Pioneers of professional practice: an interview with a CRNA. Interview by Sister Sarah Bertler

Developing professional interdependence is imperative to ensuring clinical outcomes for patients as well as outcomes within the structure of the integrated health care models where advanced practice nurses (APNs) will provide care. Defining roles and building partnerships that are based on trust and result in synergy provide both challenges and opportunities critical to the future success of care providers in integrated health care models.     

Integrated health care and the advanced practice nurse

As state-designed Medicaid reforms are enacted and commercial insurance carriers begin to manage care, advanced practice nurses (APNs) must be ready to aggressively pursue opportunities for clinical participation. Understanding the contractual obligations of becoming a provider, as well as adopting strategies for successful participation in these emerging integrated networks, will be critical for APNs. Successful contracting requires a carefully defined set of practice activities and a willingness to become a team player in a complex organization.     

Considerations for ethical practice in managed care.

How does one maintain an ethical practice while facing the requirements and limits of a health care system that is dominated by managed care? Psychologists are increasingly raising such questions about ethical issues when working in or contracting with managed care organizations. The authors review the process involved in ethical decision making and problem solving and focus on 4 areas in which ethical dilemmas most commonly arise in a managed care context: informed consent, confidentiality, abandonment, and utilization management-utilization review. The need for sustained and organized advocacy efforts to ensure patient access to quality health care is discussed, as is the impact of managed care's competitive marketplace on professional relationships. Hypothetical examples of typical dilemmas psychologists face in the current practice environment are provided to illustrate systematic ethical decision making. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Nurses preparing for change: their needs and concerns

As a result of decreased lengths of stay and cost-containment initiatives, fewer nurses are needed in acute care settings. The trend for community-based health care is broadening employment opportunities for nurses to work in community settings. As nurses are considering options to base their practice in community settings, it is important to understand their concerns about making this transition. The results of a qualitative study conducted to examine the concerns and educational needs of acute care nurses related to working in the community are reported. Clinical, professional, and intrapersonal skills important for a successful transition to community-based practice are identified and discussed.     

Perioperative nurse practitioners

Perioperative nursing roles are evolving in response to health care reform, technological developments, and changing opportunities for advanced practice nursing. One response to these changes is the development of the perioperative nurse practitioner role. The perioperative base for this new advanced practice role is described in this article. The advanced practice role is effective in other specialty settings and can be developed readily in a variety of surgical settings. This role requires a master's degree in nursing to provide the academic and practice preparation for clinical decision making and patient management in the perioperative setting. Future opportunities for perioperative advanced practice nursing are discussed.     

A computer simulation for teaching critical thinking skills

Telephone-based health services is a fast growing subspecialty of nursing practice. It is used in demand management and managed care organizations in a highly unregulated environment. The article presents background information and identifies the need for systematic studies of ethical implications inherent in telephone-based practice. Conclusions suggest that nurses need to become actively involved in ethical decision making related to this area of practice.     

Managed care, school health programs, and adolescent health services: opportunities for health promotion

The rapid expansion of managed care creates opportunities and dilemmas for those involved in school health and adolescent health promotion. Managed care organizations (MCOs), public health agencies, and school and adolescent health providers share certain common goals and priorities including an emphasis on prevention, cost-effectiveness, and quality of care--and a willingness to explore innovative approaches to health promotion and disease prevention. However, MCOs often face conflicting challenges, balancing the goals of cost containment and investment in prevention. In considering support for school health programs, MCOs will be interested in evidence about the effectiveness of services in improving health and/or reducing medical expenditures. Mechanisms for improving prevention efforts within MCOs include quality assurance systems to monitor the performance of health plans, practice guidelines from professional organizations, and the contracting process between payers and health care providers. Development of partnerships between MCOs and schools will be a challenge given competing priorities, variation in managed care arrangements, structural differences between MCOs and schools, and variability in services provided by school health programs.     

Roles of advanced practice nurses in oncology

Managed care is a process of health-care management that integrates financing, cost-containment strategies, and business principles with the delivery of health care. Managed care's rapid transformation of specialty practices, such as oncology, is redirecting classic nursing functions toward market initiatives that value the design of care/case management systems and the implementation of multidisciplinary "patient-centered" care models. As health-care systems continue to evolve, advanced practice nurses (APNs) are redefining their roles and enhancing their skills to meet the demands of the marketplace. Advanced practice nurses are defined as registered nurses who have met advanced educational and practice requirements and are prepared at the graduate level. This paper will identify the four established APN roles: nurse practitioner (NP), nurse anesthetist, nurse midwife, and clinical nurse specialist (CNS), as well as highlight the nurse practitioner and clinical nurse specialist as the leadership APN roles within oncology practice. The adaption to managed care has identified new functions and created opportunities for these APN specialties that are being viewed both competitively by other oncology health-care providers and creatively by managed-care organizations. The integration of these emerging roles within the new advanced nursing market and their contributions to oncology care are also discussed.     

Hand cutting instruments

Challenges and opportunities for Advanced Practice Nurses are explored during the paradigm shift in health care. Role development is presented from a historical perspective, and current role activities are discussed related to accountabilities for care management. Advanced Practice Nurses with practitioner skills of care management coupled with a nursing framework for practice can deliver cost-effective primary care in a variety of settings.     

Synergistic effect of Epstein-Barr virus and tumor promoters on induction of lymphoma and carcinoma in nude mice

BACKGROUND: The core business of hospitals now requires, for both competitiveness and quality improvement reasons, that hospitals move beyond their physical and conceptual walls to form community partnerships. THE HOSPITAL'S ROLE AS A PARTNER IN COMMUNITY-BASED HEALTH IMPROVEMENT SYSTEMS: Hospitals, as organizations that are significant health care, social, and economic institutions in their communities, should play a leading role in mobilizing resources for such community-level health improvement efforts. MOVING OUTSIDE THE WALLS TO IMPROVE QUALITY: Three examples of extending hospital efforts into the community demonstrate that improvement of a problem involving hospital care can derive from a collaborative, community-based activity. In Boston, infection control--once a standard, strictly in-house procedure--has been forced by altered patterns of hospital use to become a largely community-based process. In Chicago, a variety of health care providers and community representatives have worked effectively to reduce mortality and morbidity in a single disease (asthma) model. In Akron, Ohio, Lifelink program hospitals, working together with community agencies and groups in a door-to-door neighborhood program, improved the effectiveness of prenatal care and the quality of birth outcomes. CONCLUSION: Efforts to work with community groups to improve health status should not be simply an optional do-good endeavor, as they have often been in the past, but rather an essential part of quality improvement and good business practice. Marketplace incentives will increasingly reward hospitals that are able to form successful community partnerships.     

Emerging trends in mental health policy and practice

The continuing deinstitutionalization of patients in public mental hospitals and the growth of managed care are fundamentally altering mental health practice. Managed care provides opportunities for achieving parity of insurance coverage between mental and physical illness, but serious problems persist in integrating mental health, substance abuse, and general medical care and assuring an appropriate range of services and programs for persons with serious mental illness residing in community settings. Hospital and community care are poorly coordinated, and hospital care needs to be integrated into a more balanced system of services. Important new roles are emerging for purchasers, patient advocates, and mental health authorities.     

Rehabilitation psychology practice, ethics, and a changing health care environment.

Rapid changes in the health care environment have brought about ethical and professional challenges for rehabilitation and rehabilitation psychology. The response of rehabilitation psychologists to the threats and opportunities of these challenges will have an impact on the welfare of persons with disabilities and the future of the profession. Managed care organizations have focused their efforts on the management of acute illness. Ethical concerns are being raised about patient access to care, self-determination, confidentiality, provider accountability, and marketing in managed care systems. Rehabilitation psychologists' skills in program development and outcome evaluation place them in a key position to influence the changes in the health care environment. To be effectual, however, fundamental changes must be made in research psychology practice, education and training, research focus, and professional activities. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Managed care: Strongly conflicting views.

Presents opposing viewpoints on the issue of managed care. R. R. Blanck considers managed care, if well regulated, to be rationed care with ethics. The example of the military's managed health care system (TRICARE) is presented as a model for the civilian community, and an initiative managed care program, BEHAVIORALCARE, is discussed. K. Shore contributes an argument in opposition of managed care, calling it immoral because it makes people powerless. It deprives patients of 3 basic rights: choice, privacy, and decision making. Because it cannot be adequately regulated, it should be replaced with a more pro-patient and democratic system. (0 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Community health centers and quality of care: a goal to provide effective health care to the community

The uniqueness of community health centers provides for a sound environment for total quality management (TQM). Structure, process, and outcome are valued equally under TQM. With strong management leadership and a framework for quality of care, community health care specialists (e.g., advanced practice nurses) can easily incorporate the TQM measurement criteria in their daily practice routines. By applying the principles of TQM, the community health center will advance toward its goal of enhancing the effectiveness of health care delivery to a community and its members in partnership with the community.     

Reproducibility of different methods for diagnosing and monitoring diabetic neuropathy

The subspecialty of allergy and immunology, like all medical specialties, has been dramatically impacted by the managed care revolution. Many of the changes that have been imposed by our environment are likely to persist, including increased emphasis on efficiency of practice and cost-effectiveness of treatment modalities. It is predicted that these changes will decrease the involvement of allergists and immunologists in the primary treatment of patients with allergic rhinitis and mild asthma, in favor of management by generalists with subspecialty consultation. Conversely, outcomes studies demonstrate the cost-effectiveness of management of moderate to severe asthma by an allergy and immunology subspecialist. It is thought probable that HMOs will recognize this fact and implement it as a pattern of practice. The allergist and immunologist will continue to offer, uniquely, expertise in allergic history taking, patient education, environmental control, and management of allergic inflammation. He or she will also be afforded an opportunity for practice expansion, particularly as an expert consultant, into other areas of immune inflammation, such as autoimmunity and graft rejection. Potentially new and increasingly specific products of the pharmaceutical and biotechnology industries will enhance these opportunities for practice expansion by physicians who combine intellectual understanding with practical expertise in patient management. Realization of these new opportunities will require us to work together as teachers and role models to communicate the excitement of our subspecialty to new physicians. Allergy and immunology is a subspecialty with a bright future, provided that we have the will and the insight to deal effectively with our challenges and to master opportunities that our science presents to us.     

Advanced practice nursing certification: where do we go from here?

Certification requirements for advanced practice nurses (APNs) vary between APN specialties and the certification agencies. This variability perpetuates confusion for APNs, the health care system, and the public. Recommendations are made for the certification of APNs: (1) standardization of the certification process for APNs, (2) consistency in the requirement for graduate level education for all APNs, (3) regulation requiring certification for practice in all states, and (4) nurse practitioner (NP) program accreditation or preaccreditation for eligibility to take the certification examination. To support these recommendations, two questions are considered: Where are we now in certification? Where do we need to go?     

The aesthetes of chitons. III. Shell surface observations

The federal legislation mandating Professional Standards Review Organizations to monitor the decision making of physicians regarding their patients is a method unique to the United States to control medical care costs according to prevailing professional criteria. Other countries, so far, depend largely on health service structures, reimbursement methods, and arbitrary government budget limitations. Our dislike of highly structured delivery systems has pragmatically moved us in the direction of monitoring diagnostic and therapeutic decision making. PSRO is mandated at a time when there is no systematic methodology with validated criteria for monitoring medical practice. This will likely lead to subtle sabotage of PSRO by the medical profession justified by quality standards which are the professions' prerogative. It is conceivable that quality standards will rise and, therefore, costs. The drive for monitoring physician decision making is understandable even when there is no methodology. It then behooves medical schools to conduct research on methodologies of monitoring services, a possible favorable side-effect of the legislation. An unfavorable side-effect may likely be that the criteria will be based exclusively on technical medical considerations and ignore the personal and social attributes of patients which should affect the decision making of physicians. Medicine will then become even more technocratic than it is now. All countries are converging at various degrees of intensity in establishing planned limits to expansion, examining possibilities of monitoring physician decision making and capping this off with arbitrary budget ceilings. The state of the art of health services management appears to permit no other recourse.     

Still spending dollars, still searching for sense: advanced practice nursing in an era of regulatory and economic turmoil

Regulatory and market forces are dramatically affecting the practice prospects for advanced practice nurses (APNs). Examples include the designation of APNs as primary care providers by for-profit capitated systems, the elimination of "geographic" practice boundaries by the advent of telepractice, and the revision of governmental reimbursement provisions for entire categories of APNs. Educational, political, and economic challenges necessitate an increased APN leadership role in national and state policy reform efforts.     

Accumulation of chylomicron remnants in homozygous subjects with familial hypercholesterolaemia

Despite the obvious differences between the USA and UK health care systems, they share the characteristics of being motivated and managed in relation to cost and process rather than quality (the improved health status of patients). Whilst governments and insurers across the world use the rhetoric of quality, they, as epitomized by the behaviours of UK and USA decision makers, fail to define, measure and implement quality outcome policies. These behaviours are examined and some of their causes are explored briefly. Competition, as designed and used in public (e.g. UK National Health Service) and private (e.g. USA managed care) markets is shown to fail both to identify quality outcome targets and to provide evidence-based and efficient mechanisms to motivate decision makers to be orientated towards continuous quality outcome improvement in health care. A central policy challenge is, consequently, not just the measurement of quality outcomes but also their management into practice.     

Coping with transition: neonatal nurse practitioner education for the 21st century

As neonatal intensive care nurses face downsizing and/or cross-training, new opportunities are emerging for advanced practice nurses in follow-up care of neonatal intensive care unit graduates, case management, quality improvement, and community hospital care. This article identifies current issues in neonatal nurse practitioner (NNP) education as the model has shifted from hospital-based, certificate programs to graduate degree programs offered by colleges/universities of nursing. Opportunities for increasing NNP role flexibility and recommendations for bridging the transition to a 21st century education model for neonatal advanced practice nurses are also discussed. Despite the turmoil of change and uncertainty, the future for neonatal advanced practice nurses is positive. Successful nurses will master the skills of adaptability, flexibility, self-directed learning, leadership, and the provision of relationship centered care. Neonatal nursing educators must constantly monitor clinical practice and re-evaluate the curriculum to ensure the necessary knowledge and skills for successful practice can be achieved from the educational program. It is critical that faculty are cognizant of emerging trends and changing roles in the practice area. Additional learning opportunities may be required for graduates to successfully move into the next century.