"Who does what in health care?" Earlier in the twentieth century, the answer was clear: physicians practiced medicine and nurses provided services ranging from housekeeping to patient care. Today, as we approach the twenty-first century, the answer is no longer clear. Articles in this posting guide clinicians, administrators, educators, and researchers to find the answer to the question, "who does what in health care?"
Dr. Jacox, in the first article, notes that we now have more than 200 different allied health occupations co-existing alongside of the traditional professionals. Some of these occupations perform work that nursing used to do; others have carved out new areas. This growth in the number of health care roles has produced a health care system delivering large amounts of inappropriate care and a cost higher than society is willing to pay. The high price of health care has resulted in upheaval as leaders in government, public policy, education and service rush to control the cost.
Dr. Jacox suggests that nursing can survive these tumultuous times by clarifying its core identity.
Dr. Jacox suggests that nursing can survive these tumultuous times by clarifying its core identity. Nursing has attempted to do this for the past 50 years by delineating nursing concepts, theories, and classification systems. Yet the unfinished task of managing nursing's overlap with other professions remains. Another continuing identity challenge is managing diversity within nursing. This diversity, a potential source of strength and role opportunities, can also weaken nursing through excessive internal dispute. Dr. Jacox suggests that addressing the bottom line, i.e., showing how nursing can improve outcomes while decreasing costs, will help to establish our core identity. Research is desperately needed to assist in this process.
Society has already started addressing these challenges for nursing. One example is thePew Health Professions Commission report, "Critical Challenges; Revitalizing the Health Professions for the Twenty-First Century" (1995). Dr. Fagin's article examines this landmark report that is having a major impact on all the health professions; she raises challenging questions, supports many recommendations, yet questions others. Regarding manpower issues, the Report recommends closing some associate degree and diploma programs. Dr. Fagin asks whether this will necessitate increasing the size of baccalaureate programs to maintain quality care for society.The Report also recommends preparing baccalaureate graduates for care management positions. Dr. Fagin supports this recommendation if the Report implies the management of carefor a group of patients, but warns that preparing this level of students for management that doesnot include direct care may well lower the overall quality of care. Nursing has a good record in responding to mandates for change. Yet the criteria for determining the response must always be the same: preparing our graduates to deliver quality patient care. Nursing's response to the Report must include research on the effects of new practices on patient outcomes, publicizing the results of this research, and impacting local and national policy through these research findings.
In the third article, Dr. Kerfoot critiques the current "rush to redesign," noting this is a phenomenon that will always be with us. What we can learn from today's rush to redesign can guide us in the years ahead. She questions whether we have gone too far in delegating roles to the unlicensed assistive personnel (UAP) and cross-trained unlike specialties when we should have cross-trained personnel across the continuum of care. Quality care will be enhanced when we can guarantee consumers a baseline level of performance for the UAP and demonstrate hardcore quality outcomes associated with redesigned roles. The common issue in all current redesigns, notes Dr. Kerfoot, is the concern about RN skill mix. She asks, "How low can you go without jeopardizing care?" We do not know the answer to this question. Yet, patients continue to receiver care without being informed this care comes to them via an unproven model of care delivery. Dr. Kerfoot asserts we have very little data about the effectiveness of various roles in health care because we lack adequate funding to evaluate the outcomes of these roles. Thus, as health care providers we are making monumental changes in how we care for patients without knowing whether we are improving patient care or making it worse.
In summary, Dr. Jacox calls attention to the importance of clarifying nursing's core identity, Dr. Fagin identifies the need for to prepare our graduates to deliver quality patient care, and Dr. Kerfoot highlights the risks associated with unproven models of care deliver. All authors emphasize the essential role of research in answering the question of "Who Does What in Health Care?" All authors recognize that the constantly changing sociopolitical environment will place us in a continual search for the answer to this question. Please contribute to this search by reading the articles, and sharing you insights, experiences, and data with the editor of OJIN. Write a manuscript or letter to the editor about this important topic.
Published December 30, 1997