What changes have nurses made to healthcare

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Efficiency will be maximized by reducing waste, avoiding duplicative care, and appropriately using specialists. Outcomes will be tracked over longer periods of time—making care integration and care across the continuum a mandate. Institutions and providers will be incentivized for keeping people well so as not to need acute hospital or emergency department ED service, for meeting care and prevention criteria, and for ensuring the perceived value of the healthcare experience or patient satisfaction is high.

This forces a shift from a provider-centric healthcare system where the provider knows best to a delivery system that is patient-centric and respectfully engages the patient in developing self-management and behavioral change capacity.

Funds have been made available through the ACA via the CMS to help providers invest in electronic medical records and other analytics needed to track outcomes and to provide support in developing the skills and tools needed to improve care delivery and transition to alternative payment models McIntyre, We have been experiencing the first wave of changes toward value-based care for years. In October , the CMS began denying payment for hospitals' extra costs to treat complications that resulted from certain hospital-acquired conditions HACs.

These events represent rare, serious conditions that should not occur. Some of these HACs occur more commonly and have a comparatively greater impact on cost. This CMS policy was directed to accelerate improvement of patient safety by implementation of standardized protocols to prevent the event. Today, we have the Hospital Acquired Condition Reduction Program, implemented prior to the ACA but formalized under this Act to broaden its definition of unacceptable conditions.

It uses financial penalties for high quartile scores in rates of adverse HACs. Lowering these rates has occurred with careful monitoring and surveillance for events, implementation of evidence-based best practices, creating checklists to ensure processes are followed, and transferring patients out of EDs and critical care units as soon as possible. Bundled payments, a model reimbursing two or more providers for a discrete episode of care over a specific period of time, are being used in orthopaedics for some spine and total hip and knee arthroplasty surgical procedures.

A fully bundled payment system extends beyond the institution, as it includes the surgeons and all other providers involved in the care of the patient during and after surgery. In this bundled model, lump sum payments are given to the institution to cover the episode of care from the preservice or presurgery period, through the procedure itself, and to a postservice period, generally anywhere from 30 to 90 days after surgery.

This eliminates fee-for-service where one payment is made to the hospital, a second payment to the surgeon, and other payments to the anesthetist, the physical therapist, homecare, etc. The bundled payment is a prenegotiated type of risk contract in which providers will not be compensated for any costs that exceed the bundled payment.

In addition to breaking down the current payment silos, bundles set quality standards to further the IOM aims of healthcare that eliminates duplication and waste, increases efficiency, uses evidence-based protocols to maximize outcomes, and engages the patient in building capacity for self-care Enquist et al. The Comprehensive Care for Joint Replacement model is a bundled approach targeting higher quality and more efficient care for Medicare's most common inpatient surgical procedures—hip and knee replacements.

Institutions under this model have reengineered patient care processes and standards developing standardized clinical pathways to enhance reliability or consistency in care. Processes identified as important include comprehensive patient teaching spanning from the preadmission phase to the postdischarge recovery phase, standardized order sets, early mobilization, redesign of services for colocation for patient rather than provider ease, use of nurse practitioners to champion the pathway and ensure compliance, and implementing efforts to move patients from the hospital to home with home healthcare as opposed to hospital to inpatient rehabilitation to home with home healthcare Enquist et al.

Practicing in a bundled model requires that organizations examine the distribution of costs across the service or episode, identify, understand, and eliminate variation, map evidence-based pathways of care, coordinate care with providers across the continuum, and use ongoing evaluation and analytics to identify where care can be managed more efficiently and effectively American Hospital Association, n.

Moving forward, we will see greater attention to addressing preventive and chronic care needs across an entire population. The emphasis will be on interventions that prevent acute illness and delay disease progression and will require a true interprofessional team model to accomplish. Accountable Care Organizations ACOs and Patient-Centered Medical Homes are expected to improve primary care and care across the continuum by incentivizing providers to be accountable for improving patient and population health outcomes through cost-sharing approaches to reimbursement.

It is more than the traditional health visit and will require a focus on both the individual and the population to advance health. Primary healthcare under the ACA stresses prevention, health promotion, continuous comprehensive care, team approaches, collaboration, and community participation Gottlieb, , p.

If ACOs are to achieve their goals to improve the health of populations and realize a positive profit margin, they will need to adopt new ways of thinking about health. There is growing awareness that overall health outcomes are influenced by an array of factors beyond clinical care. As can be seen, health outcomes defined as length and quality of life are determined by factors in the physical environment, social and economic factors, clinical care, and health behaviors.

Using this framework, it is easy to recognize the critical need to incorporate behavioral factors and social context when trying to improve well-being and health outcomes. Individual behavioral determinants include addressing issues related to diet, physical activity, alcohol, cigarette, and other drug use, and sexual activity, all of which contribute to the rates of chronic disease.

The social and physical contexts together comprising what is called social determinants of health of where a person lives and works influence half of the variability in overall health outcomes, yet rarely are considered when one thinks of healthcare.

If we are to achieve true population health, it will be essential to have models in which clinical care is joined with a broad array of services supporting behavioral change and is integrated or coordinated with other community and public health efforts to address the social context in which people live and work. Used with permission. The Future of Nursing: Leading Change, Advancing Health asserts that nursing has a critical contribution in healthcare reform and the demands for a safe, quality, patient-centered, accessible, and affordable healthcare system IOM, To deliver these outcomes, nurses, from the chief nursing officer to the staff nurse, must understand how nursing practice must be dramatically different to deliver the expected level of quality care and proactively and passionately become involved in the change.

These changes will require a new or enhanced skill set on wellness and population care, with a renewed focus on patient-centered care, care coordination, data analytics, and quality improvement.

Transformation and the changes required will not be easy—at the individual or systems level. Individually, it requires an examination of one's own knowledge, skills, and attitudes and whether that places you as ready to contribute or resist the coming change.

At an organizational level, it requires an analysis of mission, goals, partnerships, processes, leadership, and other essential elements of the organization and then overhauling them, thus disrupting things as we know it. The reality is that everyone's role is changing—the patients', physicians', nurses', and other healthcare professionals'—across the entire continuum of care.

Success will come if all healthcare professionals work together to transform and leverage the contribution of each provider working at full scope of practice. Achieving patient-centered, coordinated care requires interprofessional collaboration, and it is an opportunity for nursing to shine.

We must shift from a care system that focuses on illness to one that prioritizes wellness and prevention. This means that wellness- and preventive-focused evaluations, wellness and health education programs, and programs to address environmental or social triggers of preventable disease conditions and care problems must take an equal importance of focus as the disease-focused clinical intervention that providers deliver Volland, What does this look like in the real-world orthopaedic setting?

For example, workplace programs to assess and prevent back and other musculoskeletal diseases and disabilities or fall-reduction programs held in the community to improve mobility for seniors both address specific populations with an aim of keeping the group well and preventing musculoskeletal injury.

Upstream of joint surgery could entail intervening prior to surgery with programs around weight loss and exercise that could prevent many chronic musculoskeletal disorders and ultimately avoid or delay surgery and improve outcomes in the case that surgery is needed. At the organizational and individual practitioner levels, wellness means thinking about the patient beyond the current event hospital or office and considering what must be assessed or done to maximize the person's wellness.

For example, a year-old woman presents to the ED for a fall. She identified that she had been having some leg edema and could not wear her normal shoes so was walking in a slipper-type shoe and slipped.

The acute episode is treated by obtaining an x-ray film to rule out fracture and a cardiac review to determine cause for edema. A wellness perspective would go further and consider what are the possible risks for future falls—a gait analysis would be done, screening for osteoporosis would be arranged for, and a plan to prevent or reduce risk to prevent subsequent falls and potential fractures would be implemented with possible referral to a Matter of Balance program that could support the patient with strategies to reduce falling and increase strength and balance.

Knowing the answer to these questions allows for the development of a more individualized, holistic plan of care that can begin at the moment and subsequently be coordinated and managed across the continuum by RNs and other providers no matter the care continuum setting.

Whether looking to stay well or recover from acute illness or live well with chronic illness, there are few community-based programs that meet one's rehabilitation and wellness needs. Nursing and other healthcare professionals such as therapists and social workers are well positioned to lead entrepreneurial ventures that partner with community centers YMCAs, adult day care, housing, etc.

Another necessary characteristic of the transformed healthcare system must be an unwavering focus on the patient. Patient- and family-centered care , rather than provider-centric care, is essential if patients and families are to assume responsibility for self-management. The IOM defines patient-centered care as:. Health care that establishes a partnership among practitioners, patients, and their families when appropriate to ensure that decisions respect patients' wants, needs, and preferences and that patients have the education and support they need to make decisions and participate in their own care.

Practicing from a patient-centered approach means acknowledging that patients, not providers, know themselves best and realizing that quality care can only be achieved when we integrate patients and families into decision making and care and focus on what is important to patients. Without this, we will never deliver value. It helps define patient-reported outcomes or outcomes of medical care that are defined by the patient directly. Engaging the patient in shared decision making and shared care planning with patient-reported outcomes at the center of the plan of care is essential for patient activation in self-management.

With patient-reported outcomes in mind, nurses can partner with patients in providing client education and coaching to strengthen the patient's capacity toward goal achievement. Use of motivational interviewing and action planning as a strategy to assist patients with behavioral change is a needed skill.

With action plans and goals at the forefront, the nurse provides ongoing information on treatment plans, provides coaching and counseling to build self-confidence in relation to new behaviors, coordinates reminders for preventive and follow-up care, and ensures that handoffs provide the next set of providers with needed information to continue the plan of care and avoid duplicative ordering.

An integrated care continuum is posited to be a key strategy for achieving the triple aim—better quality, better service, and lower costs per unit of service. But what is the continuum and what is the role of the nurse in care coordination across the continuum?

The continuum of care concept was proposed in and was conceptualized as a patient-centered system that guides and follows individuals over time potentially from birth to end of life through a comprehensive array of seamless health, mental health, and social services spanning all levels and intensity of care Evashwick, The World Health Organization , p.

As the continuum consists of services from wellness to illness, from birth to death, and from a variety of organizations, providers, and services, ongoing coordination to prevent or minimize fragmentation is critical. All patients need care coordination as it serves as a bridge—making the fragmented health system become coherent and manageable—an asset for both the patient and the provider.

For some patients, a more intensive form of care coordination is needed and may be assigned a care manager to oversee their condition and changing care needs during the different trajectories of their chronic illness.

Others may require a time-limited set of care and coordination services to ensure care continuity across different sites or levels of care. This care, referred to as transitional care, has been a major focus, as it has been validated that transitions represent high-risk periods for safety issues and negative outcomes because of lack of continuity of care Enderlin et al.

To contend with these issues, the ACA set goals to reduce fragmentation of care. Numerous transitional care models such as Naylor's Transitional Care Model, Coleman's Care Transitions Program, and Project Re-engineered Discharge have demonstrated efficacy in reducing readmissions, reducing visits to the ED, improving safety, and improving patient satisfaction and outcomes ANA, ; Enderlin et al.

Care coordination is not something that is delegated to one individual or unique to an individual who may hold the title of care coordinator or navigator. All nurses, no matter what their role, must prioritize care coordination.

With this in mind, all nurses should move away from the notion of discharging patients, which implies that their responsibilities for care are finished. In contrast, nurses should provide care with a mind to transitioning the patient to the next level or stage.

Transitioning implies a joint responsibility for care coordination over time. It is often the nurse at the point of care who has formed a relationship with the patient and learned important aspects of the patient's social context, challenges in managing the patient's health, and the patient's priorities of care. This information is invaluable and must be integrated into the plan of care for the patient across the continuum of care. For those with more complex care needs, especially those with multiple chronic illnesses, there is a need for a specialized role to ensure that care is coordinated across the continuum.

Care coordinator roles grounded in acute care or primary and ambulatory case or care managers, population health managers, patient navigators, healthcare coaches, transition coaches may be held by individuals with different professional and nonprofessional roles. Nurses have both the clinical and management knowledge and skill set needed to assume key coordination roles. Strong clinical knowledge grounded in the evidence is a priority characteristic for the care coordinator as this individual must be able to select and implement care processes and systems reflecting best practices, implement rapid-cycle improvements in response to clinical data, and track and analyze trends.

Lack of this requisite clinical knowledge will impede implementation of best practices and potentially impede strong interprofessional collaboration and communication that must be exquisite within a well-coordinated delivery system. Nurses have this unique clinical knowledge, making them ideal for navigating care across the continuum.

We can only improve the care and health of populations if we truly understand the care we deliver. Understanding the care requires data. Nurses in the transformed healthcare system will need to be able to gather data and track clinical and financial data over time and across settings.

Tracking of key metrics treatments, health status, functionality, quality of life must occur at the individual and population levels. This gives needed information to understand the particular issues the individual patient is facing. Improving care at the individual level requires consideration of information on the population from which the individual is drawn. The first step in understanding populations is to have a much deeper understanding of the patient population in order to drive better outcomes.

To achieve the triple aim, it will be essential that we track outcomes over time related to psychosocial status, behavior change, clinical and health status, satisfaction, quality of life, productivity, and cost. These data are used in predictive modeling to stratify the population according to disease state or risk profile. This information can then be used to engage patients in timely, proactive, tailored manner based on their needs.

Using stratification, those at no or low risk will be recipients of health promotion and wellness and care. Those at moderate risk will require more intensive interventions, ranging from health risk management to care coordination and advocacy.

Those who are at high risk and are high utilizers require further disease or case management services Care Continuum Alliance, ; Verhaegh et al. These data are used at the individual level to align the type of care with the patient need and at the organizational level to focus resources on segments of the population at greatest need. Outcome data are one piece of the information needed for improvement.

With outcomes in mind, one needs to examine what can be done to improve outcomes related to the experience, efficiency, or effectiveness of care. Use of shadowing as a technique to examine the real-time care experience provides valuable data on process flow, patient experience, and team communication. Combining shadowing data with Lean Six Sigma methodology or with rapid-cycle improvement processes is an approach for ongoing quality improvement that must be integrated into role expectations of the professional care team.

This is not an independent effort. In today's practice environment, interprofessional learning collaboratives targeting specific populations i. These collaborative groups as organized through quality departments, local hospital associations, the Institute of Health Innovation, and professional medical and nursing associations use benchmark data, shared either from their own facilities or from registries i.

This is complemented by discussions and sharing around best practices and system approaches to improvement that can be implemented in rapid improvement cycles at the point of care where the interprofessional team collaborates on an identified problem, process issue, or care gap, looking together for what is best for the patient.

There is no doubt that nurses are poised to assume roles to advance health, improve care, and increase value. However, it will require new ways of thinking and practicing. Shifting your practice from a focus on the disease episode of care to promoting health and care across the continuum is essential.

Truly partnering with patients and their families to understand their social context and engage them in care strategies to meet patient-defined outcomes is essential. Gaining greater awareness of resources across the continuum and within the community is needed so that patients can be connected with the care and support needed for maximal wellness.

Tracking outcomes as a measure of effectiveness and leading and participating in ongoing improvement to ensure excellence will require exquisite teamwork as excellence crosses departments, roles, and responsibilities. For 28 additional continuing nursing education activities on health care reform, go to nursingcenter.

The authors have no conflict of interest to declare. Orthopedic Nursing. Orthop Nurs. Published online Feb 7. Susan W. Salmond and Mercedes Echevarria. Author information Copyright and License information Disclaimer. The work cannot be changed in any way or used commercially without permission from the journal. Abstract Factors driving healthcare transformation include fragmentation, access problems, unsustainable costs, suboptimal outcomes, and disparities. Table 1. Drivers of Change. Cost More resources are devoted to healthcare per capita in the United States than in any other nation.

Comparing with others, GDP spending for health is Healthcare spending in the United States is 4. The rapid increase in healthcare spending in the United States over the past two decades and its anticipated growth in the coming years can be tied inextricably to the increasing number of people with multiple chronic illnesses. Autonomy the right, and obligation, to use your knowledge, skills, and judgment in the manner you believe is best for your patient, within evidence-based accepted practice limits is stressed over standardization.

Yet, there are care protocols and other types of evidence-based processes where greater efficiencies and safer outcomes result from standardized work central line protocols, wound care, perioperative use of prophylactic antibiotics, deep vein thrombosis protocols; Leape, , p.

The U. Despite higher level of spending, the hospitals in the United States documented to readmit an average of one fifth of Medicare patients within 30 days after discharge. Reports indicate that Most healthcare organizations have a hierarchical structure that inhibits communication, stifles full participation, and undermines teamwork Leape, These financial and structural incentives restrict potential for better patient care outcomes and effective resource allocation.

The older population—persons 65 years or older—numbered Those 65 years and older will grow to By , there will be about 98 million older persons, more than twice their number in The fastest growing group is those older than 85 years. Older adults transitioning between hospital units and settings often experience inconsistent nursing care and more adverse care incidents such as nosocomial infections, delirium, falls, and medication errors Enderlin et.

Noncommunicable diseases such as diabetes, heart disease, stroke, and cancer are now the leading cause of death in the world Lytton, It requires more than a focus on acute illness but behavioral approaches to modify risk factors including poor diet, obesity, and inactivity. Medicare fee-for-service spending accounts for more than three fourths of the total Medicare spending. Incidence of chronic illness projected to grow with aging demographics and rising obesity epidemic. Open in a separate window.

Driving Factors for Change: Changing Demographics Changing social and disease-type demographics of our citizens is also fueling the mandate for change. Voluntary Change Is Not Enough As a nation, we have taken incremental steps toward achieving better quality and lower costs for decades. Table 2. Safety must be a system property of healthcare where patients are protected from injury by the system of care that is intended to help them.

Reducing risk and ensuring safety require a systems focus to prevent and mitigate error. Care and decision making must be evidence based with neither underuse nor overuse of the best available techniques.

Care must be respectful and responsive of individual patient's culture, social context, and specific needs, ensuring that patients receive the necessary information and opportunity to participate in decisions and have their values guide all clinical decision making about their own care. The system must reduce waits and harmful delays. The system must avoid waste, including waste of equipment, supplies, ideas, time, and energy.

Care must be provided equitably without variation in quality because of personal characteristics such as race, gender, ethnicity, geographic location, and socioeconomic status. Enter Healthcare Reform Continued skyrocketing of healthcare costs, less than impressive heath status of the American people, safety and quality issues within the healthcare system, growing concerns that cost and quality issues would intensify with changing demographics, and the reality that there were 50 million Americans uninsured and 40 million underinsured in the United States ushered in the Patient Protection and Affordable Care Act of Salmond, Table 3.

In these models, providers are rewarded for achieving preestablished quality metrics. The quality metrics for acute care organizations targets the experience of care HCAHPS , processes of care such as processes to reduce healthcare-associated infections and improve surgical care , efficiency, and outcomes i.

The key point for practitioners is total familiarity with how quality is being defined and measured. Knowing this allows for full participation in what must be done to achieve the quality. Value-Based Purchasing VBP This approach switches the traditional model of healthcare fee structure from fee-for-service where reimbursement is for the number of visits, procedures, and tests to payment based on the value of care delivered—care that is safe, timely, efficient, effective, equitable, and patient-centered.

In VBP, insurers such as Medicare set annual value expectations and accompanying incentive payment percentages for each Medicare patient discharge. Shared Savings Arrangements Approaches to incentivize providers to offer quality services while reducing costs for a defined patient population by reimbursing a percentage of any net savings realized.

New programs and models of delivery and payment Hospital-Acquired Condition Reduction Program Under the ACA, Medicare payments for hospitals that rank in the lowest performing quartile for conditions that are hospital-acquired i. Upcoming standards will be expanded to include methicillin-resistant Staphylococcus aureus infections CMS, n. To reduce admissions, hospitals must have better coordination of care and support. Hospitals with relatively high rates of readmissions will receive a reduction in Medicare payments.

These penalties were first applied in to patients with congestive heart failure, pneumonia, and acute myocardial infarction. In time, , , and day readmissions will be examined.

Accountable Care Organizations ACOs The ACO is a network of health organizations and providers that take collective accountability for the cost and quality of care for a specified population of patients over time. Incentivized by shared savings arrangements, there is a greater emphasis on care coordination and safety across the continuum, avoiding duplication and waste, and promoting use of preventive services to maximize wellness.

Better coordinated, preventive care is anticipated to save Medicare dollars, and the savings will be shared with the ACO. Medical homes share common elements including comprehensive care addressing most of the physical and mental health needs of clients through a team-based approach to care; patient-centered care providing holistic care that builds capacity for self-management through patient and caregiver engagement that attends to the context of their culture, unique needs, preferences, and values; coordinated care across the continuum of healthcare systems including specialty care, hospitals, home healthcare, and community services and supports.

Such coordination is particularly critical during transitions between sites of care, such as when patients are being discharged from the hospital; accessible care that minimizes wait times and includes expanded hours and after-hours access; and care that emphasizes quality and safety through clinical decision-support tools, evidence-based care, shared decision making, performance measurement, and population health management and incorporation of chronic care models for management of chronic disease AHRQ, PCMH Resource Center.

The CMS has supported demonstration projects to shift its clinics to the medical home model. Bundled Payment Models Bundles are single payment models targeting discrete medical or surgical care episodes such as spine surgery or joint replacement. Bundles provide lump sum to providers for a given service episode of care inclusive of preservice time, the procedure itself, and a postservice global period, thereby crossing both inpatient and outpatient services.

Can be for a procedure or an episode of care The margin positive or negative realized in this process depends on the ability of the different organizations and providers to manage the costs and outcomes across the care continuum.

The Medicare Comprehensive Care for Joint Replacement model is a bundled care package aimed to support better and more efficient care for those seeking hip and knee replacement surgical procedures. The bundle covers the episode from the time of the surgery through 90 days after hospital discharge.

Private insurers and businesses are offering bundled payment packages for their participants to receive specialized joint or spine care at approved high-quality, cost-effective facilities. For example, Lowe's and Walmart arrange for no-cost knee and hip replacement surgical procedures for their 1.

These companies will cover the cost of consultations and treatment without deductibles along with travel, lodging, and living expenses for the patient and the caregiver The Advisory Company, Table 4. Shifting Paradigms From the Past to the Future. The Past The Future Payment for illness or sick care that is triggered by visits to providers and procedures done Payment for prevention, care coordination, and care management at the primary care level Greatest financial award for specialized services Payment for populations—shared risk for use of specialized services Provider-centric, provider as expert Patient-centric, patient as partner No accountability for inadequate quality.

Leadership focused on siloed area of care Team-based, collaborative care requiring integration of care across the continuum Nursing not leading or not recognized for their contribution to care Nursing finding their voice and take an active role in shaping the future of healthcare. When nursing began it had very little to do with formal medical training and everything to do with your gender and willingness to do the job.

In the early days of nursing, women learned medical skills from their mothers or other women in the same profession. Women were caretakers, so nursing was just an extension of what their roles at home were anyway.

Today, the nursing profession has changed drastically. Time has done a lot for many career paths, but the nursing field has seen drastic changes to help the efficiency of medical care. There are more training programs, better hospitals, more responsibility, a sense of family, and a focus on patient care in the nursing industry that has saved lives and created generations of dedicated medical professionals.

Training for nurses was very rudimentary in the beginning of the profession. Many of those that were sick were offered care by mothers and family members, not outside health providers. In the United States, lectures and instruction manuals were offered for women to learn how to give care to women during childbirth and postpartum period.

The Civil War caused many more women to join the rising number of hospitals offering nurse training that was more of an apprenticeship than the training programs we see later. Today, the qualifications for nurses are very specific and in depth. There are a wide variety of nursing programs, specialties, degrees, and certifications for different types of nursing, but all of them require the student to pass different certifications in order to provide health care to patients.

In the first half of the 20 th century, nurses were taught basic health care skills as well as hospital etiquette, such as how to address patients, how to dress, and to treat patients like they are guests in their home. Now nursing training is focused on the academic side—and not so much on wearing stockings and addressing patients by their surname.

The health care setting used to be in the home or on the battlefield for many women in the nursing field. There was a clear preference and need for health care to be practiced at home whenever possible. Home visits were more common than visits to the hospital, which were mainly reserved for those that were extremely ill, badly injured, or near death.

Nurses are now medical professionals that are needed in schools, correctional facilities, or the military. Nurses are even traveling to fulfill nursing needs across the United States while gaining experience and pay. The setting for nurses really started to change with the added training for nurses that made them more respected medical personnel and not just women who focused on assisting doctors and giving sponge baths.

With the added responsibility came the need for nurses all over the country, and many women flourished with this career path working in hospitals more than just providing care in the home. The change in responsibilities for nurses stem from a few changes in the field, including more comprehensive training, changing views of women, and the need for medical professionals growing quickly.

When training for nurses became more extensive and required schooling, the education system started teaching nurses tasks that were originally reserved for physicians.

This allowed physicians to concentrate on higher levels of education themselves and nurses were allowed more decision making for their patients. Once women started to become more respected and allowed to enter the workforce, obtain nursing degrees, and have more responsibilities in the medical industry, the nursing perception began to change. Now the role of the nurse is not easy to define for many medical professionals.

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