March 10, 2023

Opinion | When Nurses Lead: The Adapted Public Utility Model

Opinion | When Nurses Lead: The Adapted Public Utility Model

Cover image artist: Rebekah Chickering

Disclaimer: The views and opinions expressed in this article are those of the writer and do not necessarily reflect the views or positions of

From Despair to Hope

Workshops on retention, creating resilience and combating burnout flood my inbox while nurses fight for staffing ratios to protect themselves and their patients.  But I am not interested in these topics.  I want to focus on what has caused so much suffering and demoralization.

During the Great Pandemic Pause, I realized that my entire career had been spent teaching civility, teamwork and leadership in order to create a truly safe practice environment. But despite all my efforts, conditions for patients and providers were even worse than when I started.  I was discouraged and despondent – until I met Dr. John Silver whose work gave me more hope than I had felt in decades. Together with a team of nurses, we started  

Structure > Process > Outcomes

A famous systems researcher theorized that structure dictates process which in turn dictates outcomes (Donabedian). Efforts to improve the outcomes of burnout, short staffing, adverse events, etc. are futile and nurses are leaving- because thus far, we have only focused on the processes.  What our country needs is a new structure that rewards wellness, quality, and outcomes to replace our current structure that incentivizes disease, quantity and volume. 


One day a CFO was taking me on a tour of his town’s new 350 bed hospital when I asked, “Who is the major employer in this town?  I didn’t see any industry.”

The CFO answered proudly, “Why we are of course!  Most people work here at the hospital.”

“Well, what is the plan when the community is healthy, and the beds are empty?” I asked.

After a pause he replied, “I don’t understand the question.”

There is no plan. Our current system is not designed to support hospitals when their beds are empty or to prevent illness and disease.  That’s why chronic disease, cancer, depression, diabetes, obesity, etc. have increased and our life span is decreasing.  That’s why we pay more than any other country for mediocre outcomes and nurses are leaving while corporations make millions.  That’s why nothing will change until we change the system.

Goals of the Adapted Public Utility Model

After evaluating health systems all over the world, Dr. Silver found that the system that would meet all 7 of his goals is the Adapted Public Utility Model: equitable access, quality-based care, targeted and evidenced based distribution of resources, equitable and positive outcomes, cost efficiency, social accountability, and nurse led interdisciplinary administration.

(Just for fun, google the goals of the American health care system – because there aren’t any)

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Why Nurse Administered?

Nurses are educated differently than physicians.  They are trained to look at the whole person and to address the cause of illness. Nursing is a service, and caring for patients is aligned with the ethics and values of their profession.  When you align structure to values there is a coherence in the system that releases a tremendous amount of energy: autonomy, power, creativity, and innovation.

What is an Adapted Public Utility?

A public utility is one that provides certain classes of vital services to the public like sewer, water, heat and sanitation.  There is historical precedence for health care as a public utility.  In 1935 Franklin D. Roosevelt said that “if a community is not satisfied with the service rendered…it has an undeniable right to set up it's own governmentally owned and operated service”.  And that is exactly what happened with electricity!

Health as a Vital Service

Imagine that when you receive your utility bill there is another line that says “Health” and that all you pay is one reasonable monthly fee – no insurance, no surprise ambulance bills or copays for diagnostics.  Everything is covered.  Every American would have a trusted provider and healthcare services would be locally determined based on need because each zip code has its own unique challenge.  A system of collaborative care clinics would report to a regional authority (made up of nurses, physicians, educators, community leaders) that would be affiliated with a major university.  Financing would also be enhanced by state and federal funding – but the cost would continually decrease over time because the focus would be on prevention by addressing the social determinants of health (the infrastructure of the health utility system).  The reason we say “adapted” is because this “utility” has a unique administrative structure, a modified and sustainable financing mandate, and a partnership relationship with the communities it serves. 

Until now, health care has thrived as a profitable business and as a commodity. The missing link that would restore balance to our system and power to Nursing is health as a service.  Nurses have a front seat to pain and suffering and recognize that we all have the same pre-existing condition: we are human.  Together we can imagine into being a system that rewards prevention and wellness, unleashes the autonomy of nurses, and changes the downward trajectory of disease in America.  That’s my focus!

Interested? Learn more at

Kathleen Bartholomew, RN, MN uses the power of story and her background in sociology to illuminate the healthcare culture in her presentations, books, and Op-Eds.  For over twenty years she has spoken to nurses, physicians, and leaders about how to nurture relationships that create a culture of safety. Her TEDx talk challenges our covert belief that some people are more important than others.