The Opportunity That Is Nursing

THIS IS A PERIOD OF GREAT DISLOCATION AND ENORMOUS OPPORTUNITY in health care in the United States. What strikes many as a chaotic, confusing, and conflicting change from the past is, in fact, a process of fundamental realignment of purposes, processes, and people. In this transition, much that has seemed familiar and comfortable will be altered, some of it ultimately for the worst and, hopefully, more of it for the better. None of the institutions or the professions that have constituted health care in the United States is exempt from this change, but all have the opportunity to actively participate in it. Needless to say, these are both trying and tempting times for professional nursing. I would like to explore three ideas related to this change, starting with a cursory look at five trends, or macroforces, that are now shaping health care and will continue to do so. Understanding these macroforces and tying strategic redirection to them will be critical to the long-term success of hospitals, professional schools, nursing practice in general, and the careers of individual nurses. These forces will demand a response from the constituent elements of the health care delivery system, and they merit exploration. Finally, I will focus my analysis on what must be done strategically in nursing education, practice, and leadership. The Macroforces Shaping Health Care The first trend is the emergence of the market as an essential driver in the governing structure of health care. In the past, health care was a collection of small private practices and solo community-based institutions. For the most part, these nonprofit institutions controlled their own destiny. Because of the peculiar way in which health care was financed in the United States, they were, by and large, exempt from public or private control beyond the self-regulation of the professions themselves. This was fine until the system grew so large in size that it consumed over 12 percent of the productive effort of the nation and showed no sign of stopping. The cost, coupled with the inability to insure everyone in the nation and recognition of the enormous variations in treatment patterns and health care outcomes, led to an effort to produce policy-driven reform. When this effort failed, the market stepped in and has contributed most of the energy and direction for the rationalization of the health care resources of the nation. Each of the market players -- purchasers, health plans, providers, and consumers -- has different expectations, resources, and advantages. In the past, these differences were less obvious, as the increasing costs of care were easily passed on with higher prices. With the market entering into the equation, price competition became important; these elements must now compete with one another to deliver something of value to the customer. Values vary from one customer to another, but basically revolve around issues of cost, consumer satisfaction, and quality. Although most of the resources in health care may remain in the not-for-profit sector, the benchmarks for success will increasingly be defined by the market's demands for these three values. Over the past five decades, health care in the United States has focused almost exclusively on the individual recipient of care and the services that an individual provider could provide. The separation of the costs of care from its delivery made such an orientation possible. The second trend is the increasing challenge within health care to balance the needs of the individual within a broader social context. In part, this trend is driven by cost, but it is also a recognition of the need to improve the health of the overall population by effective public health interventions and to ensure health outcomes through the use of sophisticated organizational resources. Perhaps no other change will have as great an impact on health care professionals. Because of their traditional orientation to care delivery within organizations and teamwork, this change could be a significant development for nursing. …