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Director's Letter

There are currently more than 93,000 nursing personnel working in the Veterans Health Administration, the largest single job category among the nearly 365,000 VA employees. While nurses are central to any healthcare system, they are especially important in a national integrated system like VHA, which serves many smaller communities where physician supply is limited. Advanced practice nurses such as nurse practitioners have become a mainstay of VA primary care and, thanks to newly expanded practice authority, can practice independently in VA facilities in all 50 states. Registered nurses play critical roles in PACT teams as care coordinators providing proactive, team-based care. Most interventions studied by HSR&D, from smoking cessation to preventing healthcare associated infections or falls, to improving functioning of PACTs have nurses at their center. I got fresh insight into the qualities and adaptability of VA nurses at a recent meeting of five teams from across VA who are implementing demonstration projects of PACT Intensive Management, a program of intensive outreach to VA's highest-risk and most challenging patients. Nurses (RNs and NPs) were the critical core of multi-disciplinary teams; they performed home visits, coordinated social and psychiatric support, co-attended specialty care appointments, called family members, and most importantly, became the face of a VA that could be counted on to go the extra mile for our most in-need Veterans.

VA also has a distinguished history of nurse investigators, especially in HSR&D, and helped by the Nursing Research Initiative, a mentored award program more than 20 years old. The articles in this issue highlight the work of some of our best nurse-scientists studying issues central to nursing practice in VA: the roles of nurses in chronic care management, their interaction with telehealth, and their central role in improving patient safety.

Due to their distinct training, and more extensive contact with patients, nurses are in many ways better equipped than physicians to help lead and examine several of the important changes happening in Veteran care: 1) the movement to proactive, team-based care; 2) the evolution from a physician-centric system focused on treating illness to a patient-centered delivery system focused on "whole health;" and 3) the integration of technology into ongoing care. Understanding the full impact of these changes requires going beyond simple measures of medical interventions and outcomes, but requires understanding of how patients communicate with their healthcare team; how best to support patient behavior change; and how to foster stronger engagement with and trust in the healthcare system. It is gratifying to see the contribution of VA nurses and nurse-researchers as VA undergoes this important evolution.

David Atkins, MD, MPH, Director, HSR&D