If Nurses Ruled
RNs envision a nurse-run health care system with an emphasis on wellness, prevention and patients

By Cathryn Domrose
November 5, 2003

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.

Better than a cure

In a health care system run by nurses, nurse practitioners in community clinics would take care of people before they became ill, giving immunizations, doing screenings, providing diet and nutrition programs, treating minor conditions before they turned into something bigger and managing chronic illnesses.

"Then the only people in the emergency rooms would be those who really needed it," Keck said.

Such clinics already exist in pockets across the United States. In clinics run through a program at the University of Wisconsin, Milwaukee, College of Nursing, nurse practitioners see people "where they live, learn, work and play," Lundeen said. For example, a mother with a toddler in tow and a baby on her hip might run into a nurse she knows in the hall on the way to her day care center. The young mother mentions she's not getting much sleep because her baby is crying a lot at night.

The nurse has her step into the clinic next to the day care center, checks the baby's ears and finds an infection. While she's there, she asks if the baby is up-to-date on immunizations and gives a necessary vaccination. She notes that she hasn't seen the 2-year-old in a while. How is she doing? She asks if the mother is still thinking about getting her GED and tells her about a study program at a nearby community center. She asks if the woman's mother is still living with her. Last time, her blood pressure was high. Has she had it checked recently?

In a 15-minute encounter, the nurse uses a "pre-emptive strike" to prevent a trip to the emergency room with a screaming baby who has a raging ear infection, Lundeen said. She also brings the baby up-to-date on immunizations, checks on the 2-year-old, sends a reminder to get an elderly woman's blood pressure checked and gives the mother some peace of mind about her crying infant.

"Health care becomes part of the routine of that mom's day," Lundeen said. "It seems so simple, doesn't it? This is how people need to live their lives."

Nurses also understand how issues such as gun safety, air quality and safety regulations relate to the health of a community, said Rep. Carolyn McCarthy, LPN, D-N.Y. "It's the whole lifestyle, it's everything you do. These things are all connected to good health care." They understand the importance of having good mental health as well as good physical health, she said. If nurses made the laws, there would be parity for mental health coverage. "They know that someone can't see a therapist one or two times and expect a cure."

Easy access

Almost as important as wellness and prevention, nurses said, is access to health care. "From a nurse's perspective, access and payment should be something that's universal," Porter-O'Grady said.

People, especially in underserved areas, would have better access to health care through community clinics and an improved system of home care. In a nurse-run health care system, every new mother would receive a visit from a home care nurse to make sure that she was doing well, and that the infant had his or her first well-baby exam by a pediatrician or pediatric nurse practitioner.

"Health care was never meant to be a cash cow, something just to make money," said Rep. Eddie Bernice Johnson, MPH, RN, D-Texas. "It was meant to be a service. If nurses were in charge, I think it would be a good balance. I think the focus would be on the patient and not on the bottom line, which is the dollars."

Nurses' ideas on health care payment plans varied. Some suggested states and employers be allowed to pool their risks to increase negotiating power with insurance companies. "I think there's a place for health insurance" in a nurse-run system, Porter-O'Grady said, but it should adhere to much stricter standards than a regular business.

Capps suggested lowering the age for Medicare, expanding Medicaid to cover the working poor and creating programs to assist employers in insuring workers. Nurses would make prescription medicines part of almost any coverage, she said.

"It's not easy, but there's no reason why we can't do it," she said.

Some states, Capps noted, are looking at ways to provide universal coverage, and depending on how these systems work, the notion could become more popular in the rest of the country.

Many nurses thought universal coverage, with the federal government as the primary payer, would ensure that everyone received affordable health care. "I think most nurses would tell you that that would make the most sense," said Cheryl Johnson, RN, clinical nurse 3 at University of Michigan Health System in Ann Arbor, president of United American Nurses and vice president of the Michigan Nurses Association.

But this does not mean unlimited health care, she added. In fact, nurses, who assess and triage patients all the time, take the same discerning look at the health care system.

"Health care is a finite resource and to treat it as if it were infinite is insane," Johnson said. "How good a system do you need? Do you have to have absolutely everything? We don't need a lavish system if we work for prevention."

Assuring access means making some tough decisions as a society, Keck said. "We literally treat people to death. Other societies don't do that. We have tried to do all things for all people in all ways and I'm not sure at the end of the day that we have something that's better."

Learning curve

A nurse-run health care system would emphasize education, both for health care professionals and the public, much more than today's system does, nurses said. A Congress full of nurses long ago would have passed the Nurse Reinvestment Act to help pay for nurses' education, Capps said. Nurses also would insist on more training and education for nursing assistants, Keck said.

Many nurses envisioned nurse practitioners in every school, working as primary providers for people in the school community as well as offering health education and fitness programs, guidance on nutrition and school meals and making sure that children were exercising.

Nurses also would focus on technology to reduce nurse stress, including documentation and physical lifting.

"We've got tons of technology to tell us what's going on inside a patient," said Barbara Blakeney, MS, ANP, RN, president of the American Nurses Association. "What we don't have enough of is the technology that helps the nurse physically take care of the patient."

Designer care

Under a nurse-run system, hospitals would be designed with the needs of patient and worker safety in mind. Technology to move and lift patients would be designed within the rooms, so nurses wouldn't have to spend 20 minutes looking for a bulky piece of equipment. A "no-lift" policy, similar to what Blakeney has seen in Europe, would mean that, except for emergencies, lifting simply would not be part of a nurse's job.

Nurses also would insist on data entry systems that streamline paperwork and avoid duplication. Home health care nurses would not have to wait until their children went to sleep to spend four hours documenting their patient visits-they would type or speak the information into handheld computers or laptops as they collected it, Blakeney said.

Nurse-run hospitals would return to their true business-patient care-instead of profits and physician convenience. "This is not about making money for insurance companies," said Kathleen Sanford, RN, vice president of nursing at Harrison East Bremerton (Wash.) Hospital and administrator at Harrison Silverdale Hospital. "This is not about the opportunity to give people cushy jobs." Yes, she said, hospitals should run in the black. But money should go back into patient care and supporting those who care for patients.

Nurses would schedule operating room surgeries in accordance with when the most patients were coming in-not according to when physicians wanted to do their outpatient procedures, Blakeney said. They could close units if they didn't have enough staff and manage staffing patterns according to patient acuity.

"While physicians would continue to admit patients, I think it could be up to the nurse to discharge them," Blakeney said, because nurses are in a better position to know when patients and their families are ready for discharge.

Team approach

Nurses would improve the team approach to health care, said Judy Sweeney, MSN, RN, associate professor at Vanderbilt University and first-year-level director for the nurse practitioner program. Nurses would be working on discharge planning the moment a patient is admitted to the hospital. They would understand the importance of coordinating home health, mental health, spiritual care and other professionals into the patient's care, she said.

Physicians would continue to play an important role in health care, nurses added. They would continue to provide research, expertise and diagnose and treat illness. "That's their training," Keck said.

But in a nurse-run system, nurses would be equal partners with the physicians. Physicians would diagnose and prescribe. Advanced practice nurses could implement a plan of care and continue to assess patients, she said. "The model now is still pretty heavily focused on the physician's role."

Nurses also would demand and get more respect from physicians and administrators, Sanford said. They would sit on hospital boards and would be consulted about hospital policy changes. "If nurses ran the system, there would be a better relationship between doctors and nurses," she said.

"We would say, 'We're your equal and we're going to work together.' "

Senior support

A nurse-run system also would deal differently with issues around aging and dying. "They'll probably pay attention to it, which is a lot different from what we have now," said Bernice Buresh, a health journalist and co-author, with Suzanne Gordon, of From Silence to Voice: What Nurses Know and Must Communicate to the Public, a book about the need for nurses to speak out.

Now, older people go to the doctor, get more medications and go home, Buresh said. "It's not really a care system at all." Nurses would look at ways to manage chronic illnesses through other methods than strictly medication. They would look for environmental and social factors that might affect an elderly person's health.

Porter-O'Grady, a nurse gerontologist, said nurses would be more in tune with the idea of "aging in place," keeping people at home rather than sending them to institutions. The largest part of the U.S. population is between 45 and 70 years old, he noted. Money will be insufficient to care for everyone in institutions.

Nurses would work to provide more home care, elderly support services and aging communities where people could support each other. "We need to keep people independent for as long as life permits," he said.

Nurses also would focus on palliative care and quality of life rather than new interventions for people who did not have much longer to live. They probably would allow more people to die than the present system does, Sanford said.

Waste not

Many nurses said they would not ask for more money to spend on a nurse-run health care system. "I think the distribution is inadequate," Porter-O'Grady said. "I think we have as much waste in health spending as anywhere else."

The United States spends about $6,000 per person on health care annually, far more than any other country, Buresh said. But the country is ranked 37th by the World Health Organization in health care quality, she said. "We fritter away 35 percent to 50 percent of our health care dollars on administration, marketing, lack of coordination in health care facilities, middlemen, profit-making and fraud."

Lundeen estimates that costs saved from reduced emergency room visits alone could provide enough money to set up community clinics in most urban areas. Blakeney quoted a report estimating that 39 cents of every health care dollar was spent on administration, something that could easily be reduced with better methods of documentation. Something as simple as legislation requiring that all insurance companies use the same billing codes would save an enormous amount of money and nursing time, she said.

Nurses would make great cost-cutters because they are the ones at the bedside, seeing where the waste occurs, Johnson said. "Most nurses are cost-effective up the wazoo. Nurses could tell you right now about waste because they're usually standing around crabbing about it."

If nurses were working directly with the pharmacists, she said, they wouldn't have to spend time dissolving pills because patients are too ill to swallow them. If they worked with architects, they could help design patient rooms that saved nurses time lifting, turning and walking.

Because nurses know how much care actually costs-and because they have nothing to gain by overcharging the system-they could design a Medicaid and Medicare reimbursement system that accurately reflected how much should be spent on each patient, Johnson said. Nurses' notes would count as much as physicians' notes in determining reimbursement, Sanford said.

"Nurses could tell which patients are the most difficult, consume the most care and should be paid more for," Sanford said.

Nurses also see duplication in tests and procedures that could be avoided with good patient management, Sweeney said.

One specialist might order an ECG, not realizing that the patient had just had an ECG a week ago, ordered by another physician. "Was there a true need for that duplication?" she asked.

A nurse assigned to manage the patient's care would be able to assess whether the patient needed the second test. That manager could save the system money and help guide the patient through the maze of hospital care, she said.

Although money would have to be spent at first on both preventive and acute care, as more chronic illnesses were prevented or delayed by prevention, the money spent on acute care would decrease, nurses said.

"If we could delay the onset of hypertension or diabetes in adults as little as five years," Blakeney said, "the impact on those people's quality of life, as well as the health care expenses, would be huge."

Lundeen illustrated the difference between a nurse's view of how to allocate health care resources and today's approach with an old nursing joke:

A group of health professionals was at a picnic on a riverbank. Suddenly, they saw a few people struggling in the river, drowning. They dragged the people out and the doctors started doing CPR. More drowning people came shooting down the river. The group dragged them out and started working on them. Some survived, some didn't. As they worked to save the drowning victims, the doctors saw a group of nurses running upstream. They called to the nurses to stop and help them. The nurses called back, "We're going up the river to see who's pushing them in."

"If nurses ran the health care system, would we stop doing CPR at the other end?" she asked. "No. But we'd at least send a few people up the river."

Contact Cathryn Domrose at kaguilar@well.net