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Updated: May 2

John Silver Ph.D RN

What is our history? What role should nursing play in the delivery of health, and thus healthcare, in the United States? How can we align the values and goals of the health care system with the goals and ethical obligations of Nursing? How can WE control our practice environments at every level?

These are all critical questions, questions as yet unanswered by our professional organizations, or only sporadically cited in Nursing academia. To be fair, the ACCN does include a reference to “creating a healthcare system driven by the needs of patients and families…”, but no vision of what that means has been put forward. In fact, no Nursing group has been able to put forward a complete nursing vision of what healthcare would look like if it was designed by Nursing- until now.

How does our history tie into this? I would argue that many of the original nursing leaders in this country, dating back to Dorothea Dix (yes, I know, she wasn’t a nurse), came from or focused on social activism. In particular, I would like to focus on the efforts of Lillian Wald and direct readers to her ideas and what she accomplished in New York. Her clear vision to seek out and deliver services to people in need, and her understanding that child health and public health were critical components of health in communities, provides clear evidence of the power of Nursing. I would also argue that Nursing lost that perspective after the passage of the Medical Practice Acts almost 100 years ago.

The development of the Nurse Practitioner level of care in the 1960’s, and the subsequent expansion into many arenas of care by NP’s has allowed for a re-analysis of the intended role of “Nursing” to become the socially active force that this country needs. In terms of the “Circle of Nursing”, the NP movement has been a critical component in restoring the mission and vision of Nursing, but the work is not done. As of Feb. 1st, 2023, only 26 states allow full practice authority (FPA) with many others requiring protocol agreements with physicians or restricting NP practice. Here is a link to an excellent analysis by Marymount University-

But even if NP’s HAD independent practice in all 50 states, it would not complete the “circle of nursing”. Nursing, and thus our association(s), have to reflect the actual family of those providing “nursing” care. It starts where the vast majority of “nursing” services are delivered, in the home by family members. Our “circle” includes not only those family members, but also the army of home health aides, an increasing number of community health workers, the Patient Care Associates we find in long term care, clinics and hospitals, as well as the LPN/LVN level of care, which are particularly focused in long term care facilities.

The ANA, for example, only recognizes the RN/NP level of practice, and in some states, the political interests of RN’s come into conflict with the political representatives of these other groups, such as Unions. Unfortunately, the LPN/LVN/PCA/community health workers, and family care providers struggle with little, if any, political, structural, or social support in most areas. This works against our interests as RN’s if we truly want to be the socially active force our founders envisioned in delivering health and healthcare to our nation. Understanding this, advocating for it, and working towards this inclusivity will also help complete the circle of nursing.

Finally, completing the circle must include offering a nursing vision for a truly integrated, community focused health system. The nursing administered system proposed here must reflect the need to focus on prevention, primary care, and acute disease care... holistically. It must also transition the current profit-driven disease care system into one that sees health and thus health care as a community partnership based on trust. Until now, no such vision has been presented.

The system must also reflect and empower the ethical imperatives of Nursing:

Provision 2 The nurse’s primary commitment is to the patient, whether an individual, family, group, community, or population.

Provision 4 The nurse has authority, accountability and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to provide optimal patient care.

Provision 6 The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care.

Provision 8 The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities.

The system design being proposed here re-aligns Nursing with these ethical obligations, and re-aligns all of the care giver ethical frameworks which are reflected in the goals and the design of the new system.

Here are the 7 goals which will direct the “new” system design:

Equitable, targeted, data driven access appropriate to every communities needs

Quality evidence based care

Equitable, targeted, and evidence based distribution of resources

Interdisciplinary practitioner led administration so that the system is congruent with their values and maximizes their skill sets

Equitable and positive outcomes

Cost efficiency

Social accountability and a mandate for direct public reporting.

Under this design, there will no longer be a need for insurance. No more bankruptcies, no more deductibles, no more co-pays. And yet, we’ll cover everyone living in our country.

The full system design being presented here includes the goals, the administrative structure, the much needed nursing based community assessment tool, the sustainable financing plan (not single payer), and the mechanism to mandate community engagement as partners in the process. It also empowers providers to contribute up to the scope of their practice, hopefully eliminating the endless cope of practice battles that have plagued us for the past 60 years. Philosophically, it changes healthcare from one based on individual billable interactions to what healthcare really is, an adapted Public Utility.

This new vision also integrates Public Health, Academia, EMS, and community based resources into the administrative decision making process. It opens up the entire system to research, but also to clinical placements so that students come out of the academic disciplines with a holistic view of health and healthcare.

Most importantly, this system design opens up the doors to NP innovation in delivering health and healthcare. The NP movement is a distinct advantage in several countries besides the U.S., including Canada and Australia. While Canada and Australia are still struggling with the “autonomy” role of the NP, New Zealand is even farther along than the U.S., given that “the NP role is similar to that of the role in the U.S. Though there are only about 300 NPs in New Zealand, the profession is continually evolving and growing. Considered by the Ministry of Health as highly skilled autonomous health practitioners with an education in advanced nursing and clinical training, New Zealand NPs are able to make diagnoses, order and interpret diagnostic and laboratory tests, and write prescriptions within their area of competence with the same authority as physicians. Often, NPs in the region are the lead health care provider for patients.” Thus, autonomous practice is recognized in all of New Zealand, as opposed to only 26 states in the U.S..

All of these initiatives are critical to “completing the circle of nursing”. It does, however, change our vision and mission. Here is the new vision and mission being proposed:

The vision- to lead an integrated, holistic, wellness centered healthcare system that addresses the needs of all our communities.

The mission- to become the independent socially active force America needs to achieve the vision.

These stand in direct contrast to the vision and mission proposed by the ANA:

Vision- A healthy world through the power of nursing.

Mission- Lead the profession to shape the future of nursing and health care.

It’s somewhat difficult to imagine how the ANA intends to move towards a healthy world or “lead the profession” when it represents only 4% of U.S. nurses.

There are so many advantages with this new system design. The state based regional systems are now cooperative, not competitive. This allows them to negotiate for everything from equipment to drug pricing. Given our political environment, it appears Congress is unable or unwilling to allow Medicare to negotiate drug pricing, but these regional councils would be able to, and we could begin to enjoy the prices single payer countries like Canada enjoy. As importantly, the state based regions could cooperate in addressing everything from pandemics to regional disasters, sharing resources and personnel as needed.

I would argue that each of these areas are vital to completing the circle of nursing. But if nursing is to be that socially active force in terms of goals, it should also be a socially active force in and of itself. This means abandoning the useless battle against the Associate Degree Nursing (AND) programs, which supply an opportunity for many people who are unable to attend the limited number of BSN programs, or unwilling to wait for years to gain access. It is truly ironic how many of the most ardent BSN requirement proponents themselves started as ADN’s. More importantly, there are simply not enough BSN programs to meet the needs in healthcare. Even if the ANA has apologized for this effort, that apology has not yet trickled down to many facility educators, many of whom still discriminate regarding clinical placements.

Let’s complete the circle and become what our history intended us to be.

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