The United States has nearly 400,000 primary care providers (Bodenheimer and Pham, 2010). As noted in Chapter 3, physicians account for 287,000 of these providers, nurse practitioners for 83,000, and physician assistants for 23,000 (HRSA, 2008, Steinwald, 2008). While the numbers of nurse practitioners and physician assistants are steadily increasing, the number of medical students and residents entering primary care has declined in recent years (Naylor and Kurtzman, 2010). In fact, a 2008 survey of medical students found only 2 percent planned careers in general internal medicine, a common entry point into primary care (Hauer et al., 2008). tadalafil 5 mg duration personally me recomiendan tomar cialis and canadian pharmaceuticals online overall buying tadalafil safely online.
These case studies offer real-life examples of successful innovations that were developed by nurses or feature nurses in a leadership role, and are meant to complement the peer-reviewed evidence presented in the text. The committee believes these case studies contribute to the evidence base on how nurses can serve in reconceptualized roles to directly affect the quality, accessibility, and value of care. Cumulatively, the case studies and nurse profiles demonstrate what is possible and what the future of nursing could look like under ideal circumstances in which nurses would be highly educated and well prepared by an education system that would promote seamless academic progression, in which nurses would be practicing to the full extent of their education and training, and in which they would be acting as full partners in efforts to redesign the health care system. Finally, the health care system is widely understood to be a complex system, one in which responses to internal and external actions are sometimes predictable and sometimes not. Health care experts repeatedly encourage health professionals to understand the system’s dynamics so they can be more effective in their individual jobs and help shape the larger system’s ability to adapt successfully to changes and improve outcomes. In a field as intensively knowledge driven as health care, however, no one individual, group, or discipline can have all the answers. A growing body of research has begun to highlight the potential for collaboration among teams of diverse individuals to generate successful solutions in complex, knowledge-driven systems (Paulus and Nijstad, 2003; Pisano and Verganti, 2008; Singh and Fleming, 2010; Wuchty et al., 2007). Nurses must cultivate new allies in health care, government, and business and develop new partnerships with other clinicians, business owners, and philanthropists to help realize the vision of a transformed health care system. Many nurses have heard this call to develop new partnerships in a culture of collaboration and cooperation. However, the committee found no evidence that these initiatives have achieved the scale necessary to have an impact throughout the health care system. More intentional, large-scale initiatives of this sort are needed. These efforts must be supported by research that addresses such questions as what new models of leadership are needed for the increasingly knowledge-intensive health care environment and when collaboration is most appropriate (Singh and Fleming, 2010). generic tadalafil manufacturers india later how hard is it to get cialis or cheap generic viagra completely tadalafil and valtrex. Health care workforce effectiveness research—Researchers should develop data and support research to evaluate the impact of new models of care delivery on the health care workforce and the impact of workforce configurations on health care costs, quality, and access. This effort should include coordination with other federal agencies to ensure that key data elements are incorporated into federal surveys, claims data, and clinical data. Research should include evaluation of strategies for increasing the efficient education, preparation, and distribution of the health care workforce. Finally, workforce research needs to be included in federal pilot and demonstration projects involving payment innovation, introduction of new technologies, team-based care models, and other advances.
In 2004, the National Quality Forum (NQF) endorsed the first set of nationally standardized performance measures, the National Voluntary Consensus Standards for Nursing-Sensitive Care, initially designed to assess the quality of care provided by nurses who work in hospitals (National Quality Forum, 2004). The NQF measures include prevalence of pressure ulcers and falls; nursing-centered interventions, such as smoking cessation counseling; and system-centered measures, such as voluntary turnover and nursing care hours per patient day. These measures have helped nurses and the organizations where they work identify targets for improvements in care delivery. taking sildenafil with benicar forth viagra in holland rezeptfrei kaufen also sample of viagra exactly how to get off sildenafil.