Opportunities for Nurses Under the Affordable Care Act
On Friday, the California Institute for Nursing and Health Care released its landmark report, Nurse Role Exploration Project: The Affordable Care Act and New Nursing Roles, identifying top new roles for Registered Nurses (RNs) in the era of health care reform. The paper, funded by a grant from the California Wellness Foundation (TCWF), is the result of 9 months of research and collaboration with leaders in healthcare from across the state of California. Although the paper focuses on California’s nursing shortage needs, it is a comprehensive analysis and a forecast of how nursing roles will evolve and expand under health care reform.
Little attention has been paid to the additional nursing roles evolving out of health care reform aside from the primary care APRN role. There is a need to study and evaluate the new roles of:
Care coordinator
Faculty team leader
Informatics specialist
Nurse/family cooperative facilitator
To ensure nurse education has been restructured and enhanced to address these and other new roles.
The new roles for RNs were identified through a multi-step process designed to elicit possibilities from a cross-section of professionals most directly involved in nursing and healthcare. The process began with a series of facilitated convenings throughout California that involved representatives of academia, practice, government, payers and consumers. Survey work was conducted to determine additional key information, to verify consensus on the resulting recommended new roles, and to gather input on steps to actualize them.
The path to changing our health system from a focus on disease/illness care to wellness and prevention will be bumpy. Like the California Institute for Nursing and Health Care, the American Hospital Association also convened a group in 2011 to study the impact the PPACA will have on hospitals and noted in its first two recommendations:
The professional workforce in the future will be smaller, and the work itself will be different than it is today. Projections for nursing and primary care physician shortages have been published widely, and the shortage of primary care physicians will only be exacerbated by increased demand for their services by 2014. This will be due to the aging population, the addition of an estimated 32 million patients into the system as a result of ACA, and the increasing movement of chronic disease care into the ambulatory arena.
2. To function as seamless, efficient teams, all health care professionals (both current and future) need to be trained in inter-professional educational settings. This represents a major challenge for our centers of professional education to innovate in the redesign of both pre-clinical and clinical curricula.
And, reinforcing the findings of the California Nursing Institute, the AHA also noted:
One common characteristic of these high-functioning primary care systems is the emergence of new team members who help connect patients with providers and community resources such as health coaches, health care navigators, population assistants, “promotoras de salud” or community health aides. Some receive formal training while others are trained on the job by a clinician and work through community health clinics. Oftentimes, these individuals also train new recruits interested in similar positions. There is compelling data that shows these new team members can have a positive impact on adherence to treatment plans, can help make links to community resources, contribute to better outcomes, and help lower costs. These roles are still being fully defined as to the level of education needed or desired.
Organized nursing needs to: 1. Identify methods to ameliorate the workforce use inconsistencies that will arise with transition of our health system;
2. Embrace new roles; identify how the traditional role of nursing can be transitioned to address the new needs of a wellness and primary care system;
3. Create specific academic curricula to address the change;
4. Think about whether these roles should be LPN, RN or APN;
5. Brand and market the new roles as nursing roles; and
5. Message, educate and inform academia, the public and nursing organizations about the new roles, the transitory approach to change; and about the need to actively recruit nursing students for these roles.
In terms of licensure, as we address the new roles there is a need to re-evaluate traditional educational paths and scopes of practice for the RN and the LPN. The future of nursing focuses on advanced practice, but there is a need to rethink the entire continuum of nurse licensure. RNs have been educated for role expansion as well. However, without a college degree mandate for licensure, the occupation has been stigmatized by other health professionals which require college degrees for entry. Nurses frame the debate about baccalaureate education entry in terms of history and culture without looking at how other health professionals with college degrees have carved scopes out of nursing and positioned themselves as comparable health providers who receive comparable incomes to nursing.
The LPN role and scope has been diluted by the community health worker and other created positions designed to address emerging health needs. Also, organized registered nursing organizations have not done enough to incorporate LPN/LVN practice into academic progression to RN licensure. Opportunities exist for nursing to affirmatively and aggressively address LPN scope and education; and if the nursing profession does not, LPNs will continue to be utilized inappropriately which is used to diminish the economic value of all nurses; and further diminishes clear RN opportunities and growth expansion.
LPNs also should see the value of restructuring their role – it will provide clarity about their role/responsibilities in the newly designed health setting; reframe their role as technical professionals and reinforce their economic value and role.
RN salaries are not developed in a vacuum. Nurse leaders report high job satisfaction, but are not as happy about their benefits and compensation, according to the American Organization of Nurse Executives’ 2013 AONE Salary and Compensation Study. Their comments were made despite the fact that these leaders reported earning an average annual salary of $100,000-$130,000, and some earn two or three times that amount.
“Survey results underscore a diverse profession,” said the paper’s authors. “On the other hand, certain key themes emerge and illustrate core trends for nurse leader compensation.” However, when compared to other male-dominated health professionals with comparable skills/responsibilities, nurses are woefully under compensated. Unless and until nurses start to define the value of all nurses – LPN/LVN, RN and APN – others will use the fractures within the profession to undercut salaries and mandate work outside of traditional scopes of practice.
With redesign of health delivery, so should we consider redesign and expansion of health licensure to buttress not just practice but economic parity. Nurses are required for the success of health reform. Let’s use this need to push for equity in salary and compensation.
A complete copy of the report is available on the CINHC website at www.cinhc.org.