The State of the Science of Neuroscience Nursing Practice
Joanne V. Hickey
The current growth and development of the neurosciences is nothing short of phenomenal, and the translation and integration of the new scientific knowledge into practice is a formidable challenge for health professionals. To provide a context for appreciating contemporary neuroscience nursing practice, this chapter begins with a brief examination of the dynamic health care system in which neuroscience nurses practice.
THE STATE OF HEALTH CARE AND PRACTICE
The first decade of the 2000s has been focused on quality, patient safety, and measurable patient outcomes in health care. The second decade continues with these foci, but underscores, with a new urgency access, cost, and value. The imperative for evidence-based care grounded in a foundation of science and research is the goal of the health care agenda. A 2008 Institute of Medicine (IOM) roundtable report1 sets the following goal, “by 2020, 90% of clinical decisions will be supported by accurate, timely, and up-to-date clinical information and will reflect the best available evidence and informed personal preference.” Current estimates report that about 20% of care is evidence based. There is much work to be done to meet such a goal. The exponential growth of new knowledge coming from basic and clinical research has expanded the scientific basis for significant developments in all areas of practice including the neurosciences and neuroscience nursing. The impact of new knowledge on practice is evident in the striking strides made in neurology, neurosurgery, neuroradiology, neurogenetics, neuropharmacology, and neurorehabilitation, balanced by the increased complexity of the knowledge required for clinical reasoning and decision making. New treatment options continue to raise questions about access, quality, cost, and ethical implications. Meanwhile, the knowledge explosion in the neurosciences and emerging subspecialties are encouraging many neuroscience nurses to become subspecialists in the care of specific neuroscience populations such as stroke, and to assume new roles as clinicians and advanced practice nurses (APNs). With the new roles come new levels of responsibility and accountability.
However, the current health care system is not a match for societal needs in the 21st century. New paradigms of inclusive health care for individual and population health are driving the need for new models of practice and care. Community engagement and partnerships between health care facilities and the unique community that it serves are supporting community empowerment with a strong and powerful voice for patient-centered and communitycentered care. Cultural competency and culturally appropriate care is demanded by the public. With an enhanced active decision-making role of the public in their health care, the need for an informed public is clear. The information comes from a variety of sources, both credible and noncredible. The public needs to be guided to recognize credible sources of health information. Within this vein, health education has added the dimension of health literacy to communicate and educate all people so that they are informed about health care. This is the challenging practice environment in which the neuroscience nurse practices, that is, a health care system that is being substantially redesigned with multiple fundamental changes that require significant changes in how we practice and deliver care.
THE INFORMATION SOCIETY
For centuries, mankind was engaged in the slow transformation from nomadic hunter-gatherers and warriors to communities of farmers dependent for survival on the soil, a strong extended
family, and community networks during the agricultural revolution. During this era, the limited health care available was primarily home care provided by family members’ home remedies, sometimes with the assistance of a lay midwife or a poorly trained physician. This age was followed by the rise of the industrial revolution, which began in the 19th century and was well under way in the middle 1800s. Jobs shifted from the farms to the city factories, where a variety of industries manufactured products that the general population craved. The massive rural to urban shift brought with it the major societal change in family structure from an extended family to a nuclear family, creating radical, social, political, economic, and health care delivery changes. Rampant communicable diseases and deplorable workplace conditions posed major health problems. Extended families were not available to care for sick family members and health care shifted to hospitals. As the causes of common communicable diseases were understood, effective treatment options became available. People began to live longer and, as a result, chronic illness replaced acute and communicable diseases as the prevalent health problem in the population.
family, and community networks during the agricultural revolution. During this era, the limited health care available was primarily home care provided by family members’ home remedies, sometimes with the assistance of a lay midwife or a poorly trained physician. This age was followed by the rise of the industrial revolution, which began in the 19th century and was well under way in the middle 1800s. Jobs shifted from the farms to the city factories, where a variety of industries manufactured products that the general population craved. The massive rural to urban shift brought with it the major societal change in family structure from an extended family to a nuclear family, creating radical, social, political, economic, and health care delivery changes. Rampant communicable diseases and deplorable workplace conditions posed major health problems. Extended families were not available to care for sick family members and health care shifted to hospitals. As the causes of common communicable diseases were understood, effective treatment options became available. People began to live longer and, as a result, chronic illness replaced acute and communicable diseases as the prevalent health problem in the population.
Today we live in an information society, and the US economy has shifted. White-collar workers outnumber blue-collar workers. A manufacturing economy is rapidly being replaced by an economy based on services and using information and knowledge. The workplace is becoming smaller as information businesses grow in importance and computer technology allows easy access to the information superhighways regardless of physical location. The emphasis in the Information Age is on knowledge work, knowledge-intense organizations, collaboration, and accountability.2 Workers are generally classified as knowledge workers. This is an era that offers great opportunities for nursing, for patients, and for health care in general. With the promise comes the upheaval of rapid transition and transformational change. As knowledge workers in this recast health system, where knowledge becomes outdated rapidly, nurses are subject to a high-intensity intellectual environment. The breadth of change experienced today signifies movement into a new era, an era that is still undefined.3
The fiber of the American culture is undergoing radical changes as the current political, economic, and societal structures that were erected to support an industrial economy are collapsing or being transformed to meet the needs of an information society. Concurrently, the health care industry is undergoing major transformation as it struggles to align itself with the needs and demands of contemporary society and a new evolving global paradigm. The only thing certain for the future of health care is change, like it or not.
TRENDS SHAPING HEALTH CARE DELIVERY
The complexity of the health care system is mind-boggling. Powerful political, economic, demographic, sociological, technological, and health trends are shaping the health care delivery system as the nation endeavors to meet the growing health needs and expectations of its widely diverse population. These trends are summarized in Chart 1-1 and are discussed briefly to provide a framework for understanding their influence on the health care system. The overlapping nature of the trend categories speaks to the interrelatedness of trends, so that some of the discussion is overlapping. For efficiency, trends have been placed in the most logical category.
Legislation and Regulations
The national political agenda reflects the multitude of political attitudes and processes that have tremendous impact on economic, demographic, sociological, and technological trends. Therefore, it is important to be aware of the importance of the legislative process in influencing societal and health care trends. The current debate about the Affordable Care Act (ACA), enacted in 2010, has a farreaching impact and continues to be implemented with many unanswered questions about provisions and cost. The ACA was designed to provide health care for all and includes an emphasis on preventive services, and thus, primary care.
The national mandate for comprehensive, affordable, quality health care for all Americans continues with the added caveat of safe care. The Institute of Medicine has published several important reports addressing quality and safety. To Err Is Human: Building a Safer Health System4 shocked the nation with reports of 98,000 hospital deaths annually attributable to medical error. This report stimulated a wave of critical examination of how care is rendered, the work environment in health care facilities, and practice patterns that may lead to error. Crossing the Quality Chasm: A New Health System for the 21st Century5 offers recommendations to improve the quality of health care through substantial changes in the health care system. Health Professions Education: A Bridge to Quality6 addressed the need to prepare clinicians to meet both the needs of patients and the requirements of a changing health system. The new vision for all programs engaged in the clinical education of health professionals was summarized as follows6:
All health professionals should be educated to deliver patientcentered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics.
The mandate for quality has stimulated a national dialogue about what is meant by quality and how it should be measured. Implicit in quality is safe care. As a result, a number of governmental and nongovernmental groups now collect data that are used for benchmarking against self, like cohorts, and national standards. It has also stimulated an examination of the health workforce, especially nurses and the work environment in which they practice. The interrelatedness of patient safety and the work environment of nurses have been addressed by the Institute of Medicine report entitled Keeping Patients Safe: Transforming the Work Environment of Nurses.7 This report examined key elements of the work environment of nurses that have an impact on patient safety and provided recommendations for improvements in health care working conditions designed to increase patient safety. These recommendations are in various stages of consideration and implementation.
Finally, layers of federal and state regulatory agencies assume responsibility for multiple aspects of health care including eligibility and available services. For example, the Center for Medicare and Medicaid Services (CMS) is a major federal agency that has authority and responsibility to regulate the Medicare and Medicaid programs. The CMS is the largest purchaser of health care in the United States. Through its rules and regulations, the CMS has significant control on how practitioners provide care, as well as who can be reimbursed for professional services and at what level of reimbursement. These are important considerations that relate to the quality of care and safety of patients.
CHART 1-1 Trends Influencing the Health Care Delivery System | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Economic Trends
Cost containment and cost effectiveness continue to be driving forces affecting all aspects of health care delivery. Matured managed care programs, focused on cost containment, are developing integrated models of care with more community-based care to contain cost. Subacute units, home health care, hospice care, and various outpatient services are being expanded and justified based on cost savings. Preventive and health promotion measures keep people healthy or identify problems in the early, less costly interventional stage. In addition, more rehabilitation programs are being developed that are designed to assist people to be as functional and as independent as possible, thus limiting disuse syndromes, disabilities, and other problems requiring more expensive care. Reimbursement for preventive, health promotion, and rehabilitative services is supported in the ACA.
Fees for health care services in the United States are largely set by formulas promulgated by the federal and state governments such as the CMS and by third-party insurers. Employed individuals with health care benefits are often baffled by the array of health care plans and health care packages from which to choose. They are also being required by their employers to assume a greater portion of health care premiums. Some employers no longer offer health care insurance as a benefit of employment. Rather than hiring permanent employees, some positions are now filled with temporary or parttime employees who are not provided with health care benefits.
Demographics
There are two major demographic trends impacting on health care in the United States: the growing number of elderly and the increasing cultural diversity associated with increased immigration.
The changing age profile of America will be the greatest force shaping health care for the next 40 years. The nation’s baby boomers, those 76 million people born between 1946 and 1964, will drive the nation’s health care consumption curve up steeply as they enter the age spectrum where the manifestations of chronic illness predominate. The demographic prediction of the 65 years and older population are telling for 2000, 2010, and 2030, respectively, as 35 million (12.4% of total population), 40 million (13%), and 71.5 million (19.7%).8 Those 85 years of age and older are the fastest-growing segment of the population. With aging, eventually comes an overall increase in chronic illnesses such as coronary heart disease, arthritis, chronic obstructive pulmonary disease, and Alzheimer’s disease. The greatly increased prevalence of these diseases and others will impose an increased burden on the health care system and require a redirection of scarce societal resources toward these needs. It is not just the elderly who have chronic illness. Other age groups are also burdened. Although management of chronic illness is causing a major shift in health care from acute to chronic care, with the projected number of elderly, the strain on the health care system is undetermined. Equity in distribution of health care resources for all segments of society will need to be addressed.
Related ethical decision making is likely to focus on the care provided for the growing number of chronically ill elderly and other age groups who have a substantially decreased quality of life. It is well documented that the use of health care resources is highest during the last year of life and that these resources are often expended with little or no gain in quality or quantity of life. The underdevelopment of less costly community-based care and support services to assist the elderly and their families in managing their needs in their homes has led to utilization of the highcost alternative, hospital care. Independent healthy elderly, on the other hand, need help with continued health promotion and preventive measures to keep them healthy and independent. There is a growing realization that the impending stress posed by the graying of America and chronic illness on the health care system has serious consequences for the future health of all sectors of the US economy.
The second major demographic trend to shape health care in the 21st century is the greatly increased infusion of multiple ethnic and culturally diverse groups into the United States. This reality is changing the economics, process, and structure of health care delivery. The primary migration from Western Europe in the first half of the century has been replaced by an influx of people from Asia, Africa, and Central and South America. Smaller but growing numbers are coming from the Muslim countries of the Middle East and the newly configured countries of the former Soviet Union. A relatively small number come through the traditional and legal immigration channels.
Immigrant groups bring with them ethnic and cultural values that include belief-value systems about health and illness throughout the life cycle. Western medicine may be held suspect by members of these groups and may be rejected in favor of their own ethnic and folk medicine. Health care professionals must nevertheless understand and respect their cultural values and strive to develop cultural competence and implement programs that are culturally sensitive as well as effective. Education of both health care providers and health care recipients with the goal of easing the transition and blending of native and American cultures is necessary if mutual needs are to be addressed.
Sociological Trends
Unlike temporary fads and fashions, deep-rooted trends in attitudes and values develop over generations in reaction to shared experiences on community, national, and global levels. They, therefore, have a tremendous impact on the ways in which people interact with societal institutions. Of the numerous sociological trends influencing society in general and the course of health care in particular, the following few are discussed briefly because of their relevance to practice: changing values, lifestyle changes, quality of life, and family caregivers.
Changing Values
Individual values and attitudes toward health are formed, in part, by the information to which one is exposed. As more and more information has become widely available, consumers have become more active in choosing, evaluating, and criticizing the products and services available to them, including health care.
The internet, television, and the print media are the principal sources of consumer health information. Computer technology and the internet are growing in importance with all segments of society. For example, PubMed and online computer health bulletin boards are easily accessible by the public, and many people are using them to become informed about their health and medical problems. The quality of the information varies and consumers are not always able to discern the accuracy and completeness of the information. As a result, more consumers are actively participating in making decisions about their health and health care options. They no longer follow recommendations of health providers without question or discussion of options. Consumers are also interested in complementary and alternative medicine (CAM) to augment their health care such as herbal therapy, homeopathic treatments, and relaxation therapies. The demand for information and involvement in decision making has created a new industry of educational material for the consumer.
Lifestyle Changes
Broad dissemination of information about the health implications of smoking, alcohol consumption, drug abuse, poor diet, overweight, sedentary practices, stress, and sexual practices has had an enormous impact on behavior. Counteractive lifestyle changes are decreasing disease frequency and severity. Failure to heed health promotion and disease prevention recommendations, however, continues to be a serious public health problem. For example, Healthy People 2010 and now Healthy People 2020 have set national goals for a multitude of health issues for the nation such as obesity, including childhood obesity.9, 10 Two third of adults and almost one third of children are overweight or obese. This represents all age groups, urban and rural dwellers, and majority and minority populations.11 The report goes on to say that the epidemic of excess weight is associated with major causes of chronic disease, disability, and death. Obesity-related illness is estimated to carry an annual cost of $190.2 billion per year.11 Obesity has been identified as a national priority for treatment and prevention to address the ominous human and economic consequences associated with obesity.
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