By Eileen T. O'Grady
Dr. Eileen T. O'Grady is a certified adult nurse practitioner and Wellness Coach who has practiced in primary care for over 15 years.
She holds three graduate degrees from George Washington University and George Mason University in nursing as well as public health and a PhD in nursing. She currently serves as a visiting professor at Pace University in Manhattan where she teaches doctoral nursing students about health policy and ways of knowing and being to the next generation of nurse practitioners. Visit her website for upcoming presentations and recent publications or information on her coaching practice.
The Definitive Form of Civic Engagement: One of Our Own Runs for Congress
All Imaginable Futures Are Not Equally Possible
Harvesting Research on Healthcare Costs
The Stubbornness of Facts
To the Class of 2011 APRN Graduates and the Hopeful Future
APRNs Boldly Form Medical Homes
Political Polarization Creates Tribal Politics
Weighing the Pig Won’t Fatten It
Rolling Out Reform Despite Political and Legal Challenges: The Tug of War for Public Opinion
The Voices Grow Louder
The Renaissance of Primary Care: Primary Care Is Too Important
Optimism as a Political Act
On Not Being Heard
Stay Nonpartisan in a Partisan World
The 5 NP Political Issues and the One Solution
Lessons from Wild Geese
February 2010
You do not have to be good.
You do not have to walk on your knees for a hundred miles through the desert, repenting.
You only have to let the soft animal of your body love what it loves.
—Mary Oliver, excerpt from her poem “Wild Geese”
In her poem “Wild Geese,” Mary Oliver emphatically reminds us that we don’t have to be good; rather, we ONLY must allow ourselves to do and love what we do well. Of course, this is the challenge: to stand on solid ground and pursue what we believe are our unique talents and gifts. When our talents and gifts meet the world, we are all better for it; the world responds.
I recently had the honor of reviewing dozens of NP applications for a grant. What struck me in many of the letters of recommendation from peers and supervisors was the repeated statement that the applicant was “well-liked.” I am reminded of the wild geese who are quite effective in being who they are; they do not concern themselves with being liked. As NPs, we ONLY must allow ourselves to do and love what we do well. I wonder if our unspoken NP value of wanting to be “good” or “liked” has eclipsed our capacity to stand up and speak out about the inequities and counterproductive policies that we see every day in health care.
Last fall, when I reviewed the newly published document AMA Scope of Practice Data Series: Nurse Practitioners, I was reminded of the line in Oliver’s poem, “You do not have to be good.” The AMA document lacks vision or ideals for an improved health system and in no way hints at how to solve the most perennial and complex problems in US health care. There was a swift and cohesive response from the nursing community. (See “Nurses Respond to the AMA.”) We need not spend any more of our precious resources on this.
APRN Consensus Model
We must not let others define us. The AMA paper could intensify our resolve to be sure that each state implements the 79 definitions or recommendations in the APRN Consensus Model for APRN Regulation. This model is our solution. Its implementation is key to our future success as it relates to expanded access to NPs. The APRN Consensus Model provides consistency to states and institutions across our Licensing process, Accreditation of NP programs, Certification process, and Educational programs (LACE). The AMA paper could represent a call for NPs across the nation to work with intense concentration, velocity, and clarity of purpose in getting LACE implemented.
It may not be our business to respond to what another profession says about us, especially when the opinion is based on factual errors. Our business is to accelerate the implementation of the recommendations in the LACE document so that state practice acts are modernized and nursing’s professional standards are met across the country. Our business is to be sure NPs are prepared at the highest level and practicing without restrictions in every state. Only then will we be able to meet surging demands for health care as more people become insured in coming years, the baby boomers reach eldership, and chronicity explodes. Implementing the APRN consensus document will set us free and strengthen our political power by standardizing our profession and removing unnecessary barriers to practice.
Lewis Carol said, “If you don’t know where you are going, any road can get you there.” The APRN Consensus Model serves as a decisive roadmap. It is the glue that cements NPs firmly into a regulatory framework that makes sense to policymakers, patients, and NPs.
So, we don’t have to be good. Rather, we must boldly accelerate the implementation of the APRN Consensus Model so that APRNs today and in future generations can grow the profession on more solid ground. We don’t have to be good, but we must lead the states, with urgency, in opening up archaic state nurse practice acts to modernize and comply with the APRN Consensus Model, which is our national standard. We must approach our future without timidity or self-doubt, and we must not accept narrow, constricting, and inaccurate definitions of who we are and what we can do. Rather, we must let the soft animals of our bodies love what they love.
Health Reform Bill: From Silence to Success
It is unclear whether comprehensive health reform is possible in the current political climate in Washington. There is broad consensus across both parties on 2 central principles: value-based purchasing (bundling payments; placing the risk for inefficiency with the delivery system, not the payors) and a stronger orientation towards a consumer-driven, transparent health care market. Sharp differences emerge in how to get these ideals in place, and at the heart of the partisan divide is the role of the federal government. Health care exchanges, public-private entities to regulate the free market, would serve as a cocoon for regulating the insurance industry and go a long way in meeting these 2 major ideals.
Interestingly, nursing and especially advanced practice nurses have been largely invisible in the public, 2-year health policy debate. I looked for and have not seen mention of nurses and their positions on health care reform in any of the lay press. I have seen little from nurses on health care reform in the health policy press, television news, and Congressional testimony.
This invisibility in the public debate, although discouraging, was not the case on Capitol Hill. Whether intentional or not, silence in the public discourse seemed to have no impact on the significant nursing provisions in bills of both congressional chambers. That is, while NPs were largely invisible from the sometimes bizarre directions of the health reform debate, a number of nurse-centered provisions wound up in both the House and Senate versions of the bill. The army of NP lobbyists and government relations diplomats made this happen. Some of the provisions highly relevant to NPs include:
Removal of a 10% cap for doctoral students receiving grants through the Advanced Nursing Education Program (Title VIII of Health Resources and Services Administration)
Expansion of a Title VIII program for nurses who agree to serve as faculty members upon graduation
An increase in the loan amount that schools can offer students though the Nurse Faculty Loan program
Expanded seminal nursing research, including maternal, infant, and early childhood home visiting programs and community-based care transition programs
Authorization of a Medicare graduate nurse education demonstration program to explore how advanced practice registered nurses could participate in a new health care system
A number of provisions to expand APRN practice and reimbursement, such as:
— a grant program for nurse-managed health clinics
— language that prohibits a health plan or insurer from discriminating against health care providers with respect to participation and coverage
— increase in the payment rate for nurse-midwives for covered services, from 65% of the rate paid a physician to the full rate
Establishment of a national workforce commission to implement workforce planning and analysis
A new competitive state health care workforce development grant program
Provision of a 10% payment bonus for primary care services
Establishment of value-based purchasing to provide incentive payments for inpatient rehabilitation facilities, long-term care hospitals, hospice providers, home health providers, and skilled nursing facilities that meet certain quality performance standards
Demonstrations to test bundled payments for acute care and post-acute care under the Medicaid program
A Medicaid global payment demonstration project
A payment incentive program for transitional care services
To determine the real impact of health care reform, it is important to remember the law of unintended consequences. Nurse practitioners must apply their emancipatory knowledge to the health care reform arena, as we are in a unique position to recognize social and political injustices or inequities. It is up to NPs to continue to notice if injustices persist as health reform unfolds. With the increased corporatization of health care, it is important to ask:
What is invisible?
Who benefits?
What are barriers to health care beyond the control of the individual?
Who is oppressed in the reformed system?
How are health care disparities being addressed?
Workforce Development
Last December, President Obama signed the FY2010 omnibus appropriations bill into law. The Nursing Workforce Development Programs (Title VIII of the Public Health Service Act) received an historic $243.872 million—marking an all-time high and a $72.841 million increase over the FY2009 funding level. The National Institute of Nursing Research received a 2.7% funding increase ($145.66 million) over the FY2009 level.
According to preliminary findings of a 2009 survey of the American Association of Colleges of Nursing, enrollment in master’s and doctoral degree nursing programs increased significantly compared with the previous year. Nursing schools with master’s programs reported a 9.6% increase in enrollment and a 10.5% increase in graduations. In doctoral nursing programs, overall enrollment rose by 20.5%. Doctor of nursing practice (DNP) programs accounted for the largest share, with a 40.9% increase in enrollment. In 2009, the number of students enrolled in research-focused doctoral programs (i.e., PhD, DNSc) increased by 4.1%.
Interest in nursing careers remains strong, but many individuals seeking to enter the profession cannot be accommodated. Preliminary data from the same survey show that 39,423 qualified applicants were turned away from 550 entrylevel baccalaureate nursing programs in 2009. This number is comparable to final data reported for the last 4 years. Based on information from 318 schools of nursing, the primary barriers to accepting qualified students at nursing colleges and universities continue to be a shortage of faculty and an insufficient number of clinical placement sites. The final report will be available in March 2010 at http://www.aacn.nche.edu/IDS/index.htm.