Intern
ati
o
n
a
l
Jo
urn
a
l
o
f
P
u
b
lic Hea
l
th Science (IJ
P
HS)
V
o
l.4
,
No
.1
, Mar
c
h 201
5,
p
p
.
2
7
~
36
I
S
SN
: 225
2-8
8
0
6
27
Jo
urn
a
l
h
o
me
pa
ge
: h
ttp
://iaesjo
u
r
na
l.com/
o
n
lin
e/ind
e
x.ph
p
/
IJPHS
Public Health Promoti
o
n:
Auton
o
my of th
e Em
ergency Nu
rs
e
Practitioner
Cher
yl
A
nn
A
l
exan
der
1
,
Lido
ng
Wa
ng
2
1
Department of Nursing,
Un
iver
sity
of Phoen
i
x,
USA
2
Department of Engineeri
ng
Technolog
y
,
Mississippi Va
lley
S
t
ate University
, US
A
Article Info
A
B
STRAC
T
Article histo
r
y:
Received Dec 05, 2014
Rev
i
sed
Jan 20, 201
5
Accepted
Feb 14, 2015
The purpos
e of this
paper is
to exam
ine s
e
ver
a
l
ke
y
is
s
u
es
in heal
th car
e
reform. From the Patien
t
Protection a
nd Affordable Car
e
Act of
2010 to the
choler
a epid
em
ic in Haiti
, globa
l heal
th car
e ref
o
rm
is
neces
s
a
r
y
to prom
ote
health and welln
ess among all nations. Th
er
e is
an intern
ation
a
l
shortage of
nurses
and
nurs
i
ng
fa
cult
y
.
Am
ong
the provid
e
rs, it is also necessar
y
to
examine autono
my
of the most up and coming nu
rse provider: the
emergen
c
y
nurse practitioner.
Keyword:
Aut
o
n
o
m
y
Ev
alu
a
tion
and in
terv
en
tion
Infectious diseases
Nu
rsi
n
g s
h
ort
a
ge
Pub
lic h
ealth pro
m
o
tio
n
Copyright ©
201
5 Institut
e
o
f
Ad
vanced
Engin
eer
ing and S
c
i
e
nce.
All rights re
se
rve
d
.
Co
rresp
ond
i
ng
Autho
r
:
Lid
ong
W
a
ng
,
Depa
rt
m
e
nt
of
En
gi
neeri
n
g
T
echn
o
l
o
gy
,
Mississip
p
i
Valley State Un
iversity,
1
400
0
Hw
y, 82
W
e
st, I
ttaBen
a
,
Mississi
p
p
i
38
941
, U
S
A
.
Em
a
il: lwan
g
2
2
@
st
u
d
e
n
t
s.t
n
tech
.ed
u
1.
INTRODUCTION
Alth
oug
h th
e
Un
ited States sp
end
s
m
o
re
on h
ealth
care t
h
an
all th
e i
n
du
st
rialized
n
a
tions, 65
m
illio
n
resid
e
n
t
s still r
e
m
a
in
u
n
i
n
s
u
r
ed
[1
]. Th
e Patien
t
Pro
t
ection
and
Affo
rd
ab
le Care Act (ACA) was en
acted
in
2
010
in
an
atte
m
p
t to
so
lv
e
th
e prob
lem
o
f
th
e mill
io
n
s
with
ou
t in
su
ran
ce. Tho
u
s
ands o
f
p
a
g
e
s long
, m
a
n
y
leg
i
slato
r
s h
a
d
n
o
t
read
the wh
o
l
e b
ill
nor d
i
d
th
ey
und
er
st
an
d
it.
It
p
a
ssed
with
Dem
o
cratic
su
ppo
rt only
an
d
n
o
t
o
n
e
Rep
ublican
v
o
t
e su
pp
orted
its en
act
m
en
t. Th
e
b
ill’s m
a
j
o
r pro
v
i
sio
n
s
w
ill tak
e
effect in
2014, 20
18,
and 2020.
Dubbed “Obam
acare”
by ske
p
tica
l
, resistant Re
publicans, t
h
e
bill has
been a source
of c
ontroversy
sin
ce its in
cep
tio
n
.
Althou
gh
th
ere
was
d
i
ssatisfacti
o
n
with
th
e cou
n
t
ry’s h
ealth
care syste
m
, th
e ACA was
rel
a
t
i
v
el
y
un
p
o
pul
a
r
a
n
d
t
h
e
s
u
b
j
ect
of
m
a
ny
de
bat
e
s. R
ece
nt
l
y
t
h
e
AC
A
has
bee
n
un
de
r
fi
re
as t
h
e s
u
b
j
ect
of
lawsu
its clai
m
i
n
g
th
e
b
ill v
i
o
l
ates th
e p
u
b
lic’s civ
il rig
h
t
s. Lawm
ak
ers con
tin
u
e
to
d
e
b
a
te th
e eth
i
cs b
e
h
i
nd
th
e b
ill an
d
org
a
n
i
zation
s
such
as th
e Am
e
r
ican
Med
i
cal Asso
ciatio
n
(AMA) and
th
e
Am
erican
Asso
ciatio
n
o
f
Retired
Perso
n
s
(AARP) co
n
tinu
e
t
o
argue ag
ains
t th
e eco
n
o
m
ics o
f
th
e h
ealth
care
refo
rm
b
ill [2
].
Th
e In
stitu
te of
Med
i
cin
e
(IOM)
esti
m
a
tes
b
e
tween
44
,0
00
an
d
99
,00
0
p
e
o
p
l
e d
i
e
in
ho
sp
itals
ev
ery
year from
m
e
dical errors. Medical erro
rs are
the eighth leading ca
use
of
death i
n
the
US. T
h
e
US
ranks last
o
u
t
of
1
6
industr
ialized
n
a
tion
s
i
n
r
e
g
a
rd
s t
o
d
eath
s
as a
resu
lt of
m
e
d
i
cal er
ro
rs.
Statistics f
r
o
m
th
e
I
O
M
av
erag
e
o
n
e
i
n
fiv
e
patien
t
s are read
m
itted
to
th
e ho
sp
ital
with
in
30
d
a
ys
of d
i
sch
a
rg
e. The av
erag
e
p
e
r cap
ita
expe
nse
f
o
r
a
US
pat
i
e
nt
i
s
$
8
,
5
0
8
,
sec
o
n
d
onl
y
t
o
N
o
rwa
y
[1]
.
Cru
c
ial to
t
h
e
ACA is ev
ery Am
erican
’s
rig
h
t
t
o
h
ealth
i
n
suran
ce.
Fed
e
ral fu
nd
ing
on th
e
b
ill is
expecte
d
to re
ach $938
billion over a
deca
de, accordi
ng to a non-partisa
n
Congressional Budget Office
r [3].
States
m
a
y be expecte
d
to
fund th
ei
r own pri
v
ate insura
nce exc
h
a
n
ges
,
but m
o
st states are waiting to see
wh
at
h
a
p
p
e
n
s
to
th
e
Ob
am
a ad
m
i
n
i
stratio
n
’
s b
ill after a
Su
prem
e Co
u
r
t
d
ecision
or th
e Nov
e
m
b
er electio
n
Evaluation Warning : The document was created with Spire.PDF for Python.
I
S
SN
:2252
-88
06
IJP
H
S
V
o
l
.
4,
No
. 1,
M
a
rc
h 20
1
5
:
2
7
– 36
28
resu
lts m
a
y rep
eal p
a
rt or the en
tire
b
ill [4
]
.
An
ad
d
ition
34
m
i
l
lio
n
p
e
ople are exp
ected to
b
e
on
t
h
e ro
lls of
th
e in
su
red
lists b
y
20
21
, i
n
creasing
th
e
p
e
rcen
tag
e
o
f
non-elderly Am
ericans wit
h
ins
u
rance
from
83% to
9
5
% if th
e
AC
A surv
iv
es its
cu
rren
t leg
a
l battles. On
e st
ron
g
po
in
t in
favo
r
o
f
t
h
e refo
rm is th
e o
p
p
o
rtu
n
ity
for health care
preve
n
tion. T
h
e ACA
ha
s an
op
po
rt
u
n
ity to
reorien
t
th
e Am
erican
h
ealth
care syste
m
to
a
health preve
n
ti
on system
rather tha
n
a hea
lth care system
.
Curre
ntly 95
% of m
e
di
cal
dol
l
a
rs i
s
spent
on
medical care a
n
d only 1-2% i
s
sp
en
t
o
n
preven
tio
n [5
].
The
AC
A
has
fi
ve
c
o
st
c
o
nt
r
o
l
t
o
ol
s:
t
h
e C
a
d
illac tax, excha
n
ges,
co
m
p
arative e
ffective
n
ess
researc
h
, a
nd t
h
e i
n
depe
n
d
en
t
paym
ent
adv
i
sory
b
o
ar
d. T
h
ese t
o
ol
s hel
p
co
nt
r
o
l
spe
n
di
n
g
an
d b
u
d
g
e
t
for
cont
rolling hea
lth care spendi
ng in the c
o
m
i
ng
decade
.
Medicare and Medicaid spe
n
di
ng is out of control.
Th
e
AC
A is
usin
g so
m
e
to
ols to
cu
t co
sts and
d
e
v
e
lo
p
a m
o
re com
p
arative c
o
st
per service
health care
syste
m
. Th
e
health
in
su
ran
c
e ex
ch
an
g
e
s
will en
su
re that p
e
o
p
l
e
will g
e
t
go
od
d
e
als on
insuran
c
e as the
co
m
p
etitio
n
wi
ll d
r
iv
e prices l
o
wer;
o
r
so th
at is th
e
p
r
o
j
ected
scen
ari
o
[6
].
Prob
ab
ly th
e
m
o
st n
o
t
ab
le asp
ect
o
f
th
e ACA is t
h
e i
n
d
i
v
i
du
al m
a
n
d
a
te of t
h
e
b
ill. Th
is m
a
n
d
a
te is
t
h
e su
b
j
ect
o
f
l
a
wsui
t
s
a
nd c
ont
ro
ver
s
y
.
T
h
e i
ndi
vi
d
u
al
m
a
ndat
e
req
u
i
r
e
s
t
h
at
som
e
5
0
m
i
ll
i
on u
n
i
n
sure
d
Am
erican
s b
uy in
su
ran
ce
b
y
2
014
. Th
is “lig
h
t
en
i
n
g
ro
d
”
o
f
th
e
b
ill con
t
ain
s
th
e
v
e
ry h
eart of th
e AC
A.
Pre
v
entive
services can be
s
e
rve
d
unde
r the indi
vi
dual
m
a
ndat
e
. T
h
e
AC
A c
h
a
nge
s
t
h
e way
Am
eri
cans
percei
ve health by
prom
oting public
healt
h
as they ta
ke
on the
s
e ins
u
ra
nce
policies a
n
d receive
health ca
re
for th
e first ti
me in
so
m
e
cases [7
].
The AC
A is changi
ng the fac
e
of health care in A
m
er
i
ca, go
o
d
or
bad
.
A
m
er
icans spend millions of
d
o
llar
s
on
h
ealth
car
e ev
er
y year
. Th
e gover
n
m
e
n
t
is in
ter
v
en
ing
b
y
m
a
n
d
a
ting
pu
b
lic h
ealth
insur
a
nce f
o
r
all, in
essen
ce b
y
p
r
o
m
o
tin
g
a p
u
b
lic h
ealth p
o
licy.
Org
a
n
i
zatio
n
s
such
as th
e AMA and
AARP
will co
n
tinue
to
fig
h
t
on
as th
e argu
m
e
n
t
s o
v
e
r th
e AC
A co
n
tinu
e
. Po
litics will d
r
iv
e th
e b
ill u
n
til th
e Su
prem
e Co
u
r
t h
a
s
h
eard
th
e case o
n
th
e
g
r
o
und
s fo
r th
e ind
i
v
i
du
al
m
a
n
d
a
te. Wh
ile m
a
n
y
h
a
v
e
n
e
v
e
r read th
e b
ill in
i
t
s e
n
tirety,
h
ealth
care
refo
rm
is n
ecessary; wh
eth
e
r or
n
o
t
it is i
n
th
e fo
rm
o
f
t
h
e
AC
A rem
a
in
s to
be seen.
W
i
t
h
in
th
is cu
ltu
re of h
ealth
care reform
, i
t
is i
m
portant that seve
ral fac
t
ors are e
x
am
ined s
u
c
h
as
n
e
w
g
r
adu
a
te n
u
rses, t
h
e auto
no
m
y
o
f
th
e n
u
rse practitio
n
e
r wh
ich
wi
ll b
eco
m
e
a d
r
iv
ing
fo
rce beh
i
nd
pr
o
v
i
d
er
s i
n
r
u
ral
an
d
ur
ba
n
areas i
n
t
h
e c
o
m
i
ng y
ears,
an
d se
veral
gl
o
b
a
l
factors
that dri
v
e health
ca
re. In
t
h
i
s
pap
e
r,
hea
l
t
h
care re
fo
r
m
, econom
i
c
s
and t
h
e ne
w
g
r
ad
uat
e
, t
h
e s
h
ort
a
ge o
f
n
u
r
s
es, aut
o
n
o
m
y
of t
h
e
e
m
erg
e
n
c
y
nu
rse practitio
n
e
r, acu
te
g
l
ob
al issu
es
will b
e
exa
m
in
ed
.
2.
ECONOMICSAND THE
NEW GRADUATE
Cli
m
a
t
e ch
ange will h
a
v
e
a
stron
g
im
p
act
o
n
th
e
fu
t
u
re
o
f
nu
rsi
n
g. M
o
st nursing
st
u
d
e
n
t
s leav
e
nu
rsi
n
g sc
ho
ol
wi
t
h
t
h
e h
o
p
e
of fi
ndi
ng a
jo
b ri
g
h
t
aw
ay. After all, there is a n
a
tio
nal n
u
r
sing
shortag
e
.
Ho
we
ver
,
t
h
e fact
s
m
a
y
fal
l
i
n
a far di
ffe
rent
eco
n
o
m
i
c di
rect
i
on f
o
r t
h
e new
gra
d
u
a
t
e
. Whi
l
e
nat
i
onal
statistics in
d
i
cate th
e curren
t
n
u
rsing
sho
r
tag
e
will g
r
ow
t
o
o
v
e
r on
e
m
i
l
lio
n
n
u
rses
b
y
th
e
year 20
20
, n
o
t
all
regi
ons
m
a
y
be affect
e
d
by
t
h
e s
h
o
r
t
a
ge
. C
u
r
r
ent
gr
ad
uat
e
s are
fi
n
d
i
n
g i
t
m
o
re di
ffi
c
u
l
t
t
o
fi
nd
j
o
bs i
n
som
e
reg
i
o
n
s
. Reason
s for th
e
d
i
fficu
lties in
find
i
n
g
a job
in
cl
ud
e: nu
rses ret
u
rn
i
n
g
t
o
th
e
wo
rk
force du
e t
o
th
e
eco
no
m
i
c recessio
n
, m
o
re nurses in
creasi
n
g ho
urs, and
in
creased co
m
p
etitio
n
for av
ailab
l
e slo
t
s
[8
].
Nu
rsi
ng
scho
o
l
s are ill-p
r
ep
ared
to
h
a
n
d
l
e th
e cu
rrent eco
no
m
i
c
sta
t
e o
f
th
e job
mark
et. C
o
n
t
ri
b
u
tin
g
factors in
clu
d
e
:
d
i
fficu
lties
in
find
ing
clin
ical
sites,
d
ecreased
n
u
m
b
e
rs o
f
facu
lty,
and
risi
n
g
nu
m
b
ers o
f
nu
rsi
n
g
scho
o
l
ap
p
lican
ts [9
]. In th
is
p
a
p
e
r, th
e cu
rren
t eco
n
o
m
ic state
o
f
nu
rsi
n
g educatio
n
an
d th
e jo
b m
a
rk
et will b
e
ex
am
in
ed
with reg
a
rd
to th
e
20
08
Reg
r
ession
.
Desp
ite th
e curren
t
reg
r
ession
,
jo
b
s
i
n
th
e health
care
field ha
ve rem
a
ined
steady.
W
ith the num
b
er
of
Am
eri
cans gr
owi
n
g ol
de
r
and
3
8
% o
f
h
o
s
pi
t
a
l
i
zed pat
i
e
nt
s com
p
ri
sed
of
ol
de
r Am
eri
cans,
nu
rses a
r
e st
i
ll
in
h
i
gh
d
e
m
a
n
d
[1
0
]
.
Ad
am
s repo
rts
o
n
a
n
e
w in
itiativ
e b
y
Mich
ig
an’s Oak
l
and
State Univ
ersity to
d
i
v
e
rsify
its n
u
r
sing
educatio
n
p
r
og
ram
to
in
clu
d
e
m
o
re clin
ical sites
an
d
b
e
tter trai
n
i
ng
for its n
e
w g
r
adu
a
tes. A lack
o
f
facu
lty and
d
i
fficu
lty in
fin
d
i
n
g
clin
ical
sites
m
a
k
e
it d
i
fficu
lt to
p
r
epare stud
en
ts adeq
u
a
tely to
m
e
et th
e
n
eeds
o
f
em
p
l
o
y
ers l
o
ok
i
n
g to
fill v
acan
c
ies [9
].
At Oa
k
l
an
d
State Un
i
v
ersity,
p
a
rtn
e
rship
s
with
h
ealth
care
o
r
g
a
n
i
zatio
n
s
are
h
e
lp
ing
t
o
fill th
e g
a
p
b
e
tween
find
ing
clin
ical sites and
ad
jun
c
t facu
lty [1
0
]
.
W
i
t
h
th
e dwin
d
ling
supp
ly o
f
exp
e
rien
ced
nu
rs
es, m
o
re an
d
m
o
re h
o
s
p
itals will h
a
v
e
to
fill
vacancies
with inexperie
n
ced nurses.
Withi
n
the
next
dec
a
de, a
50% tur
nover
of
nurs
es is expecte
d
. To
com
b
at
t
h
ese st
at
i
s
t
i
c
s, nurse
resi
de
ncy
p
r
o
g
r
am
s have bee
n
i
m
pl
em
ent
e
d
by
som
e
st
at
es and
n
u
rsi
ng sc
ho
ol
s
to pre
p
are
nurs
ing stude
n
ts to meet
the challenge
s of
the
workforce [11]. T
h
is incr
eases t
h
e com
p
etence
level
of
ne
w
gra
d
uat
e
s.
The e
xpect
at
i
ons
o
f
ne
w
g
r
ad
uat
e
ed
ucat
i
on
have i
n
cr
eased
by
h
o
sp
i
t
a
l
s
. Nur
s
i
n
g
sch
ool
s a
r
e
in
creasing
l
y inv
e
sting
in
techn
o
l
o
g
y
su
ch
as si
m
u
lato
rs
.
Better train
i
n
g
will h
e
lp
n
e
w g
r
ad
u
a
tes
find
job
s
faster t
h
an trad
itio
n
a
l
p
r
og
ram
s
. In
add
ition
,
coo
p
e
ration b
e
tween
org
a
n
i
zatio
n
s
and
n
u
rsing
scho
o
l
will
streng
th
en
the
n
e
w grad
u
a
te
jo
b m
a
rk
et [12
]
.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
J
PH
S I
S
SN
:
225
2-8
8
0
6
Pu
bl
i
c
He
al
t
h
Pro
m
ot
i
o
n
:
A
u
t
o
n
o
my
of
The
Emer
gency
N
u
rse Pr
act
i
t
oner
(
C
heryl
An
n
A
l
exan
d
er)
29
Terry and
Wh
i
t
m
a
n
[9
]
report th
at
n
u
rsing
sch
o
o
l
s
will
n
e
ed to
rise to m
eet
th
e econ
o
m
ic ch
allen
g
es
facing nursing stude
nts.
C
r
eat
ive
m
e
t
hods i
n
finding
jobs a
n
d rec
r
uitm
ent efforts will
only enha
nce t
h
e
ne
w
gra
d
uat
e
ex
per
i
ence. N
u
rse e
ducat
ors m
u
st
st
ri
ve t
o
pre
p
a
r
e students to
meet real
worl
d challenges s
o
that
find
ing
a
jo
b is no
t on
ly easier, bu
t
o
f
fers a mo
re secure
fu
t
u
re.
Clim
a
t
e change has
bee
n
fore
told as
the
bi
ggest
glob
al e
v
e
n
t in this ce
ntury. T
opics
s
u
c
h
as
how t
h
e
global clim
ate
affects
nursing and
how
it affects health care are im
portant to
al
l
m
e
di
cal
pr
ofe
ssi
o
n
al
s.
To
pi
cs
in
un
d
e
r-d
e
v
e
lo
p
e
d
co
un
tries su
ch
as Ebo
l
a an
d
C
h
o
l
era
will h
a
v
e
a larg
e im
p
act o
n
th
e crisis
o
f
n
u
rsing
i
n
th
e US. Nursing
stud
en
ts m
u
st b
e
prep
ared
to
m
eet th
e ch
allen
g
e
s
o
f
g
l
obal h
ealth
care
b
y
find
ing
so
lu
tio
ns
fo
r ca
re.
3.
THE
SHO
R
T
A
GE OF NU
RSES A
N
D
I
T
S
GLOB
ALI
M
P
ACT
Fel
d
st
ei
n (
2
0
1
1
) [
2
]
defi
nes t
h
e n
u
rsi
ng s
h
o
r
t
a
ge as t
h
e de
m
a
nd fo
r n
u
r
s
es great
er t
h
a
n
t
h
e num
ber
o
f
nu
rses
willin
g
t
o
work
for a p
a
rticu
l
ar wag
e
.
Nursing
period
ically ex
perien
ces cyclic sho
r
tag
e
s th
at
b
e
g
a
n
as early as the 1960s. Gove
rnm
e
nt
agenci
es, sch
o
o
l
s
of
nu
rsi
n
g, a
nd
pr
ofe
ssi
o
n
al
n
u
rsi
ng a
g
e
n
ci
es hav
e
worked tog
e
ther
o
v
e
r t
h
e years to so
lv
e th
e
n
u
rsing
sh
ort
a
ge. The
nu
rsi
n
g
s
h
ort
a
ge was
p
r
edi
c
t
e
d
at
1
0
%
i
n
2
005
an
d b
y
20
20
, cou
l
d grow
to 29
% of
the en
tir
e
nu
r
s
i
n
g
p
opu
latio
n
[13
]
.
Fo
r
n
e
w graduates, cu
rren
t
p
r
ed
ictio
n
s
m
i
g
h
t
b
e
d
i
re
r. Health
care faciliti
es are ab
le to
h
i
re all th
e
expe
ri
ence
d
nu
rses t
h
ey
wa
nt
at
curre
nt
wa
g
e
s i
n
m
o
st
st
ates. Fo
r exam
pl
e, i
n
Ne
vada
,
m
a
ny
new g
r
a
duat
e
s
are ha
vi
n
g
a di
ffi
cul
t
t
i
m
e
fi
ndi
n
g
j
o
bs due to econom
i
c
factors, a sat
u
ra
t
e
d m
a
rket, and no-vaca
ncy ra
tes in
area h
o
spi
t
a
l
s
.
Ho
we
ver
,
t
h
er
e i
s
hope f
o
r t
h
e new g
r
a
duat
e
s as t
h
e avera
g
e age fo
r t
h
e cur
r
ent
w
o
rki
n
g
nur
se
i
s
47
-y
ears.
O
v
er
90
0,
0
00
of
t
h
e est
i
m
a
t
e
d
2.
6 m
i
l
l
i
on wo
rki
ng
regi
st
ere
d
n
u
rs
es are
5
0
o
r
o
v
er
. The
r
e ha
s
been a rece
nt i
n
fl
ux
of
nurses
return
i
n
g to
t
h
e wo
rk
fo
r
c
e due to
th
e poo
r
eco
n
o
m
y. Th
er
e is also
in
cr
eased
j
ob
d
i
ssatisf
action asso
ciated
w
ith
nur
sing
i
n
to
d
a
y’
s h
e
alth car
e ar
en
a; attr
ib
u
t
ed to incr
eased technolo
g
i
es,
in
creased
p
a
tien
t
acu
ities, an
d in
creased
p
h
y
sical
d
e
m
a
n
d
[1
4
]
.
Th
ese factors m
a
y
h
a
v
e
co
n
t
ri
bu
ted
t
o
al
l
e
vi
at
i
ng
t
h
e
cur
r
ent
dem
a
nd fo
r nu
rses
t
e
m
porari
l
y
.
Whet
her
or n
o
t
t
h
ere a nursi
ng s
h
o
r
t
a
ge re
al
l
y
exi
s
t
s
i
s
a quest
i
o
n n
o
o
n
e can ans
w
e
r
at
t
h
i
s
poi
nt
.
So
m
e
ex
p
e
rts lik
e Beall say yes. In
h
e
r op
in
i
o
n, th
e
recessi
on
has
rel
i
e
ve
d
t
h
e
dem
a
nd f
o
r n
u
r
ses t
e
m
p
o
r
ari
l
y
d
u
e
to
a
po
or eco
n
o
m
ic situ
at
io
n
,
bu
t th
e t
h
reat for h
i
g
h
v
a
can
cy rates still co
n
tinu
e
s i
n
so
m
e
areas and
in
the
fu
t
u
re
for m
o
st areas. By th
e
year 20
25
, some 2
6
0
,
0
0
0
nurses
will b
e
n
e
ed
ed to
care
for th
e
p
a
tien
t
s i
n
h
ealth
care facilities in this co
untry [15]. This is especially troubli
ng for
seve
ral reasons
.
The Institute of Medicine
(I
OM
)
de
vel
o
ped
seve
ral
re
com
m
e
ndat
i
o
n
s
f
o
r
n
u
rses
i
n
20
1
0
t
h
at
c
oul
d st
r
o
ngl
y
im
pact
t
h
e fut
u
re
o
f
nu
rsi
n
g
[1
6]
.
For
exam
pl
e, nu
rses s
h
oul
d
pract
i
ce t
o
t
h
e fu
ll ex
ten
t
of
th
eir edu
cation and training,
achieve
hi
g
h
er e
d
ucat
i
o
n
,
an
d
be f
u
l
l
part
ners
wi
t
h
phy
si
ci
ans
,
am
on
g
ot
he
rs.
Ho
weve
r, t
h
e real
sh
ort
a
ge l
i
e
s
wi
t
h
nu
rsi
n
g fac
u
l
t
y
[
15]
.
The
nu
rsi
ng
s
h
o
r
t
a
ge
pe
ri
o
d
i
cal
l
y
cy
cl
es t
h
r
o
ug
h
out
t
h
e
Am
eri
can n
u
rs
i
ng
hi
st
o
r
y
.
P
r
edi
c
t
i
ons
f
o
r
th
e 20
20
shortag
e
seem
to
lo
o
m
larg
e, ho
wev
e
r,
m
a
ny nurses are
middle-age
d
a
r
e working close to
ret
i
r
em
ent
.
The curre
nt
rel
i
e
f
from
t
h
e nursi
ng s
h
o
r
t
a
ge ha
s fo
ol
ed som
e
educat
ors a
nd
of
fi
ci
al
s i
n
t
o
thi
n
ki
n
g
t
h
e sh
ort
a
ge i
s
goi
ng a
w
ay
.
Ho
weve
r, t
h
e
l
u
l
l
i
s
proba
bl
y
t
e
m
porary
and
based
o
n
t
h
e eco
n
o
m
y
[13]
.
Ed
ucat
or
s,
pr
o
f
essi
o
n
al
o
r
ga
ni
zat
i
ons
, an
d
t
h
e fe
deral
g
ove
r
n
m
e
nt
sho
u
l
d
act
n
o
w
t
o
g
r
ow
pr
o
g
ra
m
s
t
o
increase
t
h
e nursing base. Nursing
fa
culty are experie
n
cing a gl
obal s
h
ort
a
ge as
well. T
h
e
ove
rall number
of
nursing
faculty has stea
dily decreased
with
i
n
th
e last d
e
cad
e
.
Ov
er
7
5
,
000
nur
sing
studen
t
s ar
e t
u
rn
ed aw
ay
fro
m
p
r
og
ram
s
du
e to th
e lack
o
f
app
r
op
riat
e facu
lty. Th
is
is an
o
ngo
ing
g
l
ob
al pro
g
ram
.
Th
e n
u
rsing facu
lty
sh
or
tag
e
is due to
a co
nf
lu
en
ce of
fact
o
r
s,
i
n
cl
udi
ng t
h
e
gl
obal
m
i
grat
i
on o
f
n
u
r
ses,
an agi
n
g fac
u
l
t
y
, a
r
e
du
ced
yo
unger
f
acu
lty h
i
r
i
n
g
p
o
o
l
, d
e
cr
eased
satisf
actio
n
w
ith
th
e f
a
cu
lty r
o
le, lack
o
f
f
und
ing
an
d
p
o
o
r
salaries, a see
m
ing persistent devaluation
of
facu
lty by academ
ic
institutions
, increa
sed de
pe
nde
nc
e on
co
n
ting
e
n
t
facu
lty, and
o
v
e
rall redu
ctio
n in
fu
ll tim
e eq
u
i
v
a
len
t
(FTE) facu
lty. Th
ere seem
s to
be no
con
s
ens
u
s
o
r
pl
an am
on
g
n
u
rsi
n
g
p
r
ofess
i
onal
s
t
o
fi
x t
h
i
s
gr
owi
n
g
p
r
o
b
l
e
m
al
t
hou
gh
m
o
re an
d
m
o
re
literature
is bei
n
g
publishe
d. Table 1 [17]
illustrates glob
al cha
n
ge
necessary to
fi
nd sol
u
tions to the
nursi
ng
shortage
.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
S
SN
:2252
-88
06
IJP
H
S
V
o
l
.
4,
No
. 1,
M
a
rc
h 20
1
5
:
2
7
– 36
30
Tabl
e 1. Gl
o
b
a
l
sol
u
t
i
o
ns
t
o
t
h
e nu
rsi
n
g sh
o
r
t
a
ge
Solutions
Percentage
(%)
I
n
ter
n
ational cooper
a
tive policies an
d pr
ogr
am
s
10.
00
M
a
naged m
i
gr
atio
n
6.
67
E
ducational par
a
dig
m
change
28.
33
Rem
oval of bar
r
i
ers
9.
17
Centr
a
lized data
& str
a
tegy
30.
83
Stable fundin
g
8.
33
Nur
s
e scholar
ship
3.
33
Co
m
p
etitive facult
y sala
ry
3.33
4.
AUTO
N
OM
Y
A
S A STATE OF
BEIN
G
F
O
R
THE EMER
GENCY
NU
RSE PR
ACTITION
E
R
Au
t
o
no
m
y
fo
r th
e
nurse p
r
act
itio
n
e
r (NP)
is an
o
ngo
ing
p
r
actice d
e
b
a
te and
o
n
e
th
at affects qu
ality
care, safety, a
n
d can
determ
ine the course of the devel
opm
ent
of c
u
r
r
ent
and
fut
u
re
NP
pr
o
g
ram
s
i
n
t
h
e US.
For the em
ergency NP, a
u
tonom
y is a pres
sing iss
u
e
re
lated to
practice
because not only do
patients
prese
n
t
to
th
e em
erg
e
ncy roo
m
(ER) in
em
erg
e
n
t
con
d
ition
s
, t
h
ere
are m
a
n
y
o
p
p
o
rtun
ities for NPs in
t
h
e ER t
o
act
au
ton
o
m
o
u
s
ly
b
y
treatin
g
m
i
n
o
r inju
ries, commo
n
illn
esses,
as well as trau
m
a
as it p
r
esen
ts. Em
erg
e
ncy NPs
pract
i
c
i
n
g i
n
r
u
ral
a
r
eas
m
a
y see a
n
y
num
ber
of
t
r
a
u
m
a
pat
i
e
nt
s i
n
d
e
pe
n
d
ent
l
y
a
n
d
be
pre
p
are
d
t
o
t
r
e
a
t
t
h
ese
pat
i
e
nt
s as
wel
l
as any
t
r
eat
i
n
g
phy
si
ci
an
w
o
ul
d i
n
t
h
e case
.
Safe
p
r
act
i
ce i
s
an
i
m
port
a
nt
part
of
a
u
t
o
no
m
ous
NP
practice as it d
eals
with kn
owing li
m
i
tatio
n
s
yet be
in
g ab
le to
m
a
in
tain
a standard lev
e
l
o
f
care
b
y
refe
rrin
g
,
tra
n
s
f
er
rin
g
,
or
sim
p
ly
sen
d
in
g
fr
o
m
fast-track
to the m
a
in ER.
State and
fe
der
a
l
st
akeh
ol
de
rs
wa
nt
to
see th
at NPs can
m
a
in
tain
a safe, au
ton
o
m
o
u
s
p
r
actice th
at will n
o
t
j
e
o
p
a
rd
ize th
e qu
ality o
f
care o
f
the
p
a
tien
t
o
r
th
e safety o
f
th
e p
a
tien
t
. Ed
u
cation
a
l p
r
og
ram
s
m
u
st
g
ear th
em
se
lv
es fo
r the fu
ture of n
u
rsin
g
and
the di
ffe
rences
ahea
d that
will em
body c
h
a
n
ges in the
wa
y
nursi
n
g is pra
c
ticed so that
whe
n
NPs
gra
duate
th
ey will b
e
stro
ng
, co
m
p
etent, and
read
y
for au
tono
m
o
u
s
practice.
4.1. I
d
en
tification
of Pr
actic
e
Issue
A sel
ect
g
r
o
u
p
of st
a
ff
fr
om
t
h
e U
n
i
v
er
si
t
y
of
C
a
l
i
f
or
ni
a at
S
a
n F
r
anci
sc
o
(
U
C
S
F
)
(
2
01
1)
[1
8]
p
u
l
l
e
d
t
oget
h
e
r
a
pr
oj
ect
t
h
at
exam
ined t
oday
’
s au
t
o
n
o
m
ous p
r
ac
t
i
ce of n
u
r
s
i
n
g
and
w
h
at
w
o
u
l
d be e
xpect
e
d
once
t
h
e next
wa
ve
of f
u
l
l
y
i
n
sure
d heal
t
h
care c
ons
um
ers
hit the health care
arena
.
Using
data fro
m
th
e R
o
b
e
rt
Wood
Jo
hn
son Foun
d
a
tion
,
staff
was ab
le to d
e
term
in
e th
at to
m
eet q
u
a
lity g
u
i
d
e
lin
es
for th
e
n
e
x
t
g
e
n
e
ration
of healt
h
care consum
ption,
new lines of autonom
y
m
u
st
be de
vel
o
ped
.
To m
eet
these
needs, educators a
nd
st
ude
nt
s al
i
k
e
m
u
st
be eager t
o
t
a
ke
o
n
a
ne
w vi
e
w
of
nurs
ing i
n
this
heal
th care
s
o
ciety and exam
ine the ne
xt
step in health
care provisio
n. NPs in partic
ular m
u
st be prepa
r
ed
to ste
p
up and take their place as prim
ar
y
p
r
ov
id
ers for
man
y
p
opu
latio
n
s
. R
u
ral areas will b
e
in
h
i
gh
d
e
m
a
n
d
fo
r staffi
n
g
th
e NP du
e t
o
a
si
m
ilar
p
h
y
sician
sho
r
t
a
g
e
[18
]
an
d
NPs will b
e
ex
pected
to
act auto
no
m
o
u
s
ly at rural ERs. Ph
y
s
ician
co
llabo
ratio
n
is still req
u
i
red
fo
r m
a
n
y
st
ates. Ho
wev
e
r, in
so
m
e
st
at
es th
ere are
gu
id
elin
es allowing
ind
e
p
e
nden
t
NP
practice.
4.
2. B
a
ck
gr
ou
nd In
f
o
rma
ti
o
n
IOM
’
s recom
m
endat
i
on t
o
al
l
o
w ad
vance
d
pract
i
ce n
u
rs
es practice to the lim
its of their scope of
pract
i
ce base
d on t
h
ei
r e
ducat
i
on an
d t
r
ai
ni
n
g
. I
O
M
recom
m
endat
i
o
n
s
i
n
c
l
ude rem
ovi
n
g
rest
ri
ct
i
ons t
h
a
t
l
i
m
i
t
adva
nce
d
prac
tice nurses from
fully using their skills
. Som
e
suggestions include e
xpa
ndi
ng Me
dicare to
i
n
cl
ude
NP
s as
pri
m
ary
pro
v
i
d
ers a
n
d i
n
c
r
ea
se rei
m
bursem
e
nt
f
o
r t
h
e ser
v
i
ces pr
ovi
de
d j
u
st
as
phy
si
ci
ans ar
e
r
e
im
b
u
r
sed now
.
A
m
en
d
t
h
e Med
i
car
e pr
og
r
a
m
to
allo
w NPs t
o
per
f
o
r
m
ad
m
i
ss
io
n
assessm
en
ts and
co
m
p
lete ad
m
i
ssio
n
requ
irem
en
ts for p
a
tients to
en
ter sk
il
led
facilities a
n
d
h
o
m
e h
ealth
ag
en
cies. Th
ese,
am
ong
ot
her a
c
t
i
ons, ca
n
be
nefi
t
N
P
s
by
pr
o
v
i
d
i
n
g t
h
e
m
u
ch neede
d
aut
o
nom
y
i
n
cl
i
n
i
cal
set
t
i
ngs. R
u
r
a
l
situ
atio
n
s
,
especially fo
r emerg
e
n
c
y NPs,
will b
e
n
e
fit
the
m
o
st fro
m
c
h
ang
e
s i
n
th
e
way reim
b
u
r
semen
t
is
prese
n
ted
and NPs practice
[16].
Acco
r
d
i
n
g t
o
a
su
rvey
co
n
d
u
c
t
e
d
by
Se
rm
o (
2
0
1
1
)
[
19]
,
m
o
st
phy
si
ci
an
s bel
i
e
ve
t
h
at
i
nde
pe
nde
nt
NP
p
r
actice
will n
o
t
in
crease qu
ality h
ealth
care an
d
wi
ll
n
o
t
d
ecrease
co
sts
asso
ciat
ed
with
h
ealth
care
sp
en
d
i
n
g
. In
stead
, m
a
n
y
b
e
liev
e
th
at care q
u
a
lity will
b
e
red
u
c
ed
an
d
co
sts will
b
e
in
creased. Mo
st
p
h
y
sician
s
b
e
li
ev
e ph
ysician-run
serv
ices
wi
ll b
e
m
o
re effi
cien
t and
prov
i
d
e b
e
tter
qu
ality o
f
care th
an
th
at of
a NP. For em
ergency NPs, thi
s
is a crucial blow
because
it is im
perative the autonom
y
th
at advanced
practice
n
u
rses seek
b
e
ap
pro
v
e
d
and
d
a
ta sho
w
n
th
at q
u
a
lity n
o
t
on
ly in
creases
qu
ality o
f
care
bu
t cu
ts costs as well.
Th
is
will len
d
au
tho
r
ity to
the ro
le
o
f
th
e emerg
e
n
c
y
NP
as a so
le
p
r
ov
id
er and
m
a
k
e
a step
toward
ch
angi
ng
today’s
healt
h
care e
nvironment.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
J
PH
S I
S
SN
:
225
2-8
8
0
6
Pu
bl
i
c
He
al
t
h
Pro
m
ot
i
o
n
:
A
u
t
o
n
o
my
of
The
Emer
gency
N
u
rse Pr
act
i
t
oner
(
C
heryl
An
n
A
l
exan
d
er)
31
4.3. Quality
I
m
provement
Caro
lyn
Clan
cy [7
] send
s a clear m
e
ssag
e
to
ER p
a
tien
t
s abo
u
t
qu
ality. A
q
u
a
lity in
teract
io
n
con
s
ists
o
f
m
a
n
y
step
s
to
m
a
in
tain
th
e safety o
f
th
e p
a
tien
t
. Th
ese in
clud
e v
e
rb
al read
b
a
ck
ord
e
rs, o
m
ittin
g
co
stly
tests th
at are u
n
n
ecessary, and
cu
ttin
g
wait ti
m
e
s. E
m
erg
e
n
c
y NPs h
a
v
e
a ro
le in
th
is in
m
a
n
y
ways.
In
h
e
r
p
o
d
cast, Clan
cy ex
p
l
ain
s
th
at
a n
e
w
fro
n
tier o
f
m
e
d
i
ci
n
e
is co
m
i
n
g
an
d
NPs will b
e
a driv
ing
fo
rce i
n
seeing
th
at th
ese qu
ality facto
r
s are i
m
p
l
e
m
en
ted
.
NPs
will u
s
e
au
ton
o
m
y to
see th
at co
stly te
sts are o
m
it
ted
an
d
cut
wait ti
m
e
s b
y
t
r
eatin
g
m
i
n
o
r
i
n
juries qu
ick
l
y with
ou
t a
lon
g
wait b
e
tween
triag
e
and
seei
n
g
a
ph
ysician
.
Th
is
will also
b
e
g
i
n
to eli
m
in
ate
left witho
u
t
t
r
eatm
e
n
t
cases (LWOT), a co
mm
o
n
o
ccurren
ce in tod
a
y’s ERs.
Clan
cy [7
] go
es o
n
t
o
talk
abo
u
t
th
e
p
a
rad
i
gm sh
ift co
m
i
n
g
fro
m
cu
re to
qu
ality care. NPs are in
th
e
p
r
i
m
ary
p
o
s
ition
t
o
prov
id
e
qu
ality care b
y
sp
end
i
ng
m
o
re ti
m
e
at th
e b
e
d
s
id
e,
talk
in
g
t
o
th
e
p
a
tien
t
in
lay
m
an
’s
term
s, an
d
prov
id
ing
ex
ten
s
i
v
e d
i
sch
a
rg
e ed
u
cation
.
Many co
n
s
u
m
ers are shop
p
i
ng
for qu
ality h
ealth
care.
Havi
ng a
qual
ity initia
tive in
place that a
d
dresses th
e
m
o
st co
mm
on causes
for c
o
m
p
la
ints in the ER can
al
l
e
vi
at
e
m
a
ny po
or h
o
s
p
i
t
a
l
pat
i
e
nt
sat
i
s
fact
i
on sco
r
es. U
nde
rsc
o
ri
ng
N
P
aut
o
nom
y
i
n
t
h
e ER
so t
h
at
NPs
can
fu
nct
i
o
n i
n
depe
n
d
ent
l
y
w
h
en
n
ecessary
i
n
t
h
e
ER
ca
n
onl
y
a
d
d t
o
p
a
t
i
e
nt
sat
i
s
fact
i
o
n as
N
P
s
fu
nct
i
on t
o
th
eir fu
ll po
ten
tial, esp
ecially in
rural settin
g
s
. In
rural settin
g
s
,
q
u
a
lity h
ealth
care beco
m
e
s d
e
p
e
nd
en
t
on
NPs b
e
i
n
g
allo
wed
to
fun
c
tion
au
tono
m
o
u
s
ly as
m
a
n
y
ti
mes th
e NP is th
e first co
n
t
act p
a
tien
t
s h
a
v
e
with
t
h
e
em
ergency
ca
r
e
sy
st
em
.
4.4.
How is
Autonomy Me
asured?
Th
e A
m
er
ican
N
u
rses A
s
sociatio
n
(
A
N
A
) str
o
ng
ly ad
vo
cates au
tonomy f
o
r
ad
v
a
nced
p
r
actice
nu
rses.
I
n
Fi
g
u
r
e
1 [
2
0]
p
r
o
v
i
d
ed
by
A
N
A
,
t
h
e
pi
n
n
acl
e
of
adva
nce
d
pract
i
ce nu
rsi
n
g i
s
a
u
t
o
nom
y
.
Fig
u
re
1
.
Ou
tco
m
e = Safety,
Qu
ality
,
and
Ev
id
en
ce-b
a
sed
Nursing
Practi
c
e
Th
e
g
o
a
l
fo
r ad
v
a
n
c
ed
p
r
acti
ce nu
rses is to ach
ie
v
e
an
outco
m
e
o
f
“safe, qu
ality, ev
iden
ce-b
a
sed
nu
rsi
n
g” care
t
o
t
h
e po
pul
at
i
on q
u
al
i
f
i
e
d t
o
pract
i
ce t
o
For t
h
e em
ergency
NP, t
h
e
out
c
o
m
e
desi
red i
s
rem
a
ining in t
h
e sc
ope
of
practice as set forth
by the
nurs
e practice act of the
stat
e licensing
board. R
eaching
au
ton
o
m
o
u
s
p
r
actice is th
e g
o
a
l fo
r
p
r
o
v
i
d
i
ng
th
e three qu
alities
to
ach
ieve th
e o
u
t
co
m
e
o
f
“safe, qu
ality, and
evide
n
ce-base
d nursi
ng
pra
c
tice”. The quality indicat
ors use
d
are found withi
n
the pyram
i
d: “nursi
ng
pr
ofe
ssi
o
n
al
s
c
ope
o
f
p
r
act
i
ce, st
an
dar
d
s
of
pra
c
t
i
ce,
code of ethics
, a
nd ce
rtif
ication
of sp
ecialty, n
u
rse
p
r
actice act and
ru
les an
d
regu
latio
n
s
, in
stitu
tio
n
a
l
po
licies and
pro
c
edu
r
es, and
self-d
eterm
i
n
a
tio
n
”
[20
]
. The
co
n
c
ern
for NPs who
breach
an
y o
f
th
ese q
u
a
lity in
d
i
cat
o
r
s is th
at q
u
ality
care will
d
eclin
e an
d
patien
t
o
u
t
co
m
e
s will
suffer.
Also
,
NP cred
ib
ility
will d
e
crease in
t
h
e eyes
of
p
h
y
sician
s, oth
e
r NPs,
the fed
e
ral
g
o
v
e
rn
m
e
n
t
, o
t
h
e
r stak
eho
l
d
e
rs, and
p
a
tien
t
s. Th
e n
e
ed
to
main
tain
q
u
a
lity o
u
t
co
m
e
s is
cru
c
ial for th
ose who
seek aut
o
nom
ous practice as
e
m
ergency NPs or as NPs in
gene
ral. Safet
y
issues arise as well when
any of
these fact
ors a
r
e neglecte
d
or
ignore
d.
Patient safety is
also jeopa
r
dize
d when t
h
es
e factors are at ignore
d and
NPs are subj
ect to
lo
se cred
ibilit
y as
p
r
im
ary prov
id
ers
wh
en
th
is h
a
pp
en
s.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
S
SN
:2252
-88
06
IJP
H
S
V
o
l
.
4,
No
. 1,
M
a
rc
h 20
1
5
:
2
7
– 36
32
4.
5.
Au
to
no
m
y
:
A B
r
e
a
ch
i
n
C
o
s
t
s
and
C
o
nt
rol
Midlevel provi
d
ers
suc
h
as e
m
ergency
NPs
ha
ve ar
e
showing a
greater
usage in the ER
ove
r the
last
few y
ears.
Ac
cor
d
i
n
g t
o
a r
e
po
rt
by
Gri
n
de an
d C
a
m
a
r
go [
2
1]
, 1
2
.
7
% of al
l
ER
pat
i
e
nt
s were
seen by
mid
l
ev
el p
r
ov
i
d
ers in
20
06
.
A growing
concern
b
y
p
h
y
si
ci
an
s fo
r
q
u
a
lity o
f
care
h
a
s been
no
ted
in
th
e
article.
Th
e con
c
ern
s
l
i
sted
in
clu
d
e
t
h
e sup
e
rv
ision o
f
th
e m
i
d
l
ev
el p
r
ov
id
ers. Fo
r ap
prox
im
at
ely six
millio
n
v
i
sits,
em
ergency
N
P
s have
repl
a
ced p
h
y
s
i
c
i
a
n
s
as pri
m
ary em
ergency
pr
o
v
i
d
er
s. C
o
ncer
ns,
ran
g
i
n
g fr
om
decreasi
ng sta
ff re
source
s of prim
ary e
m
erge
ncy phys
icians, rising c
o
sts of em
ergency care,
financial
d
i
fficu
lties o
f
so
m
e
h
o
s
p
itals,
an
d
t
h
e reim
b
u
rsem
en
t issu
es o
f
so
m
e
in
su
ran
ce co
m
p
an
ies an
d
t
h
e Cen
t
ers for
M
e
di
care an
d
M
e
di
cai
d (C
M
S
).
Ove
r
al
l
,
e
m
ergency
phy
s
i
ci
an
s in
th
e Grind
e
and
Camargo
article [21
]
see
m
co
n
c
ern
e
d abou
t th
e qu
ality o
f
care au
t
o
nom
o
u
s
NPs ar
e g
i
v
i
n
g
th
eir
patien
t
s b
a
sed
on
th
e ed
u
cation
and
tr
ain
i
ng
pr
ogr
am
s
th
at ar
e now
available
.
T
h
e cost of t
r
aining a NP
is no
t so
far less t
h
an
t
r
ain
i
ng
an
MD,
howe
ver, as NPs training re
quire e
x
tensive
pre
p
aration
a
n
d in
dept
h training bey
o
nd the baccalaureate level
.
Em
ergency
NP
s have an o
p
p
o
r
t
u
ni
t
y
i
n
t
h
e com
i
ng y
ears t
o
m
a
ke a di
ffere
nce i
n
t
h
e qual
i
t
y
dat
a
and hel
p
cut
costs
ass
o
ciated with rep
eat
v
i
si
t
s
and rea
d
m
i
ssi
ons.
4.6. Microsys
t
ems
Clin
ical
micro
s
yste
m
s
are a way to
v
a
lidate clin
ical sy
ste
m
s fo
r patien
t
s, fam
ilies,
an
d
o
t
h
e
r
providers. For
e
m
ergency
NPs, the cl
i
n
ical micro
s
yste
m
p
r
esen
ted
in th
is p
a
p
e
r is th
e am
b
u
l
ato
r
y co
mm
u
n
ity
set
t
i
ng w
h
ere
NPs ca
n f
unct
i
on a
u
t
o
nom
ousl
y
as pri
m
ary
pro
v
i
d
e
r
s. T
h
ese r
u
ral
set
t
i
ngs se
r
v
e as p
r
i
m
ary
checkpoints for NPs
as
they treat
pa
tien
t
s
bo
th
em
erg
e
n
tly and
n
on-urg
e
n
tly. Th
e p
a
tien
t
’s
jo
urn
e
y throug
h
t
h
e ru
ral
ER
whe
r
e care i
s
pr
o
v
i
d
e
d
by
t
h
e NP set
s
up a uni
q
u
e m
i
cr
osy
s
t
e
m
and conce
n
t
r
i
c
vi
e
w
for t
h
e
h
ealth
care pro
v
i
d
e
r. Patien
t
s an
d
fam
ilies
wan
t
q
u
a
lity h
ealth
care an
d
ev
id
en
ce-based
care from th
e
p
r
ov
id
er
on
duty. Fo
r
th
e em
er
g
e
n
c
y N
P
, pr
ov
id
i
n
g
ev
id
en
ce-b
a
sed
care is essen
tial to
m
a
in
tain
in
g
a so
lid
pract
i
ce an
d
g
o
o
d
out
c
o
m
e
s. Heal
t
h
care s
y
st
em
s are i
n
t
h
e b
u
si
ness t
o
devel
op m
o
re
pat
i
e
nt
rel
a
t
i
o
nshi
ps
and inc
r
ease
patient load [22]. Em
ergency
NPs
can contri
but
e
t
o
t
h
i
s
by
usi
n
g
pr
o
f
essi
o
n
al
i
s
m
,
pract
i
ce, a
n
d
p
u
rp
o
s
e. Retain
ing
caring
, co
m
p
eten
t h
eal
th
care prov
i
d
ers is essen
t
ial in
a ru
ral
micro
s
ystem
.
W
ill,
ex
ecu
tion
,
id
eas, and
flow
are essen
tial to
th
e
surv
i
v
al of a m
i
crosyste
m
.
In a
rural
m
i
crosystem
,
the
e
m
erg
e
n
c
y
NP can
co
n
t
ri
bu
te to
th
e
b
y
b
e
i
n
g
pro
activ
e in
leg
i
slativ
e actio
n
s
related
t
o
p
r
actice,
j
o
i
n
ing
and
main
tain
in
g
me
m
b
ersh
i
p
in
n
a
tio
n
a
l org
a
nizatio
n
s
,
m
a
in
t
a
in
in
g
sk
ill b
a
se b
y
atten
d
i
n
g
co
nferen
ces and
wo
rk
sh
o
p
s, a
n
d co
nt
i
n
ui
n
g
t
o
pr
om
ot
e research a
nd t
h
eo
ry
i
n
pra
c
t
i
ce. Th
e
m
i
crosy
s
t
e
m
i
s
im
port
a
nt
be
cause
i
t
i
s
vi
ewed
by
t
h
e pat
i
e
nt
an
d c
onsi
d
ere
d
i
m
port
a
nt
by
t
h
e pat
i
e
nt
’s
dec
i
si
ons.
As
so
o
n
as a
pat
i
e
nt
i
s
i
n
a
relatio
n
s
h
i
p
with
th
e em
erg
e
ncy NP, th
e
p
a
tien
t
is in
vo
lv
e
d
in the microsyste
m
and has a
share
d
stake i
n
the
o
u
t
co
m
e
s. Th
e pro
cesses th
at
th
e
NP
u
s
es to g
e
t to th
e
end
resu
lt,
wh
eth
e
r it is o
r
d
e
ring
l
a
b
o
r
X-ray, writin
g
a prescri
p
tio
n,
o
r
sim
p
ly g
i
v
i
n
g
d
i
sch
a
rg
e i
n
stru
ctio
ns
, i
n
v
o
l
v
e
s t
h
e
p
a
tien
t
in
ou
tco
m
es. Qu
ality ou
tco
m
es is
th
e g
o
a
l of th
e NP and
for quality
o
u
t
co
m
e
s to
b
e
m
e
t, th
e
NP m
u
st b
e
a
w
are
o
f
all th
e p
r
ocesses th
at
m
a
k
e
u
p
th
e m
i
cro
s
yste
m
.
Th
e
p
a
tien
t
, th
e settin
g (ru
r
al
ER),
t
h
e p
r
o
cesses (writin
g
a
pr
escri
p
tio
n, etc.), and
th
e
p
a
tien
t
all co
nstitu
te a
m
i
cro
s
yste
m
[2
2
]
.
To
en
sure
th
e p
a
tien
t
is satisfied
, t
h
e
NP
u
s
es ev
id
en
ce-b
a
sed
nu
rsi
n
g.
4.
7.
Publ
i
c
He
al
th
M
a
n
a
ge
ment
Ov
ercrowd
i
n
g
o
f
t
h
e ER is increasing
l
y b
e
co
m
i
n
g
a prob
lem
fo
r bo
th
rural an
d
m
e
tro
politan
ERs in
t
h
e U
S
.
Un
de
rst
a
ffi
ng
, f
e
we
r p
r
ovi
ders
av
ai
l
a
bl
e, an
d
ho
sp
ital clo
s
ures are
p
r
ob
lems th
at con
tinue to
cont
ri
b
u
t
e
t
o
t
h
e ove
rcr
o
wdi
n
g i
ssue
s
faci
n
g
ER
s t
oday
.
E
m
ergency NPs can
justify
the
increase i
n
aut
o
nom
y
n
eed
ed to
wo
rk
as so
le provid
e
rs i
n
rural
ERs,
work
un
su
p
e
rv
ised
i
n
metro
p
o
litan
ERs to
care
for min
o
r
in
ju
ries
or illnesses, an
d serv
e as
first
po
in
t of co
n
t
act
fo
r t
h
e em
erg
e
n
c
y p
a
tien
t
. M
a
n
a
g
e
rs
rep
o
rt a h
i
g
h
lev
e
l o
f
satisfactio
n
with
th
e
u
s
e of em
erg
e
n
c
y NPs in
th
e ro
le as p
r
im
ary p
r
ov
id
ers,
fa
st track providers, and
as poi
nt
o
f
car
e pro
v
i
d
ers
.
N
P
s t
oday
exe
r
c
i
se a hi
gher l
e
vel
of e
xpe
rt
i
s
e and aut
o
n
o
m
y
t
h
an i
n
t
h
e past
.
Pro
f
essi
onal
d
e
vel
o
pm
ent
,
educat
i
o
nal
,
a
n
d t
r
ai
ni
ng
pr
o
g
ram
s
are
m
o
r
e
i
n
de
pt
h a
n
d
req
u
i
r
e m
o
re cl
i
n
i
cal
t
i
m
e
and m
o
re i
n
de
pt
h t
r
ai
ni
ng t
h
a
n
i
n
pre
v
i
o
us y
ears a
s
wel
l
[2
3]
.
Acc
o
r
d
i
n
g t
o
C
a
m
po et
al
.
,
N
P
s
rep
o
rt
m
o
re con
f
i
d
e
n
ce i
n
per
f
o
rm
ing
p
r
oced
ur
es
and
m
a
ki
ng
de
ci
si
ons i
n
a
u
t
o
nom
ous
p
o
si
t
i
ons
. T
h
i
s
st
ud
y
i
s
a
n
i
m
p
o
r
tan
t
landmark
stu
d
y
as it fin
d
s
th
at NP au
t
o
no
m
y
is n
ecessary an
d
ach
i
ev
ab
le for practitio
n
e
rs wh
o
work in
bo
th
rural and
m
e
tro
p
o
litan
setting
s
.
On
th
e
jo
b train
i
ng
co
n
s
i
s
ted
of so
m
e
o
f
t
h
e
NP learn
i
ng,
ho
we
ver
,
m
u
ch
of t
h
e t
r
ai
ni
ng
was
l
earne
d
du
ri
n
g
cl
i
n
i
cal expe
rience
s. Validating c
linical expe
riences i
s
i
m
portant whe
n
discussing NP
a
u
tonom
y
because
it
is
i
m
portant to ac
hieve a
se
nse
of cre
d
ibility to the
educat
i
o
nal
sy
st
em
s t
h
at
are pr
od
uci
ng e
m
ergency
NP
s
.
Som
e
proc
edu
r
es
per
f
o
r
m
e
d were i
n
t
ubat
i
o
ns
,
in
sertion
of cen
t
ral lin
es, admin
i
stratio
n
of lo
cal an
es
th
et
ic an
d
stitch
i
ng
a wou
n
d
,
and
ad
m
i
n
i
stratio
n
of
a
ner
v
e bl
oc
k [
2
3]
. It
i
s
vi
t
a
l
t
o
val
i
d
at
e t
h
e i
m
port
a
nce o
f
t
h
ese p
r
oced
u
r
e
s
si
nce t
h
ey
ca
n be t
h
e bac
k
b
one
of
many e
m
ergency proce
d
ure
s
. Autonom
ous practice in
a rural setting carries with
it a necessity to be
Evaluation Warning : The document was created with Spire.PDF for Python.
I
J
PH
S I
S
SN
:
225
2-8
8
0
6
Pu
bl
i
c
He
al
t
h
Pro
m
ot
i
o
n
:
A
u
t
o
n
o
my
of
The
Emer
gency
N
u
rse Pr
act
i
t
oner
(
C
heryl
An
n
A
l
exan
d
er)
33
p
r
o
f
icien
t
with sk
ills and
p
r
o
c
ed
ures. Cred
ib
i
lity is
essen
tial
and
v
a
lid
atin
g
sk
ills
th
rou
g
h
p
r
actice wh
et
her on
th
e job
o
r
th
rou
g
h
clin
ical
p
r
actice is critical to
th
e au
t
o
nomy o
f
NPs i
n
t
h
e
rural settin
g.
4.
8. C
o
ncep
tu
al
Fr
amew
ork
Acco
r
d
i
n
g t
o
Quat
t
r
i
n
ni
and S
w
a
n
[2
4
]
, Dona
be
di
an
’s st
ruct
ure
-
p
r
ocess
-
o
u
t
c
om
e conce
p
t
u
al
fram
e
wo
rk
p
r
ov
id
es a u
s
efu
l
to
o
l
for em
erg
e
n
c
y NPs.
Th
e
q
u
a
lity o
f
care
p
r
ov
id
ed
is no
t
on
ly i
m
p
o
r
tant, bu
t
so i
s
t
h
e st
ruct
ure
of
t
h
e
phy
si
cal
and
or
ga
ni
zat
i
onal
pr
op
ert
i
e
s of t
h
e se
t
t
i
ngs. T
h
e
pr
o
cess o
f
care a
n
d t
h
e
ret
u
r
n
of
t
h
e
p
a
t
i
e
nt
’s heal
t
h
st
at
us are a
di
r
ect
out
c
o
m
e
of t
h
e em
ergenc
y
NP.
As a
co
nse
que
nce
of
c
ont
act
with
th
e NP, the p
a
tien
t
can
ex
p
e
rien
ce eith
er a p
o
s
itiv
e
or n
e
g
a
tiv
e
o
u
t
come. Th
ere are two
lev
e
ls of care in
t
h
e
Do
na
bedi
a
n
m
odel
:
i
n
t
e
r
p
ers
o
nal
a
n
d
t
echni
cal
ca
re
.
Each
outcom
e reflects the
patient’s i
n
volve
m
ent i
n
h
i
s or
h
e
r own
care and
t
h
e p
r
ov
id
er’s
abilit
y to
p
r
ov
ide care
for th
e p
a
tien
t
.
On
a secon
d
a
ry level, th
e
patient’s
outc
o
mes also include the c
o
st of th
e h
ealth
care, len
g
t
h
of stay, wait ti
m
e
, an
d p
a
tien
t
satisfactio
n
[2
4]
. The
nece
ssi
t
y
of pr
o
v
i
d
i
ng a co
nce
p
t
u
al
fram
e
work
whe
n
worki
ng
with any co
nc
ept suc
h
as aut
o
nom
y
is to
p
r
ov
id
e a firm
b
a
sis
for th
e
d
e
v
e
lop
m
en
t
o
f
practice gu
id
elin
es and
ev
id
en
tiary su
ppo
rt
fo
r ev
i
d
en
ce-
base
d pract
i
ce.
5.
CASESTUDI
E
S
5.
1.
C
a
se S
t
u
d
y
O
n
e:
C
h
ol
er
a
Haiti is exp
e
ri
en
cing
o
n
e
of
th
e larg
est Cho
l
era
ou
tb
reaks in
h
i
sto
r
y as a resu
lt of lack
o
f
prop
er
san
itatio
n
and water su
pp
ly du
e t
o
t
h
e
20
10
earthqu
ake th
at
ripp
ed
th
e co
un
try ap
art. A m
u
ltit
u
d
e
o
f
or
ga
ni
zat
i
ons
i
n
cl
u
d
i
n
g UN
I
C
EF,
t
h
e
Wo
r
l
d
Heal
t
h
O
r
g
a
ni
zat
i
on (
W
H
O
),
an
d
t
h
e U
n
i
t
e
d Nat
i
o
n
s
(U
N)
,
who
s
e
wo
rk
ers are su
sp
ected
o
f
b
r
i
n
g
i
ng
th
e d
i
sease to
Haiti o
r
i
g
in
ally, h
a
v
e
form
e
d
team
s o
f
rel
i
ef and
recov
e
ry si
n
c
e th
e ep
id
em
ic
h
it th
e cou
n
t
ry so
m
e
m
o
n
t
h
s
after th
e
q
u
a
k
e
[25
]
. The in
tern
ation
a
l co
m
m
u
n
ity
h
a
s sup
p
o
r
ted
Haiti th
ro
ugh
ou
t th
e ep
idem
i
c
and
thro
ugh
th
e su
ppo
rt
o
f
o
r
g
a
n
i
zatio
n
s
su
ch as t
h
e
WHO an
d
UN, funds
ha
ve helpe
d
pay
for m
e
dical care and
vaccina
ti
ons. Now, support is n
ecessa
ry to preve
n
t
Haiti’s
ch
o
l
era ep
id
emic fro
m b
ecomin
g
en
d
e
m
i
c. Ev
en
b
e
fo
re
th
e earthqu
ak
e, Haiti’s san
itatio
n
and
water
su
pp
ly
w
a
s f
a
r
b
e
l
o
w
o
t
h
e
r
Car
i
bb
ean
coun
tr
y stand
a
rd
s; now
th
e ti
m
e
h
a
s co
me to
sho
r
e
up
th
e w
a
ter
supp
ly and
neg
o
t
i
a
t
e
wi
t
h
go
ve
rnm
e
nt
of
fi
ci
al
s t
o
i
m
pro
v
e sa
ni
t
a
t
i
on
st
anda
r
d
s
[2
5]
.
Ex
pert
s cal
l
e
d
fo
r m
a
jor
do
nat
i
o
n
s
f
r
om
cont
ri
b
u
t
i
ng c
o
u
n
t
r
i
e
s i
n
2
0
12 a
s
wat
e
r a
nd s
a
ni
t
a
t
i
o
n
co
n
tinu
e
t
o
b
e
a prob
lem
in
th
e ev
o
l
v
i
ng
Ch
o
l
era
ou
tbreak
.
Th
e Presid
en
ts of
Haiti and
th
e Do
min
i
can
R
e
pu
bl
i
c
j
o
i
n
ed t
h
e
Pan
Am
eri
can He
al
t
h
Or
ga
ni
zat
i
on/
Wo
rl
d
He
al
t
h
Or
ga
ni
zat
i
on
(P
AH
O/
WH
O)
,
UNICEF, an
d th
e Cen
t
ers
fo
r
Disease C
o
n
t
ro
l (C
DC) in
callin
g
for fun
d
s
to
bu
ild up
t
h
e in
frastru
c
ture
o
f
th
e
san
itatio
n
and
water sup
p
l
y syste
m
s in
Haiti. Repres
en
tativ
es of PAHO/
WHO, UNICEF, an
d th
e C
D
C called
f
o
r
d
ono
r countr
i
es to
r
e
lease
f
und
s
p
r
o
m
ise
d
in 201
0 fo
r reb
u
ild
i
n
g [26
]
.
Prop
er san
itatio
n and
a clean water sup
p
l
y
will b
e
g
i
n
to
sto
p
th
e crisis in
Haiti. Do
nor co
un
tries are
neede
d
t
o
m
a
ke
go
o
d
t
h
ei
r
cont
ri
b
u
t
i
ons
and
g
o
v
er
nm
ent
o
ffi
ci
al
s ne
ed t
o
m
a
ke su
re i
m
provem
e
nt
s ar
e
mad
e
. Represen
tativ
es
o
f
wo
rld
aid
e
ag
en
cies are
st
ead
ily work
i
n
g
toward
en
d
i
n
g
th
e
epid
emic in
Haiti.
5.
2.
Case
S
t
ud
y T
w
o
:
O
b
ste
t
ri
cal
C
a
re L
i
mi
ta
ti
ons
i
n
T
a
nz
ani
a
Ad
equ
a
te o
b
s
t
e
trical care is
essen
tial to
a
h
ealth
y
del
i
v
er
y
.
Preve
n
t
i
ng
bi
rt
h de
fect
s, i
n
fect
i
o
n, a
n
d
n
e
on
atal co
mp
licatio
n
s
can d
e
p
e
n
d
u
pon ad
equ
a
te an
d ti
mely
p
r
en
atal, in
tr
an
atal, an
d
po
stnatal car
e.
Econ
o
m
ic facto
r
s and
po
litic
al issu
es m
a
k
e
h
ealth
serv
ices in
th
i
r
d wo
rl
d
co
un
tries m
o
re co
m
p
licated
. Local
eco
no
m
i
es
m
a
y b
e
lagg
ing
an
d qu
alified
staff m
a
y n
o
t
b
e
av
ailab
l
e.
Global actio
n
to
im
p
r
ov
e m
a
tern
al h
ealth
ove
r t
h
e
past
f
e
w y
ears ha
s i
n
cl
u
d
ed st
udi
e
s
t
o
im
pro
v
e o
u
t
c
om
es, gra
n
t
s
, an
d al
l
o
cat
i
o
n o
f
res
o
urces
.
Si
nce
2
003
, g
l
o
b
a
l sp
end
i
ng
on
matern
al-ch
ild
health
sp
end
i
ng h
a
s in
creased fro
m
$
2
.
1
b
illio
n
in
20
03
to
$3
.5
billion in
2006 [27].
Key innovations
are
necessa
ry to preve
n
t com
p
lica
tions
due t
o
lack of fundi
ng and
adequately trained staff. For exam
ple, in
Tanza
n
ia,
a lack of ade
quat
e
resources a
n
d a lack of
hum
a
n
resources, ca
uses a
deficienc
y
in em
ergenc
y and prim
ary obstetric care
[28].
Worl
dwide aide
to s
u
fferi
ng
co
un
tries b
y
ag
en
cies su
ch
as th
e Bill
an
d
Melin
d
a
Gates Fo
und
atio
n
h
a
s d
o
n
a
ted
fun
d
s to
sh
ore up
a failin
g
syste
m
o
f
resou
r
ce allo
cation an
d
hu
m
a
n
reso
urce
d
i
ffi
cu
lties. A m
a
j
o
r
d
e
terren
t
to
imp
l
em
en
tin
g
effecting
g
l
ob
al po
licy is find
ing
q
u
a
li
fied
h
u
m
an
reso
urces. Se
cu
ri
n
g
qu
ality
p
e
rso
n
n
e
l who
are q
u
a
lified
to
wo
rk
in
obst
e
t
r
i
c
ca
re i
s
a key
c
o
m
ponent
i
n
i
m
prov
i
ng
pre
n
at
al
re
sou
r
ces i
n
Ta
n
zani
a
[
28]
.
The
pu
r
pose
o
f
t
h
i
s
essay
is to exam
ine the curre
nt trend
of
obstetric care in
Ta
nzania a
n
d
di
scuss t
h
e econom
ic assistance of
worldwid
e gran
ts in im
p
r
o
v
i
ng
o
b
s
tetric care.
Olsen
i
d
en
tified
th
e lack
of
h
u
m
an
resou
r
ces as th
e
m
a
in
ba
rrier for adequate
obstetri
cal care i
n
Tanza
n
i
a
. Lac
k
o
f
fu
n
d
i
n
g,
i
n
ade
quat
e
re
s
o
u
r
ces, a
nd a
lack
o
f
av
ailab
l
e q
u
alified
staff con
t
ribu
te to
th
is
si
t
u
at
i
on.
Ot
he
r
bar
r
i
e
rs a
g
ai
nst
a
d
eq
uat
e
o
b
st
et
ri
cal care
include l
o
w
m
o
rale a
m
ong staff [28]. Li
mite
d
funding for
obstetrical care is
also
a co
mm
o
n
p
r
ob
lem
fo
r
find
ing
resou
r
ces in
Tan
z
an
ia. Of all th
e
prob
lem
s
Evaluation Warning : The document was created with Spire.PDF for Python.
I
S
SN
:2252
-88
06
IJP
H
S
V
o
l
.
4,
No
. 1,
M
a
rc
h 20
1
5
:
2
7
– 36
34
faci
n
g
Tanza
n
i
a
’s o
b
st
et
ri
cal
cri
s
i
s
, fi
n
d
i
n
g
qual
i
f
i
e
d pe
rs
o
nnel
i
s
o
f
t
h
e
great
est
co
nce
r
n. I
n
Ta
nza
n
i
a
,
60%
o
f
su
rg
eries are carried
o
u
t
b
y
mid
-
lev
e
l p
r
actitio
n
e
rs.
Mo
st an
esth
esia, 3
9
.4
%, was p
r
o
v
i
d
e
d
b
y
n
u
rses,
fol
l
o
we
d cl
ose
l
y
by
phy
si
ci
ans at
3
1
.
3
%
.
T
oo
o
f
t
e
n
nu
rsi
ng a
ssi
st
ant
s
p
r
o
v
i
d
e
d
a
n
est
h
esi
a
sup
e
r
v
i
s
e
d
by
a
medical officer [29]. In c
r
itical tim
e
s such as
during a
c
e
sarean sectio
n, t
h
i
s
c
oul
d
m
ean t
h
e
di
f
f
e
rence
bet
w
ee
n l
i
f
e a
n
d
deat
h.
There is a poor m
i
x of servic
es a
m
ong
providers in
Ta
nza
n
ia with a rela
tively low access to basic
obstetric ca
re
and a
higher
access to com
p
re
he
nsive
obstetric care.
Most of t
h
e deliveries (62%
) we
re
conducted at c
o
m
p
rehe
nsive
obstetric ce
nters. T
h
e m
a
jo
rity of com
p
lications
(60%
) oc
curred at em
ergenc
y
b
i
rth
i
n
g
cen
t
ers, p
r
im
arily v
o
l
u
n
t
eer facilities [28
]
. Th
e co
st o
f
a sim
p
l
e
v
a
g
i
n
a
l d
e
li
very in
a h
o
s
p
ital at
a
b
a
sic ob
stetric
facility is $
6
.
30
. Th
e co
st of
a d
e
liv
ery i
n
an
em
erg
e
n
c
y clin
ic is $
1
2
.
30
. Th
e co
st fo
r su
rg
ical
d
e
liv
er
y is $69.26
[3
0
]
.
I
m
p
r
o
v
e
d
p
l
ann
i
ng
o
f
r
e
sour
ce allo
catio
n
can
o
n
ly i
m
p
r
o
v
e
serv
ices and
allow
fo
r
m
o
re a
m
o
re a
d
equ
a
te m
i
x
o
f
serv
ices. Priorities h
a
v
e
to
b
e
set b
y
g
a
u
g
i
ng
wh
at serv
ices are
m
o
st i
m
p
o
rtan
t.
Cost-a
nalysis shows
what
res
o
urces a
r
e a
v
a
ilable and
wha
t
resources
ha
ve
bee
n
s
p
ent. This
is necess
a
ry t
o
analyze the efficiency in which res
o
urces
have
bee
n
al
l
o
cat
ed. A
b
out
$0
.8
4
was s
p
e
n
t
pe
r i
n
di
vi
d
u
al
f
o
r
m
a
t
e
rnal
ser
v
i
ces an
d t
o
t
a
l
cost
s
of
p
r
eg
na
ncy
we
re a
b
ou
t
$2
0
pe
r p
r
e
g
nancy
[
30]
.
Al
l
o
cat
i
on
o
f
re
s
o
u
r
ces i
s
essen
tial in
t
h
is curren
t
g
l
ob
al eco
no
m
i
c climate where
money is
lim
ited
.
Safeg
u
a
rd
i
n
g
t
h
e ch
ildren
o
f
Tan
zan
ia is a p
r
iority fo
r so
m
e
fo
u
n
d
a
tion
s
. Th
e Bill a
n
d
Melind
a
Gates Fou
n
d
a
tio
n in
co
m
b
in
atio
n
with
t
h
e
Wo
rl
d
Health
Org
a
n
i
zation
(WHO)
o
f
fers a
gran
t t
o
streng
then
the
matern
al-ch
ild
h
ealth
care in
Africa. Th
e
g
r
an
t is wo
rt
h
$3
5,096
,9
13
and
is d
i
stribu
ted th
roug
hou
t a t
e
rm
o
f
si
x y
ears
an
d t
w
o
m
ont
hs
[2
7
]
.
Th
e n
e
ed
fo
r glo
b
a
l reform o
f
h
ealth
p
o
licy is ev
id
en
t in
the co
st o
f
h
ealth
care and problem
s
facing
Tanza
n
i
a
’s
o
b
s
t
et
ri
cal
po
pul
at
i
on.
Gl
obal
e
f
f
o
rt
s s
u
c
h
as
grants like t
h
e
WHO grant a
n
d t
h
e efforts
by the Bill
and Melinda
Gates Foundation acce
ntuate t
h
e nee
d
for
fut
u
re allocations.
6.
CO
NCL
USI
O
N
Health ca
re
re
form
is necess
a
ry in the
global m
a
rket
as without reform
,
diseases such as Ebol
a
,
Ch
o
l
era, an
d ob
stetrical prob
l
e
m
s
will co
n
t
i
n
u
e
to
ex
is
t in
th
ird-world
cou
n
t
ries,
u
lti
m
a
t
e
ly affecting
t
h
e
US
as these
disea
s
es find t
h
eir
way across i
n
ternationa
l
b
o
r
d
ers
.
T
h
e
nu
r
s
i
ng
sh
ort
a
ge
and
n
u
r
s
i
n
g f
acul
t
y
sho
r
t
a
ge s
h
oul
d be a
pri
m
ary
focu
s f
o
r t
h
e IOM
an
d
ot
her a
g
enci
es t
o
de
vel
o
p bet
t
er m
e
t
hod
s o
f
t
r
ai
ni
n
g
nu
rses a
n
d rec
r
ui
t
i
ng
n
u
rses
f
o
r t
h
e p
r
ofessi
on
. A
u
t
o
n
o
m
y
in practice for
the em
ergency
NP is a
necessi
ty for
th
e adv
a
n
cem
en
t o
f
t
h
e pro
f
essio
n
and
fo
r t
h
e prov
isio
n
of care in
bo
th
ru
ral an
d
m
e
tro
p
o
litan
settings. No
t
o
n
l
y d
o
em
erg
e
n
c
y NPs p
r
o
v
i
d
e
a h
i
g
h
q
u
a
lity
of
ca
re, NPs also
sp
end
m
o
re ti
me with
patien
t
s an
d
cont
ri
b
u
t
e
t
o
t
h
e pri
m
ary
pro
v
i
d
e
r
base t
h
at
i
s
dwi
ndl
i
ng i
n
n
u
m
b
ers. I
n
o
r
de
r f
o
r em
ergency
nu
rs
e
p
r
actitio
n
e
rs to
m
eet
th
eir fu
ll p
o
t
en
tial, qu
ality care
m
u
st
b
e
p
r
ov
id
ed, b
u
t
NPs m
u
st b
e
g
i
v
e
n
th
e au
ton
o
m
y
to
p
r
o
v
i
d
e
care in
settin
g
s
b
o
t
h
ru
ral and
metro
p
o
litan
.
NPs con
t
ri
b
u
t
e to
th
e care o
f
b
o
t
h
urg
e
n
t
an
d
n
o
n
-
ur
ge
nt
pat
i
e
nt
s, set
t
i
ng st
an
dar
d
s o
f
care
hi
ghe
r t
h
a
n
ever
wi
t
h
m
o
re t
i
m
e
spent
at
bedsi
d
e
,
l
a
ym
an’
s
expl
a
n
at
i
o
ns, a
n
d
ext
e
nsi
v
e
d
i
schar
g
e t
eac
hi
ng
. T
h
e
r
e i
s
n
o
one
a
n
swe
r
t
o
s
o
l
v
i
n
g
t
h
e
s
h
o
r
t
a
ge
o
f
pr
o
v
i
d
e
r
s
in
th
e em
erg
e
n
c
y settin
g. Emerg
e
n
c
y
NPs are trai
n
e
d to
h
a
nd
le
b
o
t
h
em
erg
e
n
t
and
n
o
n
-
urg
e
n
t
cases.
Ev
id
en
ce-b
a
sed
p
r
actice an
d
a co
mm
i
t
m
en
t
to
th
e
p
r
o
f
essio
n
pu
t em
erg
e
n
c
y NPs i
n
a
p
o
s
ition
t
o
h
e
lp
ease
the s
h
ortage
of the
prim
ary care
pr
ovi
der
i
n
t
h
e
US em
erge
ncy
r
o
om
.
ACKNOWLE
DGE
M
ENTS
Thi
s
wo
r
k
was
sup
p
o
rt
e
d
i
n
p
a
rt
by
Tec
h
nol
ogy
a
n
d
Heal
t
h
care S
o
l
u
t
i
o
ns,
I
n
c. i
n
M
i
ssi
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i
ppi
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I
S
SN
:2252
-88
06
IJP
H
S
V
o
l
.
4,
No
. 1,
M
a
rc
h 20
1
5
:
2
7
– 36
36
BIOGRAP
HI
ES
OF AUTH
ORS
Ms. Cher
y
l
Ann Alexander is a graduate of
the Univers
i
t
y
of P
h
oenix where s
h
e
earned a
dual M
a
s
t
er’s
d
e
gree
in Heal
th
care Adm
i
nis
t
ra
tion and Nursin
g, and she is currently
a
doctoral candid
a
te and will grad
uate soon. She
i
s
Chairm
an of the Board of Technolog
y
&
Health
car
e Solutions, Inc., a non
profit research
and consultant
f
i
r
m
located in Gr
eenwood,
MS, US, which promotes techn
o
log
y
solu
tions
as methods to reduce
costs and errors in
healthcar
e management and improve quality
car
e.
She has extensive clin
ical knowledge in a
wide variety
of
clinical backgr
ounds, and a
f
i
rm grasp of engineer
ing and technolo
g
y
concep
ts throug
h continuing
edu
cation and work
shops. She is a member of both engineering
and
healthcare organizations, a
nd is working as managing editor for a leading
journal in
engineering.
Dr. Lidong
Wan
g
is an
Associate Professor in
the Department
of
Engi
neering Technolog
y
at
Mississippi Valley
State Univer
si
ty
, USA. He h
a
d conducted r
e
search at th
e University
of
South Carolina, Ohio State University
,
a
nd Mississippi State University
; and
conducted
projects supported b
y
the D
e
par
t
ment of
Defens
e (DOD), the N
a
tion
a
l Science
Foundation
(NSF), and the
National Aeronautics and
Space
Administration (NASA)
before he moved to
Mississippi Valley
State Univ
ersity
in 2007. His current r
e
sear
ch inter
e
sts include: big data,
biometrics, and radio
frequ
ency
identif
ication
(
R
FID) in medical app
lications
and health
care. He has pu
blished 55 p
a
pers in various
jo
u
r
nals.Dr. Wang
has been
invited
to rev
i
ew
papers b
y
over
10 professional journals. He
ha
s also been invited b
y
four
professional
journals to
a
c
t
as the
i
r guest
e
d
itor.
He h
a
s b
een
the
Editor
-
i
n
-Chief of
the
I
n
terna
tiona
l
Journal of Au
to
mated Iden
tif
ication Technolog
y
(IJAIT) for six
years.
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