Creating the Future

June 1993

Nurses Can Shape Their Profession by Getting Involved in Healthcare Reform

Ms. Araujo is principal, and Ms. Carballo is senior partner, the Araujo Group, Park Ridge, IL.


To remain relevant in a reformed healthcare system, nurses will have to redefine and remake themselves. Three aspects of the new healthcare age—megahospitals, managed care, and redefined professional roles—will have a significant impact on healthcare professions, including nursing.

Across the United States hospitals are merging to form sophisticated networks that provide a continuum of care. Under this delivery model, nurses will play a variety of new roles and work collaboratively with the entire spectrum of health social service professionals. A related development—the growth of managed care—is an increasingly attractive option among large employers. It will also accelerate changes in the way healthcare professionals work. Managed care will force physicians to enter into appropriate group affiliations and hospitals to reconfigure themselves to meet the needs of a dynamic system that no longer requires yesterday's beds or management structures.

The future will force healthcare professionals to go through regular, radical changes in their job requirements. But it will also allow nurses and others to emerge from their task-oriented past and take on work that requires them to think, judge, and intervene.

Although many persons look to the millennium as a time to pause, take stock, make plans, and issue prophecies, the twenty-first century has, in effect, already begun in healthcare. Change is occurring so rapidly that healthcare professionals' primary goal is to "think the unthinkable": To stay within established paradigms is to become further enmeshed in problems of a system that is really no system at all. Instead, healthcare professionals must create their own future lest they become irrelevant in a future others have made.

As it has so often in the recent past, the impetus for much of the change is coming from the federal government. After years of dithering and delay, real momentum is building for national healthcare reform as President Bill Clinton's sweeping proposals evolve. Despite the tradition of gridlock, Congress will pass some sort of reform bill for one simple reason: The cost of doing nothing is too high.

The focus of healthcare reform is on the need to control costs and extend access to healthcare. The shaping of an effective legislative package will require a thorough review of all aspects of the current system. Whatever shape it eventually takes, this reform bill seems destined to transform the industry.

The transformation will be wrought on an industry already in flux. Changes in biotechnology will continue to revolutionize surgery. Changes in reimbursement and delivery systems will render some hospital traditions obsolete. Changes in hiring practices could create new varieties of workers. And changes in demographics will produce a different, older patient population.

Three aspects of the new healthcare age—megahospitals, managed care, and redefined professional roles—will have a significant impact on the professions, including nursing. Healthcare professionals and hospitals should reflect on those changes now so they can respond creatively in shaping a vital future.

The age of megahospitals has been anticipated for more than two decades. Now, emphatically, it is here. Across the United States, hospitals are merging to form sophisticated healthcare delivery networks—tertiary institutions supported by smaller, nonspecialized facilities. The reason for the trend is simple: Few institutions today can afford to be experts in everything.

Nurses will facilitate the focus on the continuum of care and the ability of these megahospitals to manage the care of an individual and his or her family. Family practitioners will orchestrate the continuum of care with appropriate specialists moving into and out of the care cycle as needed. Consumers will themselves play an important role in making the system more efficient. Larger copayments for treatment and greater familiarity with components of a community-based continuum of care will result in more cost-conscious, discerning consumers of healthcare. Managers of the continuum will emphasize health promotion and wellness and see the empowered consumer through brief hospitalizations for acute episodes.

A newly created center for the prevention of the progression of disease will maintain the patients' well-being by coordinating health education, home health assistance, extended care, hospice, and, ultimately, structured support for the family. Managed by nurses, the center will be an important contact for persons with chronic illnesses who need screening to determine their need for physician care and guidance in developing healthy life-styles. As part of the megahospital, the center will ensure that consumers maintain access to appropriate services of physicians and allied health professionals.

Megahospitals will provide all aspects of patient care, and the continuity will ultimately lead to cost savings. In this phenomenon of shifting from illness centers to facilities that focus on maintaining an individual's health, the ultimate goal is patient empowerment. This empowerment encourages a patient to choose his or her life-style, fully informed not only of consequences but of the mechanisms for support that will help maintain health and wellness. Systems will be rewarded on their ability to prevent illness and the progression of disease.

Hospitals are already experimenting with a continuum of care in which the physician and nurse collaborate to improve patient outcomes. The networks are charged with maintaining continuity of care, as well as expanding physicians' potential practice, through improved care management. Encouraging patients to contact their nurse for educational reinforcement and follow-up is only one aspect of this broad continuum of care that will be common in the twenty-first century. This vertically integrated model of healthcare may soon become the standard, finally bringing order to the U.S. healthcare system.

For nurses, the dominance of the megahospital means that the delivery of acute care will cease to be their central concern. In short, the reconfigured healthcare industry will need fewer acute care nurses. To remain employed in the field, many of today's acute care nurses will need to reeducate and redefine themselves professionally. They will need to prepare for vital roles in the industry's growth sectors—intermediate care, outpatient care, home healthcare, extended care, and, something new, community care.

Nurses' need for a more varied and complete education will pose a challenge to academic institutions. Schools will have to respond quickly to new demands by creating a curriculum that prepares students for more challenging clinical and managerial responsibilities. Schools will have to be flexible, teaching the basics of practice in multiple settings encompassing the full continuum of care. The educational system also will have to develop courses that enhance nurses' flexibility, improve their decision-making skills, and familiarize them with the profession's basic values.

In the twenty-first century, nurses will have to tap what, historically, has been one of their greatest strengths—their adaptability. With more independence, greater responsibilities, and closer ties to a wide range of other health professionals, nurses will be key members of the collaborative healthcare team.

Managed Care
In the past five years managed care organizations have experienced spectacular growth. According to a 1993 Peat Marwick study, most employees in large and midsized companies already belong to managed care plans, which aim to reduce costs and the incidence of illness through education, early diagnosis, and the effective administration of precise treatments.

Managed care has caught on because it seems to work. A 1992 survey by Health Care Investment Analysts, Inc., shows that hospitals in cities with large enrollments in managed care plans charge as much as 32 percent less for the same services as hospitals in other cities. It should come as no surprise, then, that managed care is a key element of all emerging reform proposals.

Because rapid growth continues in the managed care sector through the expansion of large groups of physicians, such as Kaiser Permanente, physicians today are caught up in the dilemmas of a system that is rapidly changing. Physicians' failure to become part of the managed care sector through the appropriate group affiliations will leave them out of the mainstream of client referrals.

Along with managed care, managed competition under a reformed system will force hospitals to be configured to efficiently meet the needs of a dynamic system that no longer requires yesterday's beds or yesterday's management structures. Care that is personalized and focused on individuals as they move through the continuum will prove to be cost-effective as we finally get creative about changing operations to match the system of the future. The issue is not decentralizing the admitting office by moving its functions to the patient care unit; rather, it is refocusing the care at its true center—the patient.

Redefined Professional Roles
Before the twenty-first century the traditional professions will have to be reassessed for their appropriateness in a changing healthcare system. Can the American public afford to have each profession struggling to meet patients' needs traditionally when "think the unthinkable" is the standard? A federally mandated reform system may consider the federalization of licensure.

A compelling fact will be that future healthcare professionals will experience regular, radical changes in their job requirements. Multiskilled healthcare workers, persons able to assist a variety of professionals, will allow nurses and others to emerge from their task-oriented past for a new practice founded in cognitive skills associated with judgment and intervention. Physicians will also play new roles, as their practice changes in radical, unanticipated ways. As healthcare professionals' roles blend, the following question arises: How will we now define our various responsibilities?

The licensure system was developed to protect the public by guaranteeing a standard of practice and education described by law. However, as it is currently constructed, it can prevent change rather than augment it. Licensure protocols need to be reviewed collectively not only to encompass the new competencies required but also to validate the need for each type of professional license. With a shrinking healthcare dollar and the myriad changes ahead, how many professions should there be and what should they do? What services do patients need and from whom should they receive them?

Preserving Values
As healthcare reform progresses, a commitment must be made to preserve the values that healthcare and its professionals espouse, values that speak to each person's individual worth and dignity. Healthcare providers will be faced with the biggest professional challenge of their lives:

  • To see the value of change that they can shape but not control
  • To remember why they entered healthcare in the first place
  • To see someone they care about in the faces of the persons they serve through a continuum of care system that is limited only by their ability to imagine—and to think the unthinkable

Nursing today is at a crossroads. Everything must be open to rethinking and revision if the profession is to make the contribution it is capable of. And nurses will have to stretch everything—their powers, their knowledge, their influence—to remain relevant to the healthcare system of tomorrow.


Copyright © 1993 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.

Creating The Future

Copyright © 1993 by the Catholic Health Association of the United States

For reprint permission, contact Betty Crosby or call (314) 253-3490.