Young Kim/NurseWeek

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Imagine a world: Where community clinics, run by nurse practitioners, take care of everyone from infants to grandparents in schools, day care centers, workplaces, churches and community center—Where school nurses teach children about good health and lifestyle habits from the time they are in preschool —Where Medicare and Medicaid reimbursement systems actually reflect the cost of caring for patients— Where emergency rooms are only for emergencies —Where good mental health is considered as important as good physical health— Where people don't have to choose between paying for groceries and paying for medications— Where the elderly stay independent and remain in their homes as long as possible— Where people are allowed to die in peace when it is clear nothing more can be done for them —Where you don't have to get sick before you can talk to someone about your health. …Welcome to a world where nurses are in charge.

WHEN WE ASKED NURSES to imagine what the nation's health care would look like if it were run according to a nursing philosophy, they were eager to share their insight. Their ideas included sweeping changes-a network of community health centers run by nurse practitioners, payment and reimbursement systems that made health care accessible to everyone-and smaller details-better technology for nurses at the bedside, a uniform insurance billing code that would save hundreds of hours in paperwork.

Almost no one suggested spending more money on health care. Most seem to think the problem lies in the way the money is spent-too much on profits, administration and intervention, not enough on patient care, education and prevention.

"If [all legislators] thought like nurses, we would be focused on people and their health needs," said Rep. Lois Capps, RN, D-Calif., one of three nurses in the U.S. House of Representatives. "We would understand how pervasive health care is in our world."

The first thing they would do, most nurses we talked to said, is switch to a system that emphasizes prevention and wellness over intervention and sickness, and looks at the health of the community as a whole.

"We're so socialized into thinking that health care means medical care that we use the words interchangeably," said Sally Lundeen, Ph.D., RN, FAAN, professor and dean, University of Wisconsin, Milwaukee, College of Nursing. "We've put our eggs into the treatment basket and allocated nearly all our resources there."

As a result, the health care system kicks into gear only when someone gets sick, said Tim Porter-O'Grady, Ed.D., Ph.D., FAAN, senior partner of Tim Porter-O'Grady Associates and associate professor of nursing at Emory University in Atlanta.

For example, he said, "I can't get any insurance for a purely preventive colonoscopy every five years" even with a family history of colon cancer. "But if I get colon cancer, my treatment will be paid for 100 percent. Even though the prevention costs are one-tenth of 1 percent of the cost of treating my colon cancer."

Considering that many costly and chronic illnesses are caused or exacerbated by lifestyle habits or environmental factors-smoking, heart disease, hypertension and diabetes among them-a system that waits until someone becomes ill doesn't make much sense anymore, nurses say.

"Nurses see the wellness aspect of patient care so much," said Becky Keck, MSN, assistant hospital director of nursing finance and operations at Vanderbilt University Medical Center.

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