Leading Teams Research Paper

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Leading Teams Research Paper



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A news article in Chemistry World has highlighted the recent work of the Cronin Group in development of a self-optimising flow system using NMR. In the latest issue of Nature, the Cronin group have described a new molecule with unprecedented characteristics that could revolutionise flash memory storage. This work has been reported in several major media outlets, including the BBC, the Hindu, …. Compared to the traditional stainless steel vessels, 3D-Printed reactionware could offer great advantages in terms of cost-effectiveness and flexibility. Naked Scientists Podcast. Naked Scientists Interview. The electrolyser was printed from polypropylene and the conductive areas were electrocoated with silver to provide a suitably conductive surface.

The ability to 3D print such devices has the potential to revolutionise the prototyping, manufacture and deployment of the electrolysers, fuel cells and flow batteries that are essential in ushering in a new era of renewable energy and energy storage. Their contribution to science covers a broad range of disciplines and highlights the diversity and impact of the engineering and physical sciences.

The list of has 10 different examples of each of the 10 types and gives a broad picture of the many different ways people work with science, making valuable contributions across UK society and the economy. Lee is listed as a science explorer along with 9 others including two recent Nobel Prize winners. Professor Lee Cronin and Dr Mark Symes recently published the results of a revolutionary new route to the splitting of water into hydrogen and oxygen. This novel technology utilises an inorganic material known as an Electron Coupled Proton Buffer ECPB to capture the hydrogen in its intermediate state of separated protons and electrons and stores them in a stable form for later release read more in this BBC news item.

The pioneering work of the Cronin Group in developing 3d printing technology for assembling chemical compounds has been featured in Discover Magazine as part of top stories of number The article can be found on the discover magazine website. The full article can be read online here and in pdf format here. Two papers from the group appeared in the latest issue of Angewandte Chemie covering very different approaches to polyoxometalate chemistry.

Prof Cronin and several of his key researchers have described the revolutionary potential of 3D printing in two videos produced by Beilstein TV, an project funded by the Beilstein Institute for the Advancement of Chemical Sciences. In the video Prof. Cronin and his team describe the process of using 3D printing technology to design and fabricate millifluidic reactionware which can be easily interfaced with an array of analytical techniques. The video demonstrates how this process can provide devices which prove to be powerful and convenient tools for both synthetic and analytical applications. These micro-reagents will exchange chemical and electronic information to jointly direct complex chemical reactions and analyses in the solutions they are poured into.

See more on the main …. See the full article on the Observer website. The force behind TED is in the power of ideas to change attitudes, lives, and ultimately the world. Miss Hong-Ying Zang and Mr Andreu Ruiz have both been selected to take part in this prestigious student Nobel Campus and both students will be presenting their work to Nobel Prize winners. Lee was also made a member of the society which is the oldest scientific society in Washington, being established in First awarded in , this prestigious prize is awarded annually to the best chemist under the age of 40 and several Nobel Prize winners including Derek Barton and Frederick Sanger were awarded the prize in the past and Cronin is the first Chemist at Glasgow to win the award in 35 years.

These reactors incorporate chemically active elements into the very structure of the reaction vessel itself providing flexible and easily reconfigurable reactor architectures for chemical synthesis. The article has attracted much attention for this emerging field and the potential implications of …. The lecture highlighted the advantages of new flow setups and 3D printing for discovery of complex chemical systems. For more information, please visit our 3D printing page. The work of the Cronin Group in collaboration with the Glasgow Solar Fuels team of researchers has been featured on Scottish current affairs programme Newsnight Scotland.

Richard Cogdell , and a live discussion with Lee Cronin about the work. The article can be found on the Dalton Transactions website. The award lecture is given in memory of Professor Bob Hay, one of the pioneers of macrocyclic chemistry in the UK. Cronin talks about inorganic chemistry and his research. Also available on YouTube. For the full profile visit the article at Angewandte Chemie here. To view the talk for free online, please visit the TED Global site. Cooper, Philip J. Interfacial membrane formation by cation exchange of polyoxometalates produces modular inorganic chemical cells with tunable morphology, properties, and composition.

These inorganic chemical cells or iCHELLs, which show redox activity, chirality, as well as selective …. The full article can be accessed on the Observer website here. Cronin group member Thomas Boyd has been selected to attend the forthcoming information exchange meeting in Columbus, Ohio on August The program will give an opportunity for students to exchange ideas and experiences with CAS staff on the subject of chemical information and informatics.

Dr Haralampos Harry N. The competition for these Fellowships is intense and gaining this award is a great achievement. For a list of speakers at the event please visit the TED Global site. The full article can be read here. In an in-depth article Prof. The Cronin Group Has recently hosted an EPSRC sponsored workshop which brought together chemists, engineers, artists and architects amongst others to explore the use of 3D fabrication equipment in a research chemistry environemnent. For more information on the participants and concepts examined, see the workshop programme. Cooper, Graham N. Newton, Mali H.

Link to Journal. The manuscript can already be viewed online by following the above link - watch out for the fully animated graphical abstract! Crystal structure of a molybdenum oxide nanowheel, 2. Miras et al. Exploring and mapping chemical space with molecular assembly trees. A robotic prebiotic chemist probes long term reactions of complexifying mixtures. Identifying molecules as biosignatures with assembly theory and mass spectrometry. A molecular computing approach to solving optimization problems via programmable microdroplet arrays. See More. June Dr. Since Assembly Theory relies on molecular complexity alone, the life detection process is … See More.

January Cronin Group Member Dr. Is it possible to design the discovery of materials using theory and experiment joined … See More. In a video interview , Prof Cronin describes how we can translate syntheses from chemical literature into code that can be implemented in robots, and how we can automate the exploration of chemical space to discover new molecules, and new insights into … See More. February Cronin Group work on random number generation featured in Vice An article on vice. The challenge solution proposes an integrated solution that leverages the Glasgow-based … See More.

The five manuscripts are: A programmable chemical computer with memory and pattern recognition Exploring the stochasticity of chemical processes in an automated robotic crystallization platform to generate random numbers 3 Intuition-Enabled Machine Learning Beats the Competition When Joint Human-Robot Teams Perform Inorganic Chemical Experiments Emergence of Function and … See More. January Novelty Algorithm Points the Way for Discovery in Organic Chemistry In a recent review published in Nature Reviews Chemistry , Cronin group researchers describe how machine learning, coupled with real-time chemistry, is set to change the way chemists discover molecules, reactions and reactivity, as well as removing researcher bias.

The digital code for these processes can be published, versioned, and transferred flexibly between platforms with no modification, thereby … See More. This includes seminars, conference talks and … See More. August Cheap networked chemical robots work together collaboratively Researchers in the Cronin group have developed a cheap, easy to operate liquid handling platform capable of performing a range of chemical reactions. This work, published in Nature Communications , demonstrates that robotic assistance in vastly different chemical processes, from inorganic crystallization to non-equilibrium oscillation manipulation is … See More. The fact that the energy is carried in an aqueous liquid form might even mean that it would one day be possible to fill up electric cars, powered by such a … See More.

August How Reduced can you Go? July 'Robo-Chemist', controlled by machine learning to explore chemical reactivity, discovers new reactions, molecules, and reactivity In a paper just published in Nature, a new approach to exploring chemical space following reactivity is presented. Link to paper See More. May Lee Cronin Awarded RSC Interdisciplinary Prize Lee Cronin has been awarded a RSC interdisciplinary prize, in recognition of his ground-breaking work exploring complex chemical systems and digitizing chemistry using artificial intelligence.

In response to receiving the award, … See More. As winner of the lectureship, Prof Cronin will present a session in his honour … See More. However, the researchers found that when replacing some … See More. February Cronin Group Researchers Discover New Antimicrobials using Machine Learning and Evolutionary Algorithms Cronin Group researchers have developed a new way to identify effective antibiotics through exploring the sequence space of antimicrobial peptides AMPs using an evolutionary algorithm. This approach could dramatically increase the number of … See More. January Protocells with Unpredictable Complexity Tamed by Artificial Intelligence In new Cronin Group research published in the journal PNAS, a robot equipped with artificial intelligence was able to build unstable oil-in-water droplets as models for new artificial life forms.

The project is part of a set of experiments to explore the formation of artificial life forms that are based upon new building blocks not found in nature, as well as the development of programmable formulations that could have applications in areas as diverse as drug delivery or new … See More. July Robots VS Humans in the search for chemical intelligence A new paper has just been published by the Cronin group that shows how machine learning can be used to search for new molecules and crystals of those molecules more efficiently that either a human experimenter or a random algorithm.

June From Autonomous organic reaction searching to time programmable drugs: Cronin group publish two papers on two consecutive days in Nature Communications Two new papers have been published in Nature Communications from the Cronin group. May Finding Aliens Using a New "Pathway Complexity" Approach The Cronin group have developed a new approach to complexity, which could help determine if objects such as molecules or artefacts were created by living systems. By using this approach, we aim to set a threshold above which the number of steps required at a minimum would be so high that it would be unlikely or … See More. May Lee Cronin: Brexit threatens UK's status as a global leader in science Lee Cronin, writing in the evening standard, has described the danger of the current Brexit negotiations harming the UK science base, and damaging its position as a global leader in science.

The satellite was launched in partnership with SpacePharma, a company specialising in microgravity experimentation, aboard the Indian … See More. The software … See More. It is hoped that the structure could open new avenues in the exploration of the transition between … See More. October New gigantic Palladium macrocycle opens the way to a library of nano-structures Cronin group researchers have developed a new screening approach to cluster discovery, which could pave the way for developing a new library of nano-structures. September Cronin Group develop affordable robotic 3D-printed antibiotic testing devices Researchers in the Cronin group have demonstrated the development of a cheap 3D-printed device for quickly testing which drugs are most effective at treating a specific bacterial infection.

By examining plausible values for these parameters, the likelihood of origin of life events on … See More. June Lee Cronin and Sara Walker discuss reconceptualising the origin of life in Science In a recent issue of Science, Lee Cronin and Sara Walker discuss a new approach to understanding the transition from non-living to living systems. By challenging historical assumptions and taking a multidisciplinary approach, they suggest that researchers could develop a new type of complexity-first based model, expanding the types of chemistries to be explored, which would … See More.

The full article can be found here See More. April 3D printing of versatile reactionware for chemical synthesis brings digitalization of chemistry a step closer A new paper by the Cronin group has been published in Nature Protocols describing methods for the 3D printing of reactionware for chemical synthesis. The steps of the process describe the design and preparation of a 3D digital model of the desired reactionware device … See More. March Autonomous chemical synthesis seen as a game-changing technology for food production Cronin Group technology being developed towards the digitization of chemical space has been highlighted as a potential game-changer for global food production.

August The ultimate answer to the ultimate question is Molecular electronics is set to … See More. One does not set out on a planned sailing trip when the weather is bad. Instead, one makes sure that the boat is ready, the crew is ready, and the intended course and destination are understood by all. And then, when the weather breaks, one can say, "OK, we can go now," and be off the dock within the hour. Lying in wait Sigmund Freud once said, "He who knows how to wait need make no concessions. To wait until the time is right, on the other hand, offers at least the possibility of a fundamental alteration in how work is construed and accomplished.

One of the great features of work organizations for those who aspire to change them is that it is rarely a long wait for something to happen that destabilizes the system and thereby offers an opening for change. Perhaps a senior manager leaves. Or an organizational unit enters a period of rapid growth or belt-tightening. Or one organizational unit is merged with another. Or the entire organization acquires, or is acquired by, another. Or financial disaster seems about to descend upon the enterprise. Or a new technology is introduced that requires abandonment of standard ways of operating.

All of these, and more, offer opportunities for change: The balls go up in the air, and the prepared leader brings them back down in another, better configuration. All systems regularly move back and forth between periods of relative stability and periods of turbulence, and it is during the turbulent times that change occurs. Learning and change almost never occur gradually and continuously, with each small step followed by yet another small forward step. Instead, an extended period when nothing much seems to be happening is followed by a period of rapid and multidimensional change, and then by yet another period during which no visible changes are occurring.

This pattern is called punctuated equilibrium , and it characterizes the evolution of the species, human development, adult learning and organizational change. They know that during turbulent times major interventions have a greater chance of success and that even small changes may yield disproportionately large effects. Like preparation, waiting is work. One feels as if nothing is happening and, worse, that no one is doing anything constructive to stem further organizational deterioration.

Anxious leaders cannot bear the wait, initiate change too soon, and fail to achieve their aspirations. Change-savvy leaders wait. Forcing the issue Sometimes leaders decide that the wait for turbulence is taking too long and toss a few balls into the air themselves, personally manufacturing a bit of chaos in hopes of creating just enough instability to give change a chance. Theater director Anne Bogart occasionally does that when stymied by an artistic problem during rehearsal:. It is tempting to exhort organizational managers to follow Bogart's courageous lead and take action that hastens the arrival of turbulence, thereby allowing change to occur sooner rather than later. Political revolutionaries regularly do this to accelerate the fall of a regime that is viewed as undesirable.

Organizational leaders would never condone subversion, inciting public disobedience, or promoting violence to bring their enterprises to a state of readiness for change, of course. But they do the organizational equivalent of those political acts when they take actions that cannot be ignored and that make it literally impossible for the system to continue on its present path. Examples abound. The executive team leader described in Chapter 7 eliminated a significant number of jobs and then allowed incumbents to apply for newly defined roles in a reconfigured organization. Other leaders may choose to impose a significant across-the-board budget cut. Although purportedly done to achieve cost savings, the more important function of large budget cuts may be to force everyone to rethink how they do their business.

That is what the management team of Sealed Air Corporation did when it deliberately increased the company's debt burden, using the proceeds to pay a substantial dividend to shareholders. According to economist Karen Wruck, that action, taken when the firm's financial performance was fully satisfactory, forced managers to find ways to improve internal control mechanisms that they almost certainly would not otherwise have considered. So can preemptive abandonment of a technology, a product line, or even a geographical location that has long been part of the organization's identity. Boeing not headquartered in Seattle? Never could happen. Except that it did, and one has to wonder if the decision to move to Chicago was at least partly driven by a hope that the move would jar the organizational balls into the air and allow, if not invite, fresh thinking about how Boeing does its business.

Draconian strategies that make it literally impossible for a system to continue operating in its traditional ways always introduce plenty of turbulence and therefore always offer the opportunity for constructive change. But, as many political and organizational revolutionaries have learned the hard way, such strategies by no means guarantee that the changes that are initiated will turn out to be good for the organization, for its people, for those it serves, or even for the leaders who fomented the revolution. People get hurt in revolutions, even those who lead them, and even when they are successful.

And what it can cost We have seen that, in many organizational circumstances, creating the conditions that actively support work teams must be more a revolutionary than an evolutionary undertaking. That is what it eventually turned out to be for Hank, the semiconductor plant production manager discussed in previous chapters. Recall that Hank was remarkably successful in convincing managers much senior to himself to alter compensation, maintenance, and engineering policies or practices so they would better support the work of his production teams.

The teams continued to perform well, but eventually their rate of improvement slowed considerably. And Hank still kept them on a relatively short leash, retaining unto himself decision-making authority about those matters he considered most important. David Abramis and I finished up our research at the plant, which showed that although there was much to admire in what Hank had created, the teams were not really self-managing. The production teams, he declared, would now be called "asset management teams" and they would be given authority to manage all of their resources in pursuing collective objectives. The transition to asset management teams was difficult, as transitions always are when decision-making authority and accountability for outcomes are altered.

No matter how many times it was explained to them in team meetings, some team members seemed unable to understand that they now really were running their own part of the business. These responses are not uncommon when people have to come to terms with the fact that they are now the ones who call the shots and who will have to take the heat if things do not go well. Eventually the changes "took," teams accepted and began to use their new authority, and performance measures for Hank's fab reached new highs. Indeed, his unit was more profitable than any comparable unit not just in the plant but in the entire corporation.

By all measures, Hank had a great success on his hands. Not long thereafter, I received one of my occasional telephone calls from him. They've decided that some changes need to be made in my area, and the main change is going to be me. That was the reason Hank was given for his termination. In my many years of organizational research I have often seen managers whose units had extraordinarily high employee satisfaction get sacked because their productivity was subpar.

However, regulations in many states result in APRNs not being able to give care they were trained to provide. The committee believes all health professionals should practice to the full extent of their education and training so that more patients may benefit. A paper commissioned by the committee 13 points out that the United States was one of the first countries to regulate health care providers and that this regulation occurred at the state—not the federal—level.

Legislatively, physician practice was recognized before that of any other health profession Rostant and Cady, These provisions. Most APRNs are in the opposite situation. At any point in their career, APRNs can do much more than they may legally do. As APRNs acquire new skills, they must seek administrative or statutory revision of their defined scopes of practice a costly and often difficult enterprise.

As the health care system has grown over the past 40 years, the education and roles of APRNs have continually evolved so that nurses now enter the workplace willing and qualified to provide more services than they previously did. As the services supported by evolving education programs expanded, so did the overlap of practice boundaries of APRNs and physicians. APRNs are more than physician extenders or substitutes. They cover the care continuum from health promotion and disease prevention to early diagnosis to prevent or limit disability. These services are grounded in and shaped by their nursing education, with its particular ideology and professional identity. NPs also learn how to work with teams of providers, which is perhaps one of the most important factors in the successful care of chronically ill patients.

Although they use skills traditionally residing in the realm of medicine, APRNs integrate a range of skills from several disciplines, including social work, nutrition, and physical therapy. Almost 25 years ago, an analysis by the Office of Technology Assessment OTA indicated that NPs could safely and effectively provide more than 90 percent of pediatric primary care services and 75 percent of general primary care services, while CRNAs could provide 65 percent of anesthesia services.

OTA concluded further that CNMs could be 98 percent as productive as obstetricians in providing maternity services Office of Technology Assessment, APRNs also have competencies that include the knowledge to refer patients with complex problems to physicians, just as physicians refer patients who need services they are not trained to provide, such as medication counseling, developmental screening, or case management, to APRNs. As discussed in Chapter 1 and reviewed in Annex , APRNs provide services, in addition to primary care, in a wide range of areas, including neonatal care, acute care, geriatrics, community health, and.

Most NPs train in primary care; however, increasing numbers are being trained in acute care medicine and other specialty disciplines Cooper, The growing use of APRNs and physician assistants has helped ease access bottlenecks, reduce waiting times, increase patient satisfaction, and free physicians to handle more complex cases Canadian Pediatric Society, ; Cunningham, This is true of APRNs in both primary and specialty care.

In orthopedics, the use of APRNs and physician assistants is a long-standing practice. NPs and physician assistants in gastroenterology help meet the growing demand for colon cancer screenings in either outpatient suites or hospital endoscopy centers. Because APRNs and physician assistants in specialty practice typically collaborate closely with physicians, legal scope-of-practice issues pose limited obstacles in these settings. Regulations that define scope-of-practice limitations vary widely by state.

In some states, they are very detailed, while in others, they contain vague provisions that are open to interpretation Cunningham, However, the majority of state laws lag behind in this regard. As a result, what NPs are able to do once they graduate varies widely across the country for reasons that are related not to their ability, their education or training, or safety concerns Lugo et al. For example, one group of researchers found that 16 states plus the District of Columbia have regulations that allow NPs to see primary care patients without supervision by or required collaboration with a physician see Figure As with any other primary care providers, these NPs refer patients to a specialty provider if the care required extends beyond the scope of their education, training, and skills.

Other legal practice barriers include on-site physician oversight requirements, chart review requirements, and maximum collaboration ratios for physicians who collaborate with more than a single NP. There are fundamental contradictions in this situation. Educational standards—which the states recognize—support broader practice by all types of APRNs. National certification standards—which most states also recognize—likewise support broader practice by APRNs. Moreover, the contention that APRNs are less able than physicians to deliver care that is safe, effective, and efficient is not supported by the decades of research that has examined this question Brown and Grimes, ; Fairman, ; Groth et al.

NOTE: Collaboration refers to a mutually agreed upon relationship between nurse and physician. Courtesy of AARP. All rights reserved. No studies suggest that care is better in states that have more restrictive scope-of-practice regulations for APRNs than in those that do not. Yet most states continue to restrict the practice of APRNs beyond what is warranted by either their education or their training. Box provides an example of the variation in state licensure regulations, detailing examples of the services an APRN would not be permitted to provide if she practiced in a more restrictive state Safriet, In addition to variations among states, the scope of practice for APRNs in some cases varies within a state by geographic location of the practice within the state or nature of the practice setting.

Several states permit APRNs to provide a broad list of services, such as independently examining patients, ordering and interpreting laboratory and other tests, diagnosing and treating illness and injury, prescribing indicated drugs, ordering or referring for additional services, admitting and attending patients in a hospital or other facility, and directly receiving payment for services. In other states, however, those same APRNs would be prohibited from providing many of these services.

The following list provides examples of restrictions that APRNs face in states that have adopted more restrictive scope-of-practice regulations. These restrictions could greatly limit the ability of APRNs to fully utilize their education and training. Current laws are hampering the ability of APRNs to contribute to innovative health care delivery solutions. Some NPs, for example, have left primary care to work as specialists in hospital settings Cooper, , although demand in those settings has also played a role in their movement. Others have left NP practice altogether to work as staff RNs. For example, restrictive state scope-of-practice regulations concerning NPs have limited expansion of retail clinics, where NPs provide a limited set of primary care services directly to patients Rudavsky et al.

Similarly, the roles of NPs in nurse-managed health centers and patient-centered medical homes can be hindered by dated state practice acts. Credentialing and payment policies often are linked to state practice laws. A survey of the credentialing and reimbursement policies of managed care organizations revealed that 53 percent credentialed NPs as primary care providers; of these, 56 percent reimbursed primary care NPs at the same rate as primary care providers, and 38 percent reimbursed NPs at a lower rate Hansen-Turton et al. As discussed above, some states require NPs to be supervised by physicians in order to prescribe medications, while others do not. In this survey, 71 percent of responding insurers credentialed NPs as primary care providers in states where there was no requirement for physicians to supervise NPs in prescribing medications.

In states that required more physician involvement in NP prescribing, insurers were less likely to credential. Of interest, this was the case even though the actual level of involvement by the physician may be the same in states where supervision is required as in states where it is not. Also of note is that Medicaid plans were more likely than any other category of insurer to credential NPs. Although there is a movement away from a fee-for-service system, Table shows the current payment structure for those providing primary care.

Precisely because many of the problems described in this report are the result of a patchwork of state regulatory regimes, the federal government is especially well situated to promote effective reforms by collecting and disseminating best practices from across the country and incentivizing their adoption. The federal government has a compelling interest in the regulatory environment for health care professions because of its responsibility to patients covered by federal programs such as Medicare, Medicaid, the VA, and the Bureau of Indian Affairs.

Federal actors already play a central role in a number of areas that would be essential to effective reform of nursing practice, especially that of APRNs. They pay for the majority of health care services delivered today, they pay for research on the safety and effectiveness of existing and innovative practice models and encourage. This section is based on a September 10, , personal communication with Barbara J. The federal government also appropriates substantial funds for the education and training of health care providers, and it has an understandable interest in ensuring that the ever-expanding skills and abilities acquired by graduates of these programs are fully utilized for the benefit of the American public.

In particular, the Federal Trade Commission FTC has a long history of targeting anticompetitive conduct in health care markets, including restrictions on the business practices of health care providers, as well as policies that could act as a barrier to entry for new competitors in the market. The FTC has responded specifically to potential policies that might be viewed predominantly as guild protection rather than consumer protection, for example, taking antitrust actions against the American Medical Association AMA for policies restricting access to clinical psychologists to cases referred by a physician and for ethical prohibitions on collaborating with chiropractors, podiatrists, and osteopathic physicians.

The Board had prohibited nondentists from providing teeth-whitening services. The FTC alleged that by doing this the Board had hindered competition and made it more difficult and costly for consumers in the state to obtain this service. Principles of equity would suggest that this subscriber choice would be promoted by policies ensuring that full, evidence-based practice is permitted for all providers regardless of geographic location. Finally, the Centers for Medicare and Medicaid Services CMS has the responsibility to promulgate rules and policies that promote access of Medicare and Medicaid beneficiaries to appropriate care.

CMS therefore should ensure that its rules and polices reflect the evolving practice abilities of licensed providers, rather than relying on dated definitions drafted at a time when physicians were the only authorized providers of a wide array of health care services. For several decades, the trend in the United States has been toward expansion of scope-of-practice regulations for APRNs, but this shift has been incremental and variable.

Most recently, the move to expand the legal authority of all APRNs to provide health care that accords with their education, training, and competencies appears to be gathering momentum. In , after 5 years of study, debate, and negotiation, a group of nursing accreditation, certification, and licensing organizations, along with several APRN groups, developed a consensus model for the education, training, and regulation of APRNs see Appendix D. The stated goals of the APRN consensus process are to:.

The consensus document will help schools and programs across the United States standardize the education and preparation of APRNs. It will also help state regulators establish consistent practice acts because of education and certification standardization. And of importance, this document reflects the consensus of nursing organizations and leaders and accreditation and certification boards regarding the need to eliminate variations in scope-of-practice regulations across states and to adopt regulations that more fully recognize the competence of APRNs. AARP, a. Meanwhile, after passage of the ACA, 28 states began considering expanding their scope-of-practice regulations for NPs Johnson, Expanding the scope.

Twenty-five percent of the U. People who live in rural areas are generally poorer and have higher morbidity and mortality rates than their counterparts in suburban and urban settings, and they are in need of a reliable source of primary care providers NRHA, The case study in Box , describing an NP in rural Iowa, demonstrates the benefits of a broad scope of practice with respect to the quality of and access to care. Generalist nurses are expanding their practices across all settings to meet the needs of patients.

Expansions include procedure-based skills involving, for example, IVs and cardiac outputs , as well as clinical judgment skills e. On the other hand, given the projected nursing shortage, task shifting to overworked nurses could create unsafe patient care environments, especially in acute care hospitals. To avert this situation, nurses need to delegate to others, such as LPNs, nursing assistants, and community health workers, among others.

A transformed nursing education system that is able to respond to changes in science and contextual factors, such as population demographics, will be able to incorporate needed new skills and support full scopes of practice for non-APRNs to meet the needs of patients see Chapter 4. Increasing access to care by expanding state scope-of-practice regulations so they accord with the education and competency of APRNs is a critical and controversial topic. Practice boundaries are constantly changing with the emergence of new technologies, evolving patient expectations, and workforce issues.

Yet the movement to expand scopes of practice is not supported by some professional medical organizations. Professional tensions surrounding practice boundaries are not limited to nurses and physicians, but show a certain continuity across many disciplines. Psychiatrists and psychologists have been disagreeing about prescriptive privileges for more than two decades Daly, In the dental field, one new role, the advanced dental hygiene practitioner, functions under a broadened scope similar to that of an APRN.

The American Dental Association does not. T he passage of the Affordable Care Act will give millions of Americans better access to primary care—if there are enough providers. In , 23 percent of NPs in the United States worked in rural areas and almost 41 percent in urban communities, where most provided primary care services to underserved populations Hooker and Berlin, In rural communities, NPs may be the only available primary care providers, and it is important that they be able to practice independently, if need be, although they value collaboration with physicians and other providers regardless of state authorization. Iowa is one of 22 states where advanced practice registered nurse APRNs —NPs, certified nurse mid-wives, certified registered nurse anesthetists CRNAs , and clinical nurse specialists—practice without physician oversight and one of 12 states that permit them to prescribe without restriction Phillips, Several studies have shown that APRNs produce outcomes comparable to those of physicians and that the care they provide encompasses 80 to 90 percent of the services provided by physicians Lenz et al.

A qualified health care professional is a terrible thing to waste. Jones attributes those successes to the diligence of Iowa nurses and others interested in promoting access to care, who:. Jones invited legislators to her clinic ;. Evidence that it is safe to remove restrictions on APRNs comes from an annual review of state laws and regulations governing APRNs that now includes malpractice claims in its analysis. The Pearson Report documents no increase in claims registered in the Healthcare Integrity and Protection Data Bank in states where APRNs have full authority to practice and prescribe independently. The report also notes that the overall ratio of claims against NPs is 1 for every NPs in the nation, compared with 1 for every 4 physicians Pearson, A mother brings her son for an appointment with nurse practitioner Cheryll Jones, who provides high-quality care in the rural community of Ottumwa, IA.

Likewise, physical therapists are challenging traditional scope-of-practice boundaries established by chiropractors Huijbregts, The AMA has consistently issued resolutions, petitions, and position papers supporting opposition to state efforts to expand the scope of practice for professional groups other than physicians. The SOPP in particular, an alliance of the AMA and six medical specialty organizations, was an effort on the part of organized medicine to oppose boundary expansion and to defeat proposed legislation in several states to expand scope of practice for allied health care providers, including nurses Croasdale, ; Cys, The SOPP, with the assistance of a special full-time legislative attorney hired for the purpose, spearheaded several projects designed to obstruct expansion of scopes of practice for nurses and others.

These projects included comparisons between the medical profession and specific allied health professions on education standards, certification programs, and disciplinary processes; development of evidence to discredit access-to-care arguments made by various allied health professionals, particularly in rural areas of a state; and identification of the locations of physicians by specialty to counter claims of a lack of physicians in certain areas Cady, Other organizations, such as the American Society of Anesthesiologists and the American Association of Family Physicians AAFP , have also issued statements that do not support nurses practicing to their fullest. See for example, AMA.

Action has been taken at the state level as well. At the time of release of this report, the case had not yet been heard. A study by Dulisse and Cromwell found no increase in inpatient mortality or complications in states that opted out of the CMS requirement that an anesthesiologist or surgeon oversee the administration of anesthesia by a CRNA. As noted earlier in this chapter, the contention that APRNs are less able than physicians to deliver care that is safe, effective, and efficient is not supported by research that has examined this question Brown and Grimes, ; Fairman, ; Groth et al.

Opposition to this expansion is particularly strong with regard to prescriptive practice. Similar questions have been raised about the content of nursing education see the discussion of nursing curricula in Chapter 4. Some individual physicians support expanded scope of practice for NPs. In addition to support for expanded scope of practice for NPs among some physicians, public support for NP practice is indicated by satisfaction ratings for retail-based health clinics.

Approximately 95 percent of providers in these clinics are NPs, with the remaining 5 percent comprising physician assistants and some physicians. Such public support can be backed up with high-quality clinical outcomes Mehrotra et al. Despite opposition by some physicians and specialty societies, the strong trend over the past 20 years has been a growing receptivity on the part of state legislatures to expanded scopes of practice for nurses. There simply are not enough primary care physicians to care for an aging population now, and their patient load will dramatically increase as more people gain access to care. This initiative has had an important impact on access to care.

For this study, respondents were randomly recruited to participate in the IOM survey activity via e-mail; others were allowed to join the survey by volunteering when they visited the site. The majority of respondents have specialties in cardiology 6 percent , family medicine 35 percent , internal medicine 26 percent , and oncology 4 percent. The remaining physicians surveyed are distributed across a wide range of specialties.

States with broader nursing scopes of practice have experienced no deterioration of patient care. In fact, patient satisfaction with the role of APRNs is very high. Nor has expansion of nursing scopes of practice diminished the critical role of physicians in patient care or physician income Darves, With regard to the quality of care and the role of physicians, it is difficult to distinguish states with restrictive and more expanded scopes of practice. Finally, the committee believes that the new medical home concept, based on professional collaboration, represents a perfect opportunity for nurses and physicians to work together for the good of patient care in their community.

The U. A fragmented health care system is characterized by weak connections among multiple component parts. Fragmentation makes simple tasks—such as assigning responsibility for payment—much more difficult than they need to be, while more complex tasks—such as coordination of home health care, family support, transportation, and social services after a hospital stay—become more difficult because they require following many separate sets of often contradictory rules. As a result, people may simply give up trying rather than take advantage of the services to which they are entitled. An examination of fragmentation in hospital services explores its origins in American pluralism, historical accident, and the hybridization of business and charity Stevens, A review by Cebul and colleagues identifies three broad areas of fragmentation: 1 the U.

In the United States, there is a disconnect between public and private services, between providers and patients, between what patients need and how providers are trained, between the health needs of the nation and the services that are offered, and between those with insurance and those without Stevens, Communication between providers is difficult, and care is redundant because there is no means of sharing results. For example, a patient with diabetes covered by Medicaid may have difficulty finding a physician to help him control his blood sugar. If he is able to find a physician, that individual may not have admitting privileges at the hospital to which the patient is transported after a hypoglycemic reaction.

After the patient has been admitted to the emergency room, a new cadre of physicians is responsible for him but has no information about previous blood sugar determinations, other medications he is taking, or other health problems. The patient is stabilized and a discharge is arranged, but he is. Home follow-up is needed, but the visiting nurse agency is certified to provide only two visits when the patient could use five.

No one calls the initial primary care physician to share discharge planning or information, and no one gives the patient a summary of the visit to take to that physician. The ophthalmologist will not accept the patient because of his status as a Medicaid recipient. A major challenge to repairing this fragmentation lies in the fee-for-service structure of the payment system, which indiscriminately rewards increasing volume of services regardless of whether it improves health outcomes or provides greater value MedPAC, Within this system, the contributions of nursing are doubly hidden.

Accounting systems of most hospitals and health care organizations are not designed to capture or differentiate the economic value provided by nurses. Thus, all nursing care is treated equally in its effect on revenue. The effect on the provision of health care is difficult to document, but a closer look at staffing ratios suggests some of the consequences. Barriers to measuring and realizing the economic value generated by nurses exist outside the hospital setting as well. In many states, APRNs are not paid directly but must be reimbursed through the physician with whom they have a collaboration agreement. Payments are funneled through the physician provider number, and the nurse is salaried.

For years, professional nursing organizations have sought to counter the inequitable aspects of the fee-for-service payment system by lobbying to increase the types of services for which NPs can independently bill Medicare, Medicaid, and other providers. They have had some success in that regard in the past Sullivan-Marx, As McClellan and Wilensky testified to the committee in September , while fee-for-service is not going to disappear any time soon, its future is severely limited in any sustainable health care system. A full exploration of all the benefits and caveats of such alternative payment proposals is beyond the scope of this report. Yet the tendency of human nature is to follow the practices and behaviors with which one is most familiar.

Without the presence of nurses in decision-making positions in these new entities, the legacy of undervaluing nurses, characteristic of the fee-for-service system, will carry over into whatever new payment schemes are adopted. The services of nurses must be properly and transparently valued so that their contributions can fully benefit the entire system. Expanding their services to the private insurance market is another matter altogether. The health care reform experience of Massachusetts shows the extent to which corporate policy can negate government regulation.

NPs are required to collaborate with a physician and may prescribe drugs only under a written collaborative agreement with a physician Christian et al. As a matter of policy, one major New England carrier stated that it would not list NPs as PCPs unless required to do so by the legislature. Eventually, Massachusetts passed a second health care reform law in that amended the. Massachusetts was thereby able to expand the supply of its PCPs without changing its scope-of-practice laws Craven and Ober, The actions of private insurance companies toward APRNs are having an effect on government-funded programs as well.

However, federal and state governments are increasingly turning to the private sector to manage these programs Hansen-Turton et al. NCQA, which administers the recognition for the medical homes, is a physician-dominated organization receiving its member dues from physicians. Its board, although currently reconsidering its stance on whether NPs can lead medical homes, has decided that physicians are more able to serve in PCMH leadership positions. The original concept for the medical home came from physicians, and NCQA adopted their principles of operation. NCQA has appointed an advisory committee to review the policy that medical homes must be physician led. Meanwhile, the Joint Commission is developing a competitive certification program that will allow for leadership by NPs.

As the health care system undergoes transformation, it will be imperative that patients have highly competent nurses who are adept at caring for them across all settings. It will be just as important that the system have enough nurses at any. Both having enough nurses and having the right kind of highly skilled nurses will contribute to the overall safety and quality of a transformed system. Although the committee did not focus solely on the upcoming shortage of nurses, it did devote time to considering how to retain experienced nurses and faculty. Some solutions have been researched, proposed, and reproposed for so long that it is difficult to understand why they have not yet been implemented more widely.

High turnover rates continue to destabilize the nurse workforce in the United States and other countries Hayes et al. Figure indicates some of the reasons that have been cited for not working in the nursing profession. For nurses under 50, personal or family reasons were most frequently cited. The costs associated with high turnover rates are significant, particularly in hospitals and nursing homes Aiken and Cheung, The literature shows that the workplace environment plays a major role in nurse turnover rates Hayes et al.

Staff shortages, increasing work-. Includes only RNs who are not working in nursing. Tables and , respectively, show the intentions of nurses with regard to their employment situation e. Much of the data showing the impact of reducing turnover by focusing on workplace environment comes from the acute care setting. Nonetheless, these data are instructive in their demonstration of a triple win: improving the workplace environment reduces nurse turnover, lowers costs, and improves health outcomes of patients. For example, the Transforming Care at the Bedside TCAB initiative is a national program that engages nurses to lead process improvement efforts so as to improve health outcomes for patients, reduce costs, and improve nurse retention Bolton and Aronow, TCAB relies on nurses developing small tests of change that are continuously planned, assessed, and rapidly adopted or dropped, with each round building on previous successes.

Some employers have also discovered that making it easier for nurses to obtain advanced degrees while continuing to work has increased retention rates. Chapter 4 includes an example of this phenomenon from the Carondelet Health Network in Tucson, Arizona. Based on workforce data Carondelet regularly collects for use in its strategic planning, the network has concluded that its educational efforts have had a positive effect on recruiting and retention. Its percentage of staff as opposed to contract nurses has increased from Because so many newly graduated nurses have begun seeking work at Carondelet, the average age of its staff nurses fell from 50 years in to High turnover rates among newly graduated nurses highlight the need for a greater focus on managing the transition from school to practice Kovner et al.

Some turnover is to be expected—and is even appropriate if new nurses discover they are not really suited to the care setting or employer they have chosen. However, some entry-level nurses who leave first-time hospital jobs leave the profession entirely, a situation that needs to be avoided when possible. In a survey of entry-level nurses, those who had already left their first job cited reasons such as poor management, stress, and a desire for experience in a different clinical area Kovner et al. In , the Joint Commission recommended the development of nurse residency programs—planned, comprehensive periods of time during which nursing graduates can acquire the knowledge and skills to deliver safe, quality care that.

This recommendation was most recently endorsed by the Carnegie study on the nursing profession Benner et al. Versant 24 and other organizations have launched successful transition-to-practice residency programs for nurses in recent years, while the University HealthSystem Consortium UHC and the American Association of Colleges of Nursing AACN have developed a model for postbaccalaureate nurse residencies Goode and Williams, ; Krugman et al. These needs included developing skills in ways to organize work and establish priorities; communicate with physicians, other professionals as well as patients and their families. In addition, nurses and employers indicated the need for nurses to develop leadership and technical skills in order to provide quality care Beecroft et al.

Meanwhile, the National Council of State Boards of Nursing, after reviewing the evidence in favor of nursing residencies, has developed a regulatory model for transition-to-practice programs, recommending that state boards of nursing enforce a transition program through licensure NCSBN, Residency programs are supported predominantly in hospitals and larger health systems, with a focus on acute care.

This has been the area of greatest need since most new graduates gain employment in acute care settings, and the proportion of new hires and nursing staff that are new graduates is rapidly increasing Kovner et al. It is essential, however, that residency programs outside of acute care settings be developed and evaluated. Chapter 2 documents the demographic changes on the horizon; the shift of care from hospital to community-based settings; and the need for nursing expertise in chronic illness management, care of older adults in home settings, and transitional services.

In this context, nurses need to be prepared for new roles outside of the acute care setting. It follows that new types of residency programs appropriate for these types of roles need to be developed. Several community care organizations are already acting on their own perceived need for a residency-type program lasting 3 months or longer for new employees. At the Visiting Nurse Services of New York, nurses receive a great deal of education and training on the job. There are a few successful transition-to-practice initiatives in the field of public health, although they are commonly called internships, orientations, or mentoring programs.

For example, the North Carolina State Health Department has begun a pilot effort with four public health departments in an effort to educate new nurses about population-based health. The 6-month mentoring program is being used as a recruitment and retention tool and has very explicit objectives, including an increase in retention and understanding of population health and a willingness to serve as a mentor as the program goes forward. Two public health departments and three community health centers not only collaborated to diversify the nurses entering public and community health settings, but also offered them paid traineeships to transition into their settings.

The public health departments partnered with the Wisconsin Center for Nursing and a collaborative of five baccalaureate schools of nursing to first boost the community health curriculum in those schools and then help with the development of the internship upon graduation for 17 nurses. The program has been successful in recruiting more minorities into community and public health settings with the knowledge they need to practice successfully outside of the acute care setting.

Financial support was secured from a variety of sources, including foundations, corporations, and partnership members themselves. The program is new and is currently undergoing an evaluation to deter-. Much of the evidence supporting the success of residencies has been produced through self-evaluations by the residency programs themselves. For example, Versant has demonstrated a profound reduction in turnover rates for new graduate RNs—from 35 to 6 percent at 12 months and from 55 to 11 percent at 24 months—compared with new graduate RN control groups hired at a facility prior to implementation of the residency program Versant, Other research suggests residencies may be useful to help new graduates transition into practice settings Goode et al.

The committee focused its attention on residencies for newly licensed RNs because these residencies have been most studied. Looking forward, however, the committee acknowledges the need for RNs with more experience to take part in residency programs as well. Such programs may be necessary to help nurses transition from, for example, the acute care to the community setting. The committee believes that regardless of where the residency takes place—whether in the acute care setting or the community—nurses should be paid a salary, although the committee does not take a position on whether this should be a full or reduced salary. Loan repayment and educational debt should be postponed during residency, especially if a reduced salary is offered.

The intensity and demands of providing service in the complex setting of a federally qualified health center FQHC , Flinter testified, often discourage newly graduated NPs from joining an FQHC and the clinics from hiring newly graduated NPs. The goal was to ensure that new NPs would find the training and transition support they needed to be successful as PCPs. Residency provides a continuing opportunity to apply important knowledge for the purpose of remaining a safe and competent provider in a continuous learning environment. Paying for residencies is a challenge, but the committee believes that funds received from Medicare can be used to help with these costs. In , about half of all Medicare nursing funding went to five states that have the most hospital-based diploma nursing programs Aiken et al.

The diploma programs in these states directly benefit from receiving these funds. Most states, however, and most hospitals do not receive Medicare funding for nursing education. The committee believes it would be more equitable to spread these funds more widely and use it for residency programs that would be valuable for all nurses across the country. As discussed in Chapter 2 , the population of the United States is growing older and is becoming increasingly diverse in terms of race, ethnicity, and. Like the U. Over the past three decades, there has been a profound shift in the age composition of nurses.

In , approximately 50 percent , full-time equivalents [FTEs] of the workforce was between the ages of 20 and 34, while only 17 percent , FTEs was over the age of Since the s, the number of FTEs in the nursing workforce has doubled, and there has been a dramatic increase in the number of middle-aged and older RNs. From to , the number of nurses over age 50 more than quadrupled, and the number of middle-aged nurses aged 35—49 doubled to approximately 39 percent , These older and middleaged nurses now represent almost three-quarters of the nursing workforce, while nurses younger than 34 now make up only 26 percent Buerhaus et al.

Figure shows the age shift in the nursing workforce that has occurred over the past two decades. The figure shows that since , the nursing workforce has grown older, as reflected by more RNs reporting that they fall within the older age categories with each successive survey. At the same time, the figure indicates that in both and especially , the number of young RNs in the workforce was growing relative to earlier years. As other similar recruitment initiatives followed, more, younger people chose to become nurses, reversing a year trend of declining entry into nursing by young people.

The shift in the age composition of the nursing workforce can be attributed in part to the large number of baby boomers who became RNs in the s and s, followed by much smaller cohorts in the later decades Buerhaus et al. These smaller cohorts were a result of not only the decrease in births, but also a decrease in interest in the profession during the s and s when women began entering other professions that had typically been dominated by men Staiger et al. The physician workforce has also been aging, but in much smaller numbers.

Figure compares the average age of nurses with varying levels of education with that of physicians and physician faculty. Between and , the number of physicians aged 50—64 grew by 77, FTEs, while the number of RNs in that same age group grew by almost five times as many , FTEs Staiger et al. Compared with the size of the nursing workforce, however, the size of the physician workforce is less dependent on interest in profession. The supply of physicians is influenced more by institutional factors that govern the number of available slots in medical schools and residency. For example, the supply of physicians was deliberately expanded in the s with the introduction of the Medicare and Medicaid programs but has remained fairly constant since then. This pattern has resulted in large successive cohorts of physicians who are replacing smaller groups of retiring physicians Staiger et al.

As the coming decades unfold, nurses and physicians will continue to age. Many of the large numbers of older RNs will retire, and increasing numbers of middle-aged RNs will enter their 50s. Although the number of younger RNs has recently begun to grow, the increase is not expected to be large enough to offset the number of RNs anticipated to retire over the next 15 years Buerhaus et al.

To fill gaps created by retirement and the increasing demand for nursing services, resulting in part from an aging population and increased rates of insurance coverage, the nursing workforce will need to expand by attracting younger. Throughout much of the 20th century, the nursing profession was composed mainly of women. While the absolute number of men who become nurses has grown dramatically in the last two decades, from 45, in to , in HRSA, , men still make up just over 7 percent of all RNs HRSA, Overall, male RNs tend to be younger than female RNs, with an average age of Men are also more likely to begin their careers with slightly more advanced nursing degrees HRSA, Efforts to recruit more men into the civilian nursing profession have had minimal success, and a body of research indicates gender-based reasons for entering the nursing profession.

The evidence is generally thin, but men tend to list factors associated with security and professional growth that led them to the nursing profession: salary, ease of obtaining work, job security, and opportunities for leadership. By contrast, women tend to list factors that represent social encouragement from family or friends Zysberg and Berry, While more men. To better meet the current and future health needs of the public and to provide more culturally relevant care, the current nursing workforce will need to grow more diverse. Previous IOM reports have found that greater racial and ethnic diversity among providers leads to stronger relationships with patients in nonwhite communities.

These reports argue that the benefits of such diversity are likely to be felt across health professions and to grow as the U. Because nurses make up the largest proportion of the health care workforce and work across virtually every health care and community-based setting, changing the demographic composition of nurses has the potential to effect changes in the face of health care in America. Although nurses need to develop the ability to communicate and interact with people from differing backgrounds, the demographic characteristics of the nursing workforce should be closer to those of the population at large to foster better interaction and communication AACN, a.

Numerous programs nationwide are aimed at increasing the number of health professionals from underrepresented ethnic and racial groups. It is managed by nurses with the help of a volunteer family practice physician. Since its inception, a goal of the program has included attracting greater numbers of minority persons into nursing and other health professions and providing opportunities to enhance. This section draws on a September 8, , personal communication with Kay T. Nursing careers and educational pathways are now formally included in job-related programs implemented by the Presbyterian Community Center PCC. For example, over the past 2 years, PCC has selected 50 community residents into the Changemaker program, which targets to year-olds to engage them in self-discovery, goal setting, and progress toward career goals, with the condition of giving back to the community.

Each year about four to six Changemakers examine health careers in depth. HNC included nursing and health careers in the proposal that funded this pathway and provides supervised clinical experiences, mentoring, part-time job opportunities where possible, and education about nursing. Community health students and faculty now provide education at the community middle school regarding careers in nursing. Last year no African American student was accepted. Dialogue with faculty led to an examination of policies that resulted in the omission of minority students. Literally hundreds of undergraduate and graduate nursing students from several academic institutions have supervised learning experiences in the community.

These include at least 10 undergraduate community health nursing students each semester, a class of 30 graduate nursing students enrolled in a health promotion class each year, and 2 or more NP students based in the clinic each semester. About 5 NP and 10 undergraduate students participate in a Back to School event each fall where Harambee offers school physicals and immunizations for underserved middle school students. The nurse workforce is slowly becoming more diverse, and the proportion of racially and ethnically diverse nursing graduates has increased by 10 percent in the last two decades, growing from Nonetheless, additional commitments are needed to further increase the diversity of the nurse workforce.

Steps should be taken to recruit, retain, and foster the success of diverse individuals. One way to accomplish this is to increase the diversity of the nursing student body, an issue addressed in Chapter 4. The ACA will bring new opportunities to overcome some of the barriers discussed above and use nurses in new and expanded capacities. All four initiatives have shown enough promise that they were selected to receive additional financial support under the ACA. Depending on their outcomes, these exemplars may lead the way to broader changes in the health care system.

They can also terminate or modify programs that are not working well. These types of decisions had previously been allowed only after congressional action. However, it wishes to emphasize to the Center for Medicare and Medicaid Innovation that each of these four initiatives depends on high-functioning, interprofessional teams in which the competencies and skills of all nurses, including APRNs, can be more fully utilized. New models of care, still to be developed, may deliver care that is better and more efficient than that. Nursing, in collaboration with other professions, should be a part of the design of these initiatives by shaping and leading solutions.

Innovative solutions are most likely to emerge if researchers from the nursing field work in partnership with other professionals in medicine, business, technology, and law to create them. The ACO is a legally defined entity consisting of a group of primary care providers, a hospital, and perhaps some specialists who share in the risk as well as the rewards of providing quality care at a fixed reimbursement rate Fisher et al. Payment for this set of services, as provided for in the ACA, will move beyond the traditional fee-for-service system and may include shared savings payments or capitated payments for all services. The goal of this payment structure is to encourage the ACO to improve the quality of the care it provides and increase care coordination while containing growth.

ACOs that use APRNs and other nurses to the full extent of their education and training in such roles as health coaching, chronic disease management, transitional care, prevention activities, and quality improvement will most likely benefit from providing high-value and more accessible care that patients will find to be in their best interest. The concept of a medical home was first developed by pediatricians in the late s AAP, Medical homes play a prominent role in the ACA, but the law is not consistent in its terminology for them. The latest phase of the broader nursing strategy at the VA, for example,. Previously, primary care providers physicians and NPs at the VA felt that they were not receiving enough professional support to do their jobs effectively.

The new strategy calls for including staff nurses on the primary care teams.

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