Job title: Nurse.
Job details: Provides nursing care to patients in collab. w/physicians & other disciplines. Dep. on qualif., may operate advice call line, perform indep. research, order Rx, conduct mental-health assessments, teach in comm.-based and academic settings, manage health centers, and/or oversee $50M clinical trials.
Desired start date: Yesterday.
Number of positions required: 1 million in U.S. by 2020.
In other words, Bernadette Melnyk holds a position with substantial bearing on virtually every corner of the U.S. health-care system.
Dr. Melnyk, dean of Arizona State University’s College of Nursing and Health Innovation, oversees her university’s most intimate interface with its community. And today she stands in the middle of a dramatic struggle between demographic and fiscal forces.
What makes Dr. Melnyk a force of her own is the ability to respond administratively to the immediate struggle and at the same time see beyond it, applying a researcher’s creativity and analytical rigor to profound problems that most of us haven’t begun to consider.
The most well-publicized challenge she confronts is a numbers crunch:
Year by year, the population rapidly grows in the communities that ASU and other institutions supply with freshly minted nurses. Within those communities, members of the Baby Boom generation are reaching the age when their interactions with the health-care system will become more frequent, complex, and costly. Simultaneously, vacancies from retirement are steadily increasing within the nursing profession, where the average age of nurses is approaching 50.
But educating and training new nurses is costly–both for health-care providers and academic institutions–and in a deep global recession, funding for training is going down, not up.
For instance, the Arizona Daily Star recently reported that Tucson Medical Center will cut the number of University of Arizona nursing students it supports this fall from 16 to 8; Carondelet Health Network is eliminating all 40 positions it typically funds. Despite state budget cuts, Northern Arizona University is for now clinging to its fall admissions target for its bachelor’s-level nursing program; UA, though, will be trimming admissions by nearly one-third. And fall admissions to Dr. Melnyk’s program at ASU will drop 27 percent, from 300 to 220.
So in the immediate future, all indications are that the nursing shortage will worsen, not improve.
In the budget spotlight
The likelihood of that unwelcome trend has entered the consciousness of the general public–witness the outcry last October that greeted ASU’s announcement of cuts to its Polytechnic and West campus bachelor’s-level nursing programs. More dismay followed with the announcement, in February, that the Polytechnic and West programs would be closed altogether, with students folded into ASU’s Downtown Phoenix program.
As much as any other cost-cutting measure Arizona’s universities have adopted during the past year, the decision to scale back ASU’s nursing program, which had seen rapid growth for several years, was a marker of how severe budget challenges had become have become for Arizona’s public universities.
Consequently, Dr. Melnyk has now been placed in a more-visible role than deans typically occupy, one where a core responsibility is highlighting for average citizens–and legislators who will likely continue grappling with state budget deficits into 2010–the true costs incurred by underfunding nursing training.
“We have 99,000 patients dying every year from medical errors,” Dr. Melnyk says, citing a figure that tops the number of annual deaths from prostate and breast cancer combined. “With the nursing shortage,” she adds, “that’s going to continue to climb.” And, as she often notes, Arizona’s per-capita number of nurses is significantly lower than the United States as a whole.
Envisioning new roles for nurses
At the same time that she is publicizing the negative consequences of underfunding training for new nurses, though, Dr. Melnyk is also working to communicate the transformative benefits that the entire nation would enjoy if policymakers could not only make a sufficient investment to eliminate the nursing shortage, but do something more intellectually ambitious: redefine the space nurses should occupy within the health-care system.
“In terms of policy, I think that federal officials haven’t turned enough to nursing to help solve the broader health-care crises we’re having,” Dr. Melnyk says. “We, as nurses, aren’t being placed in sufficient numbers at the tables that have the influence to make large-scale change.”
Take, for instance, the routinely-cited burden that emergency-room care places on the bottom lines of hospitals, insurers, and ultimately the companies and individuals who pay insurance premiums. Nurse practitioners could help.
“We spend so much money in our health-care system by not providing enough access to primary-care providers,” Dr. Melnyk says. “People end up in overloaded emergency rooms, and then tons of money is spent providing care in emergency departments that could be provided by nurse practitioners.” (Dr. Melnyk was herself educated as a nurse practitioner, specializing in pediatric nursing, before pursuing her doctoral training.)
“We know that nurse practitioners could provide high-quality care at lower cost,” she explains. “Funding and preparation of nurse practitioners is key, then–although that doesn’t start to address the problem we have with not enough bachelor’s-level nurses at the bedside.”
It was in part the platform to make such arguments, and the opportunity to push for a redefinition of nursing’s role, that Dr. Melnyk sought when she came to ASU from the University of Rochester in 2005.
An opportunity to innovate
“When ASU first called me, I was humbled, but I told them I didn’t have any interest,” she recounts. At the time, she was deep in an interview process for the nursing dean’s position at Duke University. She hadn’t ever imagined picking up and resettling in the Southwest.
But then-Provost Milton Glick was insistent; he learned that Dr. Melnyk would be delivering a keynote address at a conference in Arizona and arranged to meet her for an hour at Sky Harbor Airport, where he made his pitch about what she might accomplish at ASU.
“The provost sparked my curiosity about (ASU President) Michael Crow and the university’s partnerships with the community and the state of Arizona,” Dr. Melnyk says. “I decided to come back and meet President Crow. I recognized him as a visionary, someone who can make things happen. I’m a person who loves to make things happen rapidly, and I saw that it was a good fit. I was impressed to learn what he was willing to invest in the college to take it to the next level.”
Most immediately, Dr. Melnyk set to work building ASU’s nursing program into the largest in the country. The state of Arizona at that time enjoyed a budget surplus, then-Gov. Janet Napolitano had expressed a desire to address the nursing shortage, and ASU had decided that it was up to the challenge.
In her first six months on the job as dean and Distinguished Foundation Professor of Nursing at ASU, Dr. Melnyk brought in 23 new faculty. Her first year also saw the launch of a Doctor of Nursing Science degree program and the establishment of the Center for the Advancement of Evidence-Based Practice (CAEP), which aims to bring a sharp focus on outcome data and research findings to a wide range of health-care practice areas.
In 2006, Dr. Melnyk guided the nursing college’s move to ASU’s Downtown Phoenix Campus, where it was renamed the College of Nursing and Healthcare Innovation. (This spring, it became the College of Nursing and Health Innovation.) In 2007, the college added two more doctoral-level programs.
“The college has always had a good reputation for running high-quality educational programs, but it needed to have its research program enhanced, and its national reputation in niche areas needed to grow,” she says. “We’ve now established a national and international reputation in evidence-based practices with the CAEP, and we’re being nationally recognized for our broader approach to innovation.”
Today, with comparative-effectiveness research moving from being a buzzword to perhaps becoming a national policy priorty, the college’s reputation and weight in the health-care community is growing rapidly.
The focal point of the college’s push for innovative health care–and an asset that has rapidly drawn interest from major bioscience and biotechnology industry players–is the Center for Healthcare Innovation and Clinical Trials (CHI&CT), which was launched in 2007 when ASU won a highly competitive “University as Entrepreneur” grant from the Ewing Marion Kauffman Foundation. Collaborators come from the College of Engineering, the College of Design, and the School of Business.
“We wanted to become known for innovation in everything we do, and we wanted to broaden our scope to attract interdisciplinary people into the college,” Dr. Melnyk says. “The Center enables us to become involved in testing new health-care devices and new models of health-care delivery. We’re working with bioscience firms now, as well as with the clinical-research industry, which is growing tremendously in Arizona.”
Along with a shortage of nurses, Dr. Melnyk explains, the health-care field is contending with a deficit of clinical-research managers. Thus, ASU has launched a master’s level program in clinical research management, as well as a graduate certificate in clinical-research management. Through the CHI&CT, ASU is now managing clinical trials directly for companies.
“For now, we only specialize in low-risk trials, such as a new device to assist in recovery for stroke patients, and an ultrasound device for the treatment of acne,” Dr. Melnyk says. “But these are wonderful opportunities for students, as well as our faculty and staff. We’re drawing in people who can think out of the box, people who are posing new solutions to many challenges in health care.”
Evidence-based practice for children’s health care
The health-care challenge that Dr. Melnyk is personally most passionate about is pediatric mental-health promotion, a realm in which she has identified extraordinary potential for nursing professionals to head off future problems–from acute mental-health crises to chronic physical ailments, substance abuse, and domestic violence.
“One in four children have mental-health problems,” Dr. Melnyk explains, “but typically their interactions are with primary-care providers who don’t have the in-depth knowledge and skills to screen, assess, and identify mental-health problems. When those primary-care providers do see a problem, they feel pressure to treat it, but usually don’t have the training to do so appropriately. They might wait six months, as problems worsen, before referring a patient for full psychological evaluation.”
A major part of the solution, Dr. Melnyk says, is ensuring that the health-care providers who first see patients are trained to conduct basic mental-health assessments. Since her arrival at ASU, the university has become a proving ground for this approach: at ASU’s five nurse-practitioner-run health centers, every patient who walks in the door receives screening for depression.
“Rarely do primary-care providers integrate the mental-health piece as well as our health centers do,” she says. “As nurse practitioners, we’re focused on health promotion and prevention. We believe in addressing the whole needs of the person.”
Dr. Melnyk says that to implement such an approach broadly will ultimately require buy-in from all of the players–academic institutions, health-care providers, and insurers. That is the direction she is now moving with one of her own ongoing lines of research, examining an evidence-based educational and behavioral intervention that she developed for parents, called COPE–Creating Opportunities for Parent Empowerment.
COPE is aimed at parents of children who are born prematurely; pre-term children are at high risk for many physical and mental-health problems, but their parents also routinely experience problems, from usually manageable stress about their children’s health and the cost of their care, to debilitating depressive and anxiety disorders.
Dr. Melnyk’s research has demonstrated that delivering the COPE program to parents of pre-term infants while the children are still in the neonatal intensive care unit (NICU) not only improves parents’ coping abilities, but also reduces the length of the infants’ stay in the NICU–providing a major cost-savings. NICU stays cost $1,250 to $2,000 per day.
“We have some hospitals beginning to use COPE,” she says. “My goal now is to make sure that it begins to be implemented in every children’s hospital in the country.”
Achieving that ambitious goal, though, will depend on those hospitals making substantial initial investments, since NICU staff must be trained in the specific evidence-based regimens of the COPE program. And delivery of the program will have to be covered by insurers. To that end, Dr. Melnyk recently led a training for Amerigroup, a Dallas-based insurer, showcasing the effectiveness of the program. She says she believes that insurer is the first of many that will come on board.
The fact that achieving such systemic, cost-saving changes is indeed within reach provides a compelling argument for restoring funding lost in the current economic downturn. Innovations such as those emerging from the college Dr. Melnyk leads appear to be the most likely means for the nation to change its dubious reputation for high-expense, low-quality health care.
And Dr. Melnyk believes that despite immediate fiscal woes, that restoration of funding will happen.
“For now, we’re looking at other strategies,” she says, “writing grants like crazy, of course, and becoming more entrepreneurial and innovative in ways that will generate revenue. I know that we will continue to grow rapidly.”
For more information:
“Nursing program in need of funding,” Arizona Republic, 01/10/2009
“Reducing Premature Infants’ Length of Stay and Improving Parents’ Mental Health Outcomes With the Creating Opportunities for Parent Empowerment (COPE) Neonatal Intensive Care Unit Program: A Randomized, Controlled Trial,” Pediatrics, 10/16/2006