By Clif Cleaveland
Prevention and primary care are crucial if a reformed heath-care system is to be affordable and effective.
The Accountable Care Act, which Congress passed in March, will enable at least 32 million previously uninsured Americans to obtain health insurance. Their enhanced access to care will worsen an already significant shortage of primary health-care providers.
Medical schools cannot begin to train replacements for an aging work force of primary- care physicians. The best solution rests with broadening the roles of nurses and more fully integrating them into clinical practice. This is among the conclusions of a recently released study by the Institute of Medicine and the Robert Wood Johnson Foundation.
America's 3 million nurses already constitute our largest category of health professionals. Their invaluable roles in hospitals, clinics, home health settings, and public health agencies are well recognized. Most are registered nurses (RNs) who completed their training either in diploma or bachelor of science in nursing (BSN) programs.
Advanced practice registered nurses (APRNs) typically undertake an additional two to three years of academic and clinical study to prepare for careers in education, governmental service, or as nurse practitioners. BSN degrees are usually a prerequisite.
Some graduate programs, such as the one at Vanderbilt University, permit students with non-nursing degrees to enter three-year Masters of Science in Nursing programs so long as they have completed background courses in relevant sciences and have achieved high scores on the Graduate Records Examination.
The majority of applicants for APRN training have spent several years in nursing practice and have already attained a BSN.
APRNs who choose careers as nurse practitioners may select from a variety of options: family, adult, gerontological, psychiatric, pediatric, and women's health. For certification, they must pass a rigorous national examination. Some programs also offer an optional year of residency training to bridge the gap between academic preparation and practice.
Some students proceed to doctorate degrees in nursing to pursue careers in teaching, research and health policy. A challenge in the education of nurses is expansion of faculties to meet demands of more students and more complex curricula.
Licensure to practice is regulated by individual states. Some, such as Oregon, Washington, Arizona, and Tennessee permit APRNs to undertake broad, clinical responsibilities including prescribing medications. Typically, an APRN will establish a contractual relationship with a physician-consultant. Other states, influenced by physician groups who fear competition, place tight restrictions on what APRNs may do. Georgia is regarded as a highly restrictive state.
More than 5000 APRNs are licensed in Tennessee. The School of Nursing at UT-Chattanooga accepts 20 students into its family nurse practitioner concentration each year. The curriculum is focused in the areas of pediatrics, women's health and adult medicine. Graduates are in high demand throughout our region. Scholarships and loan-repayment plans are available.
The Institute of Medicine report outlined four recommendations for transforming the profession of nursing:
* Nurses should practice to the full extent of their training. This means uniform standards for licensure.
* Nursing education should permit easier progression thorough the various undergraduate and graduate options.
* Nurses must be full partners in shaping and delivering health care.
* Careful collection and analysis of health data is essential to plan for the nation's needs in medical manpower.
Forty years ago I served as a clinical instructor for the first two APRNs at Vanderbilt University. At the time, no one could anticipate the roles that APRNs might fill. More than 500 APRNs currently practice in various in-patient and out-patient settings at Vanderbilt Medical Center.
The future of primary health care in America very much depends upon a robust system of educating and empowering APRNs.
Contact Clif Cleaveland at cleaveland1000@comcast.net.