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Oregon Nurse Online Article [Principles of Change in Health Care Reform] [02/25/13]

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Nurses’ Use of Principles to Participate in Health Care Reform at the Ground Level

By Sue B. Davidson, PhD, RN, CNS, ONA Assistant Executive Director Nursing Practice, Education & Research

As health care reform has begun to roll out in Oregon, Coordinated Care Organizations (CCO) have been formed and new roles have been proposed, such as the community health workers, peer wellness support coaches, and personal health navigators. Changes in processes, focus and systems of nursing are being proposed at the level of hospitals and associated health care systems, such as changes in care delivery models, nurse staffing, and nurse practices.

To assist direct care nurses who are reviewing and responding to such proposals, ONA has recommended the use of ONA’s four-point “Principles of Change”:

  • Request and get involved in collaboration
  • Outcomes of change(s) must be more than just cost savings
  • Tests of change(s) must occur before becoming permanent
  • Laws, scope of practice and nursing’s code of ethics cannot be disregarded

What follows are three scenarios where the principles enabled direct care nurses to actively respond to proposals for change in health care.

Scenario one features a mid-sized acute care hospital of about 200 beds. There is an active bargaining unit, professional nursing care committee (PNCC), unit-based practice councils, and hospital nurse staffing committee. Proposals were made within the nursing division to change the structure and functions of unit-level nursing leadership and to disband the rapid response team. Direct care nurses utilized the principles by asking for collaboration with hospital administration, seeking data on best practices in rapid response teams across the US, by developing a “test of change”, and applying the scope of practice and code of ethics to the analysis of the change. Collaborative meetings with nurses and administration continue as these issues move toward resolution. Although not easy, nurses need this framework to respond to change by engaging, rather than withdrawing.

Scenario two is about another acute care hospital of approximately 300 beds. The hospital has been visited by two consulting groups in previous years in an effort to reduce the cost of care and operations. There is an active bargaining unit, PNCC, nurse staffing committee and unit-based practice councils. One unit is beginning its journey with Releasing Time to Care. Proposals made by the consulting group for significant reductions in unlicensed assistive staff were being implemented. A sudden and extended surge of seriously ill patients being admitted coincided with the lack of assistive personnel and insufficient numbers of registered nurses. In response, nurses have filed staffing reports and debriefs have occurred in the staffing committee and at the unit level. A request to collaborate, analysis of outcomes of that time period, and reaffirmation of the scope of practice, code of ethics and nurse staffing law is ongoing.

Scenario three involves a 100-bed acute care hospital. The hospital’s leadership has focused solely on cost reduction in the absence of outcomes or tests of change. There has been upheaval in nursing administration and leadership has fluctuated at the unit-level. There is a bargaining unit and PNCC, but the hospital nurse staffing committee has struggled to be effective. System-level changes are rarely reviewed with staff, and consequences of these changes are significant. Requests to collaborate are not welcomed, outcomes of change are not shared, and tests of change do not occur. Laws, scope of practice and nursing’s code of ethics are hampered or ignored. What options do direct care nurses have in this scenario? The principles hold, even in this scenario. Nurses can ask for collaboration, and ask, and ask. They can ask for more than just financial data (e.g., patient-related outcomes) related to changes, nurses can ask for tests of change. They can insist that they are not required to violate their practice or ethics. If there is no responsiveness, then they can report through Staffing Request and Documentation Forms and through confidential calls to the Oregon State Board of Nursing and/or the Oregon Health Care Regulation and Quality Improvement division. In this scenario, where the environment of care is falling apart, nurses still must review, respond and persist in bringing the principles of collaboration forward.

The principles developed by ONA have been distributed, but it is unclear whether they have been used, whether they have brought nurses into discussion around nursing practice issues, or whether they have not been useful. To help provide feedback, we are asking you to tell us your stories. The Cabinets on Nursing Practice & Research, and Human Rights & Ethics would like to invite you to contact ONA’s Professional Services and share your stories and experiences. As we begin to receive your stories about the use of these Principles of Change, we will develop a method to share these stories with others.

In summary, the principle of collaboration, meaningful outcomes, tests of change, and respect for the law, scope of practice and code of ethics can guide us as health care reform begins to touch every aspect of our practice lives. ONA’s hope is that using these principles enables you to achieve the best possible outcomes for your patients.

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