be reimbursed for providing services clearly has an impact on who performs those services. The federal Medicare payment system uses the Current Procedural Terminology (CPT) classification of payment codes developed and sold by the American Medical Association as the basis for reimbursing providers for services delivered.

Until recently, the CPT committees approving codes and setting economic values for services were composed entirely of physicians. In response to strong efforts by the American Nurses Association, a nurse practitioner was appointed to the CPT committee that defines codes and a clinical nurse specialist to the committee that sets economic values for services. Accompanying organized medicine's efforts to define the services and their values have usually been attempts to restrict direct reimbursement to physicians.

In response to a payment system that has strongly favored physicians, organized nursing has tried to convince the U.S. Congress to mandate direct reimbursement to advanced practice nurses (APN) in federal health care programs. The recent passage of legislation mandating direct reimbursement to APNs in all clinical settings and all geographic areas represents a significant change in payment policy that should have a substantial impact on how APNs practice.

Restricting scope of practice through licensing laws and reimbursement policy illustrate only a few of the many ways in which organized medicine has used its political power for much of the latter part of this century to determine who has been permitted to provide and be paid for providing health care services. As noted above, during the past 10-15 years, insurers, payers, and administrators have increased their participation in medical decision making in the attempt to reduce the growth of health care costs. The increased pluralism in decision making is causing revolutionary changes in a system that usually experiences only incremental changes.

These factors are not the only ones that influence the composition of the health care workforce and the division of labor in health care. Their identification is meant to emphasize the sociopolitical context in which the health care workforce is determined and to serve as a basis for suggesting some implications for nursing. In a separate article in this issue, Claire Fagin (1997) discusses some of these same issues as well as others considered by the third Pew Commission on the health professions.

Key Issues for Nursing

Three nursing issues related to the health care workforce are:

• How to manage the overlap with other occupations and still maintain nursing's core identity.
• How to manage the diversity within nursing and still have enough unity to exert political power on behalf of nursing.
• How to demonstrate nursing's ability to produce desired patient outcomes at a low cost.

The first two issues are longstanding ones that have been much debated within the nursing literature. The third is related to the first two and is more recent.

As noted above, the two major types of professionals delivering health care prior to the mid-20th-century were physicians and nurses, whose roles overlapped but also were quite distinct. Following World War II and the proliferation of hospitals, nurses provided a broad range of services within the hospital, ranging from housekeeping to patient care. Over the years, organized nursing worked to rid nurses of "non-nursing" housekeeping, clerical and similar tasks with more or less success. As technology increased, new technician positions were created to deal with the technology. Similarly, areas of practice once considered part of the nurse's role, such as physical therapy, diet therapy, social work, and hospital administration, gradually developed into separate occupations. At the same time as this was occurring, the role of nurse practitioner was being developed in the mid-1960s by Loretta Ford, a nurse and Henry Silver, a physician. In the nurse practitioner role, services traditionally performed only by physicians were blended with traditional nursing skills to produce a practitioner who could deliver needed services to rural and inner-city populations who had limited access to medical care.

As roles were differentiated out of nursing and nurses began to assume more physician responsibilities, the overlap between nursing and other occupations increased and remains. The increased complexity and overlap with others created problems within nursing in trying to define itself clearly. Attempts to differentiate nursing from other occupations, particularly physicians, resulted in a search for nursing concepts in the 1950s and for nursing theories in the 1960s and 1970s.

In the 1980s and 1990s nursing developed its own classification systems of problems, interventions, and patient outcomes sensitive to nursing care. The key issue in all of these efforts has been how to acknowledge the overlap of nursing with other occupations and still maintain nursing's core identity. It is an issue not likely to be finally resolved, and how it is expressed at any time greatly influences what nurses do.

The changing scope of nursing has contributed to the second issue, which is how to manage the diversity within nursing. The diversity is in educational preparation, types and levels of practice, theories and research methods, practice sites, age of patients cared for and numerous other areas. Nursing has long debated the degrees most appropriate for practice, who should do what in nursing, who should accredit and certify nursing programs and nurses, and similar issues. Given the broad scope of nursing and the enormously increased complexity and differentiation in health care workers, the wide diversity in nursing reflects what has happened more generally in the health care system and should be expected to continue.

Positive aspects of the diversity are that nurses can move into a health care setting and work with any kinds of patient and with nearly any kinds of problem. This has made nurses a part of the workforce in great demand for whatever new roles have been created that required someone with a clinical background and good organizational skills. Such roles have included risk management, quality assurance, case management, clinical trials coordinator, and patient care manager among numerous others. The diversity can be a source of great strength and increased role opportunities, but can also be a source of weakening nursing through excessive internal dispute (see the OJIN issue devoted to Accreditation of Nursing Schools). To the extent that organized nursing uses its energies and resources in internal disputes, it dissipates its resources and the collective will to unify in promoting nursing's interests in the broader health care arena. It is crucial that organized nursing resolve its internal disputes with greater dispatch and turn its attention outward to the rapidly changing health care scene. A major issue in health care today is promoting evidence-based practice that produces desirable patient outcomes at the lowest cost. There is great need to demonstrate nurses' ability to provide cost effective care.

All health care workers increasingly will be expected to use empirical evidence as a basis for their practice and to show that the practice can reduce costs. If a new drug can effectively replace a surgical procedure at half of the cost, this is a cost improvement. If one method for preventing decubitus ulcers requires less nursing time and is equally or more effective than another, the former method is preferable from a cost perspective. With regard to who provides a service, if a nurse practitioner can manage patients with chronic illnesses equally as well as or better than a primary care physician and at a lower cost, the nurse practitioner is the cost effective choice. If unlicensed assistive personnel can carry out certain tasks as well as licensed nurses, then the unlicensed assistive personnel is the wiser economic choice. All of these decisions hinge not only on the cost of two methods of treatment or two different health care workers, but also on evaluating the quality of the care given and its impact in producing desirable patient outcomes. The emphasis on finding less expensive treatments and less expensive ways to provide care will continue to occupy center-stage in the health care arena for some time to come, and nurses must play a major role both in conducting the research and in delivering the case.

Nursing's ability to participate effectively in defining its role in health care delivery will increasingly require a determined and unified approach by various groups within nursing. Nursing must demonstrate through research, and not only by assertion, the impact that various nursing skill mixes and nursing interventions have on patient outcomes and costs.

Author

Ada Jacox, PhD, RN, FAAN
Ajacox@CMS.C.Wayne.edu

Dr. Jacox is professor and Associate Dean at Wayne State University College of Nursing. She has published extensively in the area of socio-political influences on the practice of nursing. She is currently studying the influence of legal and economic constraints on advanced practice nursing.