Portal de Periódicos da CAPES

International perspectives

2000; Wiley; Volume: 47; Issue: 2 Linguagem: Inglês

10.1046/j.1466-7657.2000.00019.x

1466-7657

Mary OʼNeil Mundinger, Judith A. Oulton, Victor West, James B. Bissell, K Stallknecht, Ronald Saint, Shelagh Murphy, Beverly Malone,

Nursing Roles and Practices

The nursing community and policy makers in the USA have responded enthusiastically to the publication of a study that ‘puts to rest the issue of the competency of nurse practitioners in primary care’, says Dr Mary O. Mundinger, PhD, Dean of Nursing at Columbia University, New York, USA. Dr Mundinger and her colleagues enrolled 1316 patients in a randomised trial comparing the effectiveness of nurse practitioners with physicians in a primary care setting. Data following 6 months of care showed no significant differences between nurse practitioners and physicians for any measurement of patient satisfaction. The study results demonstrated statistically significant changes in patients’ health care status within 6 months whether they were cared for by a nurse practitioner or physician. According to study results, patient outcomes for nurse practitioners and physicians within the traditional medical model of primary care do not differ, the researchers reported in the January 5 issue of the Journal of the American Medical Association (JAMA). ‘We were the first to compare nurse practitioners and doctors who have the same authority in the same setting for the same kinds of patients’, Dr Mundinger said. ‘The other unique feature is our rigorous randomised design and large number of patients. Our study should not be looked at in isolation – it should be considered in the context of numerous other studies showing the same outcome. The issue of competence has been studied and published in the literature, usually by physician investigators, for 25 years. We have simply confirmed the evidence of smaller, earlier studies.’ In the months since the study was published, the response from nurses and policy makers has been extraordinarily positive, according to Dr Mundinger, while the physician community has been quiet. ‘Those physicians sought out for comment acknowledge somewhat reluctantly that it was a very well-designed and well-conducted study. They then focus on the study’s limitations which were, of course, well-known to us and which we reported in JAMA.’ Limitations identified by the researchers included: the study drew upon a primarily Hispanic Medicaid population; it lasted for only a year; and providers were faculty members from a university medical centre and therefore not necessarily typical of providers in non-academic practice settings. ‘Even with these limitations, the results are powerful and profound’, said Dr Mundinger. ‘Following our study, revisiting the competency issue would be a waste of researchers’ money and time.’ Dr Mundinger believes that the study results make the market for nurse practitioners in primary care even more secure: ‘In the last few years the USA has moved very quickly to increase the authority of nurse practitioners and I think this study supports and encourages that trend’. In almost half the states, nurse practitioners practice free of any requirement for physician supervision or collaboration, and in every state nurse practitioners have some level of independent authority to prescribe medications and devices. Eligibility for hospital admitting privileges is regulated by state law. The federal Balanced Budget Act of 1997 expanded direct Medicare reimbursement to nurse practitioners in all non-hospital sites and removed any requirement for physician supervision. Nurse practitioners are eligible for direct Medicaid reimbursement in every state, and for commercial insurance reimbursement for primary care services within the limits of state law. ‘I think the results of our study should make everyone in the health care system feel even more interested in and confident of partnering with a nurse practitioner’, said Dr Mundinger. ‘Patients should feel safe and confident when they select a nurse practitioner for their care. Physicians should feel confident if they want to go into a joint practice with a nurse practitioner or extend their own practice by adding a nurse practitioner, and specialists should feel comfortable accepting referrals from nurse practitioners and responding to them as peers.’ Dr Mundinger and her colleagues have moved on to a new study evaluating whether nurse practitioners are more likely than physicians to incorporate prevention, education and health promotion in their primary care practice. ‘Nurses are trained to emphasize disease prevention, health promotion and education, and coordination of community resources. Can we show that this basic nursing perspective infuses the primary care given by nurse practitioners?’ said Dr Mundinger. ‘We are conducting a focused evaluation of our nurse practitioner practices with commercially insured patients here at Columbia. By comparing our practice with published evidence of how physicians incorporate these measures in their practice, we hope to show that nurse practitioners bring a “value added” component to primary care.’ Jan Harrington The Board of Directors of the newly incorporated and revitalized Florence Nightingale International Foundation (FNIF) met for the first time at ICN’s Geneva headquarters in April. The meeting marked the official launch of the new FNIF as a working foundation formed for the purposes of advancing nursing education, research and services for the public good. The Foundation, which was incorporated in the United Kingdom in February 1999, is the successor to the original FNIF, established in 1932 as a permanent memorial to Florence Nightingale. The first Directors of the new FNIF are (from left to right): Judith Oulton (Secretary to the Board), Chief Executive Officer of ICN; Victor West, Director of the Royal National Pension Fund for Nurses Council, United Kingdom; James Bissell, Chief Executive Officer of Hôpital de La Tour S.A. and Healthcare Network, USA and Switzerland; Kirsten Stallknecht (President of the Board), ICN President; Ronald Saint, an interna- tional business executive from France; and Shelagh Murphy, ICN Board, United Kingdom. At their inaugural meeting the Directors undertook to establish programmes in four areas: awards and scholarships, research, programme/project management, and governance and management programme. Initial efforts will focus on the International Achievement Award, development of regional and practice awards for excellence in nursing internationally, and travel awards to assist nurses attend conferences or to study nursing practice abroad. To strengthen nurses’ and midwives’ impact on improving health, the World Health Organization (WHO) Regional Office for Europe, the International Council of Nurses (ICN) and the International Council of Midwives (ICM) have issued a joint call for a HEALTH21 nurse and midwife public health campaign. Over 5 million nurses and midwives in the European Region are being asked, through their national associations and government chief nurses, to rededicate their skills and experience to achieving the goals of HEALTH21: the health for all framework of the WHO European Region. HEALTH21 nurses and midwives will take an oath and receive a specially designed rainbow heart pin to wear. The first oath-taking ceremony took place at the Second WHO Ministerial Conference on Nursing and Midwifery in Munich, Germany in June. Ministers attending the Conference were asked to sign a Munich Declaration aimed at supporting nurse and midwife leadership in health and health care and removing obstacles to action. ‘It is clear that nurses and midwives are at the heart of most effective health care teams, especially in primary health care’, said ICN President Kirsten Stalknecht, the conference keynote speaker. ‘Nurses and midwives working in many different capacities will make major contributions to HEALTH21. Nurse policy-makers, managers, educators and clinicians are already leading initiatives that improve the health of the population as a whole, and narrow the gap in health. The HEALTH21 nurse and midwife movement will make all these contributions more visible and inspire new initiatives.’ The rapid advances in knowledge and technology require nursing research to produce evidence that can support sound health policy. The International Council of Nurses (ICN) has created a Research Network to serve as a forum for exchange of ideas, experience and expertise, and as a resource bank for global nursing and health research. The network links research nurses, practising nurses, other health professionals, policy makers and the public. Currently 103 nurses are members of the ICN Research Network. Members have expertise in many areas, including quality and outcome of care, infection control, chronic illness, long-term and rehabilitation care, organization and delivery of health care, phenomenology and hermeneutics, nurse practitioner roles, hospice care and pain management, and poverty and health. The ICN Research Network will advance nursing by: • Identifying trends in nursing/health research. • Providing opportunities for exchange of research knowledge and experience. • Promoting ICN’s and others’ work in research. • Organizing meetings and conferences. Communication among network members occurs through a variety of channels: the Network Bulletin, meetings and conferences, and a special page on ICN’s website: http://www.icn.ch/resnet.htm. To become a network member, please complete and return the form found on the website. The nursing and midwifery profession in Africa has a new vehicle for sharing experiences, skills and knowledge. The Africa Journal of Nursing and Midwifery (AJNM) was recently launched as a forum for research findings and/or other relevant health related information. To be published twice yearly, the journal is the first publication of its kind aimed specifically at the approximately 2 million nurses and midwives in Africa. ‘At the dawn of a new millennium, Africa is faced with a myriad of challenges’, said Editor Laetitia King, PhD, RGN, RM, RNT, RNA, CHN. ‘The AJNM offers a much needed opportunity for nurses and midwives to publish in their own journal as they work toward contributing to solutions to the many health related problems facing the continent’. Professor King is Head of the Department of Advanced Nursing Sciences at the University of South Africa. She is also Director of the World Health Organizations’s Collaborating Centre for Post-graduate Distance Education and Research for Nursing & Midwifery Development. The journal will accept contributions in English, French and Portuguese. In addition to research findings, it will offer a regular feature on current international health related developments and WHO policy decisions. For information about the AJNM, contact the University of South Africa, PO Box 392, UNISA, 0003 Republic of South Africa. In October 1999 the Governor of California approved legislation requiring hospitals in the state to maintain minimum nurse-to-patient ratios. The new law should allow nurses to deliver improved care to patients at a time when institutions may institute cost-cuts that can adversely affect the patient. As its Department of Health Services establishes the new standards, California will become the first state in the USA to require such ratios throughout a hospital. The new law also further secures the nurse’s scope of practice in California. Hospitals may no longer ‘assign unlicensed personnel to perform nursing functions in lieu of a registered nurse and may not allow unlicensed personnel to perform functions under the direct clinical supervision of a registered nurse that require a substantial amount of scientific knowledge and technical skills . . .’. The legislation further states that ‘no registered nurse shall be assigned to a nursing unit or clinical area unless that nurse has first received orientation in that clinical area sufficient to provide competent care to patients in that area, and has demonstrated current competence in providing care in that area’. Coincidentally, the legislation was approved about two months before the Institute of Medicine’s (IOM) Committee on the Quality of Health Care in America released its report titled, ‘To Err Is Human: Building a Safer Health System’. The IOM’s report cited two large studies that found that adverse events occurred in 2.9% and 3.7% of hospitalizations, respectively. The report states: ‘in both of these studies, over half of these adverse events resulted from medical errors and could have been prevented’. Suggesting that ‘a comprehensive approach to improving patient safety [was] needed’, the IOM included its own recommendations for improvements in the quality of care in the USA. Those recommendations have since prompted substantial debate throughout the American medical and hospital community. Perhaps in time, the IOM report and California’s example will prompt other states to pass similar legislation, particularly if medical errors decrease in California, and the reduction can be traced to the requirements imposed by the new law. Tina Rae Eskreis Nelson, RN, JD, is an Adjunct Professor in the School of Nursing at New York University. Formerly she was Assistant Attorney General for the State of New York and defended cases brought against nurses, hospitals and doctors. She currently serves on two committees of the New York State Nurses Association. Beverly L. Malone, PhD, RN, FAAN, was appointed Deputy Assistant Secretary for Health within the U.S. Department of Health and Human Services (DHHS) early this year. From 1996 to 2000 she served as President of the American Nurses Association. In her new role, Malone serves as the Senior Advisor to the U.S. Assistant Secretary for Health, David Satcher, MD, and also provides advice and counsel to U.S. Secretary for Health Donna E. Shalala on public health and science issues. INR staff member Jan Harrington spoke with Dr Malone recently about her new appointment, and her goals and aspirations for nursing and health care in the USA. INR: Nurses are delighted about your new appointment and your ability to bring nursing’s perspective to the table at this important policy-setting level. Do you think their expectations of what you can do for nursing may be too high? Dr Malone: Absolutely not. If we keep our expectations incredibly high, we’ll make something happen. I’m clear that the world didn’t start when I was appointed to this position and it won’t end when I leave. Our work is really about collaboration, pulling together the right people, and building partnerships and coalitions. The advocacy that we need to do for patient care is larger than any one of us – it’s a passion that binds us together and creates energy. Nurses need to have high expectations because we have an extraordinary amount to accomplish. And guess what, I have high expectations for all of you. INR: How do you plan to enhance visibility for nurses in your new position? Dr Malone: I don’t want people to think I’m the only nurse here. Many nurses work within the federal system and part of my job is to take advantage of every opportunity I have to highlight my colleagues. Now that I am here, my role is to widen the door for other nurses to come in. INR: What would you identify as the top three challenges for health care in the United States today? Dr Malone: We must figure out a way to create a universal plan of health care for the nation. To me that is the challenge for the next decade and beyond, and it is a huge challenge. We have to reach the point where all Americans have access to health care. Right now we’re moving toward that goal in incremental steps. As an example, President Clinton has included in his budget for next year extending the Children’s Health Insurance Program (CHIP) to the parents of the children who are covered. We need all kinds of creative strategies to increase access to health care until everyone is covered. A second enormous challenge for the public and for nursing is the growth of genetic technology. As we move forward in this area, we must figure out how to maximize our research and discoveries, and at the same time protect the public from abuse, and safeguard the individual’s privacy and confidentiality. Achieving the Patients’ Bill of Rights is another important health care issue for the nation. Every person who lives in the United States deserves to have rights as a patient, including not being discriminated against and having access to health care. INR: What do you see as the challenges for nursing? Dr Malone: If we are to make a difference in this millennium, we need the strength of our numbers. We need the power of our 2.6 million nurses in the USA to have some leverage in terms of decision-making at the state, congressional and international levels, and to maximize our ability to advocate for our patients. Organized nursing must accommodate all the diversity of opinion and experience that exists among nurses today. This was the vision that guided me during my tenure as President of the American Nurses Association (ANA) – a vision shared by many of my colleagues. We used the metaphor of building a house with enough rooms to include all nurses in the USA – enough rooms for diverse groups to be part of ANA and yet be able to maintain their autonomy and continue to grow. INR: Does this inclusiveness extend to nurses around the world? Dr Malone: Absolutely. As nurses we must understand that health care is global and not just national and local. One of my areas of responsibility in my new position is international health, out of the Office of Public Health Science. I learned so much from representing American nurses in the Congress of National Representatives of the International Council of Nurses (ICN) and working with nurses from so many nations. When President Clinton appointed me as a member of the U.S. delegation to the World Health Assembly (WHA) in Geneva, I further broadened my knowledge of international health care issues. Working with ICN and the WHA opened my eyes to all the possibilities and to an understanding that there are no geographical boundaries to keep illness at bay. As nurses we have to consider international health care issues and be ready to work with colleagues in other countries. We need to know how to come together and advocate, and yet respect the autonomy of nurses in different nations and appreciate that their health care systems are different from our own. INR: In addition to your other qualifications, does being a nurse bring specific capabilities and skills to your new position? Dr Malone: I’m honoured to part of the nursing profession and the skills I learned as a nurse help me every day. I think nurses are some of the most humane people in the world. Nursing gave me the ability to work with any patient, so as a public-policy person I can work with anyone. Also nurses are organisers – we love to get things done and to maximize our accomplishments. We love to please people and, while this may work against us, it also works for us because we’ll work terribly hard to make sure good things happen. The blend of being a nurse and a clinical psychologist has been a potent background for me. INR: You bring a wealth of experience in working with the nation’s leaders in health care, especially in minority populations. Dr Malone: I’m clear that being an African-American nurse is a special ‘value added’ part of me. The President’s initiative to eliminate ethnic and racial disparities fits nicely with my own identity as a person, and it authorizes my ability to touch minority people and to say, ‘there is room for you in this government’. We care about the inequities that have plagued us for generations, and not just African-Americans but all minorities. The Clinton administration is committed to eliminating these disparities by the year 2010. So I see opportunities – let’s get together and make it happen. While nursing has probably done a better job than other disciplines in bringing diversity into the profession, we still have a lot of work to do. Only about 10% of all nurses in the United States are people of colour, and probably 4–5% of those nurses are African-American. It’s still nothing to crow about. INR: Will you be able to continue mentoring nurses in your new position and how do you plan to do so? Dr Malone: I’m more than happy to act as a mentor. I myself have benefited from wonderful mentors. One was the phenomenal nurse, Dr Hildegard Peplau, who died last year. My background is psychiatric nursing and she was the mother of that field. Another of my mentors is Dr Hattie Besset. When she initiated the ANA Minority Fellowship Program, there were less than 20 nurses of colour in the entire United States. This program has now graduated more than 250 doctorally prepared minority nurses including African-Americans, Hispanics, Asians and Pacific Islanders. The first Native American nurse graduated from that program. I am a graduate of the program. So Dr Besset’s work and her philosophy that there has to be room for us all has been an inspiration for me in my work. INR: What advice would you give to nurses about seeking appointed or elected positions in the government? Dr Malone: Be active in your nursing association. Be verbal, and when you have the opportunity, speak up. You also need to have a base of operation. People have to know you’re there. If I had not been positioned at the ANA, I probably wouldn’t have been seen or heard. As we plan our careers, we need to consider that there is another part of us that has to fit with the professional piece and that’s our personal life. Reaching whatever career height you desire doesn’t mean you have to exclude the family piece of your life. As nurses, we need to appreciate the wholeness of ourselves and to learn to take better care of ourselves. I value my family life and I acknowledge the stresses that it always places on my professional life. I always take my family into account as I make my way along this professional path that I’m travelling. An international nursing satellite meeting will take place in Durban, South Africa just prior to the XIIIth International AIDS Conference in July 2000. To be held on July 8, the satellite meeting is intended to empower nurses and midwives to break the silence surrounding the HIV/AIDS epidemic. The meeting is sponsored by the Southern African Development Community (SADC) Nurses and Midwives, and organized by the Democratic Nurses Organization of South Africa (DENOSA). The programme, to be conducted in English, will explore the impact of HIV/AIDS on both the professional and personal lives of nurses and midwives. Other objectives include: to address current clinical and nursing management issues of persons infected with HIV/AIDS and support strategies for those affected; to share information on effective HIV/AIDS education and prevention; and to identify an expanded role for nurses and midwives in HIV/AIDS-related research. Further information may be obtained by contacting DENOSA at denosahq@mweb.co.za or via Fax: 27 12 3440750.