New models of nursing care.

IN THIS ISSUE of Frontiers of Health Services Management, Janet Quinn adds her voice to the growing chorus calling attention to the crisis facing nursing in the United States, and indeed the world, and offers potential solutions to assist in addressing the crisis. The particular solution she advances, the creation of Nightingale units, to organize and deliver nursing care is an example, albeit a very creative one, of a larger set of recommendations centered on the issue of changing the work environment and practice model of nurses. It is an important set of suggestions that must be considered as a part of the overall collection of responses that institutions, policymakers, and professional leaders in education and practice make to this important healthcare reform. To understand the value of these suggestions, consider them in the context of the overall nursing crisis and critique them in the broader set of considerations that surround workplace and profession change. The current situation confronting nursing in the United States is real, profoundly complex, and long term in its implications (National Center for Health Workforce Analysis 2002; Kimball and O'Neil 2002; AHA 2002). The drivers of this situation include the aging U.S. population and the corresponding growth in demand for care services, the collateral aging of the health professional population, the greater competition to employ the smaller entry-age group of potential workers, the extreme pressure within healthcare for higher quality and cost containment at a time when levels of acuity are growing, and a proliferation of new demands brought on by technological change and innovation. In nursing, these general trends are exacerbated by more opportunity for women in the workplace, lack of significant innovation in the practice model, and significant separation between education and practice. Unilateral actions or quick fixes will not likely address a problem, or set of problems, as complex as this. A variety of studies and reports have been conducted over the past two years. Their recommendations can generally be classified into one or more of the following categories: 1. Redistribute the RN supply-recruit within the existing pool 2. Increase the RN supply-enlarge the pipeline by increasing the numbers of those trained 3. Change the work environment-make the work sustainable 4. Improve understanding of the value of the worker-use RN skills more extensively 5. Change the utilization and compensation model-focus on pay and benefits 6. Create new regulatory standards-regulate staffing ratios and overtime 7. Improve data on the workforce-at the national, state, and institutional levels 8. Strengthen leadership at all levels-make more of what we have Quinn's recommendations fall into the third and fourth categories. They represent efforts to alter the work environment so that the strengths and competencies of the nursing profession may come forth. The changes that are proposed by Quinn would represent a major innovation in professional work and would likely result in significant expense as well. As consistent with the literature as the creation of Nightingale units may be, it is essential to put them in the context of broader, systemwide considerations if a reform such as this is to be fully understood. First, and perhaps most important, Nightingale units establish innovation at a point where the health system has by and large failed. By this I mean that inpatient services often represent a failure of the system to address a care or service need in a way that could have been provided less expensively, better as to the quality of outcome, and, perhaps, in a way that is more desirable for the patient. As good as a Nightingale unit might be in providing inpatient care for an amputation associated with diabetes, for example, it can never overcome the underinvestment in the primary care that a community health nurse or nurse practitioner might have provided that could have prevented the need for the procedure. …