Volume 7; Number 1, Spring 2006.
Many lay observers today view nurses and pharmacists as peripheral figures in the health care system. The roles of physicians are consistently recognized and even vaunted, leaving the roles of nurses and pharmacists too often unacknowledged and undervalued. The result is that many people today believe that these professionals are merely intermediary figures, rather than skilled practitioners in their own right. This image of nurses and pharmacists is deeply erroneous when laypersons hold it, and it verges on the destructive when policy makers embrace it. To ignore nurses and pharmacists is to ignore the wealth of data on the measurable improvements in health outcomes and cost savings that they offer in current and expanded roles. This issue of the Harvard Health Policy Review places the positions of nurses and pharmacists in policy perspective, exploring the ways in which employers, educators, and government officials are and should be expanding these roles to improve public health while reducing public costs.
We begin with a challenge to the public invisibility of nurses, through a Features Section that calls attention to the contemporary and changing relationships that nurses and patients share. Oskouie and colleagues reveal that the ethic of caring that binds nurse to patient is highly variable, demonstrating how the expression of this ideal can be facilitated-or impeded-by a wide array of personal, patient, and professional characteristics. Bushy shows that professional, social, and financial factors affect not only the quality of care, but its very delivery, by recounting how these factors divert care from the under-populated regions of the United States. Whereas these articles examine how social contexts can impede medical care, other articles in the Features Section reveal how nurses can build upon their medical expertise to tackle pressing social problems. McNeese-Smith and colleagues argue that nurses are well positioned to combat the mounting problem of substance abuse in India, finding that nurses readily counseled patients on both the health implications and the social impact of substance abuse. Dixon and colleagues likewise see considerable potential for social change by nurses, who, in addition to offering patients advice on the avoidance of environmental toxins, can provide leadership on environmental community action projects.
We continue by situating these nurse-patient relationships in their broader professional context, as our In Focus Section explores the rapidly changing relationships between nurses and other health care providers. Benner and colleagues place nurses' interactions with patients within broader practice networks, arguing that medical error among nurses can only be addressed when examined in relation to the professional constraints they encounter in hospitals. These professional contexts affect not only patient outcomes, but also nurses themselves; as West and colleagues reveal, nursing retention rates suffer considerably amidst disadvantageous programs for hiring and promotion. Perhaps the most contested professional context in which nurses find themselves is their relationship with physicians. Rosenstein and O'Daniel chronicle the routine tensions that divide nurses from physicians and recommend that hospital policies and programs be established to avert these disruptive occurrences. These routine tensions can explode into public debates at moments when professional prerogatives are shifting, and, to this end, Lindsay and Pfeil explain that the expansion of British nurses' prescribing powers resulted in destructive competition, rather than constructive complementarity, among nurses and physicians.
These professional problems encountered in nations like the United States and the United Kingdom have resulted in a widespread nursing shortage with sweeping international implications. Our International Section attends to the burgeoning practice of nursing migration by examining the economic incentives that drive the businesses and nations involved in the process. Kingma offers a global financial perspective on nurse migration, describing the vast array of organizations in supplier and recipient nations alike that are reaping profits in response to the crisis. But the financial incentives that drive nurse importation may not stabilize the nursing system; as Buchan cautions, the financial factors that have brought Filipino nurses to the United Kingdom fluctuate, rendering them highly mobile and, therefore, volatile workers. These nurses from the Philippines have long been critical figures in the international nursing market, but, as several articles in the International Section suggest, other nations may soon mount significant challenges to their dominance. Xu argues that China is now approaching nurse exportation as a means of national economic development, but contends that nurses must now confront the significant cultural barriers that divide them from recipient countries. Aitken advocates the training of Indonesian nurses for the international market, explaining that this has the potential to enhance domestic health outcomes.
Having examined nurses' expanding professional roles, we conclude with analysis of the changes afoot in contemporary pharmaceutical practice domestically and abroad. Hritcko offers an overview of these developments, arguing that the profession has undergone a "paradigm shift" from product-centered to patient-centered practices with educational, professional, and legal ramifications. Zeind and McCloskey situate that paradigm shift in historical developments ongoing since the 1940s, describing the rise of the ethic of pharmaceutical care and contemporary pharmacists' educational preparation for and professional commitment to the provision of drug information to patients.
While the ethic of pharmaceutical care prevails, that ideal has yet to be fully integrated into local practice. Van Mil and Schulz reveal that, despite the growing consensus on pharmaceutical care, pharmacy practices in Europe and Canadian pharmacy remain strikingly heterogeneous in their contexts and approaches. Nor has the ideal of pharmaceutical care been fully implemented in the United States. Fincham argues that pharmacists have failed to fully acknowledge problems of medication misuse and abuse among patients, and he contends that pharmacists must play an active role in designing treatment regimens that account for compliance levels. Youmans and colleagues assert that pharmacists can even embrace roles that extend beyond medication management, suggesting that a recent federal initiative has paved the way for pharmacists to lead vaccination and smoking cessation programs.
The last articles of the issue further elaborate on the legal implications of these professional shifts. Malloy and DeBellis describe how the recently enacted Medicare Prescription, Drug, and Medication Modernization Act further encourages pharmacists to engage in collaborative drug therapy management programs. But such expanded opportunities are not without their liabilities, and Kiel argues that American courts have permitted inconsistent pharmaceutical care by limiting pharmacists' responsibilities to educate patients to the information they choose to provide.
This issue of the Harvard Health Policy Review suggests that where nurses and pharmacists practice patient care, vast medical, financial, and even social improvements can result. In order to reap these indubitable benefits, it remains for us to confront the professional and legal barriers to expanded nursing and pharmaceutical practice.