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The healthcare industry in the United States has continued to change dramatically over the past few years transforming the roles of nurses and escalating their opportunities. The advanced nursing practitioner shortage is a result of an increasing number of the hospitalized patients who are older and more acutely ill. The paper assesses the impact of technology because expanding technological advances lead to prolonged life which in turn requires more highly skilled personnel.

Researchers state that the need for fundamental reform of the United States care system is more necessary nowadays than in the last two decades. Policy makers say that a bold action is called for to create a healthcare system that is responsive to the needs of consumers and provides equal access to safe, high-quality care for every citizen and resident in a cost effective manner. Advanced practices of nurses bring unique perspective to the healthcare policy development because of their education, training, professional values and ethics, advocacy skills and experimental background.

In the context of the advanced practices of nurses, understanding the health care reforms in which they work is an important foundation for the successful practice.  APNs need to understand fundamental aspects of the structure, operations, scope and features of the healthcare delivery system. They should have a clear picture of the means by which the healthcare delivery system is financed, including national healthcare expenditures and sources of payment. While addressing the issue of the effects of healthcare reform to the APNs, the paper puts more emphasis that the ultimate goal should be to provide high-quality, cost-effective care besides taking part in the design and implementation of programs in a variety of systems.

Background

The assurance of medical science with the detailed new treatments, majority of which can be customized to individualized genetic profiles has changed the profession of advanced nursing practice. This promise seems to fly in the face of our ability to solve the grave dilemma and fallout of the country’s 47 million uninsured or underinsured citizens (Vallano, 2008). Kline & Huff (2007) say that while nurses stay away from the promising forecast of excellent job growth and opportunity on the one hand, they also find themselves faced to the large workloads and concerns about being able to provide safe patient care due to a nursing shortage. 

Vallano (2008) established that during 1990s in the onset of the current health care revolution, social, political and economic factors led to the onset of the managed care with its monetary restraint and cost containment. Kline & Huff (2007) mentioned that the managed care in the United States came up from a disorganized system and developed methods of the oversight that capped payments to health care providers with the aim of reducing costs. Despite the surplus of advanced nursing practitioners created by the economic necessities of downsizing, Vallano (2008) says that a paralleled nursing shortage was predicted to grow more severe as the demand for nurses outstripped the supply of qualified nurses willing to work. This has impacted the advanced practicing nurse today as well as influenced the quality of the patient care (Kline & Huff, 2007).

According to Loveridge & Cummings (1996), the federal government as well as the general populace noted that health care is a scarce resource and that no longer can people receive all the health care services they require. The advanced nursing practice was in the middle of this health care revolution and nurses were supposed to have the knowledge and understanding of the healthcare economics to compete and survive (Loveridge & Cummings, 1996). 

Advanced nursing practitioners stated that health care costs could be reduced by nurses’ involvement in decision making related to the health care delivery and by better association between physicians and nurses (Loveridge & Cummings, 1996). As a result of the health care revolution, Kline & Huff (2007) note that APNs who want to have a successful career during the best and the worst times in health care without sacrificing personal wellbeing, will learn to thrive on change. The health care industry and the nursing profession will continue to position and reposition themselves to meet the needs of both patients and workers (Kline & Huff, 2007). 

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Kline & Huff (2007) learned that APNs belong to the generation of nurses bridging the gap between old and new, past and future, now and what will be. Vallano (2008) indicated that life within those parentheses challenged the nursing professional and personal wholeness and well-being as they worked to maintain their footing in a constantly changing world.

Platform on Potential Effects of Healthcare Revolution on Advanced Practice Nursing

The following platform has an impact on all aspects of health and healthcare delivery, such as APNs deliver, health care, who receives care, the types of the services received, reimbursement, and the types of providers and organizations that provide health care.  Kline & Huff (2007) indicated that boards of the advanced practice of nursing and each state’s nurse practice act have an impact on professional expectations and what a nurse does. After the health care revolution, the federal laws and rules related to Medicare and Medicaid address the issues, such as reimbursement for the advanced practice of nurses. Finkelman & Kenner (2012) mentioned that “how nursing care is provided and what care is provided by APNs is greatly determined by Medicare, Medicaid, nurse practice acts, and other laws made by the federal state and local governments” (p. 159).  

DeNisco & Barker (2012) defines advanced practice of nursing as an application of the expanded range of practical, theoretical knowledge and research based on the competencies to phenomena experienced by patients within specialized clinical area of the larger discipline of nursing. Stanley (2011) says that this term distinguishes these nurses with the advanced skills from those who practice as more traditional staff nurses and allows for a distinction between the nurses functioning at a more specialized level than the registered nurse. Kline & Huff (2007) further says that a common characteristic of these roles is the application of a greater breadth of knowledge and complexity of decision making to the issues arising from the nursing care.

Since the inception of the advanced practice of nursing, health policy and regulatory advances enabling practice have made some steps forward with an unprecedented swiftness and congruity (DeNisco & Barker, 2012). These advanced practice roles seem to have captured the imagination and interests of nurses who seek to be involved in more independent decision making and relief from what has caused an increasingly stressful hospital environment. DeNisco & Barker (2012) noted that “the role of the advanced practice of nurses has expanded well beyond initial expectations, and demands on practice continue to increase” (p. 22).

Nursing shortage

Following the health care reforms in the United States, there has been a nursing shortage which directly impacts care delivery. This occurs due to the lack of the right number and type of nurses for care needs and not having enough faculties to provide the education needed to increase the number of graduates (Finkelman & Kenner, 2012). The healthcare reform of 2010 addressed the issue of nursing shortage and how to increase the number of APNs by increasing funding for all levels of nursing education and to increase the number of the qualified faculty. Another major issue related to nursing shortage is a mandatory overtime (Stanley, 2011). There is a need to limit the amount of overtime that healthcare facilities are permitted to mandate to 12 hours per workday or 60 hours per week (Finkelman & Kenner, 2012). Mandatory overtime should be permitted in case of declared emergency or unforeseeable catastrophic events. 

Increase in the Cost of Health care

After the health care reforms took place, the cost of treatment in the United States rose. Finkelman & Kenner (2012) noted that there is no doubt that there are better drugs, treatment nd technology today to improve health and meet treatment needs for many problems. Studies indicate that defensive medicine, in which the physician and other healthcare providers order tests and procedures to protect themselves from lawsuits, increases the costs. Cost of health care has affected advanced practice of nurses because the cost containment and the cost effectiveness has become very important (Stanley, 2011). Health care reforms often focus on reimbursement, control of costs and greater control of decisions making in the realm of reduceing costs. 

Rise in the cost of health care is attributed to the fact that the emergency services have been experiencing changes because of problems with how they have been used by patients (Finkelman & Kenner, 2012). This has been a major for APNs, because some patients use the emergency department as their private physician, coming in for services that are not acute (Stanley, 2011). This in turn has a fundamental impact on the flow of patients into and out of the emergency departments.

According to Finkelman & Kenner (2012), the increased number of patients who cannot pay for services and have no insurance coverage causes major financial problems for hospitals and APNs as well. With the reforms in care delivery in place, it is important to note that access to health care is more than just the ability to get an appointment, but it involves the availability of services at time that is convenient for the patient.

Rise in Educational Standards for APNs

Educational preparation for the advanced practice of nursing has been extended from master’s degree preparation to the doctoral completion by 2015. DeNisco & Barker (2012) noted that “this latest trend, which has the potential to revolutionize healthcare, is the topic of much debate among nursing leaders and members of other healthcare disciplines” (p. 23).The challenge is to standardize practice definitions and educational standards while building and honoring the traditions of individual countries (Stanley, 2011).

The education policy of nurses in the United States depends on the level to which the nurse aspires.Funnell, Koutoukidis & Lawrence (2008) indicated that the advanced practice of nurses is regarded as being responsible and accountable for all decisions and actions taken in relation to client’s care. Stanley (2011) notes that nursing is a dynamic profession located within an ever-changing health care system, and continuing education programs are essential in enabling nurses to remain current in nursing skills, knowledge, theory and changes in the health care policy and law. In the United States, continuing education is provided in many different forms by health care institutions, professional and industrial bodies and an ever-increasing number of private providers (Stanley, 2011).

Following the health care revolution, two major possibilities have affected APNs in relation to educational bottlenecks. Harrington & Estes (2008) indicate that the educational platform has been producing more nurses and this has increased the unattractiveness of nursing because of negative employment factors. Stanley (2011) says that a survey of nursing programs reveals that although nursing schools have experienced a strong increase in applications since 2003, now they are turning away thousands of qualified applicants.

Unfavorable Employment conditions

According toHarrington & Estes (2008), employment conditions are emerging as major cause of recruitment and retention difficulties for the advanced practice of nurses. Stanley (2011) explaines that upholding good working conditions in patient care for APNs in patient care areas is critical to the stability of the workplace environment. If the working conditions for APNs are poor, the physical and mental health of the nurses suffers, dissatisfaction grows, and nurse turnover and dropout rates increase (Stanley, 2011).

It has been noted that without good working conditions, the APNs workplace is not seen in a positive light, hence discouraging new and inactive APNs from entering or reentering the nursing profession and bedside nursing (Green & Kreuter, 2005). Following the revolution, the American Hospital Association is currently evaluating workplace issues through its Commission on Workforce. There is an increasing interest in the responsibility of consumers in health care. Finkelman & Kenner (2012) say that today, patients are more informed about health and healthcare services.         

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Theoretical Issues and Challenges

Current shifts have been important factors in shaping current nursing environment (Stanley, 2011). Scholars say that what has occurred is that many of the skills involved in the advanced practice roles have moved into the mainstream (Stanley, 2011). In the United States, the advanced practice role is evolving in diverse ways depending on the historical, political and social factors that have shaped the nursing role and educational programs in the country (Stanley, 2011).

Green & Kreuter (2005) established that nursing theories were an attempt to elucidate the nature of nursing practice, the principles on which such practice is based, and proper goals and functions of nursing in society. After the health care revolution, the development of nursing theory was an essential part of establishing professional status and independence (Funnell, Koutoukidis & Lawrence, 2008).       

Nowadays, the health care delivery system is experiencing dramatic changes. Finkelman & Kenner (2012) note that in some cases nurses with the advanced roles receive admitting privileges, meaning that they can admit their patients to the hospital from private practice or clinics. Green & Kreuter (2005) also say that following the health care reforms the United States is experiencing a lack of primary care providers, and with the change has led to increasing number of people with health insurance coverage. This implies that there will be even greater demand for these providers (Stanley, 2011).

Challenges Associated with Demographic Changes

After the health care revolution,there are several demographic changes that have influenced health care in recent decades (Green & Kreuter, 2005). These changes include the population shift from rural areas to urban centers, increasing life span, the higher incidence of long term illness and increased incidence of diseases such as substance use, mental health and cancers (Green & Kreuter, 2005).  Green & Kreuter (2005) note that the advanced practice of nurses must respond to the health changes by exploring new methods for providing care, by changing educational emphasis and by establishing practice standards in new areas.

Cultural Diversity Challenges

The platform addresses the critical issue of cultural diversity. Funnell, Koutoukidis & Lawrence (2008) indicate that America is a multicultural society which implies that nurses frequently encounter clients from cultures different from their own. This means that the advanced practice of nurses need to be open to the challenges presented by cultural diversity and seek the information they require to provide culturally sensitive care to the patients (Green & Kreuter, 2005).

Lundy & Janes (2009) note that the United States is the most culturally diverse nation in the world. For example, in 2000, almost 30% of Americans were members of ethnic minority groups, including 12.1% African American, 12.5% Hispanic and 3.7% Asian/Pacific Islander (Lundy & Janes, 2009). In the same year, statistics indicate that less than 13% of the advanced practice of nurses were members of ethnic minority groups.

It is clear that the advanced practice of nurses must be sensitive to cultural differences to be able to provide the best possible care to individuals, families and communities. Green & Kreuter (2005) also note that there is a culture of nursing that all advanced practice of nurses belong to, with their own language, values and traditions that often clashes with patients whose cultural beliefs about health care differ from those of their nurses. In addition, Lundy & Janes (2009) saay that comparing and drawing insights from methods and success of nurses in delivering care in other countries holds the promise of improving the care of the United States patients.

Promoting Safe Environment

The environment has been a concern for nursing since the health care revolution and the days of Florence Nightingale. Lundy & Janes (2009) say that the advanced practice of nurses are beginning to take a more active role in promoting environmental health, reducing environmental health risks and protecting the earth’s resources. Stanley (2011) established that with the healthcare revolution witnessed in the United States over past few decades, several nursing organizations have developed positions statements to delineate the nurse’s role in promoting environmental health. Green & Kreuter (2005) say that through the health care transformation, APNs should conduct health promotion at the wider community level and pursue environmental approaches intended to result in permanent structural changes.

Low Reimbursement

Cohen & Cesta (2005) note that reimbursement in wake of healthcare revolution has embraced new criteria for payment as health promotion strategies, surveillance, health maintenance, and care activities take the forefront. Kline & Huff (2007) mention that the present fee for service arrangements will be outpaced by population based on capitation, contractual arrangements for group’s services and other innovative financial models. Stanley (2011) proposes a realignment of financial incentives that is based on an aggregate measure of health for large populations or health plans that can be used for the maintenance and improvement of the health of populations in the country.

The main challenge within this platform is that the measurement of health status conducted by APNs must incorporate both the quantity and quality of life.  Green & Kreuter (2005) explain that reimbursement of nursing care must be viewed from two perspectives. The first is how to reimburse for nursing care services, particularly inpatient services. Studies indicate that after the health care revolution, hospitals still do not clearly identify the specific costs of nursing care in a manner that directly impacts the reimbursement (Kline & Huff, 2007). There have been major changes on how APNs are reimbursed. 

Adapting to New Technology

Since the health care revolution has advanced practice, nurses have been facing the technological challenges in providing population-based care (Green & Kreuter, 2005). Cohen & Cesta (2005) say that these challenges include defining community within a statistical and epidemiological perspective, establishing data collection methods and aggregation of information, developing information in the most meaningful and accessible format and determining the efficacy of treatment and care outcomes.

According to Kline & Huff (2007) the advanced practice operations of nurses are affected by poverty and lower social status associated with poor health, poor nutrition, low incomes and poor sanitation.  Green & Kreuter (2005) note that these problems are detrimental to vulnerable populations, including infants, children, adolescents, older people and the disabled. 

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American Nurses Association has over the time remained committed to providing all persons to ready access to affordable, quality health care services (Finkelman & Kenner, 2012). Stanley (2011) established that APNs as the pivotal health care profession is well positioned to advocate on behalf of an in concert with individuals, families and communities who are in desperate need of a well financed, functional and coordinated health care system that provides safe and quality care.  Despite the health care revolution, access to care means that care should be affordable for, available to and acceptable to a great variety of patients (Stanley, 2011). Kline & Huff (2007) say that within this platform all care should be safe, effective, timely, patient centered, efficient and equitable.

The Implications for the APN

While adapting to these challenges,Kline & Huff (2007) established that those APNs who want successful 21st century careers, need to track these and other trends in order to prepare for changing roles and to take advantage of the advanced nursing practice. One of the implications that result from the health care revolution, is the effect of technology. Vallano (2008) says that technology is not only changing how nurses work but how they learn as witnessed by the ever growing online learning venues for basic, graduate and ongoing nursing education. There are several trends in technology, which have impacted the advanced nursing practice (Kline & Huff , 2007).  These trends include telemedicine and telenursing, particularly for the remote monitoring of patients at home or in ICUs and the implementation of the portable electronic medical record (Vallano, 2008).  

The second implication is the globalization of health care. Kline & Huff (2007) indicate that the need to come up with an awareness of one’s own interpersonal and communication style is very important in becoming competent and sensitive to cultural differences. Vallano (2008) says that this has resulted in the utilization of a worldwide labor force to purchase health care products and services beyond the country’s borders. Stanley (2011) indicates that this feature allows access to products and services that may be less costly or more available, such as the technology related services.

The third implication was the commoditization of health care, which resulted in health care clinics often staffed by nurse practitioners in retail centers. Vallano (2008) says that these are emerging rapidly to satisfy consumer’s desires for services of lower cost, greater convenience and easier accessibility. He continues to say that this aspect is attractive to people with limited or no health insurance. Kline & Huff (2007) however say that it is easy for APNs to quote models and recommendations and it is even easier to pay lip service to their value in becoming more culturally competent and sensitive.

The fourth implication is cost containment. Vallano (2008) says that following the health care transformation, cost containment continues to be a prominent influence in how health care services are delivered since prices are fueled by inflation and increasing demand. For advanced nurse practitioners, Stanley (2011) says that this issue is crucial to quality patient care and just as crucial to the quality of working life balance. The necessity of coming up with a self-care practice while working in this type of challenging environment (Stanley, 2011). 

Healthcare reform has and will have an impact on nursing education, nursing practice, regulation of nursing and professional roles. Finkelman & Kenner (2012) thus state that APNs leadership will be required to help to implement the laws effectively. Stanley (2011) notes that the experiences of many APNs practicing in the real world of healthcare are motivating them to take on some form of an advocacy role in order to influence changes in policies, laws or regulations that guide the entire healthcare system. 

Conclusion

In conclusion, Funnell, Koutoukidis & Lawrence (2008) indicated that the profession of nursing is in a constant state of change. The evolution of nursing has brought us to the point where there are endless opportunities to improve the health and welfare of the patients and the communities as well. The role of the advanced practice of nurse has changed from that of a vocation to the emphasis on education and professional standards, signified by the development of competencies for the registered nurses and codes of ethics (Vallano, 2008). The role of the advanced practice of nurse is expanding and adopting new areas, such as technology in health care that is still a major challenge for these practitioners. The challenge for the future even with the above platform is to incorporate these changes into the role of the advanced practice of nurse while at the same time maintaining the standards of the profession.

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