This article describes the trends that are stimulating the redesigning of roles in health care, the concerns created by this redefinition, and the anticipated future challenges of continuing role redesign. While the evolution of roles will continue, the kind of models we should develop for the future remains unclear. Meanwhile, we are continuing to make monumental changes in health care systems without knowing whether we are improving patient care or making it worse.
Health care is a rapidly evolving industry whose rate of change has been escalated by the vastly increased sense of competition, dwindling resources, and rising demand by payers, patients, and communities for high quality, low cost, convenient service. We now find health care in a state of chaos with many politicians, consultants, and industry leaders offering dramatic solutions.
Although, this rush to redesign seems difficult, our history is replete instances of with similar rethinking of roles. Because our profession is fragmented over so many nursing organizations (more than 80 now), it has been difficult to develop, critique, and oversee the redesigns that have often been imposed from outside of nursing.
Factors Stimulating Redesign of Health Care Roles
Rethinking who does what in health care has usually been the result of four factors: (1) the supply of nurses; (2) the cost of nursing salaries; (3) rethinking the role of nursing; (4) changes in other professions in the health care system that impact nursing roles. In reality, the forces initiating change are not as distinct as these four categories might suggest; instead, overlapping factors have accounted for the pressure to change.
1. The Supply of Nurses. The history of nursing is replete with periods of oversupply that have been quickly followed by periods of undersupply. In times of short supply, there is always an effort to create a new model for a nurse-extender position to perform some of the work that was traditionally done by RNs. Unlicensed assistive personnel (UAP) were developed to assist RNs during World War II. Team nursing, the development of the licensed vocational nurse (LVN), licensed practical nurse (LPN), and the associate degree nurse (ADN) were efforts to leverage the work of the RN to the higher levels allowed by the RN nursing license and delegating work that did not have to be done by an RN to another person on the patient care team. Delivery models, such as "paired partners" developed by Marie Manthey, have been attempts to develop a close working relationship between an RN and a nurse extender.
2. The Cost of Nursing Salaries. The nursing budget has been a visible target during times of financial crisis in the health industry. Our sophisticated staffing systems make it easy to track costs and wage and salary expenses. When the costs of nursing salaries are raised, new staffing models are usually proposed to reduce them.
Our sophisticated staffing systems make it easy to track costs and wage and salary expenses. When the costs of nursing salaries are raised, new staffing models are usually proposed to reduce them.
Nursing roles have also been affected positively by the fact that nursing is less costly than other professions. With the onset of managed care and the growth of capitated contracts, the fact that Nurse Practitioners can perform 80% of the procedures usually performed by the Primary Care Physicians at a much lower cost has put them in great demand. The model of using the RN as the First Assistant in the Operating Room is becoming more viable because capitated contracts prohibit billing for physicians as First Assistants. RNs also substitute for physicians in performing utilization review for managed care companies, reviewing malpractice claims as legal assistants in attorneys' offices, and extending physician care as hospital-based Nurse Practitioners.
3. Rethinking Nursing Roles. There will always be bright, creative thinkers in nursing who are creating new roles. The Nursing Doctorate developed by Case Western Reserve University is an example of this initiative, as is the development of the Primary Nurse, the Nurse Practitioner, and the Clinical Specialist. The development of the Associate Degree Nurse and the LPN/LVN are all examples of what was at one time a creative redesign of the traditional nursing role.
Inherent in many of these models is the intent to leverage the value of nurses by differentiating the roles according to expertise, achieved competency, and, sometimes, educational level. As pioneered by Jo Ellen Koerner at Sioux Valley Hospital in South Dakota, the model of differentiated practice is an example of this kind of initiative (Koerner, Bunkers, Nelson, & Santema, 1989). Clinical ladders have also been an attempt to differentiate among nurses by developing levels of compensation according to achievements. Usually, however, the clinical ladder levels did not translate to different roles.
Some innovations have been successful and others have not. Whenever new roles are created, the face of the nursing profession is changed. The variety of nursing roles make our profession look very confusing to our peers in other professions and to our constituency.
4. Changes in Other Professions that Impact Nursing Roles. Many roles have been developed over the years from the traditional nursing platform. For example, respiratory therapists and patient educators have developed out of roles that were traditionally within the purview of nursing. When the American Medical Association announced a plan to develop Registered Technicians, the nursing profession responded with great fervor; the result was the patient care technician, who answered to the nurse instead of the physician. The development of the Pediatric Nurse Practitioner and Nurse-Midwife programs was stimulated by a shortage of physicians in desolate and rural areas. When physicians were not available, they were allowed a wide range of latitude to choose interventions; standards of practice were different, however, in populated areas where physicians were available. Recent legislation has now granted them prescriptive powers regardless of the availability of physicians. As the glass ceiling is being raised, nurses are now being appointed as CEOs, and other administrative positions in health care organizations, as well as serving on boards.
Concerns Related to Role Redesign
Roles in health care evolve and change. There has been very little research on the effectiveness of recent innovations in terms of quality outcomes and financial advantages. Now, we are hearing people ask the question "Have we gone too far in delegating roles to UAP?" As the costs of turnover, training, amount of RN time taken up in supervision, and negative public opinion associated with UAP surface, present models are being questioned to determine whether they can achieve a financially viable model that is capable of creating good outcomes.
It has become common to assign some functions to the patient care unit, which is done to varying degrees.
As the costs of turnover, training, amount of RN time taken up in supervision, and negative public opinion associated with UAP surface, present models are being questioned to determine whether they can achieve a financially viable model that is capable of creating good outcomes.
As the nurse executive takes on many more departments, the nurse executive function has become more broadly defined into that of patient care management. Other managers, in turn, also have responsibilities outside of nursing. Providing preparation for the assumption of these added responsibilities is always a concern.
The tremendous variability in skill levels of UAP across the country, the many models of delivery, and the confusing roles of the nurse all contribute to consumers' continually eroding confidence in our health care system. These issues must be addressed to regain the confidence of the public.
Some trends bear watching in the future. Cross-training of unlike specialties might be replaced by cross-training across the continuum of care. For example, nurses are now cross-trained to work in their specialty across the care continuum - e.g. caring for patients in the hospital and at the patient's home. Disease management models utilize the nurse in the outpatient setting to drive the care that is delivered in the hospital.
The RN's role continues to take on complexity usually associated with the MD's role. As these people take on more fiscal and managerial responsibility, managers need greater preparation in the field of business.
The Challenge Ahead
The challenge for health care is to provide the educational programs to support care delivery in the new models. There is a lag between the innovation of new services and the integration into the educational programs of the necessary skills to support them. For example, team nursing was being taught in schools when primary nursing was the mode of delivery. Primary nursing is still being taught when today's environment demands skills in supervising UAP and serving as the RN patient-care manager.
As we continue to develop the role of UAP, we also have the challenge of guaranteeing our consumers a baseline level of performance. Licensure provides the public with the assurance that the RN has passed a minimal level of competency testing. Although we currently have no national standard for UAP competency, the AACN and other national organizations are working on curriculum and testing to assure a national level of safe-practice.
We must determine effectiveness of new practices before we allow the wholesale adoption of models that cannot validate outcomes. Redesigns are allowed to be implemented before hard core outcomes are demonstrated in pilot projects.
We must determine effectiveness of new practices before we allow the wholesale adoption of models that cannot validate outcomes...Patients are not informed that they are being cared for within an unproven model of care delivery.
Of course, health care doesn't need more regulation. But if the government is concerned about weight-loss centers demonstrating evidence of effectiveness, shouldn't we hold people in health care to a similar level of accountability?
The common issue in all of these designs is the concern about RN skill mix. The question for now and the future is, "How low can you go without jeopardizing care?" Skill mix depends upon the ratios of nurses to patients, as well as the individual expertise of each nurse. Ongoing mortality skill mix research will provide future measures to assess the outcomes of these designs (Aiken, Smith, & Lake, 1994). Meanwhile, we remain concerned about the harm that may occur before a particular delivery model is assessed.
The issue of funding for research into models of health care is germane to accountability. Because almost all past funding has been used for clinical research, we are now implementing care models with no research to verify results. Schools of nursing continually debate the merits of a course of study for nursing administration and nursing administration research. Too often, these departments are either not in existence or are very weak departments. Our challenge is to strengthen these departments in order to make our practice safer for patients.
Professional organizations should be challenged to develop a mechanism for examining the "best practices" across the country in specialty areas as it relates to various delivery models. The most important role of the professional organization should be to develop and support best practices. Wouldn't it be wonderful if the various organizations commissioned think tanks for long-range strategic thinking about who should do what in health care in the future? Centers of Innovation could be developed to find answers to the many difficult questions surrounding delivery models.
So where does that leave us today in terms of who does what in health care? First, evolution of roles will continue into the future as a result of the four forces mentioned above. Second, the many changes that have been implemented have left us with a sense of little direction for what kind of models we should develop for the future. Adequate funding to evaluate the outcomes of various roles is not available. Consequently, we have very little data about the effectiveness of various roles in health care. Intuitively, we know what is and is not effective; unless we have good data, however, our opinions won't count. Hence, our third conclusion is that we are unfortunately making monumental changes in how we care for patients without knowing whether we are improving patient care or making it worse.
Karlene M. Kerfoot, PhD, RN, CNAA, FAAN
Dr. Kerfoot received her PhD in nursing from the University of Illinois in Chicago, and her Masters and BSN from the University of Iowa. She has held a variety of clinical, managerial, executive, and academic positions. She is a frequent contributor to the literature in the areas of leadership, management, and clinical practice. Dr. Karlene Kerfoot has been active in developing new delivery models in a variety of clinical and administrative positions. At the Memorial Hermann Healthcare System, she is actively involved in redesigning the emergency/urgent/ambulatory care of seven facilities into a regional delivery system with innovative models for delivering care. At St. Luke's Episcopal Hospital in Houston, where she served for 11 years as the Executive Vice President for Patent Care, innovative models of redesign such as the "Team Care" project, the development of the Center of Innovation and many other initiatives brought the hospital national and international recognition.
Article published December 30, 1997
Aiken, L., Smith, H., & Lake, E. Lower medicare mortality among a set of hospitals known for food nursing care. Medical Care 23(8),771-787.
Koerner, J., Bunkers, L., Nelson, B., & Santema, K. Implementing differentiated practice: The Sioux Valley Hospital experience. Journal of Nursing Administration, 19(2),13-20.