If you were to ask 10 people what they believe to be the most significant issue facing healthcare today, you might get 10 different answers. Escalating costs? Regulation? Technology disruption?

These and many other topics are worthy of discussion. Not surprisingly, much has been said in the research, within the profession, and in the news about these topics. Whether they are issues of finance, quality, workload, or outcomes, there is no shortage of changes to be addressed.

In this Discussion, you examine a national healthcare issue and consider how that issue may impact your work setting. You also analyze how your organization has responded to this issue.

To Prepare:

  • Review the Resources and select one current national healthcare issue/stressor to focus on.
  • Reflect on the current national healthcare issue/stressor you selected and think about how this issue/stressor may be addressed in your work setting.

Post a description of the national healthcare issue/stressor you selected for analysis, and explain how the healthcare issue/stressor may impact your work setting. Then, describe how your health system work setting has responded to the healthcare issue/stressor, including a description of what changes may have been implemented. Be specific and provide examples.



Growing Ranks of Advanced Practice Clinicians

n engl j med 378;25 nejm.org June 21, 2018

Growing Ranks of Advanced Practice Clinicians

Growing Ranks of Advanced Practice Clinicians
— Implications for the Physician Workforce
David I. Auerbach, Ph.D., Douglas O. Staiger, Ph.D., and Peter I. Buerhaus, Ph.D., R.N.

Throughout the history of mod-ern American medicine, phy-
sicians have made up the vast
majority of professionals who di-
agnose, treat, and prescribe medi-
cation to patients. Although de-
mand for medical services has
increased markedly over the years
(and is projected to grow more
rapidly as the population ages),
the physician supply has grown
relatively slowly. Increased dele-
gation of work, new technology,
and streamlined care processes
can help practices meet patient
needs with fewer physicians, but
still require an increasing num-
ber of health professionals.1

Physician supply is constrained
in the short run by long training
times and in the longer run by
medical school capacity and the
number of accredited residency
positions. Despite a 16% increase
in graduate medical education
(GME) slots in recent years, the
Association of American Medical
Colleges (AAMC) recently project-
ed that the supply of physicians
will increase by only 0.5% per
year between 2016 and 2030.

A growing share of health care
services are being provided by ad-
vanced practice registered nurses
(APRNs), particularly nurse prac-
titioners (NPs), who make up the
majority of APRNs, and by physi-
cian assistants (PAs). NPs and PAs
provide care that can overlap with
care provided by physicians (both
in primary care and increasingly
in other specialties), and the
AAMC recognizes this overlap in
its physician-demand forecasts.
The number of NPs and PAs is

growing rapidly, in part because
of shorter training times for such
providers as compared with phy-
sicians and fewer institutional
constraints on expanding educa-
tional capacity. Residencies aren’t
required for APRNs — though
organizations are increasingly
offering them — and education
programs have proliferated: ac-
cording to the American Associ-
ation of Colleges of Nursing, the
number of NP degree programs
(master’s or doctorate) grew from
282 to 424 between 2000 and
2016. Baccalaureate-prepared RNs
typically require 2 to 3 years of
graduate education to become
certified NPs. PA programs typi-
cally take 2 years and also don’t
require residencies. According to
the National Center for Education
Statistics, the number of PA de-
gree programs grew from 135 to
238 between 2000 and 2016.

These dynamics will have last-
ing effects on the composition of
the health care workforce and
on working relationships among
health professionals. To take a
closer look at these trends, we
estimated the number of full-time-

Removing restrictions on nurse practitioners’ scope of practice
in New York State: Physicians’ and nurse
practitioners’ perspectives

Lusine Poghosyan, PhD, RN, FAAN1, Allison A. Norful, PhD, RN, ANP-BC2, & Miriam J. Laugesen, PhD3

Background and purpose: In 2015, New York State adopted the Nurse Practitioners Modernization Act to remove
required written practice agreements between physicians and nurse practitioners (NPs) with at least 3,600 hours of
practice experience. We assessed the perspectives of physicians and NPs on the barriers and facilitators of policy
Methods: Qualitative descriptive design and individual face-to-face interviews were used to collect data from
physicians and NPs. One researcher conducted interviews, which were audio-taped and transcribed. Twenty-six
participants were interviewed. Two researchers analyzed the data.
Results: The new law has not yet changed NP practice. Almost all experienced NPs had written practice agreements.
Outdated organizational bylaws, administrators’ and physicians’ lack of awareness of NP competencies, and phy-
sician resistance and lack of knowledge of the law were barriers. Collegial relationships between NPs and physicians
and positive perceptions of the law facilitated policy implementation.
Conclusions: Policy makers and administrators should make efforts to remove barriers and promote facilitators to
assure the law achieves its maximum impact.
Implications for practices: Efforts should be undertaken to implement the law in each organization by engaging
leadership, increasing awareness about the positive impact of the law and NP independence, and promoting rela-
tionships between NPs and physicians.
Keywords: Nurse practitioners; scope of practice; primary care; policy.

Journal of the American Association of Nurse Practitioners 30 (2018) 354–360, © 2018 American Association of Nurse Practitioners

DOI# 10.1097/JXX.0000000000000040

Physicians, nurse practitioners (NPs), and physician
assistants currently provide the bulk of primary care in
the United States (U.S.) to meet the demands of an
aging population and expansion of insurance coverage
(Agency for Healthcare Research and Quality, 2014; Col-
will, Cultice, & Kruse, 2008; DeVol & Bedroussian, 2007;
Patient Protection and Affordable Care Act of, 2010). One
projection suggests an additional 52,000 physicians will

be needed by 2025 to meet the primary care demand
(Petterson et al., 2012); however, the supply of these
providers is expected to decrease (Association of Medical
Colleges Center for Workforce Studies, 2015). Conversely,
NP workforce is expected to grow. In 2013, NPs comprised
about 19% of the U.S. primary care provider workforce,
and the number of NPs will increase by 93% by 2025
(Health Resources and Services Administration, 2016),
potentially expanding the primary care capacity (Auer-
bach, et

Original Article

Predictors of Evidence-Based Practice
Implementation, Job Satisfaction, and Group
Cohesion Among Regional Fellowship
Program Participants
Son Chae Kim, RN, PhD • Jaynelle F. Stichler, DNS, RN, NEA-BC, FACHE, FAAN •
Laurie Ecoff, RN, PhD, NEA-BC • Caroline E. Brown, DEd, CNS •
Ana-Maria Gallo, PhD, CNS, RNC-OB • Judy E. Davidson, DNP, RN, FCCM



EBP beliefs,

job satisfaction,

group cohesion,
group attractiveness

Background: A regional, collaborative evidence-based practice (EBP) fellowship program utiliz-
ing institution-matched mentors was offered to a targeted group of nurses from multiple local
hospitals to implement unit-based EBP projects. The Advancing Research and Clinical Practice
through Close Collaboration (ARCC) model postulates that strong EBP beliefs result in high EBP
implementation, which in turn causes high job satisfaction and group cohesion among nurses.

Aims: This study examined the relationships among EBP beliefs, EBP implementation, job satis-
faction, group cohesion, and group attractiveness among the fellowship program participants.

Methods: A total of 175 participants from three annual cohorts between 2012 and 2014 com-
pleted the questionnaires at the beginning of each annual session. The questionnaires included
the EBP beliefs, EBP implementation, job satisfaction, group cohesion, and group attractiveness

Results: There were positive correlations between EBP beliefs and EBP implementation (r = 0.47;
p <.001), as well as EBP implementation and job satisfaction (r = 0.17; p = .029). However, no
statistically significant correlations were found between EBP implementation and group cohesion,
or group attractiveness. Hierarchical multiple regression models showed that EBP beliefs was a
significant predictor of both EBP implementation (β = 0.33; p <.001) and job satisfaction (β =
0.25; p = .011). However, EBP implementation was not a significant predictor of job satisfaction,
group cohesion, or group attractiveness.

Linking Evidence to Action: In multivariate analyses where demographic variables were taken
into account, although EBP beliefs predicted job satisfaction, no significant relationship was
found between EBP implementation and job satisfaction or group cohesion. Further studies are
needed to confirm these unexpected study findings.

The adoption and implementation of evidence-based practice
(EBP) in nursing and other healthcare disciplines are recog-
nized as essential in ensuring optimal patient outcomes and
quality of care (Aarons, Ehrhart, & Farahnak, 2014). Although
EBP is considered to be the gold standard in nursing practice,
the actual implementation of EBP has been inconsistent due
to barriers related to nursing workload, lack of organizational
support, lack

Nurs Admin Q
Vol. 42, No. 3, pp. 231–245
Copyright c© 2018 Wolters Kluwer Health, Inc. All rights reserved.

Engaging Employees
in Well-Being
Moving From the Triple Aim to the
Quadruple Aim

Barbara Jacobs, MSN, NEA-BC, RN-BC, CCRN-K;
Julie McGovern, MA, SPHR, SHRM-SCP;
Jamie Heinmiller, BS;
Karen Drenkard, PhD, RN, NEA-BC, FAAN

Anne Arundel Medical Center has been on a 3-year journey to improve employee well-being
with the assumption that employee well-being and employee engagement are interconnected.
Improvements in employee well-being will result in increased employee engagement and will
be a pivotal driver to assist the health system meet its goals. Historically, Anne Arundel Medical
Center successfully differentiated itself in the market by being the region’s high-quality, low-cost
provider of health services delivered through intense collaboration with patients and families. The
financial, quality, and patient satisfaction results are in the top percentiles nationwide. However,
as the pace of change accelerates and the organization faces increased pressure to improve
outcomes, keeping employees from becoming burned out and disengaged becomes an increasing
concern. The WellBeing framework was developed on the basis of the work of Tom Rath and
Jim Harter as the model to support Anne Arundel’s WellBeing work. The efforts around well-
being are comprehensive and impact all aspects of how work is conducted. Employee well-
being has been elevated to an equal third prong along with providing high-quality low-cost care
in a patient-centered environment. This focus on leading an employee WellBeing Program has
resulted in improved engagement scores at Anne Arundel Medical Center. Key words: employee
engagement, leadership, quadruple aim, WellBeing Program

strategic plan, “Vision 2020” in 2009, it was
developed around 5 strategic pillars: Qual-
ity, Community, Workforce, Growth, and Fi-
nance. The initial strategies tied heavily to
the Triple Aim of improving the health of
populations, improving the patient experi-

Author Affiliations: Anne Arundel Medical Center,
Annapolis, Maryland (Mss Jacobs, McGovern, and
Heinmiller and Dr Drenkard); and GetWellNetwork,
Inc, Bethesda, Maryland (Dr Drenkard).

The authors declare no conflict of interest.

Correspondence: Karen Drenkard, PhD, RN, NEA-BC,
FAAN, GetWellNetwork, Inc, 7700 Old Georgetown Rd,
Bethesda, MD 20814 ([email protected]).

DOI: 10.1097/NAQ.0000000000000303

ence, and lowering the cost of care.1 Anne
Arundel Medical Center had and continues
to have excellent outcomes, regularly receiv-
ing statewide recognition for high patient ex-
perience scores as compared with the state
of Maryland, better than average

o you ever wonder why
nurses engage in practices
that aren’t supported by

evidence, while not implementing
practices substantiated by a lot
of evidence? In the past, nurses
changed hospitalized patients’ IV
dressings daily, even though no
solid evidence supported this prac-
tice. When clinical trials finally
explored how often to change IV
dressings, results indicated that
daily changes led to higher rates
of phlebitis than did less frequent
changes.1 In many hospital EDs
across the country, children with
asthma are treated with albuterol
delivered with a nebulizer, even
though substantial evidence shows
that when albuterol is delivered
with a metered-dose inhaler plus
a spacer, children spend less time
in the ED and have fewer adverse
effects.2 Nurses even disrupt
patients’ sleep, which is important
for restorative healing, to docu-
ment blood pressure and pulse
rate because it’s hospital policy to

take vital signs every two or four
hours, even though no evidence
supports that doing so improves
the identification of potential
complications. In fact, clinicians
often follow outdated policies and
procedures without questioning
their current relevance or accu-
racy, or the evidence for them.

When a spirit of inquiry—an
ongoing curiosity about the best
evidence to guide clinical decision
making—and a culture that sup-
ports it are lacking, clinicians are
unlikely to embrace evidence-based
practice (EBP). Every day, nurses

across the care continuum perform
a multitude of interventions (for
example, administering medica-
tion, positioning, suctioning)
that should stimulate questions
about the evidence supporting
their use. When a nurse possesses
a spirit of inquiry within a sup-
portive EBP culture, she or he

can routinely ask questions about
clinical practice while care is being
delivered. For example, in patients
with endotracheal tubes, how
does use of saline with suctioning
compared with suctioning without
saline affect oxygen saturation?

[email protected] AJN � November 2009 � Vol. 109, No. 11 49

By Bernadette Mazurek Melnyk, PhD,
Ellen Fineout-Overholt, PhD, RN,

FNAP, FAAN, Susan B. Stillwell, DNP,
RN, CNE, and Kathleen M.

Williamson, PhD, RN

Igniting a Spirit of Inquiry: An Essential Foundation for
Evidence-Based Practice

How nurses can build the knowledge and skills they need to
implement EBP.

Every day, nurses perform interventions (for

example, administering medication, positioning,

suctioning) that should stimulate questions

about the evidence supporting their use.

This is the first article in a new series from the Arizona State University College of Nursing and Health Innovation’s
Center for the Advancement of Evidence-Ba


How Evolving United States Payment Models
Influence Primary Care and Its Impact on the
Quadruple Aim
Brian Park, MD, MPH, Stephanie B. Gold, MD, Andrew Bazemore, MD, MPH,
and Winston Liaw, MD, MPH

Introduction: Prior research has demonstrated the associations between a strong primary care founda-
tion with improved Quadruple Aim outcomes. The prevailing fee-for-service payment system in the
United States reinforces the volume of services over value-based care, thereby devaluing primary care,
and obstructing the health care system from attaining the Quadruple Aim. By supporting a shift from
volume-based to value-based payment models, the Medicare Access and Children’s Health Insurance
Program Reauthorization Act may help fortify the role of primary care. This narrative review proposes a
taxonomy of the major health care payment models, reviewing their ability to uphold the functions of
primary care, and their impacts across the Quadruple Aim.

Methods: An Ovid MEDLINE search and expert opinion from members of the Family Medicine for
America’s Health payment and research tactic teams were used. Titles and abstracts were reviewed for
relevance to the topic, and expert opinion further narrowed the literature for inclusion to timely and
relevant articles.

Findings: No payment model demonstrates consistent benefits across the Quadruple Aim across a
limited evidence base. Several cross-cutting lessons from available payment models several recommen-
dations for primary care payment models, including the following: implementing per member per
month– based models, validating risk-adjustment tools, increasing investments in integrated behavioral
health and social services, and connecting payments to patient-oriented and primary care-oriented met-
rics. Along with ongoing research in emerging payment models, data systems integrated across health
care and social services settings using metrics that can capture the ideal functions of primary care will
be critical to the development of future payment models that most optimally enhance the role of pri-
mary care in the United States.

Conclusions: Although the ideal payment model for primary care remains to be determined, lessons
learned from existing payment models can help guide the shift from volume-based to value-based care.
To most effectively pay for primary care, future payment models should invest in a primary care infra-
structure, one that supports team-based, community-oriented care, and measures the delivery of the
functions of primary care. ( J Am Board Fam Med 2018;31:588 – 604.)

Keywords: Delivery of Health Care, Family Medicine, Health Expenditures, Primary Health Care

Forty years ago, in the milestone “Declaration of
Alma Ata,” all member nations of the World
Health Organization declared that achieving health
for all was dependent on a foundation of primary

care.1 A quar

Shared Decision-Making in Intensive Care Units
Executive Summary of the American College of Critical Care Medicine and
American Thoracic Society Policy Statement

Shared decision-making is a central component of patient-centered
care in the intensive care unit (ICU) (1–4); however, there remains
confusion about what shared decision-making is and when
shared decision-making ought to be used. Further, failure to
employ appropriate decision-making techniques can lead to
significant problems. For example, if clinicians leave decisions
largely to the discretion of surrogates without providing adequate
support, surrogates may struggle to make patient-centered
decisions and may experience psychological distress (5).
Conversely, if clinicians make treatment decisions without
attempting to understand the patient’s values, goals, and
preferences, decisions will likely be predominantly based on the
clinicians’ values, rather than the patient’s, and patients or
surrogates may feel they have been unfairly excluded from
decision-making (1, 2). Finding the right balance is therefore
essential. To clarify these issues and provide guidance, the
American College of Critical Care Medicine (ACCM) and
American Thoracic Society (ATS) recently released a policy
statement that provides a definition of shared decision-making
in the ICU environment, clarification regarding the range of
appropriate models for decision-making in the ICU, a set of skills
to help clinicians create genuine partnerships in decision-making
with patients/surrogates, and ethical analysis supporting the
findings (6).

To develop a unified policy statement, the Ethics Committee of
the ACCM and the Ethics and Conflict of Interest Committee of the
ATS convened a writing group composed of members of these
committees. The writing group reviewed pertinent literature
published in a broad array of journals, including those with a focus
in medicine, surgery, critical care, pediatrics, and bioethics, and
discussed findings with the full ACCM and ATS ethics committees
throughout the writing process. Recommendations were generated
after review of empirical research and normative analyses published
in peer-reviewed journals. The policy statement was reviewed,
edited, and approved by consensus of the full Ethics Committee
of the ACCM and the full Ethics and Conflict of Interest Committee
of the ATS. The statement was subsequently reviewed and approved
by the ATS, ACCM, and Society of Critical Care Medicine leadership,
through the organizations’ standard review and approval processes.

ACCM and ATS endorse the following definition: Shared
decision-making is a collaborative process that allows patients, or
their surrogates, and clinicians to make health care decisions
together, taking into account the best scientific evidence
available, as well as the patient’s values, goals, and preferences.

Clinicians and patients/surrogates should use a sha

RESEARCH Open Access

Workforce planning and development in
times of delivery system transformation
Patricia Pittman1* and Ellen Scully-Russ2


Background: As implementation of the US Affordable Care Act (ACA) advances, many domestic health systems are
considering major changes in how the healthcare workforce is organized. The purpose of this study is to explore
the dynamic processes and interactions by which workforce planning and development (WFPD) is evolving in this
new environment.

Methods: Informed by the theory of loosely coupled systems (LCS), we use a case study design to examine how
workforce changes are being managed in Kaiser Permanente and Montefiore Health System. We conducted site
visits with in-depth interviews with 8 to 10 stakeholders in each organization.

Results: Both systems demonstrate a concern for the impact of change on their workforce and have made
commitments to avoid outsourcing and layoffs. Central workforce planning mechanisms have been replaced
with strategies to integrate various stakeholders and units in alignment with strategic growth plans. Features
of this new approach include early and continuous engagement of labor in innovation; the development of
intermediary sense-making structures to garner resources, facilitate plans, and build consensus; and a whole system
perspective, rather than a focus on single professions. We also identify seven principles underlying the WFPD processes
in these two cases that can aid in development of a new and more adaptive workforce strategy in healthcare.

Conclusions: Since passage of the ACA, healthcare systems are becoming larger and more complex. Insights from
these case studies suggest that while organizational history and structure determined different areas of emphasis, our
results indicate that large-scale system transformations in healthcare can be managed in ways that enhance the skills
and capacities of the workforce. Our findings merit attention, not just by healthcare administrators and union leaders,
but by policymakers and scholars interested in making WFPD policies at a state and national level more responsive.

Keywords: Workforce planning and development, Human resources in health, Healthcare delivery reform, System
change, Loosely coupled systems, Labor-management partnerships, US Affordable Care Act

As the implementation of the 2010 Affordable Care Act
(ACA) advances in the United States, many healthcare
organizations are taking bold measures to reorganize
their delivery systems and finding that in order to do so,
changes must be made to the healthcare workforce [1].
While different healthcare organizations in the United
States, be they public or private, are at very different
points in this process, commonly popular concepts in-
clude moving staff to new ambulatory and home care

settings [2]; creating new jobs relating to care coo

[email protected] AJN ▼ February 2018 ▼ Vol. 118, No. 2 43

strategies for creating a more highly educated nurs-
ing workforce.

The National Advisory Committee for the APIN NPO
selected nine states—California, Hawaii, Massachu-
setts, Montana, New Mexico, New York, North Car-
olina, Texas, and Washington—to design and test
potential models of academic progression. All nine
states were already engaged in some aspect of aca-
demic progression, and each received a two-year,
$300,000 grant with the possibility of a second. The
RWJF and the NPO considered this a laboratory in
which results could be obtained, evaluated, and shared
within that four-year time frame; all grants concluded
by the end of 2016.

APIN funded efforts on two fronts: initiatives that
remove obstacles that keep nursing students from get-
ting their BSN—such as support for partnerships be-
tween universities and community colleges to allow
seamless progression from the associate’s degree (AD)
to the baccalaureate—and employment-focused part-
nerships between schools and health care facilities
that provide students with practice experience, pro-
mote greater use of the BSN, and create employment

All of the states involved in the program developed
strategies for removing obstacles that keep nursing
students from getting their BSN. Massachusetts, Mon-
tana, Texas, and Washington, for instance, developed

Moving Closer to the 2020
BSN-Prepared Workforce Goal

In 2010, the Institute of Medicine (IOM) released its groundbreaking report The Future of Nurs­ing: Leading Change, Advancing Health. One
of the report’s recommendations was to increase the
proportion of the nursing workforce with a bachelor
of science in nursing (BSN) or higher degree to 80%
by 2020.1 When the report was released, approxi-
mately 50% of nurses in the United States had a
BSN or higher.2

Better use of the nursing workforce is one goal of
the Campaign for Action, a joint initiative of the Rob-
ert Wood Johnson Foundation (RWJF) and AARP,
created to transform health care nationally.3 Through
work conducted by the Center to Champion Nursing
in America, possible models for addressing the need
for more nurses to obtain a BSN were identified,4 and
the RWJF built on that structure in developing and
evaluating opportunities to accelerate change within
the nursing education system.

In 2012, the American Organization of Nurse
Executives (AONE)—one of the four members of the
Tri-Council for Nursing—was selected by the RWJF
as the National Program Office (NPO) for a new ini-
tiative, the Academic Progression in Nursing (APIN)
program, which was created to study the topic of
higher degrees and employment for nurses a