Health care has loved its hierarchies, monopolies, and privileged spaces. The nursing profession is pushing for a renegotiated order that breaks down the "silo" mentality and gains purchase on the power of the dominant profession of medicine—an order marked by shared authority and accountability. Today’s market forces, pressing for better care, better health, and reduced costs, are demanding efficiency through collaboration among groups who previously rarely considered themselves equals.
Optimizing scope of practice
The leading message from the Institute of Medicine’s 2010 report, "The Future of Nursing: Leading Change, Advancing Health," is that nurses should practice to the full extent of their education and training. In effect, all healthcare professionals and assistive personnel should provide care that takes full advantage of their knowledge, skills, and abilities to meet patient preferences and needs in a particular situation. Also, the least expensive caregiver should be first in line to provide care within her or his domain.
Advanced practice registered nurses (APRNs) are making gains in changing state nurse practice acts and regulations to counter the suppression of their scope of practice and enable greater access to primary care across the United States. Numerous studies demonstrating the value of care provided by nurse practitioners, in terms of equivalent quality and economic efficiencies, constitute a strong offense in breaking the monopoly held by medicine.
Blurring the boundaries
Professional boundaries codified in laws and regulations have established a traditional division of labor. Today we rebuff those boundaries, insisting on entering the space where there’s overlap of knowledge and skills, especially with physicians. The resistance we feel from physicians is expected as dominant groups seek to remain dominant, resisting standardization and popularization of care techniques.
Nurses, too, have secured boundaries, resisting intrusions of other healthcare providers. But as we realize the shift from cooperation to collaboration, from gatekeeping to sharing, and from solo expert practice to partnerships, we sense an urgency to blur the lines between nursing and allied disciplines. The new rules of engagement call for teamwork and mutual trust with partners who possess complementary skills and knowledge.
"Practice at the top of one’s education and license"
Nurses have always relied on others to assist in the delivery of nursing care. As coordinators of patient-centered care, our challenge is to embrace others—professionals, assistive personnel, and family caregivers—so that each team member frees up the time of another to respond to more complex patient needs based on their specialized skills. This vertical substitution, or skills escalation, is a key concept in allowing nurses and other professionals to practice to their full scope. Some nurses have demonstrated resistance to these changes, perhaps based on concerns about safety, loss of identity, lack of knowledge of other disciplines, or fear of delegation and the associated responsibility. As we seek to "practice at the top of our license" (or to the full extent of our education and training), we should actively support our colleagues doing the same.
Expanding roles and minds
Care teams have evolved despite entrenched roles and boundaries. Navigators, diabetes educators, and case managers come from a variety of disciplines. Pharmacists perform medication reconciliation, administer
vaccinations, and manage anticoagulation. Physical therapists provide independent assessments and noninvasive treatments. Nursing assistants and medical assistants perform a broader array of services in various settings using protocols under the supervision of a nurse or physician. Community health workers decrease use of costly emergency care and prevent hospitalizations as the first point of access for those who need primary care or help in managing chronic diseases. Myriad disciplines provide behavioral health care in an underserved sector of our industry. Family members protect loved ones’ airways, manage indwelling catheters, change dressings, and prepare feedings at home.
Nurses can help lead the transformation of health care by opening our minds and role-modeling a new egalitarianism that promotes the best use of each provider. Florence Nightingale offered these words of wisdom: "Let whoever is in charge keep this simple question in her head—(not, how can I always do this right thing myself, but) how can I provide for the right thing to be always done?" This is a lesson for nurses, physicians, and all of our other healthcare colleagues.
Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN