A Critical Review Of Current Nursing Faculty Practice

PDFlib PLOP: PDF Linearization, Optimization, Protection Page inserted by evaluation version www.pdflib.com – sales@pdflib.com CLINICAL ■ A Critical Review Of Current Nursing Faculty Practice Meghan J. Sawyer, BS, RN Ivy M. Alexander, APRN, MS, CANP Lisa Gordon, BA, RN Linda J. Juszczak, DNSc, MPH, CPNP Catherine Gilliss, RN, MSN, DNSc, FAAN INTRODUCTION PURPOSE To critically examine the current literature on nursing faculty practice, using the National Organization of Nurse Practitioner Faculties (NONPF) Guidelines for Evaluation of Faculty Practice, and to examine faculty practice models’ strengths, weaknesses, and barriers. DATA SOURCES Thirty-five articles describing models of faculty practice were identified through an exhaustive search on CINAHL and Medline. Two NONPF monographs on nursing faculty practice were used as guidelines for the critical review. CONCLUSIONS Faculty practice has become an integral component of faculty-role expectations at many schools of nursing. Workload, especially without adequate compensation, remains a hindrance to practice. The value of faculty practice time and expertise has not been sufficiently demonstrated. Integration of practitioner, educator and researcher roles remains extremely difficult and sometimes elusive. IMPLICATIONS FOR PRACTICE Faculty practice offers many advantages to schools of nursing, including educational and research opportunities for faculty and students, as well as practice sites and affordable community healthcare. Providing health care in the community presents an opportunity for independent and collaborative practice. To fully utilize the great research opportunities provided by faculty practice, more emphasis must be placed on gathering and analyzing descriptive data. KEY WORDS Faculty practice; nursing centers; joint appointments VOLUME 12, NUMBER 12, DECEMBER 2000 Faculty practice has become an integral component of faculty role expectations at many schools of nursing. However, only a few authors have offered specific definitions of faculty practice in their specific settings. This may be because there are many interpretations of the construct of faculty practice and the evolving nature of faculty practice in response to changes in health care. Budden (1994, p. 1241) has defined faculty practice as a “formal arrangement which exists between a clinical setting and a university which allows nurse academics to consult and deliver client care resulting in research and scholarly outcomes.” It may consist of any role, such as consulting, counseling, teaching or care-giving. At the Texas Tech University Health Sciences Center School of Nursing, faculty practice is defined as the “provision of direct or indirect nursing services” as a component of the faculty role (Miller, 1997, p. 10). The National Organization of Nurse Practitioner Faculties (NONPF) Faculty Practice Committee recognizes the definition of faculty practice to include multiple roles, in multiple settings, while using multiple structural and economic models (Marion, 1997). A resurgence of interest in faculty practice has been reflected in a flurry of papers published in recent years. Despite these publications, a clear model of successful faculty practice remains obscure. In an effort to clarify varying aspects of faculty practice, NONPF has published two separate monographs on the topic (Marion, 1997; Potash, & Taylor, 1993). The purpose of this review is twofold: 1) to critically examine the current literature on faculty practice, using the NONPF guidelines for evaluation of faculty practice (Marion, 1997), and 2) to examine the strengths and weaknesses of various models of faculty practice and barriers to their implementation. The NONPF guidelines for evaluation of faculty practice were originally developed by the Faculty Practice Evaluation Subcommittee of the NONPF Faculty Practice Committee. They are designed to provide criteria with which to develop and evaluate faculty practice models (Marion, 1997). The guidelines address five broad areas: a mission with specific goals, faculty role integration, nursing control, fiscal autonomy, and an interest in healthcare outcomes. Faculty practice models were identified through a literature search of the Computerized Index of Nursing and Allied Health Literature (CINAHL) and Medline. Key phrases such as faculty practice, nursing centers and joint appointments revealed thousands of publications. This list was reduced by selecting articles published from 1993 to early 1999. This subset was further culled by reviewing titles and abstracts to select publications describing faculty practice within 511 AUTHORS Meghan J. Sawyer, BS, RN is a PNP student at Yale University School of Nursing; Ivy M. Alexander, APRN, MS, CANP is an Assistant Professor, Yale University School of Nursing, ANP at Yale University Health Services, and a Doctoral Candidate at the University of Connecticut; Lisa Gordon, BA, RN is a FNP student at Yale University School of Nursing; Linda J. Juszczak, DNSc, MPH, CPNP, is a PNP at the North Shore/Long Island Jewish Health System, Department of Pediatrics, Division of Adolescent Medicine; Catherine Gilliss, RN, MSN, DNSc, FAAN, is Dean and Professor, Yale University School of Nursing. Contact Ivy M. Alexander by e-mail at ivy.alexander@yale.edu United States schools of nursing that offer graduate education. The resulting 35 articles were critically reviewed. The present analysis discusses 11 faculty practice models identified through the search. MISSIONS AND GOALS The first NONPF guideline states that institutional models of faculty practice should clearly identify missions, philosophies and goals that are applicable to all aspects of the faculty practice, provide high-quality, cost-effective healthcare and include teaching, research, and service (Marion, 1997). Although specific mission statements were rarely presented in the examined articles, the overall purpose for establishing faculty practice was usually described. The most commonly cited purposes for developing faculty practices are noted in Table 1. Although student and faculty education is of paramount importance to an educational facility, a faculty practice model that does not meet a community’s needs may not remain financially stable and autonomous. To this end, the Vanderbilt University School of Nursing Faculty Practice Plan mission is to improve the health of the community through provision of healthcare services in a scholarly model TABLE 1. PURPOSES CITED FOR DEVELOPING FACULTY PRACTICES IN GRADUATE SCHOOLS OF NURSING IN RELATIVE FREQUENCY OF MENTION • Meet perceived community health needs • Student/faculty education • Student/faculty research • Provide student/faculty practice sites • Generate revenue • Provide a visible nursing experience • Encourage health promotion and maintenance by involving clients and interdisciplinary providers 512 (Spitzer, 1997). The provision of healthcare services is integral to establishing faculty practices, as well as a means to enhance clinical teaching (Mackey, & McNiel, 1997). While the provision of affordable primary health care services is a benevolent reason for establishing a faculty practice (Craig, 1996; Hale, Harper, & Dawson, 1996; Holman & Branstetter, 1997), it is not always the primary mission of a program (Parsons, Felton, & Chassie, 1996). In addition to the traditional nursing center, possibilities for addressing an underserved population’s needs include providing managed care for current ( Jacobson, MacRobert, Leon, & McKennon, 1998) and former Medicaid recipients (Busby et al., 1996; Spitzer et al., 1996; Spitzer, 1997), as well as establishing a nurse practitioner (NP) directed primary care Student Health Center (Hale, Harper, & Dawson, 1996). Education of students and faculty was cited by numerous authors as an extremely important influence in developing a faculty practice. Education was the primary mission of at least one faculty practice (Parsons, Felton, & Chassie, 1996), while nurse-controlled student education was an important factor in others (Hutelmyer, & Donnelly, 1996; Jacobson, MacRobert, Leon, & McKennon, 1998). Establishing a nursing center is thought to provide greater educational opportunities to students (Craig, 1996; Hale, Harper, & Dawson, 1996; Holman, & Branstetter, 1997; Mackey, & McNiel, 1997) while acknowledging that nursing practice is integral to education (Miller, 1997). The preservation and advancement of nursing can be partially accomplished through research (Busby et al., 1996; Spitzer et al., 1996). A nursing center, or other academicbased faculty practice model, can provide student and faculty research opportunities (Craig, 1996; Holman, & Branstetter, 1997; Jacobson, MacRobert, Leon, & McKennon, 1998; Mackey, & McNiel, 1997), generating clinically relevant research that supports and expands primary care knowledge (Hale, Harper, & Dawson, 1996; Parsons, Felton, & Chassie, 1996). Providing practice sites for faculty (Craig, 1996; Hale, Harper, & Dawson, 1996; Holman, & Branstetter, 1997; Jacobson, MacRobert, Leon, & McKennon, 1998; Spitzer, 1997), was not always mentioned as an important consideration for establishing a faculty practice, but remains necessary for faculty practitioners to remain clinically current. Remaining current with healthcare trends can be difficult when a faculty commitment does not allow time for clinical practice, or provide an opportunity to practice within a specialty. At least one educational institution offers several different sites as opportunities for faculty practice (Busby et al., 1996; Richie et al., 1996; Spitzer, 1997). This model provides faculty with specialty practice opportunities, thus enhancing knowledge that can be transferred to students and promoting further research. Although faculty practice would not be possible in many instances if financial issues were not addressed, revenue and/or salary supplement were identified as an important aspect of the missions and goals of few faculty practices ( Jacobson, MacRobert, Leon, & McKennon, 1998; Parsons, Felton, & Chassie, 1996; Spitzer, 1997). Other, less frequently mentioned reasons for establishing faculty practice include: the importance of health promotion and mainte- JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS CLINICAL ■ nance through client involvement (Hale, Harper, & Dawson, 1996; Jacobson, MacRobert, Leon, & McKennon, 1998), establishing a visible nursing experience ( Jacobson, MacRobert, Leon, & McKennon, 1998), and the ability to impact legislative regulatory processes to remove barriers to care (Spitzer, 1997). FACULTY ROLE INTEGRATION The second guideline that NONPF puts forth is that of faculty role integration. This guideline states that a practice needs to integrate the scholarship of teaching, research, and practice, which supports faculty advancement, including promotion and tenure. Institutional support for faculty practice should be reflected in workload and practice revenue distribution. Additionally, the practice should be integrated into the local community, the academic organization, and the overall health care system (Marion, 1997). Although most practice models recognize the need for integrating the scholarship of teaching, research and practice, few clearly address promotion or tenure requirements. The need for integration into the health care system and community is realized. Integration is a financial issue; it is necessary to have community support through usage of faculty practice services for fiscal success. Institutional support regarding workload and distributing revenue is not always apparent. Faculty workload has been identified as a major obstacle to faculty practice (Hutelmyer, & Donnelly, 1996; Nugent, Barger, & Bridges, 1993). Likewise, the lack of financial incentives to compensate for the increase in workload is perceived as a hindrance to faculty practice (Bailey, 1995). Despite recognition that practitioners are often overwhelmed with competing expectations, several recent reports on faculty practice address neither workload nor compensation issues (Hale, Harper, & Dawson, 1996; Holman, & Branstetter, 1997; Jacobson, MacRobert, Leon, & McKennon, 1998; Richie et al., 1996; Zachariah, & Lundeen, 1997). Dissonance resulting from the perceived hardships of faculty practice can be minimized by valuing faculty practice and communicating this value to involved faculty. Establishing school of nursing and faculty practice plan missions that are compatible can also decrease dissonance amongst the faculty. Another way to decrease dissonance is to compensate faculty for their practice time, especially if practice time is in addition to full-time faculty duties. The value of faculty can be reflected in both workload and compensation. Several schools have constructively addressed these issues through contract negotiation and distribution of monies. In more than one instance, contracts were negotiated between the school and clinical agency for the services of faculty members. The members remain employed by the school and are not directly reimbursed by the agencies (McNiel, & Mackey, 1995; Spitzer, 1997). A faculty practice fund can be established for each practicing faculty member, providing a salary supplement for expenses incurred because of faculty practice (McNiel, & Mackey, 1995). Revenue generated from faculty practice can be distributed countless ways. At least one plan distributes net collections to the practitioners directly involved in the delivery of VOLUME 12, NUMBER 12, DECEMBER 2000 care (Spitzer, 1997). Another method is to distribute a portion of the contracted state reimbursement and also reimburse for incurred mileage costs to faculty practice plan members (Craig, 1996). Alternately, faculty can receive supplemental earnings while teaching students in their own practices through a practice plan established as a non-profit, taxexempt corporation (Parsons, Felton, & Chassie, 1996). Faculty practice revenue is sometimes not distributed to the involved faculty. Instead it is used to support the school’s programs (Miller, 1997). Perhaps the best way to evenly distribute workload and avoid overload is to construct faculty practice so that a full-time faculty member’s time can be allocated specifically to either research or clinical practice activities (LaMontagne, Pressler, & Salisbury, 1996). Despite these various efforts to compensate faculty, the time commitment for practice remains difficult. To ensure success, a school of nursing needs a workload distribution plan that balances both practice and academic responsibilities and schedules (Busby et al., 1996). Other methods to decrease dissonance include instituting a time ceiling to ensure that faculty do not work excessive hours (Parsons, Felton, & Chassie, 1996) and providing peer support and mentoring from experienced faculty (Hutelmyer & Donnelly, 1996). Although practice is required for promotion and tenure in most schools, many authors have chosen not to discuss this volatile issue. Other authors describe valuing faculty practice (Busby et al., 1996; Craig, 1996; McNiel, & Mackey, 1995; Parsons, Felton, & Chassie, 1996), but do not identify evaluation criteria. One author addresses the issue as a profound grievance of the faculty and notes that it has not been addressed constructively by the school to the approval of the faculty (Bailey, 1995). The value of faculty practice can be directly communicated (Busby et al., 1996). Merit points can communicate this value when awarded to faculty participating in the faculty practice plan during annual evaluations (Craig, 1996). Likewise, it can be rewarded in the school’s promotion and tenure policies (Busby et al., 1996; McNiel, & Mackey, 1995). In addition, faculty practice can be encouraged (Craig, 1996; McNiel, & Mackey, 1995) or required (Parsons, Felton, & Chassie, 1996) by an educational institution. By not expecting individual faculty members to take part in all areas of scholarship, but rather encouraging those on the tenure pathway to emphasize discovery, integration and teaching, and those on the clinical pathway to emphasize application, integration and teaching (University of Texas-Houston School of Nursing Policies, 1994 as cited in McNiel, & Mackey, 1995), faculty practice can be encouraged while remaining manageable. Additionally, the requirement of faculty practice can be phased in gradually. In this case, tenured and tenure-track faculty are initially given the option of not participating in a faculty practice program. Clinical faculty and tenure-track faculty who join the college after program inception are required to participate in the plan. Over time, all faculty would be expected to participate in the practice plan (Parsons, Felton, & Chassie, 1996). One of the idealistic purposes of faculty practice is to integrate teaching, research, and practice. In reality, this can prove difficult to achieve. Faculty practice at Vanderbilt University School of Nursing is designed to allocate a full513 time faculty member’s time to either research or clinical practice in addition to teaching. The family nurse practitioner (FNP) faculty in the TennCare model at Vanderbilt are required to precept graduate students while delivering primary care to patients. Some of these faculty members are involved with TennCare full-time, while others practice as a percentage of their faculty assignment. For those that are not full-time, this has represented a scheduling problem, as well as problems with role conflicts. For example, a faculty member may be in the midst of a clinical day when a student telephones to ask class subject questions (Busby et al., 1996). To prevent role conflicts between teaching and practice, some faculty have developed their own separate caseloads (Spitzer et al., 1996). Other schools also recognize the importance of integrating these roles. The faculty at the University of WisconsinMilwaukee School of Nursing strive to develop community partnerships at a community nursing center that facilitates integrating service and research, while providing quality, cost-effective care (Zachariah, & Lundeen, 1997). The faculty practice at Texas Tech University Health Sciences Center provides the opportunity for faculty to serve as role models for students, remain current in practice, implement research projects, apply research findings, and retain a link with the community. It also meets a community need by providing continuing education for area nurses (Miller, 1997). Educating students and modeling interdisciplinary collaboration are integral roles of faculty practice at La Salle University (Hutelmyer, & Donnelly, 1996), George Mason University College of Nursing and Health Science (Hale, Harper, & Dawson, 1996), and Vanderbilt University School of Nursing (Spitzer, 1997), thereby integrating practice and education. NURSING CONTROL Nursing control is the next criterion discussed in the monograph. A practice that demonstrates nursing control should reflect the different roles of the advanced practice nurse: independent, collaborative, and interdisciplinary. Additionally, evidenced-based, state-of-the-art nursing practice that reflects nursing’s ethics and theoretical underpinnings should be evident (Marion, 1997). Nursing control is present in a practice that is both operated and evaluated by nurses. Several faculty practice models successfully reflect the various advanced practice nursing roles. Vanderbilt University School of Nursing built its faculty practice plan to provide an interdisciplinary/multidisciplinary approach, incorporating NPs, physician assistants (PAs), certified nurse midwives (CNMs) and physicians, while preparing student healthcare professionals (Spitzer, 1997). The plan provides several independent, collaborative and interdisciplinary opportunities for faculty practice, including providing primary care to women, managed care to former Medicaid recipients and psychiatric services (Busby et al., 1996; LaMontagne, Pressler, & Salisbury, 1996; Richie et al., 1996; Spitzer et al., 1996; Spitzer, 1997). Likewise, the joint appointment/reverse joint appointment system at La Salle University provides various specialty practice opportunities (Hutelmyer, & Donnelly, 1996). Faculty 514 practice at Texas Tech University Health Sciences Center includes direct care, consultation, management, education and staff development (Miller, 1997), incorporating autonomous, collaborative, and interdisciplinary roles. The University of South Carolina also incorporates multiple roles, providing faculty with autonomous practice opportunities and encouraging collaboration. Contracts have included consultation, coordination and provision of nursing services, and conduction of continuing education and staff development programs (Parsons, Felton, & Chassie, 1996). In addition to fully realizing the multifaceted roles and abilities of the advanced practice nurse, there are advantages to collaborative and interdisciplinary work. Collaboration can be a valued aspect of a practice plan, such as the case of George Mason University College of Nursing and Health Science, which offers interdisciplinary services from NPs, PAs, social workers, health educators, psychologists, counselors and certified fitness professionals (Hale, Harper, & Dawson, 1996). A collaborative interdisciplinary approach can also aid in balancing power within the healthcare system. For example, organizational power can value both nursing and interdisciplinary research such as that seen in the University of Wisconsin-Milwaukee School of Nursing community nursing center faculty practice. This practice employs a variety of healthcare professionals, such as advanced practice nurses (APNs), physicians and others. This design is thought to eliminate a struggle with other providers who may serve as gatekeepers for access to research participants (Zachariah, & Lundeen, 1997). Indications of evidence-based, state-of-the-art nursing practice are less frequently identified in recent literature, most likely because excellence in practice is the standard. Recognizing the importance of evaluating practice and outcomes, the fifth guideline, discussed below, is dedicated to this topic. Providing healthcare to various underserved populations and maintaining access to care represents the overarching nursing mission to serve those in need, a direct reflection of nursing ethics and theoretical underpinnings. Vanderbilt University School of Nursing’s faculty practice program does this by serving historically marginalized populations: former Medicaid recipients, persons with mental health difficulties and women (Busby et al., 1996; LaMontagne, Pressler, & Salisbury, 1996; Richie et al., 1996; Spitzer et al., 1996; Spitzer, 1997). Likewise, each of the faculty practices noted in the literature increases access to services and many cite meeting community needs as a specific goal. These three aspects of nursing — multifaceted roles, stateof-the-art practice, and reflection of nursing ethics and theoretical perspective — all contribute to achieving nursing control. Because having nursing control supports independence and autonomy, it is reasonable to think that faculty involved in faculty practice would feel a greater sense of autonomy. Interestingly, this has not been borne out, as research comparing the sense of autonomy between faculty participating in faculty practice and those not participating did not differ (Bailey, 1995). JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS CLINICAL ■ FISCAL STABILITY A faculty practice model should be fiscally self-sufficient — able to support the faculty practice model mission and follow a developed business plan (Marion, 1997). This is probably the most decisive of the guidelines suggested by NONPF. Many schools struggle with fiscal sustainability after their original grants are depleted. Some make concessions and join other established practices, ranging from the University of South Carolina joining its School of Medicine faculty practice plan (Parsons, Felton, & Chassie, 1996) to negotiated private sector partnerships (Hutelmyer, & Donnelly, 1996; Mackey, & McNiel, 1997). Others have established contracts with state or federal government to become primary care providers for underserved populations (Busby et al, 1996; Spitzer et al., 1996; Spitzer, 1997). These methods attempt to ensure financial stability to support continuing faculty practice. Another successful option is to develop a partnership with the university to provide primary healthcare for students (Hale, Harper, & Dawson, 1996). Six specific strategies (Table 2) are suggested for achieving financial survival and fiscal success for independent nursing faculty practice (Holman, & Branstetter, 1997). The practice plans that have maintained fiscal sustainability have accomplished many of these six strategies. HEALTHCARE OUTCOMES Finally, the monograph calls for evaluation of healthcare outcomes. This includes gathering descriptive data, including client demographics, payment and costs, and faculty and student interaction time. Client health, satisfaction, and cost outcomes should also be documented. Lastly, a quality assurance plan should be in place (Marion, 1997). A few faculty practice plans have systems in place to collect such data. The University of Texas-Houston Health Science Center model installed a medical information system in 1994 to improve patient care, enhance research efforts and improve student education. The system has increased provider access to test results and facilitated research studies conducted by students, faculty, and other practitioners. Patient care has been impacted by studies on utilization of benefits, health beliefs, patient satisfaction and compliance, and smoking cessation efforts (Mackey, & McNiel, 1997). George Mason University College of Nursing and Health Science has closely monitored the number of student visits, types of visits, categories of students seen, and types of illnesses and injuries diagnosed, among other things. These data are evaluated each month by the director of the Student Health Center and quarterly by the Advisory Committee. In addition, the Center serves as a base for developing and implementing health promotion and maintenance programs conducted by students and faculty (Hale, Harper, & Dawson, 1996). Physical parameters related to particular medical conditions are measured by the multidisciplinary team at Northern Arizona University. Further evaluation is planned to explore the cost-effectiveness of care, prevention of illness, hospitalization and days lost from work or school, as well as the effect of community-based clinical experiences on student learning (Craig, 1996). In addition, Northern Arizona University, George Mason University College of Nursing and Health Science, and Vanderbilt University School of Nursing all actively measure and evaluate patient satisfaction, documenting success (Craig, 1996; Hale, Harper, & Dawson, 1996; Spitzer, 1997). Quality improvement, which tracks evidence-based, stateof-the-art faculty practice, has not historically been addressed as a fundamental aspect of healthcare, yet it is an important consideration for a faculty practice plan. Vanderbilt University School of Nursing has measured improvements in the quality and cost of healthcare when comparing their services with other providers (Spitzer, 1997). As part of its clinic’s objectives, Arizona State University notes the need for evaluating the quality of services the providers offered TABLE 2. STRATEGIES SUGGESTED FOR ACHIEVING FINANCIAL SURVIVAL AND FISCAL SUCCESS FOR INDEPENDENT NURSING FACULTY PRACTICE (Data fram Holman, & Branstetter, 1997). 1) Nurses must collect a market price for the services rendered. • Collect fees at the time of service • Involve staff in this decision to ensure an understanding of its importance 2) A realistic business and management plan needs to be developed • Especially important for practices evolving from grant supported to self-sustaining status 3) Develop effective marketing strategies • Need to reach a targeted population • Consult community leaders, interested citizens and professional groups and agencies to foster acceptance of nurses as primary care providers 4) Obtain profitable contracts and agreements 5) Cooperation with other agencies is useful. • addresses local health care needs • increases likelihood of maintaining a profitable outcome 6) Work to obtain “provider” status with selected health maintenance organizations (HMOs) • Increase assurance of reimbursement for services VOLUME 12, NUMBER 12, DECEMBER 2000 515 CLINICAL ■ (Holman, & Branstetter, 1997), but does not offer evidence of its evaluation criteria. A continuous quality improvement (CQI) committee might be best for today’s health care environment because CQI builds upon the traditional quality assurance concepts and methods while emphasizing the organization and using data to identify opportunities for improvement (Maddox, 1999). CONCLUSIONS & IMPLICATIONS FOR THE FUTURE The NONPF Guidelines provide a valuable framework for evaluating faculty practice. While faculty practice requirements remain an individual school’s choice, many issues are common across settings. In addition to the general fiscal issues facing any business, key issues challenging the future of faculty practice are the same ones that have existed from its inception. Workload, especially without adequate compensation, remains a hindrance to practice. Likewise, the value of faculty practice time and expertise has not been sufficiently demonstrated. Integration of practitioner, educator and researcher roles remains extremely difficult and sometimes elusive. Although many of these issues have repeatedly been discussed, they remain unresolved. Faculty practice offers many advantages to schools of nursing, including educational and research opportunities for faculty and students, as well as practice sites and affordable community healthcare. Providing health care in the community presents an opportunity for independent and collaborative practice. To fully utilize the great research opportunities provided by faculty practice, more emphasis must be placed on gathering and analyzing descriptive data. Successful faculty practice in schools of nursing can be achieved. Successful and unsuccessful programs, and both positive and negative aspects of models, should be disclosed. Discussion of these important aspects provides an opportunity for developing stronger, sustainable practice models. Such models will further increase autonomous practice opportunities and access to healthcare for all. survival. Nursing Economics, 15(5), 248-252. 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