HEALTH CARE DELIVERY SYSTEM, NURSING RESEARCH AS THE BASIS OF NURSING
THE HEALTH CARE DELIVERY SYSTEM
A health care delivery system is a mechanism for providing services that meet the health-related needs of individuals. The
Nursing is a major component of the
Americans are becoming increasingly confused about the services and coverage offered by the health care system. This chapter examines some of the problems and possible solutions in health care delivery.
TYPES OF HEALTH CARE SERVICES
Basically, health care services can be categorized into three levels: primary, secondary, and tertiary (Figure 4-1). The complexity of care varies according to the individual’s need, provider’s expertise, and delivery setting. Table 4-1 provides an overview of the types of care.
Primary: Health Promotion and Illness Prevention
The major purposes of health care are to promote wellness and prevent illness or disability. Traditionally, the
Unfortunately, our entire system of health care delivery is not a health care system but rather an illness care system. Services are directed to caring for an individual after disease or disability has developed rather than emphasizing preventive aspects of care (Pruitt &Campbell, 1994). Ideally, preventive care occurs in the community (e.g., homes, workplaces, schools) and emphasizes the development of healthy lifestyles.
Secondary: Diagnosis and Treatment
Most services occur within this secondary type of health care. Acute treatment centers (hospitals) are still the predominant site of delivery of health care services. There is a growing movement to have diagnostic and therapeutic services provided in locations that are more easily accessed by individuals. This trend is discussed later in this chapter.
Tertiary: Rehabilitation
Restoring an individual to the state that existed before the development of an illness is the purpose of rehabilitative (or restorative) care. In situations in which the person is unable to regain previous functional abilities, the goal of rehabilitation is to help the client reach the optimal level of self-care. Restorative care is holistic, in that the entire person is cared for—physiological, psychological, social, and spiritual aspects.
HEALTH CARE SETTINGS
The
Public Sector
Public agencies are financed with tax monies; thus, these agencies are accountable to the public. The public sector includes official (or governmental) agencies, voluntary agencies, and nonprofit agencies. Figure 4-2 shows the hierarchy of the public sector of health care delivery.
At the local level, services provided include immunizations, maternal-child care, and activities directed at control of chronic diseases. Each state varies in the provision of public health services. Generally, a state department of health coordinates the activities of local health units.
At the national level, the U.S. Department of Health and Human Services (DHHS) is administratively responsible for health care services delivered to the public. The Surgeon General is the chief officer of the U.S. Public Health Service (USPHS), the major agency that oversees the actual delivery of care services. Table 4-2 lists the USPHS agencies and their purposes.
An important part of the public sector of the health care delivery system is voluntary agencies. These not-for-profit agencies exert significant legislative influence (e.g., the American Nurses Association [ANA] and the AmericanMedical Association). Other voluntary agencies, such as the American Cancer Society and the American Heart Association, provide educational resources to the general public and to health care providers. Voluntary agencies are funded in a variety of ways, including individual contributions, corporate philanthropy, and membership dues.
Private Sector
The private sector of the health care delivery systemprimarily comprises independent providers who are reimbursed on a fee-for-service basis (the recipient directly pays the provider for services as they are provided). The variety of settings in which health care is delivered and the roles of nurses in these settings are presented in Table 4-3. These practices settings are directly influenced by social and economic factors.
HEALTH CARE TEAM
Health care services are delivered by a multidisciplinary team. Table 4-4 provides a list of health care providers. Because nurses work with other care providers on an ongoing basis, it is necessary to understand the role of each provider. Nurses coordinate the care provided by other personnel.
Nurse
What do nurses do? Nurses fulfill a variety of roles while assisting clients to meet their needs. Table 4-5 defines the most common roles of nurses. These roles are affected by changes in the health care environment. Nurses function in dependent, independent, and interdependent roles. The degree of autonomy nurses experience is related to client needs, expertise of the nurse, and practice setting.
ECONOMICS OF HEALTH CARE
The reform movement in health care has been motivated primarily by health care costs. Control of costs has shifted from the health care providers to the insurers. As a result, there are increasing constraints on reim bursement. For years, the predominant method of covering health care costs was the fee-for-service method. There was little, if any, incentive for cost-effective delivery of care (Chamberlain, Chen, Osuna, & Yamamoto, 1995). All that is changing. The
Private Insurance
The system for financing health care services in the
Managed Care
Managed care is a system of providing and monitoring care in which access, cost, and quality are controlled before or during delivery of services. The goal of managed care is the delivery of services in the most cost-efficient manner possible. Managed care seeks to control costs by monitoring delivery of services and restricting access to expensive procedures and providers.
Managed care was designed to provide coordinated services with an emphasis on prevention and primary care (ANA, 1995). The rationale for managed care is to give consumers preventive services delivered by a primary care provider (a health care provider whom a client sees first for health care) that, in turn, results in less expensive interventions.
Managed care has been in existence for years; however, it is only within the past few decades that it has received national prominence (Society for Ambulatory Care Professionals, 1994). The Health Maintenance Organization Act (passed in 1973) implemented two mandates. First, federal grants and loans were made available to health maintenance organizations (HMOs) (prepaid health plans that provide primary health care services for a preset fee and focus on cost-effective treatment measures) that complied with strict federal regulations as opposed to the less restrictive state requirements. Second, the act required large employers to provide an HMO as an option for employees for health care coverage (Society for Ambulatory Care Professionals, 1994). From their inception, HMOs have been a viable alternative to the traditional fee-for-service system.
Managed care is not a place but rather an organizational structure with a few variations. One is represented by HMOs, which are both providers and insurers. Other variations are represented by preferred provider organizations (PPOs) (a type of managed care model in which member choice is limited to providers within the system) and exclusive provider organizations (EPOs) (organizations in which care must be delivered by the plan for clients to receive reimbursement). The latter creates a network of providers (such as physicians and hospitals) and offers the incentive of consumer services with little or no copayment if these providers are used exclusively. Table 4-6 provides a comparison of independent practice and managed care organizational structures. The impact of managed care is that caregivers and institutions must change from providing as many ser vices as possible under a fee-for-service payment approach to keeping the client well and providing fewer services so as to protect their financial interests. “In a fee-for-service system, the concern is that a client might receive too many or unnecessary services; in a prepaid system, the concern is that too few services might be given in order to save the provider and the managed care plan money” (Hitchcock, Schubert, & Thomas, 1999, p. 46).
Health Maintenance Organizations
The HMOs often maintain primary health care sites and commonly employ provider professionals. They use capitated rates (a preset flat fee that is based on membership in, not services provided by, the HMO), assume the risk of clients who are heavy users, and exert control on the use of services. HMOs have been noted for their use of advanced practice registered nurses (APRNs) as primary care providers, precertification programs to limit unnecessary hospitalization, and an emphasis on client education for health promotion and self-care. Another common feature of HMOs is the practice of single point of entry (entry into the health care system is required through a point designated by the plan) through which primary care is delivered.
Primary health care is the client’s point of entry into the health care system and includes assessment, diagnosis, treatment, coordination of care, education, preventive services, and surveillance. It consists of the spectrum of services provided by a family practitioner (nurse or physician) in an ambulatory setting. Primary care providers (PCPs) serve as “gatekeepers” to the health care system in that they determine which, if any, referrals to specialists are needed by the client. To reduce costs, direct access to specialists is limited. Extensive data collection proves that APRNs are exceptionally suited to these primary provider/gatekeeper roles (ANA, 1993a). Managed care plans assume a significant portion of the risk of providing health care and, consequently, encourage both prudent use by consumers and prescription by providers.
Preferred Provider Organizations
The most common managed care systems are preferred provider organizations (PPOs). A PPO is a contractual relationship between hospitals, providers, employers, and third-party payers to form a network in which providers negotiate with group purchasers to provide health services for a defined population at a predetermined price (Society for Ambulatory Care Professionals, 1994). Even though PPOs have been very popular with the American public, it appears that HMOs are gaining in market share among the American public (Kelly & Joel, 1995). Currently, managed care is emerging as the preferred model for delivery of services.
Federal Government Insurance Plans
The federal government became a third-party payer for health care services with the advent of Medicare and Medicaid in 1965. The Health Care Financing Administration (HCFA) is a federal agency that regulates Medicare and Medicaid expenditures. Public funding is used for about 42% of total health expenditures (Schieber et al., 1994). There are myriad public programs for financing health care, with Medicare and Medicaid being the predominant ones. Medicare is the federally funded program that provides health care coverage for the elderly and the disabled. Medicaid is a jointly administered program between the federal and state governments that provides health care coverage for the economically disadvantaged.
The federal government created diagnosis-related groups (DRGs) to curtail spending for hospitalized Medicare recipients and to ensure that health care dollars would get to those who most need them. Through this system, an inclusive rate is established for each episode of hospitalization based on the client’s age, principal diagnosis, and the presence or absence of surgery and comorbidity (existence of simultaneous disease processes within an individual). Hospitals are now reimbursed only for services that are determined to be medically necessary. An accelerating trend for the federal government is to give recipients of public monies the personal right to choose, through the use of vouchers, a managed care program in the private sector.
Medicare
When Medicare was established in 1965, it was intended to protect individuals over the age of 65 from exorbitant costs of health care by providing public funds to cover the majority of health care services. In 1972, Medicare was modified to include permanently disabled individuals and those with end-stage renal disease.
Medicaid
Medicaid is a shared venture between the federal and state governments. Each state has latitude in determining who is “medically indigent,” and thus qualifies for public monies. Minimal services covered by Medicaid are defined by the federal government and include inpatient and outpatient hospital services, physician services, laboratory services (including x-rays), and rural health clinic services. States may elect to cover other services, such as dental, vision, and prescription drugs.
CHALLENGES WITHIN THE HEALTH CARE SYSTEM
The major challenges facing the
Disillusionment with Professionals
Americans believe the major problem of the health care system is greed and waste (Maraldo, 1994). Whether this problem is caused by defensive practice, consumer demand, or professional economics is irrelevant to the public. Success in reform depends on starting where the public expects it should begin—by eliminating
greed and waste. Further, Americans are suspicious of medical professionals. The high level of esteem with which medicine has traditionally been held has diminished over the past few years. Consumers are becoming increasingly tired of paying the high cost of care and question medical practices and fees (Zerwekh &
Claborn, 1994). However, the public is not suspicious (Kellogg Foundation, 1994). This positive per- of nurses ception of nurses will be important as reform initiatives are established.
Positive Perception of Nurses
Several studies (ANA, 1993a; Kellogg Foundation, 1994) verify the public’s trust iurses. The public sees nurses as part of the solution, not the problem, and believes that, if nurses were allowed to use their skills, they would significantly enhance quality and reduce cost. One survey (ANA, 1993a) inquired about consumer receptivity to nurses’ assuming expanded responsibilities. Respondents supported prescriptive authority (legal recognition of the ability to prescribe medications) for nurses and endorsed their role in performing physical examinations and managing minor acute illnesses. Nurses have limited their own vision of their roles owing to the roots of their education in the medical model (traditional approach to health care in which the focus is on treatment and cure of disease) and their socialization into the hierarchy that this model assumes.
Loss of Control
Consumers express the sentiment of feeling terrorized by the health care delivery system. They feel they have lost personal control, and they do not trust the people who represent them. Many Americans stay in unsatisfying jobs because of their health care benefits and relinquish employment mobility due to a fear of being denied a new policy because of preexisting conditions. Many American workers state that their greatest concern is the possible loss of health care coverage (Grace & Brock, 1994).
Decreased Hospital Use
In the early 20th century, hospitals focused on providing care to those who had no caregivers in the family or community. The focus of these early institutions was care not cure (Grace, 1994). The focus of hospitals changed in the mid-1940s as a result of technologic changes and the passage of the Hill-Burton Act by Congress in 1946, which provided funding for renovation and construction of hospitals. One unanticipated outcome of this act was a substantial oversupply of hospital beds. Health care costs escalated with the need to keep the hospital beds occupied. From 1945 to 1982, the demand for hospital beds steadily increased. After
Currently, hospitals continue to be the nucleus of the health care delivery system in the
As a result of the changes in reimbursement practices, hospitals are restructuring (also referred to as redesigning and re-engineering). Examples of restructuring activities include mergers with larger institutions; development of integrated systems that provide a full range of services focusing on continuity of care such as preadmission, outpatient, acute inpatient, long-term inpatient, and home care; and the substitution of multiskilled workers for nurses. Approximately 67% of registered nurses are employed by hospitals (McCloskey & Grace, 1994).
The majority of these nursing positions are direct care providers (staff nurses). In some institutions, restructur ing includes replacing registered nurses with unlicensed personnel, which may lead to decreased quality of care Nurses must ensure that cost-cutting efforts do not threaten client safety. As the average lengths of stay in hospitals decline, the acuity level of clients increases. The presence of increas ingly ill clients requires nurses who possess technical exper tise, critical thinking skills, and interpersonal competence Community based services, such as home health, will need to continue to expand to meet the increased needs of the steadily growing elderly population (Hull, 1994).
Changing Practice Settings
Most nurses currently practice in hospitals and will continue to do so in the future (Aiken, 1995). However, there is an ever-increasing need for nurses in different areas of practice. Social and political changes are affecting nurses by creating the need for expanded services and settings. Because of these changes, demand for nursing care fluctuates. For example, nursing employment outside the hospital continues to increase rapidly.
Health care expenditures for home care are rapidly increasing. It is predicted that 70%–80% of care will be delivered in the home by the year 2010 (Conger et al., 1999). Since the advent of Medicare and Medicaid,home health care has grown rapidly.
More nurses will be needed in the future due to:
• The growing elderly population will require more health care services.
• The number of people admitted to nursing homes is steadily growing.
• The number of homeless individuals, who are most often denied access to health care, is increasing.
As health care reform occurs, some nurses may be displaced from their current jobs. But overall, many more jobs will be created by the demand for greater access to health care services. Some examples of areas in which larger numbers of nurses will be required are primary care, public health, extended care facilities, and the home setting.
Ethical Issues
The United States is struggling with a major ethical conflict of cost containment versus compassionate quality care. According to Hicks and Boles (1994), no country, regardless of how wealthy it is, can provide all citizens with every health care service they desire or need.
Today, the U.S. health care delivery system is faced with the dilemma of citizens’ needs being greater than available resources. Thus, some difficult choices must be made to determine which needs will be met and which will remain unmet.
The expectation that “everything must be done to save” a dying person has created an enormous drain on the health care resources of this country. As decisions are made about allocating scarce resources, there will be much debate about the ethics involved. The appropriateness of futile life-sustaining measures must be addressed (Rowe, 1996). Nurses must continue to strongly advocate for just and ethical distribution of resources as health care reform progresses.
Vulnerable Populations
Meeting the health care needs of underserved populations is especially challenging. Groups that may be unable to gain access to health care services include:
children, the elderly, people with AIDS, the homeless, and others living in poverty. Approximately 43 million people in America had no health insurance in 1997. (US Census Bureau, 1998) Medicaid is no longer adequate to meet the needs of the medically indigent. Our current health care system neglects the overall needs of children. Children are more likely than adults to be uninsured. One in 5 children lives in families with income below the poverty level; only half of those children living in poverty are covered by Medicaid (Uphold & Graham, 1993). As the federal and state governments continue to curb expenditures for health care, more children will be declared ineligible for Medicaid. Children who are covered by health insurance have a greater degree of well-being. Approximately
Traditionally, rural areas have always had few health care providers and facilities that were easily accessible.
A large number of elderly people (approximately 45% of those over the age 65) live in rural areas (Vrabec, 1995). Because people in rural areas tend to work for small businesses or are self-employed, many of them have no health insurance. Also, many hospitals in rural areas have been closed due to economic pressures.
Usually, adults in the
It is in the best interests of society to see that those who cannot afford the basic health services are not denied such services. The entire society’s health is threatened when some sectors are denied basic care. As a group, nurses are concerned with the availability of health care services to everyone, regardless of their ability to pay (Hicks & Boles, 1994).
NURSING’S RESPONSE TO HEALTH CARE CHALLENGES
As the
Standards of Care
Another approach to the challenges experienced by the health care delivery system has been the move toward standardization of care. In December 1990, the Agency for Health Care Research and Quality (AHRQ), formerly known as the Agency for Health Care Policy and Research (AHCPR), was established with the specific charge of achieving consensus within the medical/health care community on the usual treatment of high-volume and expensive disease conditions that differ in their therapeutic management despite substantial research. More simply put, there is significant variation in the diagnosis and treatment of certain illnesses and diseases. The medical justification for such variance has been that every client is an individual and the choice of treatment is a private decision involving client and physician. AHRQ aims to identify the standards of treatment for which the health care community can be held accountable.
When AHRQ was created, the ANA recognized the need to strengtheursing practice standards. Three interdisciplinary panels chaired by nurses were created to propose standards for conditions that are highly responsive to nursing interventions. Currently, AHRQ published guidelines are available to the public and should be integral to nursing practice.
Advanced Practice
The advanced practice of nursing has evolved as nursing has become more complex and specialized. Since the late 1960s, nurse practitioners (NPs), clinical nurse specialists (CNS), certified nurse midwives (CNMs), and other advanced practice registered nurses (APRNs) have provided primary health care services to individuals, many of whom would have had inadequate or no access to services. (APRNs) possess advanced skills and in-depth knowledge in specific areas of practice. Even though there are differences in various advanced practice roles, all APRNs are experts who work with clients to prevent disease and to promote health.
There are currently more than 100,000 APRNs in the
Public versus Private Programs
The combination of public and private sector resources for health care seems to be comfortable for Americans. The competition between the two types of settings has encouraged quality and progress. Each setting provides benefits as well as drawbacks to health care recipients.
The nursing profession supports an integration of public and private sector programs and resources. Public dollars are required to help the poor and those who do not receive health care benefits through the workplace. Actual services should be available through a variety of public and private sources. To safeguard the health care system from becoming a two-tiered process based on personal resources, both the poor and nonpoor and the privileged and nonprivileged must be enrolled in the same programs. Finally, the basic required package of services must be defined in the same way in each state and required as the minimum for both public and private sector programs. The persistence for national standards must be tempered with a respect for local needs and differences. In other words, set minimal national standards, but promote local planning and implementation. Local insights are particularly critical to the public health, meaning the health of a community as an aggregate of people, and not personal health services delivered in the community.
The states’ rights philosophy prevailing in the
Public Health
Public health includes services such as immunizations, prenatal care, environmental concerns, and analysis of the prevailing disease patterns in a community. Current public health problems include:
• Increase of sexually transmitted diseases that were once nearly eradicated (e.g., syphilis and gonorrhea)
• Appearance of new fatal diseases (e.g., AIDS and the Ebola virus)
• Emergence of drug-resistant strains of tuberculosis
• Underimmunization of infants and children
• Prevalence of overweight and inadequately nourished young people
• Presence of toxic environmental conditions
For today’s needs, the medical model is insufficient. Table 4-8 presents a comparison of the medical model and the nursing model. In most instances, the nursing profession’s approach to these issues transcends a health model and looks to a social model for response and assistance. Social models view areas of health, housing, education, and employment, in fact all social welfare concerns and programs, as an integrated whole. Education for healthy living is a good example. Healthy personal behaviors from adults are possible only if they have filtered down into the schools for the purposes of educating for health and influencing the peer systems that reinforce behaviors.
Nursing’s strategic plan, as described in Nursing’s Agenda for Health Care Reform (ANA, 1991), for achieving a better balance between illness and cure and wellness and care is only an interim step. Nursing must document its effectiveness in providing quality, cost-efficient services. Establishing joint ventures, procuring grant monies and other funding sources, and conducting research are avenues that nursing must pursue to achieve these objectives.
Community Health
Parris and Hines (1995) recommend a commitment to a community-based approach to reform the system of health care delivery. Community-based care focuses on prevention and primary care. Community health nurses work in a variety of settings, including homes, clinics, workplaces, schools, church parishes, and organizations. They are skilled at providing services to populations at high risk for illness, homeless persons, aging populations, and those experiencing chronic
illness.
Regardless of the setting, fundamental principles of community care include the following (Hunt, 1998):
• Focusing on prevention
• Advocating client self-care
• Interactive nature between family, culture, and community
• Continuity of care
• Collaborative care
School Nursing
The advent of school nursing was an extension of public health nursing in the early 1900s.
This scope and immediacy of health care services is extremely significant to school children. A generation ago, programs funded by the Robert Wood Johnson Foundation demonstrated that school nurse practitioners can identify over 90% of the health problems of schoolage children and independently resolve over 80% of those problems (Igoe & Giordano, 1992). Despite these data, such services continue to be inaccessible to many children.
In 1992, HCFA funded Community Nursing Organizations (CNOs) to help meet the needs of elderly people in the community. The goal of CNOs is to provide quality health care services in a cost-effective manner. The four pilot projects (Carondelet Health Services, Tucson, AZ; Carle Clinic Association, Urbana, IL; Living at Home/Block Nurse Program, St. Paul, MN; and Visiting Nurse Service of New York, New York City) have demonstrated the following results:
• A high degree of client satisfaction
• Decreased Medicare expenditures in home care costs
• Use of less expensive equipment
• An expected decrease in emergency department costs (ANA, 1995)
Naylor and Buhler-Wilkerson (1999) call for nursing to “emphasize knowledge development related to care of vulnerable populations and the testing of innovative models of community based care,” (pp. 126–127). Examples of innovative models that meet community health care needs include:
• Columbia Advanced Practice Nurse Associates (CAPNA)—This practice, established in 1997, collaborates with Columbia University’s medical faculty to provide comprehensive services to clients in midtown Manhattan (Boccuzzi, 1998).
• North Carolina Maternal and Child Health Migrant Project—Nurses train women in migrant camps to provide health teaching and first aid (Sandhaus, 1998).
•
• Alberta Children’s Hospital in
Long-Term Care
Nurses propose a community-personal partnership in addressing long-term care and support various financial plans that enable individuals to anticipate their long-term care needs; for example, long-term care insurance, longterm care individual retirement accounts (IRAs), and accessing the equity in property and life insurance policies to use for health care costs. Nurses are also aware that need will exceed resources for many chronically ill, frail, and disabled Americans. In those cases where there is catastrophic need, government dollars must be available.
Nurses also support the concept of subacute care (short-term aggressive care that emphasizes restorative interventions before the client’s reentry into the community). The idea is not new but dates back to the Loeb Center of Montefiore Hospital in New York City in the 1960s (Kelly & Joe 1995)
TRENDS AND ISSUES
As current trends continue into the millennium, the delivery of health care services will continue to change The accompanying display lists factors that will continue to shape reform of the health care delivery system. The states and private sector will lead the way through a process to a product suited to the American character The nursing profession has reached a point in time where there are few questions about the direction or process of health care reform. As health care reform occurs, some professions will experience opportunities while others will experience losses (O’Neil, 1993). The challenge is to improve the nation’s delivery of health care services by positioning nursing to preserve its integrity and guarantee its preferred future. Nurses must continue to be in the forefront of change.
WHAT IS MEDICARE / MEDICAID?
Medicaid and Medicare are two governmental programs that provide medical and health-related services to specific groups of people in the
Medicare is a social insurance program that serves more than 44 million enrollees (as of 2008). The program costs about $432 billion, or 3.2% of GDP, in 2007. Medicaid is a social welfare (or social protection) program that serves about 40 million people (as of 2007) and costs about $330 billion, or 2.4% of GDP, in 2007. Together, Medicare and Medicaid represent 21% of the FY 2007
Both Medicaid and Medicare were created when President Lyndon B. Johnson signed amendments to the Social Security Act on July 30, 1965.
What is Medicaid?
Medicaid is a means-tested health and medical services program for certain individuals and families with low incomes and few resources. Primary oversight of the program is handled at the federal level, but each state:
· Establishes its own eligibility standards,
· Determines the type, amount, duration, and scope of services,
· Sets the rate of payment for services, and
· Administers its own Medicaid program.
What services are provided with Medicaid?
Although the States are the final deciders of what their Medicaid plans provide, there are some mandatory federal requirements that must be met by the States in order to receive federal matching funds. Required services include:
· Inpatient hospital services
· Outpatient hospital services
· Prenatal care
· Vaccines for children
· Physician services
· Nursing facility services for persons aged 21 or older
· Family planning services and supplies
· Rural health clinic services
· Home health care for persons eligible for skilled-nursing services
· Laboratory and x-ray services
· Pediatric and family nurse practitioner services
· Nurse-midwife services
· Federally qualified health-center (FQHC) services and ambulatory services
· Early and periodic screening, diagnostic, and treatment (EPSDT) services for children under age 21
States may also provide optional services and still receive Federal matching funds. The most common of the 34 approved optional Medicaid services are:
· Diagnostic services
· Clinic services
· Intermediate care facilities for the mentally retarded (ICFs/MR)
· Prescribed drugs and prosthetic devices
· Optometrist services and eyeglasses
· Nursing facility services for children under age 21
· Transportation services
· Rehabilitation and physical therapy services
· Home and community-based care to certain persons with chronic impairments
Who is eligible for Medicaid?
Each state sets its own Medicaid eligibility guidelines. The program is geared towards people with low incomes, but eligibility also depends on meeting other requirements based on age, pregnancy status, disability status, other assets, and citizenship.
States must provide Medicaid services for individuals who fall under certain categories of need in order for the state to receive federal matching funds. For example, it is required to provide coverage to certain individuals who receive federally assisted income-maintenance payments and similar groups who do not receive cash payments. Other groups that the federal government considers “categorically needy” and who must be eligible for Medicaid include:
· Individuals who meet the requirements for the Aid to Families with Dependent Children (AFDC) program that were in effect in their state on July 16, 1996
· Children under age 6 whose family income is at or below 133% of the Federal poverty level (FPL)
· Pregnant women with family income below 133% of the FPL
· Supplemental Security Income (SSI) recipients
· Recipients of adoption or foster care assistance under Title IV of the Social Security Act
· Special protected groups such as individuals who lose cash assistance due to earnings from work or from increased Social Security benefits
· Children born after September 30, 1983 who are under age 19 and in families with incomes at or below the FPL
· Certain Medicare beneficiaries
States may also choose to provide Medicaid coverage to other similar groups that share some characteristics with the ones stated above but are more broadly defined. These include:
· Infants up to age 1 and pregnant women whose family income is not more than a state-determined percentage of the FPL
· Certain low-income and low-resource children under the age of 21
· Low-income institutionalized individuals
· Certain aged, blind, or disabled adults with incomes below the FPL
· Certain working-and-disabled persons with family income less than 250 percent of the FPL
· Some individuals infected with tuberculosis
· Certain uninsured or low-income women who are screened for breast or cervical cancer
· Certain “medically needy” persons, which allow States to extend Medicaid eligibility to persons who would be eligible for Medicaid under one of the mandatory or optional groups, except that their income and/or resources are above the eligibility level set by their State.
Medicaid does not provide medical assistance for all poor persons. In fact, it is estimated that about 60% of
Who pays for services provided by Medicaid?
Medicaid does not pay money to individuals, but operates in a program that sends payments to the health care providers. States make these payments based on a fee-for-service agreement or through prepayment arrangements such as health maintenance organizations (HMOs).
Each State is then reimbursed for a share of their Medicaid expenditures from the Federal Government. This Federal Medical Assistance Percentage (FMAP) is determined each year and depends on the State’s average per capita income level. Richer states receive a smaller share than poorer states, but by law the FMAP must be between 50% and 83%.
States may impose nominal deductibles, coinsurance, or copayments on some Medicaid beneficiaries for certain services. However, the following Medicaid beneficiaries must be excluded from cost sharing:
· Pregnant women,
· Children under age 18, and
· Hospital or nursing home patients who are expected to contribute most of their income to institutional care.
All Medicaid beneficiaries must be exempt from copayments for emergency services and family planning services.
What is Medicare?
Medicare is a Federal health insurance program that pays for hospital and medical care for elderly and certain disabled Americans.
The program consists of two main parts for hospital and medical insurance (Part A and Part B) and two additional parts that provide flexibility and prescription drugs (Part C and Part D).
Medicare Part A, or Hospital Insurance (HI), helps pay for hospital stays, which includes meals, supplies, testing, and a semi-private room. This part also pays for home health care such as physical, occupational, and speech therapy that is provided on a part-time basis and deemed medically necessary. Care in a skilled nursing facility as well as certain medical equipment for the aged and disabled such as walkers and wheelchairs are also covered by Part A. Part A is generally available without having to pay a monthly premium since payroll taxes are used to cover these costs.
Medicare Part B is also called Supplementary Medical Insurance (SMI). It helps pay for medically necessary physician visits, outpatient hospital visits, home health care costs, and other services for the aged and disabled. For example, Part B covers:
· Durable medical equipment (canes, walkers, scooters, wheelchairs, etc.)
· Physician and nursing services
· X-rays, laboratory and diagnostic tests
· Certain vaccinations
· Blood transfusions
· Renal dialysis
· Outpatient hospital procedures
· Some ambulance transportation
· Immunosuppressive drugs after organ transplants
· Chemotherapy
· Certain hormonal treatments
· Prosthetic devices and eyeglasses.
Part B requires a monthly premium ($96.40 per month in 2009), and patients must meet an annual deductible ($135.00 in 2009) before coverage actually begins. Enrollment in Part B is voluntary.
Medicare Advantage Plans (sometimes known as Medicare Part C, or Medicare + Choice) allow users to design a custom plan that can be more closely aligned with their medical needs. These plans enlist private insurance companies to provide some of the coverage, but details vary based on the program and eligibility of the patient. Some Advantage Plans team up with health maintenance organizations (HMOs) or preferred provider organizations (PPOs) to provide preventive health care or specialist services. Others focus on patients with special needs such as diabetes.
In 2006, Medicare expanded to include a prescription drug plan known as Medicare Part D. Part D is administered by one of several private insurance companies, each offering a plan with different costs and lists of drugs that are covered. Participation in Part D requires payment of a premium and a deductible. Pricing is designed so that 75% of prescription drug costs are covered by Medicare if you spend between $250 and $2,250 in a year. The next $2,850 spent on drugs is not covered, but then Medicare covers 95% of what is spent past $3,600.
What about services that are not provided through Medicare?
Supplemental coverage for medical expenses and services that are not covered by Medicare are offered through MediGap plans. MediGap consists of 12 plans that the Centers for Medicare and Medicaid Services have authorized private companies to sell and administer. Since the availability of Medicare Part D, MediGap plans are no longer able to include drug coverage.
Who is eligible for Medicare?
To be eligible for Medicare, an individual must either be at least 65 years old, under 65 and disabled, or any age with End-Stage Renal Disease (permanent kidney failure that requires dialysis or a transplant.)
In addition, eligibility for Medicare requires that an individual is a
Who pays for services provided by Medicare?
Payroll taxes collected through FICA (Federal Insurance Contributions Act) and the Self-Employment Contributions Act are a primary component of Medicare funding. The tax is 2.9% of wages, usually half paid by the employee and half paid by the employer. Moneys are set aside in a trust fund that the government uses to reimburse doctors, hospitals, and private insurance companies. Additional funding for Medicare services comes from premiums, deductibles, coinsurance, and copays.
KEY CONCEPTS
• The three levels of health care services can be categorized as primary, secondary, and tertiary levels.
• Health care services are delivered by both the public (official, voluntary, and nonprofit agencies) and private (hospitals, extended care facilities, home health agencies, hospices, outpatient settings, schools, industrial clinics, managed care organizations, community nursing centers, and rural hospitals) sectors.
• The health care team is composed of nurses, APRNs, physicians, physician assistants, pharmacists, dentists, dietitians, social workers, therapists, and chaplains.
• Health care in the
• Managed care organizations seek to control health care costs by monitoring the delivery of services and restricting access to costly procedures and providers.
• Managed care plans include health maintenance organizations, preferred provider organizations, and exclusive provider organizations.
• The primary federal government insurance plans are Medicare, the program that provides health care coverage for the elderly and disabled, and Medicaid, the jointly administered program that provides health care services for the poor.
• Health care reform must address the three critical issues of cost, access, and quality of health care services to achieve equity for all Americans.
• The cost of health care has been influenced by the oversupply of specialists, a surplus of hospital beds, the passive role assumed by most consumers, and the inequitable financing of health care services.
• The challenges that the health care delivery system need to overcome are the public’s disillusionment with providers, the public’s loss of control over health care decisions, the decreased use of hospitals and the related impact on quality of care, the change in practice settings, ethical issues, and the health care needs of vulnerable populations.
• Nursing’s Agenda for Health Care Reform, written by the American Nurses Association and endorsed by over 70 professional organizations, outlines nursing’s pro-posals for easing the current problems in health care delivery.
• The Agency for Health Care Research and Quality aims to identify therapeutic standards for which the health care community can be held accountable.
• For advanced practice nurses to continue to provide access to high quality care, issues such as direct reimbursement for services, prescriptive authority, comprehensive professional liability insurance, autonomy in managed care plans, professional staff privileges in health care facilities, and adequate practice acts need to be resolved.
• A primary goal of the nursing profession within the areas of public health, community health, and longterm care is to provide health care services that emphasize prevention and primary health care to clients in these settings and thus help reduce the cost and increase the quality of health care.
NURSING RESEARCH AS THE BASIS OF NURSING
Nursing research worldwide is committed to rigorous scientific inquiry that provides a significant body of knowledge to advance nursing practice, shape health policy, and impact the health of people in all countries. The vision for nursing research is driven by the profession’s mandate to society to optimize the health and well-being of populations (American Nurses Association, 2003; International Council of Nurses, 1999). Nurse researchers bring a holistic perspective to studying individuals, families, and communities involving a biobehavioral, interdisciplinary, and translational approach to science. The priorities for nursing research reflect nursing’s commitment to the promotion of health and healthy lifestyles, the advancement of quality and excellence in health care, and the critical importance of basing professional nursing practice on research.
As one of the world leaders iursing research, it is important to delineate the position of the academic leaders in the
Nursing Research: A Scientific Basis for the Health of the Public
Nursing research provides the scientific basis for the practice of the profession. Using multiple philosophical and theory-based approaches as well as diverse methodologies, nursing research focuses on the understanding and easement of the symptoms of acute and chronic illness; prevention or delayed onset of disease or disability, or slowing the progression thereof; finding effective approaches to achieve and sustain optimal health; and improvement of the clinical settings in which care is provided (National Institute of Nursing Research, 2003). The study of professional socialization and the educational processes that best prepare nurses and nurse scientists to succeed are also appropriate foci of nursing research, given the growing demand for increasing efficiency and effectiveness in higher education and the critical need for leadership development in all areas of the nursing profession.
The critical societal issues that influence the direction of nursing research usually flow from individual- and population-based health determinants. Such health determinants are multifactorial iature, including: the physical environment for work and life; behaviors of individuals, families, and communities; biologic factors including genetic predisposition to health problems; social factors including socioeconomic position and resources; discrimination factors and the availability of social networks as well as access to and use of various health services (Longest, 2002).
Nursing research also is guided by several major national health policy directives, an example of which is Healthy People 2010: Understanding and Improving Health (U.S. Department of Health and Human Services, 2000). The two overarching goals are: 1) helping individuals of all ages to increase life expectancy and improve their quality of life, and 2) eliminating health disparities among different segments of the population in the
Today’s complex health problems are not amenable to single-discipline research approaches. While nursing, social science, and biomedical research approaches make unique and independent contributions to the public’s health, they also complement each other and bring balance to the nation’s health and research agenda. Interdisciplinary research is an essential characteristic of nursing research because multiple perspectives are required for the complex study of health and illness experiences of society.
In order for nursing to be at the forefront of knowledge generation and address societal issues and health care, nursing research must be relevant to health and illness situations, scientifically rigorous, and readily translatable into practice and health policy (Potempa & Tilden, 2004). To this end, the community of nurse scholars recognize that the science of nursing is growing rapidly and they are committed to the challenges posed by the constant progression of new knowledge.
Scope of Nursing Research
Nursing research encompasses a wide scope of scientific inquiry including clinical research, health systems and outcomes research, and nursing education research. Clinical research, based on biological, behavioral, and other types of investigations, provides the scientific basis for the care of individuals across the life span and occurs in any setting where nursing care is provided. Health systems and outcomes research examine the availability, quality, and costs of health care services as well as ways to improve the effectiveness and appropriateness of clinical practice. Finally, nursing education research focuses on how students learn the professional practice and discipline of nursing as well as how to improve educational strategies to prepare clinicians and scientists.
Clinical Research
The scope of clinical research ranges from acute to chronic care experiences across the entire life span; health promotion and preventive care to end-of-life care; and care for individuals, families, and communities in diverse settings. It is imperative for nursing research to take a farsighted approach in order to have greater impact in the future. For example, recent discoveries in the genetic basis of disease and behavior may help nurse scientists to develop more effective strategies to manage symptoms and tailor interventions.
Nursing’s expanded view of health emphasizes health promotion, restoration, and rehabilitation, as well as a commitment to caring and comfort. In this way, nursing research differs from biomedical research. The focus of biomedical science on the discovery of disease causation and cure is essential but not solely sufficient to improve health. Despite the dramatic successes of improved diagnostic and therapeutic modalities, improvements in overall health of the public require a broader approach. Some diseases are better prevented than treated, others simply cannot be cured, and suffering and irreversible changes such as aging are part of the human experience. Indeed, health can be far better maintained when it is viewed in the broader context of lifestyle, culture, and socioeconomics.
Nurse researchers study how to assist individuals and groups as they respond to health and illness experiences (e.g., reducing side effects of illness and treatment) and address social and behavioral aspects of illness and quality of life. Much nursing research is biobehavioral iature, seeking to understand the relationships among biological, behavioral, psychological, and sociological factors. These factors are integrated in all beings. For example, recent discoveries demonstrate that biological factors (e.g., genetic background, neuronal connections, and brain plasticity) affect behavioral factors and that behavioral interventions (e.g., diet and exercise) affect biological factors (e.g., cell functions).
Complex problems in human health require interprofessional approaches. Interdisciplinary research is one of three major areas defined in the National Institutes of Health (NIH) Roadmap (NIH, 2004). Nurses are uniquely qualified to lead and participate in interdisciplinary research teams because their education includes courses from all health-related disciplines (e.g., physiology, pharmacology, psychology, and sociology) and they focus on the integration of these disciplines in providing comprehensive care. The nursing research priorities identified by the National Institute of Nursing Research (NINR) illustrate the vital contributions of nurse scientists. Federal priorities evolve within the nursing community and can be found on the NINR Web site (http://www.nih.gov/ninr). These areas include chronic illnesses or conditions, behavioral changes and interventions, and response to compelling public health concerns. Particular attention is given to health disparities and vulnerable groups such as minorities, infants, youth, and older adults.
Health Systems and Outcomes Research
Nursing research on health systems and outcomes seeks to identify ways that the organization and delivery of health care influence quality, cost, and the experience of patients and their families. While research on such topics is not exclusive to any single discipline, nursing has a particular focus that brings important balance to the health and biomedical research agenda for the nation. For example, nursing research is integrated with health services research regarding issues of organization, delivery, financing, quality, patient and provider behavior, informatics, effectiveness, cost, and outcomes. It evaluates both clinical services and systematic structures in which those services are delivered; it explores appropriate balance of personnel to provide effective and efficient care while controlling costs of health care. As the health care environment changes rapidly, the consolidation of health plans and care settings continues. Large numbers of Americans are indigent and/or lack adequate health insurance and therefore do not receive even minimal health care. The containment of costs, continued problems with access to care, and efforts to develop quality care has increased the demand for nurse researchers to broaden their understanding of the research continuum to include the development of knowledge and skills in health services research. This area of research is supported largely by the Agency for Healthcare Research and Quality (AHRQ) and provides evidence on which to base clinical practice (http://www.ahrq.gov).
Nursing Education Research
Nursing education research centers on developing and testing more efficient educational processes, identifying new ways to incorporate technology in order to enhance learning, and discovering more effective approaches to promoting lifelong learning and commitment to leadership. To achieve these goals, the use of rigorous research strategies in the assessment of the teaching-learning process and outcomes at all levels of nursing education is essential from baccalaureate and graduate education through. The continuous supply of well-educated nurses is critical to maintain and enhance our nation’s health, especially in light of the changes in the demographics of the population. To this end, new strategies for recruiting and retaining bright young men and women from diverse educational and cultural backgrounds into nursing must be developed and tested. In addition, new models of nursing education are needed to prepare nurses for faculty and research positions earlier in their careers. These efforts must assume top priority if nursing research is to continue to evolve. The lack of recognition and funding for this type of research has greatly impaired progress in this area.
Scientific Integrity
Scientific integrity and the ethics of investigation transcend and are part of all nursing research ventures. Nursing’s commitment to an egalitarian application of professional standards and ethics has earned the trust of the public. Similarly, nursing research is guided by commitment to ethical standards in all phases of scientific discovery and use of knowledge. As participants in the global interdisciplinary scientific community, nurse researchers examine and debate the ethical dimensions and dilemmas inherent in designing, conducting and reporting research.
Nursing education provides grounding in major research ethical constructs from the Nuremberg Code (1947), Declaration of Helsinki (World Medical Association, 1964), National Research Act of 1974 (Public Law 93-348), and Belmont Report (NCPHS, 1979); all of which are reflected in the federal Common Rule regulating research in the United States (DHHS 45CFR46, 1991). These ethical and legal precepts simultaneously guide investigators as well as nurses caring for patients who are also research subjects.
Nurse researchers, whether working alone or within interdisciplinary teams, consider appropriate boundaries between practice and research, address conflicts of interest, provide for protection of subjects, and maintain systems of checks and balances to ensure the integrity of the research enterprise. As part of the profession’s responsibility for advocacy, nurses take appropriate action whenever scientific misconduct is identified.
Creating a Culture and Workforce for Nursing Research
Regardless of discipline, the research enterprise can thrive only when certain prerequisites are in place, including a culture supportive of research and scholarship; strong mentoring in the intellectual work of the discipline; educational programs to ensure an adequately sized and appropriately educated research workforce; and provision for necessary infrastructure and funding mechanisms to support coherent programs of research.
Cultures supportive of research and scholarship generally develop within academic institutions where knowledge development, discourse, and debate are expected and encouraged. Given the broad scope of nursing research, this also means that nurse researchers require environments that support integration of various approaches to inquiry. Collaborative research among nurse scientists that brings together a range of perspectives on a particular question will result not only in a better understanding of and coherence in the entire discipline, but also in an understanding of how knowledge from one field complements and extends learning in another. Further, contemporary research problems demand that nurse scientists move into more interprofessional collaboration, team-based work, and increase attention to the rapid progression to safe and appropriate practical application of findings (NIH, 2004).
Programs of nursing that offer baccalaureate and higher degrees lay the groundwork for the research enterprise by preparing professional nurses capable of using scientific knowledge in their practice and contributing to new knowledge. Such programs are committed to teaching and integrating nursing research as well as other relevant research (e.g., biomedical, clinical, health care services, business, public health, and health care policy) into all nursing curricula. Teaching from such a base prepares graduates to evaluate and use evidence appropriately and, with advanced preparation, generate new knowledge for nursing practice.
The ultimate goal of research training iursing at all levels is to strengthen the profession’s contribution to enhancing the health and healthcare of individuals and populations. The expectations and competencies of graduates at each level of nursing education in regard to research are described below:
- Baccalaureate programs prepare nurses with a basic understanding of the processes of research. Graduates can understand and apply research findings from nursing and other disciplines in their clinical practice. They understand the basic elements of evidence-based practice, can work with others to identify potential research problems, and can collaborate on research teams.
- Master’s programs prepare nurses to evaluate research findings and to develop and implement evidence-based practice guidelines. Their leadership skills enable them to form and lead teams within their agencies and professional groups. They identify practice and systems problems that require study, and they collaborate with scientists to initiate research.
- Practice-focused doctoral programs prepare graduates for the highest level of nursing practice beyond the initial preparation in the discipline. Graduates obtain the highest level of practice expertise integrated with the ability to translate scientific knowledge into complex clinical interventions tailored to meet individual, family and community health and illness needs. In addition, these professionals use advanced leadership knowledge and skills to evaluate the translation of research into practice and collaborate with scientists oew health policy research opportunities that evolve from the translation and evaluation processes. They are prepared to focus on the evaluation and use of research rather than the conduct of research (AACN, 2004a).
- Research-focused doctoral programs prepare graduates to pursue intellectual inquiry and conduct independent research for the purpose of extending knowledge (AACN, 2001). Graduates are expected to plan and launch an independent program of research, seek needed support for initial phases of the research program, and begin to involve others (i.e., students, clinicians, and other researchers) in that work.
- Postdoctoral programs provide graduates from research-focused doctoral programs not only with a period of time devoted fully to further developing research skills, but the opportunity to establish their research program with the formal mentorship of senior investigators. Formal postdoctoral study generally ensures that an individual’s research program is firmly launched before facing the multiple demands of any academic, clinical, or administrative position.
Just as all collegiate schools of nursing do not offer the total range of degree programs, not all academic nursing environments can offer equal support to the research enterprise. While it is understandable that many nursing schools aspire to offer the research-focused doctorate, not all schools are well-suited to this activity. In order to ensure that future nurse scientists successfully develop and sustain significant programs of research, serious attention must be paid to the research culture in which they will be trained. The major components required for the effective preparation of new scientists, as outlined in AACN’s Indicators of Quality in Research-Focused Doctoral Programs in Nursing (2001) include:
- productive research faculty who are at the cutting edge of their field of inquiry;
- environment in which mentoring, socialization of students, and a community of scholars is evident;
- coherent and well-designed programs of study, including opportunities for interdisciplinary study and research;
- adequate infrastructure and resources, and
- highly qualified and motivated students.
The next stage of development in nursing research encompasses the creation of highly dynamic research environments that enable a greater proportion of faculty to excel as scientists, in that the volume and quality of their work has a substantial influence on health care. Such environments are characterized by the following attributes: an increasing number of positions in which faculty concentrate almost entirely on research, research mentorship and research leadership; balancing of teaching, research, and service missions across the school as a whole rather than within individual faculty activities; and inclusion of students at all educational levels directly in faculty research (Potempa & Tilden, 2004).
The nursing research enterprise has made great strides over the last 30 years, and many nursing schools have well-established research environments. Nevertheless, future progress may be impeded by two worrisome trends: 1) most nursing doctorates are earned much later in life than is true in other disciplines, thus shortening the time available for an active research career, and
2) production of new nurse faculty (and in particular, new nurse scientists) is far behind what is needed now and in the future.
A significant challenge facing the nursing research community is that nurses tend to pursue doctoral study later in their careers than those in other research fields. Almost one-half (49%) of graduates from nursing doctoral programs in fiscal year 2002 were between the ages of 45 and 54 years of age, with a median age of 47 (National Science Foundation et al., 2004). Given that the median age of retirement for doctorally prepared nurse faculty is 63.1 years, they have only a limited number of years to accomplish the career goals expected at this level, such as becoming master teachers; building long-term, funded research programs; and using their expertise to shape health policy at the state, national, and international levels (AACN, 2004b; Hinshaw, 2001).
A major policy and cultural shift is needed iursing doctoral education to achieve earlier entry into research careers (National Research Council, 2005). The meaumber of years from completion of a baccalaureate degree to graduation from a research-focused doctoral program is 21.8 years for nurses, compared to 12.7 years for all research doctoral recipients (National Science Foundation et al., 2002). Likewise, the meaumber of years registered in a doctoral program prior to graduation is 1.8 years longer for nursing compared to other fields (9.3 and 7.5 years, respectively), a function of part-time study (Berlin,Wilsey, & Bednash, 2005; National Science Foundation et al., 2002). Earlier matriculation into doctoral programs and full-time study will enable graduates to establish long-term careers in academic nursing and develop sustained programs of research and teaching.
The shortage of doctorally prepared faculty will continue to exert a negative effect oursing’s research agenda well into the future by severely limiting the pool of available nurse scientists, straining the human and fiscal resources necessary for the conduct of research, and creating circumstances in which new investigators will have difficulty in establishing and maintaining productive research programs. Strategies have been identified to ensure the continued vitality of nursing research during this critical time (AACN, 2003). In addition, schools may consider exploring whether interdisciplinary faculty appointments will be useful in supporting teaching and research efforts iursing doctoral programs (Potempa & Tilden, 2004; AACN, 2003).
Importance of a Research-Intensive Environment
A research-intensive environment is essential in order to generate the science base for nursing and interprofessional practice and to educate future generations of nurse scientists. Financial support and a strong value for generating as well as disseminating knowledge must be present within departments and schools, in the larger academic institution, and at the national level.
The importance placed on the research mission by the larger institution has a major impact on a school of nursing’s research environment. In research-intensive environments, support is evident in the hiring and retention packages provided for investigators; peer and administrative review mechanisms used for appointments and promotions; availability of start-up research funds for faculty; and support for continuing faculty development in research, such as professional leaves and sabbaticals, career awards, and pilot funding. It is in this kind of environment that nurse scientists are able to engage in and/or lead interdisciplinary research activities.
Schools of nursing provide the research environment for faculty and the next generation of nurse scientists. A supportive infrastructure may include an office or center for research; concentrated centers or areas of research excellence; formative and summative mock reviews of grant applications and manuscripts; informal or formal mentorship programs; visiting scholars; and internal and external consultants. Institutional research training grants and leadership in interdisciplinary research training grants provide key infrastructure support for educating the next generations of clinical scientists. The research productivity of the faculty (including grants obtained and sustained, manuscripts published, and the number of doctorally prepared graduate faculty) and the successes of doctoral program graduates are indicators of an environment in which faculty research can flourish (AACN, 2001).
Research productivity in schools of nursing is enhanced by faculty appointed on research tracks as well as by tenure-track faculty with active programs of research. Faculty with research appointments devote their full effort to research and are often expected to generate their salaries through research funding. Research-track faculty enhance the productivity of the overall research enterprise through collaborating with tenure-track faculty as well as developing their own programs of research. As a result, faculty build research programs supported by multiple grants and greatly expand the scope and impact of their science.
Moreover, wider university support for field-specific and interdisciplinary research is crucial to enable nurse scientists to lead interdisciplinary research teams and to participate fully as team members. Policies regarding distribution of indirect cost returns, establishment of centers of excellence across disciplinary or professional boundaries, and central support for interdisciplinary work enables teams of committed researchers to exchange views and collaborate effectively to solve complex scientific problems. In such settings, research permeates the entire academic enterprise.
As adequate research infrastructure at the national level also is critical. Opportunities for nurse scientists to present their work for scrutiny and consideration by colleagues include peer-reviewed discipline-specific and interdisciplinary journals that cover the full spectrum of nursing research. In addition, regional, national, and international conferences provide wide exposure of nursing research within and outside the discipline. Nurse scientists obtain funding from a wide range of federal and private sources. Indeed, diversity of funding streams is essential to maintain a healthy research infrastructure. Federal funding sources including NINR and other NIH institutes provide funding for nursing research and support for research training for pre- and post-doctoral students, new investigators, and mid-career researchers. AHRQ funds research on the outcomes, effectiveness, and quality of health care conducted by all health professions scientists. Other agencies within the Department of Health and Human Services (DHHS) such as the Centers for Disease Control (CDC), Agency for Substance Abuse and Mental Health Services (SAMSHA), and Health Resources Services Administration (HRSA) provide funding for focused program evaluation research and demonstrations. Professional, public, and private organizations also offer competitive research funding and training support (e.g., American Heart Association, The Robert Wood Johnson Foundation, and The John A. Hartford Foundation).
Despite a documented need for more doctorally prepared research faculty and postdoctoral education, the quality of preparation possible in any academic nursing setting will be compromised if the research environment is not supported adequately. Building the research infrastructure is vital to strengthening nursing research’s impact on the public’s health and health care outcomes. Therefore, increasing the funding base available to nurse scientists is critical.
The Research
Nursing research faces a number of challenges and opportunities stemming from rapid growth and limited resources. In the past two decades, with the rapid expansion of resources for research, nursing’s contribution to evidence-based practice and health policy has increased exponentially. Even so, a number of challenges are preventing the discipline of nursing from achieving its full scientific potential.
Career Trajectories of Nurse Scientists
Basic to all other challenges faced by the nursing research community is the problematic nature of the typical nurse scientist’s career trajectory (NRC, 2005): late commitment to doctoral preparation, which in turn severely truncates opportunities for research and leadership. This traditional career pathway drastically curtails development of the research base for nursing practice because of shortened programs of investigation. In addition, it limits the ability of nurse scientists to provide multiple levels of leadership (especially national health policy leadership) and thus to impact policy. The need to change this career trajectory has instigated the development of baccalaureate-to-doctoral programs. However, in order to provide incentives for early entry into doctoral programs, future nurse scientists will require continued and expanded commitment and availability of funding, such as institutional (T32), individual predoctoral (F31), and postdoctoral (F32) fellowships.
Unfortunately, traditional nursing career pathways have not shifted dramatically. As Potempa and Tilden (2004) noted, the teaching component has dominated the tripartite academic mission, sometimes at the expense of research. Equal emphasis can be placed on research development in schools of nursing, such that curricular demands coincide with faculty research expectations. Alternative types of faculty workloads can be created to foster the development of comprehensive and cohesive programs of research at schools of nursing. These alternatives may include a system of incentives and rewards, such as attractive start-up packages and early investment by administration to sustain focused faculty research.
Impact of the Nursing Faculty Shortage on Research
Schools of nursing and affiliated health organizations are under major financial pressures to deliver educational and health services more effectively. The national shortage of nurses has prompted schools of nursing to increase undergraduate and graduate enrollments during a time when there are dire shortages of doctorally prepared faculty (Berlin & Sechrist, 2002; Hinshaw, 2001; Anderson, 2000). Shortfalls in the number of doctorally prepared faculty are influenced by two factors: 1) the impact of faculty age and retirement timelines and 2) a diminishing pool of replacement faculty (Berlin & Sechrist, 2002). These shortages pose a serious challenge to the generation of knowledge for nursing practice and health policy. This crisis will impact systematic initiatives that enhance the academic research enterprise, and it has significant implications for the long-term research productivity for the discipline. Limited financial resources in the context of a larger student-to-faculty ratio create competing demands across academic institutions in general, and specifically, influence the tripartite mission of nursing education, research, and practice. Balancing these multiple roles requires the creative integration of education and research and the use of interdisciplinary opportunities to enhance research productivity. Mechanisms that protect and promote the core mission of an environment of discovery and maintain the research infrastructure must be developed and tested. Incentives to position faculty to compete effectively for extramural research while at the same time preserving the teaching mission, should be considered. Specialized faculty assignments (i.e., clinical versus research) designed to strengthen research productivity warrant further evaluation.
Research Collaboration and Partnerships
Additional efforts to promote and support collaborations by a variety of scientists are needed. Institutions must develop effective mechanisms that improve linkages across research programs in biomedical, clinical, health services, and prevention research (
Research-Focused Doctoral Programs
The number of research-focused doctoral programs iursing has increased from
Funding for Nursing Research
Given the scope of nursing research, the increased numbers of well-prepared scientists in the scholarly community, and the multiple societal and health/illness issues demanding attention, the resources for nursing research are severely strained. To facilitate nursing research, major new sources of funds are needed to build long-term research programs and support career trajectories for nurse scientists whose programs of research are devoted to the generation of knowledge for nursing practice and health policy. Developing new centers of excellence, as evidenced by strong research-intensive nursing environments and sustained programs of translational, cutting-edge research will require considerably more resources than are currently available.
A major positive step was the establishment of the NINR in April 1986. However, while its funding has grown from approximately $11 million to $135 million, this is a small amount relative to allocations for other health science institutes (e.g., dentistry) and for major disease category funding such as cancer and Alzheimer’s disease. The budget of NINR, which doubled with the rapid increase in the NIH budget from 1999-2004, needs to be doubled once again to provide the resources for the strong additional contributions that can be made by nursing research to the health of the American public. In addition, because of the interdisciplinary nature of much of nursing research, greater diversity in the funding opportunities available to nurse scientists should be pursued, including increased funding from other NIH Institutes, AHRQ, CDC, and a wide array of foundations.
Summary
The essence of a discipline is its body of scientific knowledge, its system of values and ethics, and its societal worth. In a practice discipline such as nursing there is the added dimension of thoughtful and discriminating application of knowledge from other disciplines and perspectives (Carper, 1978). It is this complex relationship between the building of a body of science, the utilization of knowledge from multiple disciplines, and the application to practice and health policy that presents opportunities and challenges for the academic nursing community.
