decade. A fast‐forward of changes since the ACA was enacted (Collins, Bhupal, & Doty, 2019). Today, 45% of U.S. adults aged 19–64 are inadequately insured (almost the same as in 2010)
Compared to 2010, many fewer adults are uninsured today.
Despite actions by the Trump administration and Congress to weaken the ACA, the adult uninsured rate was 12.4% in 2018.
More people who have coverage are underinsured now than in 2010.
History of Health Care
Florence Nightingale observed that noise, food, rest, light, fresh air, and cleanliness were instrumental in health and illness patterns. Thus, she maintained, the aim of nursing was to put the patient in the best condition for nature to act upon her or him (Nightingale, 1865/1970). Nightingale also discovered the link between adverse patient outcomes and a lack of cleanliness and hand washing. Yet generations after the insights of Nightingale were first set forth, sporadic adherence by health care providers to hand washing continues. Although significant progress has been made in preventing some health care‐associated infection types, there is much more work to be done. On any given day, about one in 31 hospital patients has at least one health care‐associated infection. Three percent of hospitalized patients in the 2015 survey had one or more HAIs. There were an estimated 687,000 HAIs in U.S. hospitals in 2015. About 72,000 hospital patients with HAIs died during their hospitalizations (CDC, 2018b).
One hundred years ago, illnesses such as tuberculosis or pneumonia required lengthy hospitalizations and were often catastrophic for individuals and families. Today, such illnesses are preventable and are often easily treated. Vaccination programs have been used extensively to prevent the spread of communicable diseases. Additionally, surgical interventions in hospitals (e.g., tonsillectomies, appendectomies, and reproductive procedures) have improved to treat otherwise debilitating or mortal conditions. Health care is delivered by professional nursing and medical practitioners who are science based and who use evidence‐based practice. Health care is primarily directed at preventing and treating chronic and behavioral diseases. Health care advances have extended life expectancy, with the consequence of more elderly people requiring more health care for chronic and complex health problems. The majority of clinical care is still provided in hospitals, but length of stay is much shorter, and a variety of innovative models of care are now used to provide cost‐effective care for people with acute, community, and long‐term clinical needs (Health Workforce Solutions LLC & Robert Wood Johnson Foundation, 2008).
Health care‐associated infections currently result in increased length of stay, mortality, and health care costs. In addition, a Centers for Disease Control and Prevention (CDC, 2018) report estimates that the overall annual direct medical costs of health care‐associated infections in U.S. hospitals ranges from $28.4 to $33.8 billion. These infections are most often attributed to invasive supportive measures such as endotracheal intubation and the placement of intravascular lines and urinary catheters. Several studies have noted that health care‐associated infections can be prevented through a number of multidisciplinary, evidence‐based interventions, reducing the incidence of infection by as much as 70% (Anderson et al., 2007; Harbarth, & Gastmeir, 2003; Muto et al., 2005).
Structuring Hospitals Around Nursing Care
Nightingale also described the importance of structuring hospitals around nursing care. The initial design of hospitals followed that advice by building large wards where nurses could easily monitor and observe their patients. Later, hospital design evolved to placing patient rooms surrounding centrally located nursing stations. Then, as today, the physical environment of hospitals can create stress for patients, their families, and clinical staff. Research is finding links between the physical environment and patient outcomes, patient safety, and patient and staff satisfaction (Hamilton, 2003). Studies show that such elements of hospital design as exposure to natural light, private rooms, and facilities that are staff friendly and have less noise contribute to improved patient outcomes (Ulrich, Quan, Zimring, Joseph, & Choudhary, 2004).
Although little is known about how to best design the hospital environment to facilitate clinical advances and care delivery, an estimated $200 billion will be expended for new hospital construction across the United States during the next 10 years (Institute of Medicine (IOM), 2004a). The Robert Wood Johnson Foundation (RWJF), the nation's largest philanthropy devoted exclusively to health and health care, has provided funding to the Center for Health Design, a nonprofit research organization, for the Designing the twenty‐first Century Hospital Project, which is the most extensive review of the evidence‐based approach to hospital design ever conducted. Launched in 2000, the Pebble Project is a joint research effort between the Center for Health Design and health care providers. The project engages health care providers that are building new health care facilities or renovating old ones using an evidence‐based design. The project uses the latest available evidence to inform design innovations and then measure the outcomes of the innovations through carefully designed research projects. The results are shared with the larger health care community to promote change. The Pebbles Project is an example of facility design to improve quality of care (The Center for Health Design, 2011).
Collecting Data
Nightingale also astutely recognized the importance of collecting and using data to assess the quality of health care. She employed coxcomb diagrams to present visual images of the number of preventable deaths during the Crimean war (Figure 2.1) and then later in London hospitals.
Source: Florence Nightingale (1820–1910). [Public domain].
Today, data is collected through patient records, surveys, and administrative systems. From these, reports are developed, such as To Err is Human (IOM, 1999); the CDC National Vital Statistics Reports (Martin, Hamilton, Sutton, & Ventura, 2006); and The National Healthcare Disparities Report (NHDR) (Agency for Healthcare Research and Quality (AHRQ), 2005). These reports provide invaluable information, and data is displayed with charts and pictures to emphasize the successes and failures of health care throughout our nation. Evidence of significant disparities and low quality continue to demonstrate the need for significant health care improvement.
Influence of External Forces on Health Care
Recognizing the influence of external forces on care delivery and scope of practice, Nightingale also kept informed of the activities of practitioners and government policy makers (Dossey, Selanders, & Beck, 2005). With health care being the largest sector of our economy, employers, clinicians, managers, and patients all have vested interests in proposed changes to health care financing, organization, and the responsibilities and scope of practice for clinicians. Today, nursing leaders, managers, and staff need to be aware of and involved in the ongoing processes of making health policy.
Organization of Health Care
Health care systems have three main components: structure, process, and outcome. The structure component of health care includes resources or structures needed to deliver quality health care, for example, human and physical resources, such as nurses and nursing and medical practitioners, hospital buildings, medical records, and pharmaceuticals. The process component of health
