Reform Realtime

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Pressures Facing Hospitals: A Nurse's Perspective

6/5/2014 8:52:41 PM | 0 comments

By Bonnie Carl, RN, MBA

In April, four months after full implementation of the Affordable Care Act (ACA), Reform Realtime readers responded to a survey on the biggest pressures facing their hospitals. Respondents were a mixed group of administrators, healthcare professionals and consultants.



Reform Realtime also spoke with several physicians, who weighed in on recent changes and challenges.

But doctors aren't the only ones impacted by healthcare reform. Nurses are poised to play a key role in care coordination and the delivery of services like chronic disease management and preventative care.

In fact, a 2010 Institute of Medicine report recommended that nurses "be full partners, with physicians and other health professionals, in redesigning health care in the United States."

However, four years later, significant barriers remain to nurses' full participation in improving the healthcare system.

In today's post, I'll provide a nurse's perspective on the pressures facing hospitals. I'll also discuss the impact of reform on our profession and the value of involving nurses in reform efforts.

High Hopes for Change

When the ACA was signed into law in 2010, a lot of nurses had mixed feelings.

The 2010 National Survey of Registered Nurses (NSRN) found that access for the uninsured was a significant concern for the profession, with about one-third of respondents ranking it as the most important healthcare problem facing the country. And about 43 percent of nurses said that they would support federal legislation extending insurance coverage to all or nearly all of the uninsured.

However, respondents weren't very hopeful that the newly signed ACA would solve the problem. In fact, the majority felt that the legislation would have no impact or a negative impact on quality of care at their hospitals.

The ED Pressure Cooker

Of course, that NSRN survey took place four years ago before most ACA-related regulations were drafted.

In the intervening years, emergency department volumes have risen. Nurses, along with their physician colleagues, have experienced the stress of caring for more patients without an appreciable increase in space or resources. They've also been subject to mounting pressures to increase efficiency while improving patient experience.

There was hope among nurses — myself included — that full implementation of the ACA on Jan. 1 would relieve some of this pressure by providing patients with meaningful access to primary care.

Unfortunately, this hasn't been the case. As previously reported by Reform Realtime, volumes thus far have been essentially unchanged from years past. And while it's so far not evident in the organization-wide data, there's anecdotal evidence that some EDs are actually experiencing an uptick in census.

In the rundown to Jan. 1, primary care practices braced for an influx of new exchange and Medicaid patients. But interestingly, this hasn't happened. In an April 2014 survey by Medical Group Management Association, 54 percent of practices reported no increase in their patient population since Jan. 1, and 24 percent reported only a slight increase. (This despite the fact that 85 percent of practices surveyed were participating in at least one health exchange plan.)

As a consultant to CEP America's ambulatory and urgent care clinics (many of which also provide primary care services), I can confirm that expanded coverage hasn't necessarily led to better access for patients. Many who have purchased low-cost, high-deductible coverage on the health exchanges come into our clinics — only to learn that we don't accept their particular plan.

In fact, the networks on these budget plans are so narrow and the wait times for an appointment with a participating physician so long, these patients have few options for acute care other than head to the local emergency department.

For these reasons, I think acute care nurses would generally agree that issues like throughput, space constraints and patient satisfaction represent a significant challenge facing their hospitals.

Nurses Need to Play a Role in Reform

Another interesting aspect of the Reform Realtime survey was respondents' somewhat dismissive attitudes toward healthcare reform. Interestingly, only 9 percent ranked it among the top pressures facing their hospitals.

I'm not sure how many nurses responded, but I can definitely see why members of our profession would answer this way. As a group, nurses tend to be very focused on our patients and the task at hand. On a busy shift, we see a need for greater efficiency and long for more beds, but the machinations of reform are the furthest thing from our minds.

Unfortunately, the IOM's call for nursing (as a profession) to play an equal and active role in reform hasn't come true — at least not for those on the front lines. Nurses participate in many quality initiatives, but they often have little say in choosing or designing them. This is unfortunate, given nursing's patient-centered philosophy and competencies in health management and preventative care.

I believe the reasons for this disconnect are complex. Organizational culture could certainly play a role. Only 33 percent of respondents to the 2010 NSRN rated their opportunities to influence decisions affecting patient care as "good" or "very good." And it will be crucial to create cultures in which physicians value nurses' knowledge and perspective if they are to work together as equals to meet the IOM's mandate.

One thing is clear: whether or not they have a hand in designing them, nurses of the future will deliver many key healthcare services — especially as delivery shifts toward population health management.

For this reason alone, nurses need a place at the table in all conversations about care delivery. Hospitals, health systems, government agencies and other players would benefit by taking a close look at the barriers to nurses' full participation so their voices can be heard.


Bonnie Carl, RN, MBA, has over 39 years of experience including senior hospital management, inpatient and outpatient consulting and clinical ED nursing. She has combined her nursing and management expertise with process improvement and quality improvement, capacity management, and construction engineering into a comprehensive consulting portfolio. She is a frequent speaker at national healthcare conventions on the topics of hospital throughput, ED management and physician/nurse relationships.



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