How NPs Can Reform Health (Care)


For Nurse Practitioner World News, July-August 2009
By Carla Mills, ARNP

Health care reform has reached the epicenter of economic, political and social debate in this country. Legislators are correct when they say that the plans they are debating in Washington these days will affect 100% of Americans – patients and providers, employers and employees, insurers, the insured and the uninsured. In these times of economic, political and social crisis what can NPs do to help?

Health Reform: the Heart of Health Care Reform

If health care reform is our target then health reform is its bull’s-eye. Improving health and preventing disease is the most effective way to decrease both the cost of delivering care and the human suffering that is associated with disease.

Health reform is not an abstraction. It is concrete and it is measurable. In this column I will outline some simple measurements that are powerful enough to transform the health of individuals and, indeed, whole populations.

Health care reform, by contrast, is not so concrete and not so easy to measure. If health care reform is to have any chance for success it will require cooperation among many competing stakeholders each of whom is vying for a bigger piece of an ever shrinking pie. Even if such cooperation can be achieved (and that’s a big “if”), it will be doomed to fail unless health reform is at its heart.

Why Should Health Reform Be Nursing’s Mission Particularly?

If 147,000 NPs currently practicing in this country harmonize a message of health with hundreds of thousands of practicing RNs, chronic diseases in this country might finally begin to decline rather than grow. For NPs to be relevant in whatever new system is devised, it is incumbent upon us to articulate a clear and measurable path to health reform and assume an active and visible role promoting it. Using the following simple measurements as goals, every skilled nurse who reads this could begin launching this great endeavor today.

Chasing these goals is a patient-centered, performance-based and cost effective solution to health reform. No further training and no additional advanced degrees are required. All that’s necessary is for every NP and RN, regardless of specialty or practice location, to adopt these measurements as the goals and the yardstick by which patent care is delivered and measured. Once these goals are widely propagated – in clinical practice, in nursing curriculums and in every day life – nursing will be able to successfully start bringing about health reform.

Partnering with Patients

As educators NPs teach and as leaders NPs should help guide our patients in new, healthier directions. I wrote my book, A Nurse Practitioner’s Guide to Smart Health Choices, specifically to give readers tools to help them to set a course toward better health. By partnering with patients, NPs can help them control their health risks. The measurements that follow make up the core content of my book.

It is well known that chronic conditions such as high blood pressure, high cholesterol, excess weight, lack of exercise, poor nutrition, smoking, stress, anxiety and depression lead to diseases like diabetes, heart disease and cancer. I call health risks “ingredients in a recipe that cooks up a chronic disease or catastrophic health event.” If NPs will help patients control their health risks using lifestyle education and medications, we can dramatically improve their chances of avoiding a chronic disease or catastrophic event.

Risk reduction is something every NP (and RN) can take ownership of today. Regardless of specialty, if risk factor management is at the heart of NP (and RN) practice every day, during every single encounter, we can improve a lot of lives – and save some, too. Patients need more education, and NPs are the best trained teachers and clinicians to give it to them.

The Metrics of Health Reform

These simple measurements aren’t fancy or complicated. But if each one of us (patients and health providers alike) know our own measurements, understand their importance and are working to get to goal on every single one, health reform will at last be underway. Here are the fundamental measurements for performance-based health care:


Body Mass Index (BMI): < 25
Blood Pressure (mm Hg): < 120/80
Total Cholesterol (mg/dl): <200
Triglycerides (mg/dl): <150
HDL (mg/dl): Men > 50; Women > 55
LDL (mg/dl): < 70 to100
Non-HDL (mg/dl) = Total Cholesterol minus HDL: < 100 to130
Fasting Blood Sugar (mg/dl): < 100
HbA1c (%) : < 6.5 – 7.0
Waist/Hip Ratio: Men > 0.9; Women > 0.8
Waist Measurement (inches): Men < 40; Women < 35
Exercise: 240 min/wk minimum; 500 min/wk if weight loss is desired performed at your target heart rate.
Nutrition: Concerns answered and resolved.
Smoking/Tobacco Use: None.
Alcohol: less than daily and and less than 1-2 drinks/day
Stress/Anxiety on a 1 to 5 Scale (none to extreme): < 3
Depression on a 1 to 5 Scale (none to extreme): < 3
Cancer Screenings: Up to date.

Going for the Goals

Knowing is only the first step, taking actions that get to goal is what really counts. If a BMI of 25 seems impossible, getting fit isn’t. Some of my patients are surprised to learn that depression and anxiety, instead of just being their lot in life, are disease states than can be effectively treated. When these problems lift with treatment, patients’ personal happiness grows and they are in a better position to make necessary changes. Uncontrolled blood pressure and cholesterol are silent killers, and in spite of how common they are, most patients do not appreciate or respect their danger.

I have used my book with patients in my practice for a couple of years now and it’s been very interesting to see how they interact with this information. For those who want to know (and that’s not everyone), it’s proved to be a revelation. Patients come back after reading it and tell me that they finally really get it. Often for the very first time all the “eat right, lose weight and exercise” stuff they hear every day actually makes sense. They see how everything is connected and they connect with how their habitual behaviors lead to disease.

Putting Education into Practice

Most patients don’t take action right away. It may take a year or even longer before they are finally motivated to act. Change is a process that takes time. Sadly, it’s usually a scare (like a heart attack or a diagnosis of diabetes) that finally provokes behavioral change.

A therapeutic relationship really helps. I tell my patients that if their health risks caused them pain to the degree that they put them at risk, they would be begging me for treatment and medication. Instead, I have to beg them to take it. Patients need ongoing education and support to understand, move forward and then remain faithful with behavior change and treatments. Backsliding is the norm and does not represent failure.

The partnership patients enjoy with NPs is one of our strongest assets as clinicians, and we should leverage it for all its worth. Staying with patients through the ups and downs of the change process can make all the difference between success and failure.

Being Role Models

Nurse practitioners are not exempt from the health risks our patients face. As health professionals, we have the benefit of knowledge and training to guide us to better health choices, but most of us could do better.

Much is written in the NP literature about the need to improve the image of NPs and nurses in general. In spite of the fact that we are health professionals, many of us are overweight and under-exercised ourselves. Dietary habits I see in health care settings are often poor. Long hours on the job plus work and family responsibilities lead to convenience foods that lack nutritional value and make it hard for us to control our weight. Too little fresh air and exercise keep us from being as strong, healthy and vibrant as we could be.

If we are to have the credibility we need to bring about health reform we must model healthy behaviors ourselves. To reform health we must reform ourselves. To heal our patients we must also heal ourselves. NPs and patients work together as partners. Partners help each other and learn from each other. There are many roads up the mountain, and we can and should climb together toward true health reform. If NPs dare to commit to this great endeavor we can silence all our critics, solve all our “image” problems and succeed where many others have failed in reforming the health care system.

This information is offered for educational purposes only and is not intended to diagnose, prescribe or treat. For that please seek direct care from a health professional.

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