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Interviewer: It seems impossible to turn on the news and not hear something about Healthcare Reform, but what role do nurses play in these big changes? Pamela Cipriano, President of the American Nurses Association and graduate of the University of Utah College of Nursing will be sharing her insight on the future of nursing.

Announcer: These are the conversations happening inside heath care that are going to transform health care. The Health Care Insider is on The Scope.

Interviewer: Hello, Dr. Cipriano, and welcome to the studio. First, I just want to congratulate you on being the distinguished alumni for the University of Utah School of Nursing, as well as being elected as the President of the American Nurses Association within the same year. This has been quite a big year for you.

Dr. Cipriano: It really has. Thank you so much, and I'm very honored to be the distinguished alumna for this year. As you know I completed my PhD in Nursing in 1992 and it was a very rewarding experience. It's been a very important part of my career.

Interviewer: We hear a lot about health care reform but very little about how nurses play a role. Where do nurses fit into the big changes taking place in health care?

Dr. Cipriano: The Affordable Care Act is probably one of the most significant pieces of legislation that we've seen since the mid-20th century. So when we think about all the changes of now additional people having health care coverage, being able to seek care from the provider of their choice and make sure that we're also looking at the preventive health care needs, nurses are playing a significant role in that transition.

We like to think of it as nurses helping transform health care. We have nurses that are now working in settings other than the hospital, where they actually have been working in public health departments and clinics and offices, but there's been a huge expansion in the post-hospital environment. We have many more nurses working in home care and transitional care, hospital and programs, so nurses are everywhere that people need care and they're also helping to make sure that people can be independent and stay at home and stay healthy.

Interviewer: What would you say is the number one thing nurses need to be doing to tackle the issues that we're seeing in health care right now?

Dr. Cipriano: Well, there's a number of nursing issues as well as overall health care issues. I would focus attention on the Institute of Medicine's report on the future of nursing that was released on October of 2010. It really put together a road map for some of the improvements that we really need to see for nursing to reach its full potential to help transform the health care system. Those are things like really increasing the education of all nurses across the country. There are many, many efforts to make sure that nurses are pursuing not only their bachelor's degrees but advanced degrees, master's and doctoral degrees.

We want to remove the barriers to advanced practice nurses so they can practice more independently and have parity in being able to be compensated appropriately. We also have a number of efforts focused on making sure that nurses are placed in leadership positions. Even though there is over three million nurses in the United States, registered nurses, they're not necessarily always at the decision-making tables and we really believe they have a lot to offer as we look at health care. And then the fourth part of the recommendations from this report was to make sure that we have really good data about the nursing workforce because we know that as we've had nursing shortages that can lead to problems with outcomes in patient care.

So those four areas are really focused on strengthening nursing, but I think the other part of your question is really saying what else do nurses need to be involved in, in terms of helping to move the whole health care industry forward. Part of it is nurses are really great partners for patients and families. We really look to nurses to help be translators. When we think about some of the challenges and having an individual sign-up for health care insurance through the new marketplace options, nurses are there to help them.

When we think about management of chronic diseases and medications and things like that, nurses are there to help them. So nurses are really an important part of educating and partnering with the public to make sure that we're focused on the goals for the future, which include prevention, health maintenance as well as being able to get the kind of care that's necessary if you do have a situation that requires any urgent or hospital care.

Interviewer: Now you mentioned about having nurses in leadership positions. You, yourself, are a nurse who has been in a leadership position. You've just been elected as the President of the American Nurses Association which is a national organization representing 3.1 million nurses. Can you tell us what your role is there and how you hope to guide this organization in the future years?

Dr. Cipriano: The ANA is really the most comprehensive organization that does represent the interest of registered nurses in the United States. My role is really to provide leadership to our board of directors and through that, help the State Nurses Associations that are our members in addition to other specialty organizations that are affiliated organizations that work with us to do several things.

One is to really again sort of broaden the reach of nurses to be sure that they are occupying leadership positions in their communities and their states and nationally. We participate in political advocacy activities to make sure that we are supporting the kinds of laws and regulations that will improve health care.

We also look very carefully at the improvement of quality for patients and for nurses. We want an environment that not only keeps patients safe but keeps nurses safe. We also advocate strongly for healthy nurses so we have nurses engaged in doing their own health assessment, looking at their nutrition, looking at their exercise levels, their own personal screening and making sure that they're staying healthy and that their workplace supports an environment that allows them to be healthy.

We also believe it's really important that nurses make sure that they are continuing their education. We believe in lifelong learning. We believe in certification and other credentialing, but again, really focuses on nurses being able to practice to the full extent of their education and licensure. We also are supporting efforts across the country in each state to make sure that advanced practice nurses are able to practice to the full extent of their abilities as well, because they are a really important part of increasing access to care in many of our communities, particularly the underserved communities, whether they be urban or rural, the places where we know that people really need to receive health care.

So we have a broad range of initiatives that also includes strengthening our own membership across the country, but more importantly, focused on how we can make sure that health care is in the different locations where patients and families really need access.

Interviewer: That all sounds incredible. Is there one area that you are just particularly excited about for the future?

Dr. Cipriano: One of the things that we know is that health care continues to grow as one of the most important areas of our gross domestic product and as we look at employment. The registered nurse job continues to be one of the most sought after and one we continue to project the demand. Part of that demand is that the baby boom generation is living longer, wanting to be healthy, and so in addition to consuming health care services, they're also really focused on how to life a longer healthy life where they are active and can maintain the level of exercise and involvement in their communities.

So when we look at the role for nurses, we know that there is going to continue to be a very high demand, and so that's really why we're focused on making sure that we have continued federal funding support for nursing education. We just celebrated 50 years of Title A which is Nurse Training Act funds which has helped educate nurses at all levels for 50 years, and we know that when that funding is in place we don't see shortages of nurses, so we really want to maintain and increase that funding.

But in addition, we want to make sure that nurses are in roles, again, not only in the hospitals where they are critically important but across our communities, in the home, in new jobs that are really looking at the transitions of care and able to coach and manage care for patients to keep them healthy. So we see a very bright and rosy picture for nurses and a continuing demand because nurses are really a critical component to the health care team. Interviewer: Finally, can you please share where you see the future of nursing heading?

Dr. Cipriano: Nurses will continue to be very involved in advocating for patients and families, and so our relationship with consumers will only grow. Similarly, that some of the changes that we see happening is much stronger teamwork within the health care team. Education, together with other disciplines, so we would have nursing, medicine, pharmacy, social work, therapies, we're going to see a much more intense teamwork environment just as we expect that we're going to see continued improvement in the quality and outcomes because we're going to have people working together more closely, really focused on involving that patient and family in their care, in the planning, in the decision making, so that what we'll see is a health care system that is not provider-centric only, but really again is very much involving the patient and family because we think that's really important.

In addition, as we've seen the explosion of technology, we know that patients as consumers will continue to be contributing more and more data about their care, taking a greater interest in staying healthy, and nurses are often the bridge between that technology and the health care setting. We will continue to see a whole field evolve where, again, nurses are not just occupying the traditional roles that we've seen that we think about, which again are critically important but are really moving into new roles where they are helping patients and families be an active part of their care.

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I think Americans understand that we have to have change. I think that until it begins or however when it becomes personal to them, like any change, it begins to be more difficult. But I think that American's understand that the system is going to change and they are buckling their chin strap to see how it will affect them.

The areas that I am focused on now are essentially how can we drive more quickly? The concept of measuring value not volume and that isn't controversial any longer, but the implementation of it is and does begin to drive a lot of change that people are uncomfortable with.

The parable of buses, taxis, and limos basically says that there is a lot of ways to get from point A to point B and after all, what we are after is transportation in healthcare. After all, what we're looking for is good, quality care. The setting in which we get it, how fancy it is or how comfortable it is, in the context of convenience, it may be that some people will say, "I'm prepared to have a narrower network of choices for a lower premium." We've seen that begin to happen already. Those are choices that consumers can make. They can make them in any other area, and they can make them in healthcare as well.

I think that big change to the future is we are going to start to value both of those, cost and quality. As opposed to simply having access to unlimited amounts of care.

There are four basic entities or types of entities that I think are making competitive entries in the market. They are obviously hospital driven, doctor driven, insurance company driven, and a new group that I call strategic aggregators. These are unlikely entries into the market with people like Walgreens and CVS who have footprints on almost every corner and are beginning to turn parts of their retail stores into care centers. And I think we will begin to see them play much more pronounced and perhaps prominent role.

All four of those types of entities are looking to become what I refer to as a general contractor in medicine. I think that's the struggle that's happening.

We are now moving into a period where care is going to have to be much better coordinated and the question becomes in a coordinated environment, who is the general contractor and who is the sub-contractor and who is bearing the risk? And that's being redefined in every medical market in the country. No one has all of the competencies that are required.

If we look back 25 years and we looked at industries like the restaurant business or the hotel business, there were lots of independent hotels and restaurants. And now we have Marriot and Hilton and brands we know. I think health care will always be local. But I do think we will begin to see health care, particularly primary care, begin to consolidate into a series of brands that we're better familiar with and will compete on a more national or regional basis.

I'm probably more optimistic today that we're actually getting a handle on the problems of health care than I have been for some time. Because hard things are beginning to happen and people are having to make choices and they're working with certainty to get a handle on their costs. And that's not easy. It's hard. But hard things are happening and because hard things are beginning to happen my optimism goes up.

The gospel that I am trying to preach is to my colleagues in medicine, understand what's happening, learn the facts, lift up your heads enough to see what's going on around you. Understand the problem and then begin to ask yourselves "What can I do to help?"

When I started out in medicine in 1946 there was no such thing as a health care industry. The term health care industry had never been used. Nobody referred to it as an industry and nobody thought that being a physician was a business. Now we are dealing with the inevitable consequences of a health care system, which changed from a social service to a business. Just as you would predict it ignores more or less those who can't afford to pay. It exploits the opportunities to make money at the expense of the obligation to use resources conservatively in the most effective, medically appropriate way.

It invites all sorts of abuses including fraud and it's clear that it's not working and it can't work because there's a fundamental disconnect between medical care and almost all other economic activities in our society. A patient consulting a physician because they're sick, got injured, worried, or frightened that they may die or become seriously ill is not like an ordinary consumer in an ordinary market and physicians should not be like vendors in an ordinary market. Their objective should not be simply to sell whatever the consumer will buy.

Physicians are in the best position to decide how best to use the resources that we expend on health care. I've outlined what doctors might do if they wanted to. They could form multi-specialty group practices not-for-profit group practices that would be prepared to accept payment on a per capita rather than on a piece work basis, on a per capita basis for comprehensive care. There's no question that that system would work.

The only question is, how do we get it to occur politically in the current political climate? That's a big problem, we're going to have to change the attitude of the public and we're going to have to change the attitude of the legislators. It's issue of survival. We are simply not going to survive with the health care system we have now. It's going to implode. We must do something and doctors could help get it started. At least that's my hope and I think it's not unreasonable.

One of the hopeful aspects of all of this is that pretty soon half of all practicing physicians are going to be women. More and more multi-specialty groups are being formed and women are becoming a very significant part of that movement. I'm expecting that women may save the day.

Some of the most innovative things that we're thinking about right now are something referred to as milestones. So in the residency world, we're being able to now identify exactly where people are along a spectrum of skills in six different areas and with the idea and vision that as people meet those skills we can move them along the pathway and again get rid of the rigid timelines that we're currently married to.

For those of us who have been doing medical education for a long time, we know some people learn faster than others, and other people learn slower. The fact that we're facing a deficit of 90,000 physicians coming up here very soon in the next decade, we really need to be thinking about: How can we turn people out more quickly? How can we ensure that we get people in the pipeline, keep them in the pipeline, and then turn them out at the end?

The thought that keeps me up at night is probably that we're not using people's time effectively. Not just individual people, but thinking about the synergy that gets created when we bring the right people together.

Our universities without the people, the faculty, the staff, the students are really just a collection of buildings and equipment and material supplies. The people who are there are the ones who make all of this work. The faculty are incredibly dedicated people. They've made a commitment beyond just being practitioners within their own field. They've decided to come back and share that knowledge with learners.

I think we've got extraordinary potential, and the thought that we might be wasting any of that really does break my heart.

When you work in an environment like academic medicine, we have so many capable individuals, and you think about what they could do if you could get the right folks at the table at the right time to look at the kinds of problems we're facing. I think the solutions are out there. But we have to talk to each other. We have to build that shared knowledge based. We have to have that ability to catalyze one another's thinking to actually get these problems solved.

There's a saying in the medical school community that when you look at one medical school, you're looking at one school because they're all very unique. I believe that we are all very unique. But I also think that among us we have such common purpose that we really should be thinking about the things where we are catalysts for something together.

It's up to us to think about how to push the frontier about healthcare for people in the United States. So that's not about us just being unique. That's about us using our uniqueness to forge something better and stronger, and I think we've certainly got the capacity to do that.

A role of the leader of the organization can simply be to set a tone that indicates that it's okay to be innovative, it's okay to take risks, and if you are and you have some success, that's going to be recognized. That counts as much as the traditional things in academic medicine.

The models of how we provide healthcare to our patients, how we interact with our patients need to change. Also the models in the way we educate our students need to change. It's been very traditional. Institutions across the decades have changed. Course content has changed the way it's delivered.

But by and large, we're still heavily lecture-based. We should have programs where students can move onto the next subject once they've shown that they're competent in some area, rather than having to finish the semester in that particular class. You know, we're locked into these fixed time scales. Those sorts of models of education need to improve.

Then, also, the learner environment, I think, is also something that suffers from these traditions that we have in medicine. Students pick up a lot of subtle signs about how physicians interact in these environments. Not all of them are good.

There's something called the hidden curriculum, sort of what the students see and hear and experience in addition to what they're actually being taught. Sometimes the messages we're sending in those sorts of learner environments are not the best as well.

The practice of medicine now is very different than what it was when many started their practice of medicine. For some, the feeling is that it's changed for the worse. But if you look at the young students that are coming in who haven't known the previous environment, and the excitement level, and quite honestly, the competency level of the new students coming in is just astounding.

I think that spirit of enthusiasm of a bright future, it's going to be a different future, but it's going to be a bright future. The tools, the power that we have, that hopefully we can harness for the betterment of our patients, is just stronger now than it's ever been in the past.