PROVIDENCE – With all the ongoing turbulence around how the two largest health systems in Rhode Island may or may not come together in a brokered marriage, one huge overriding issue keeps getting left out of the conversation: what is the role that nursing will play in future health care delivery systems?

Nurses hold up more than half the health care delivery system, and they are the providers most responsible for achieving better health care outcomes in managing the care of patients in both inpatient and outpatient settings. But practicing nurses do not yet have a seat at the table in the current discussions around future statewide health care planning in Rhode Island.

The issues around nursing involve more than increasing the rate of reimbursement, recognizing the leadership role that nurses play, or understanding how nurse-led initiatives are developing new models of care delivery in communities such as Scituate, creating Rhode Island’s first neighborhood health station.

The challenge is: How can nurses change the conversation and become participants in the decision-making?

• One of the best places to start is with data collection and data analysis. For instance, the R.I. Department of Health conducts regular health IT surveys of licensed, practicing physicians in the state, but nurses are not surveyed. The glitch, it seems, is that the legislative mandate to conduct the surveys only mentioned doctors. What will it take to correct that?

• Another area to explore would be how data is being used in population health management metrics, critical to accountable care organizations, and the need to track the role that nurses play in patient relationships and outcomes.

• New innovative models for community-driven health – neighborhood health stations and health equity zones – seek to include the social determinants of health as key factors – the zip code where you live, the quality of housing you live in, the quality of schools your children attend, and the access to healthy food, among others.

The connection between community health needs often depends upon being able to transfer and to translate the data collected [what we learned about the person, their clinical and social needs] into a better understanding that focuses on conditions outside of the clinical setting.

If clinical settings can partner with the community [not just the population of people who “elect” to become members of a health care practice] but truly place-based community work, I believe that then we will begin to see real change.

What is missing from this discussion is the critical role that nursing can and should play.

There has been so much written about why nursing is the “silent” voice in health care settings, but it has often fallen on ears practiced in the art of selective hearing. Is it gender? Is it the inherent training of nurses to avoid conflict?

The art of nursing
On the clinical side, nurses can support people to better understand their own health care needs, take on new behaviors to prevent or manage disease. They complete screenings and offer brief or long-term maintenance support for those new behaviors. They can make clinical decisions about immunizations and other health promotion activities, provide assessments for symptom recognition through triage and direct care, and follow-up care, all within the scope of their license to practice.

That knowledge can be applied to the policies on housing [what kind we build, who are they designed for, pricing, etc.], policies on education [from early childhood through post-secondary academic or technical training], through management of available resources for socialization [including play, meeting neighbors and caring for those who have special needs], along with employment and transportation, based on that data where health becomes the easy choice.

Imagine the community where a nurse sits on the planning board, regularly meets with a community development corporation or a health equity zone about how best to meet their health challenges, and one where the nurse is seen as a necessary partner in functional housing which supports peoples special needs. [I have personally worked in this arena, with architectural students, and can testify how the input from nursing expertise in their designs made better spaces to live.

Uniquely qualified
Nurses are uniquely qualified to work in this space. A nurse with a bachelor’s degree [or higher] has been educated to assess for changes in the body that require intervention. Some of that is health and resource education, some is teaching related to management of disease, some is providing support around both ends of life, the new babies and moms, through those at the end of life.

Nurses learn about assisting people to make changes that support a health lifestyle – and that includes the activities which people and communities struggling with behavioral health issues need to address.

Nurses are in workplaces, schools, communities, hospitals, primary care practices, behavioral health providers, in your town and city senior centers, and the list goes on. They are often unseen and unheard in the discussions.

Now is the time for our voices to be heard. I believe anyone who has directly received care from a nurse recognizes the value.

Lynn P. Blanchette, Ph.D, RN, PHNA-BC, is the Associate Dean and Associate Professor of Nursing at Rhode Island College, School of Nursing.

Editor's Note: One of the issues raised in this story around the lack of data collection involving nurses in Rhode Island provoked some healthy feedback.

It turns out that the current Health IT survey conducted under the auspices of the R.I. Department of Health does include data collection for APRNs, or Advanced Practice Registered Nurses, a group that includes nurse practitioners, clinical nurse specialists, nurse anesthetists, and nurse midwives, as well as physician assistants, or PAs, since 2013. There are roughly some 2,000 licensed APRNs and PAs practicing in Rhode Island; in comparison, there are some 4,200 practicing physicians in Rhode Island.

What it does not yet include is any data from surveying practicing RNs in Rhode Island. Beyond the lack of data, a question raised, apparently by Margaret Clifton, the director of the R.I. Board of Nursing, is what the money collected in the licensing and registration of nurses is being used for. Currently, the money collected goes into the state’s general revenue fund.

The suggestion has been made to allow the Board of Nursing to have access to some of the funds generated through licensing in order to improve the collection of data about the nursing workforce in Rhode Island. Such a new licensing system could collect information about continuing education, document the settings in which nurses are working, the status of that work [whether it is part-time or full-time], and the education levels of the nurses.

For the voices of nurses to be fully heard in the context of the future decisions around health care in Rhode Island, collecting the data would seem to be an important first step. It would help to quantify the sentiments expressed by another reader of ConvergenceRI: “Nurses have played a major role in nearly all of our advocacy victories. I can only imagine what this state would be like if nurses held most of the decision-making power currently reserved for politicians and businessmen behind the scenes.”