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Nurses

On December 15, Rep. Eddie Bernice Johnson (TX-30) introduced HR 3679, The National Nurse Act of 2011.

The legislation, co-led by Rep. Peter King (NY-3), would elevate the existing Chief Nurse Officer of the US Public Health Service, to the National Nurse for Public Health, a new full time leadership position that can focus nationally on health promotion and disease prevention priorities.

Teri Mills, a Certified Nurse Educator at Portland Community College in Oregon and President of the National Nursing Network Organization (NNNO), introduced the idea of a National Nurse in a 2005 NY Times op/ed. Here is an excerpt from that article.

…Nurses are considered the most honest and ethical professionals, according to a recent Gallup poll. It’s the nurse whom the patient trusts to explain the treatment ordered by a doctor. It is the nurse who teaches new parents how to care for their newborn. It is the nurse who explains to the family how to comfort a dying loved one.

Now, I’m not saying that a National Nurse will become a household name immediately. But given all that’s at stake – the health of a nation – it seems to me that we should at least give nurses a try.

Continue reading “The National Nurse”

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After Hurricane Katrina hit New Orleans, several hundred thousand refugees descended on Dallas, Houston and other Texas cities. Many of them needed medical care. Unfortunately, Texas wasn’t prepared.

If a natural disaster hit Oregon, the victims would have fared much better. The state’s 8,500 nurse practitioners (NPs) are free to come to the aid of people in need of care, with no legal obstruction. In Oregon, nurses with the proper credentials and licensure may open their practices anywhere they choose and operate in the same capacity as a primary care physician without oversight from any other medical professionals. They can draw blood, prescribe medications, and even admit patients to the hospital.

In Texas, which has some of the most stringent regulations in the country, however, a nurse practitioner can’t do much of anything without being supervised by a doctor who must:

  • Not oversee more than four nurses at one time.
  • Not oversee nurses located outside of a 75 mile radius.
  • Conduct a random review of 10 percent of the nurses’ patient charts every 10 days.
  • Be on the premises 20 percent of the time.

Note that under the rubric of “nurse,” there are a host of subcategories. In general, nurse practitioners have the skills to prescribe, treat and do most things a primary care physician can do. They generally must have completed a Registered Nurse and a Nurse Practitioner Program and have a Masters or PhD degree. In addition, there are physician assistants, registered nurses, licensed vocational nurses, emergency medical technicians, paramedics and army medics. In most states, each of these categories has its own set of restrictions and regulations, delineating what the practitioners can and can’t do.

Continue reading “Why Not a Nurse?”

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All of us have been to fast food establishments. We go there because we are in a hurry and it’s cheap. We love the convenience. We expect that the quality of the cuisine will be several rungs lower than fine dining.

We now have a fast medicine option available to us. Across the country, there are over 1000 ‘minute-clinics’ that are being set up in pharmacies, supermarkets and other retail store chains. These clinics are staffed by nurse practitioners who have prescribing authority, under the loose oversight of a physician who is likely off sight. These nurses will see patients with simple medical issues and will adhere to strict guidelines so they will not treat beyond their medical knowledge. For example, if a man comes in clutching his chest and gasping, the nurse will know not to just give him some Rolaids and wish him well. At least, that’s the plan.

Primary care physicians are concerned over the metastases of ‘minute-clinics’ nationwide. Of course, they argue from a patient safety standpoint, but there are powerful parochial issues worrying physicians. They are losing business. They have a point that patients should be rightly concerned about medical errors and missed diagnoses at these medical care drive-ins. These nurses, even with their advanced training, are not doctors. It is also true serious or even life threatening conditions can masquerade as innocent medical complaints and might not be recognized by a nurse who treats colds and ankle sprains.

Continue reading “Minute Clinics Threaten Doctors: Who Wins?”

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The sad case of Kimberly Hiatt, a Seattle nurse who committed suicide months after being disciplined for administering a fatal dose to an infant, is starting to make the rounds. Josephine Ensign, for example, concludes her blog post on this by saying:

I am left with many questions. Why was the nurse treated so differently from the dentist or physician at the same hospital for similarly serious medication errors? If one in three hospital patients in the US experiences serious preventable adverse events and we know that it’s “the system, stupid,” why are most of our efforts put into educating patients to advocate for safer care? If nurses are simultaneously being told by hospital administrators to report errors and then facing serious retribution for making honest unintentional mistakes . . . what do I teach my students to do?

We can never know, of course, whether the suicide was related to the incident itself, the disciplinary action, or indeed, some other aspect of Hiatt’s life. But the sequence of events will cause many to draw the connection between the way Hiatt was treated after the accident and her death. In any event, though, the ambiguity as to whether or not it was connected does not take away from the kinds of questions raised by Ensign. Continue reading “I Wish We Were Less Patient”

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How many nurses does it take to care for a hospitalized patient? No, that’s not a bad version of a light bulb joke; it’s a serious question, with thousands of lives and billions of dollars resting on the answer. Several studies (such as here and here) published over the last decade have shown that having more nurses per patient is associated with fewer complications and lower mortality. It makes sense.

Yet these studies have been criticized on several grounds. First, they examined staffing levels for hospitals as a whole, not at the level of individual units. Secondly, they compared well-staffed hospitals against poorly staffed ones, raising the possibility that staffing levels were a mere marker for other aspects of quality such as leadership commitment or funding. Finally, they based their findings on average patient load, failing to take into account patient turnover.

Last week’s NEJM contains the best study to date on this crucial issue. It examined nearly 200,000 admissions to 43 units in a “high quality hospital.” While the authors don’t name the hospital, they do tell us that the institution is a US News top rated medical center, has achieved nursing “Magnet” status, and, during the study period, had a mortality rate nearly 40 percent below that predicted for its case-mix. In other words, it was no laggard.

As one could guess from its pedigree and outcomes, the hospital’s approach to nurse staffing was not stingy. Of 176,000 nursing shifts during the study period, only 16 percent were significantly below the established target (the targets are presumably based on patient volume and acuity, but are not well described in the paper). The authors found that patients who experienced a single understaffed shift had a 2 percent higher mortality rate than ones who didn’t. Each additional understaffed shift carried a similar, and additive, risk. This means that the one-in-three patients who experienced three such shifts during their hospital stay had a 6 percent higher mortality than the few patients who didn’t experience any. If the FDA discovered that a new medication was associated with a 2 percent excess mortality rate, you can bet that the agency would withdraw it from the market faster than you could say “Sidney Wolfe.”

The effects of high patient turnover were even more striking. Exposure to a shift with unusually high turnover (7 percent of all shifts met this definition) was associated with a 4 percent increased odds of death. Apparently, patient turnover – admissions, discharges, and transfers – is to hospital units and nurses as takeoffs and landings are to airplanes and flight crews: a single 5-hour flight (one takeoff/landing) is far less stressful, and much safer, than five hour-long flights (5 takeoffs/landings). Continue reading “Nurse Staffing, Patient Mortality, And a Lady Named Louise”

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If you have been at your nursing job for a while, you’ve probably almost forgotten.

Forgotten what it was like to come in to the healthcare system you now work for and realize there are hundreds of new protocols for you to learn and adhere by as a nurse. After years of routine, you now go about your day as if you actually have some choice in the way you give care.

At one point you probably did. I was not around during this age of nursing. The age when we had autonomy. Freedom to practice. Freedom to be innovative.

Today, I am somewhat saddened by the current state of the nursing profession. Don’t get me wrong: I LOVE what I do. I am so thankful for the opportunities set before me.

But whatever happened to “nursing judgment”? Or “nursing decision”?

I can’t tell you how much recently I’ve heard the phrase, “It is hospital policy that…” “You can’t do that, it is protocol that…”

I understand the need for protocols. They help us in the case that something goes wrong and the hospital gets sued. Did the nurse adhere to the protocol? If not, they will be subject to disciplinary action and take the fall. If something goes wrong and there is no protocol, the hospital can say in its defense: “There is now a protocol in place.”

Maybe a less cynical need for protocols: promote and regulate evidenced-based practice among nurses. Evidenced-based practice was developed for a reason: it brings good outcomes and protects the patients.

Even so, to me it seems we are being protocoled to extinction.

Continue reading “Nurses: Protocol -ed to Extinction?”

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Last week, we highlighted an unintended consequence of the Affordable Care Act: it will dramatically worsen an already gaping mismatch between the demand for and the supply of physician services in the US. Put simply, there aren’t enough white coats out there to care for 32 million Americans who will obtain health insurance coverage for the first time as a result of the new law. It’s not even close.

We also speculated that the recommendations made by the American Association of Medical Colleges to address the burgeoning crisis will not work. The AAMC wants Congress to increase the number of Medicare-funded medical residency training slots—essentially, to increase the pipeline for new physicians. This isn’t a bad idea except that Congress is gridlocked on a good day, bitterly divided on all things health reform, and in no mood to enact spending programs of any sort.

That brings us to an alternative solution, proposed recently by the Institute of Medicine. In a report titled, The Future of Nursing: Leading Change, Advancing Health, the IOM concluded that the best way to meet the coming tidal wave of demand for medical services is through a sweeping expansion in the roles and responsibilities of nurses.

Reasoning that nurses are cheaper and quicker to produce than doctors, the IOM recommended the implementation of incentive programs which would assure that 80% of nurses have a bachelor’s degree within 10 years, and that 10% of such nurses enter advanced degree programs. It recommended further that nurses should assume central roles in redesigned, team-based care systems, and that regulatory and institutional obstacles, including limits on nurses’ scope of practice, should be removed so that advanced practice registered nurses (APRNs, including nurse practitioners) can practice more freely. This includes increasing their power to prescribe drugs.

Continue reading “Physicians, Nurses and the Coming Transformation of our Health System”

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Pasquale

The recent City of Ontario v. Quon decision has had a mixed reception among privacy advocates. Though many are disappointed that employees’ privacy rights have once again been narrowed, some have discerned helpful dicta in the case. However, I worry that, whatever the drift of thought among swing justices, economic imperatives and cultural shifts will mean a lot less privacy in the workplace of the future. Health care in particular offers a few interesting bellwethers.

As an opinion piece by Theresa Brown explains, maintaining proper staffing levels in hospitals is becoming increasingly difficult. Surveillance systems are offering one way to address the problem; work can be performed more intensively and efficiently as it is recorded and studied. But such monitoring has many troubling implications, according to Torin Monahan (in his excellent book, Surveillance in a Time of Insecurity):

The tracking of people [via Radio Frequency Identification Tags] represents a . . . mechanism of surveillance and social control in hospital settings. This includes the tagging of patients and hospital staff. . . . When administrators demand the tagging of nurses themselves, the level of surveillance can become oppressive. . . . [because nurses face] labor intensification, job insecurity, undesired scrutiny, and privacy loss. . . . To date, such efforts at top-down micromanagement of staff by means of RFID have met with resistance. . . . One desired feature for nurses and others is an ‘off’ switch on each RFID badge so that they can take breaks without subjecting themselves to remote tracking. (122)

Like the “nannycam” employed by many a wary parent, the nurse-cam may be seen as a way to protect the vulnerable. It may also increase the accuracy of evidence in malpractice cases. On the other hand, inserting a tireless electronic eye to monitor what is already an extremely stressful job may create many unintended consequences, or deter people from going into nursing altogether. Even advocates of pervasive surveillance recognize these difficulties. Continue reading “RFID Tags for Nurses. Then Everybody?”

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Twenty-eight states are now engaged in a heated debate over the difference between a doctor and a nurse: Legislators in these states are considering whether they should let a nurse practitioner (NP) with an advanced degree provide primary care, without having an M.D. looking over her shoulder.  To say that the proposal has upset some physicians would be an understatement. Consider this comment on “Fierce HealthCare”:

“An NP has mostly on the job training…they NEVER went to a formal hard-to-get into school like medical school,” wrote one doctor.

“I have worked with NPs before, and their basic knowledge of medical science is extremely weak. They only have experiential knowledge and very little of the underpinning principles. It would be like allowing flight attendants to land an airplane because pilots are too expensive. HEY NURSIE, IF YOU WANT TO WORK LIKE A DOCTOR…THEN GET YOUR BUTT INTO MEDICAL SCHOOL AND THEN DO RESIDENCY FOR ANOTHER 3-4 YEARS. NO ONE IS PREVENTING YOU IF YOU COULD HACK IT!” [his emphasis]

Fortunately, not all physicians exhibit the same degree of rancor. Some support the movement. Another reader notes the commenter’s emphasis on just how brutal med school  can be: “The anger reflected in the previous comments reveals not only the writers’ ignorance of scholastic achievement required of Nurse Practitioners, but mainly their fear that NPs will not be under physicians’ control…Many older doctors’ schooling and experience was conducted in punitive ways, sacrificing self esteem. It seems that anything less, isn’t sufficient.”

Continue reading “Nurseanomics”

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THCB reader CARISSA PILLOW, an RN, is one of many readers who objected to the tone of the satirical post “Let’s Pay Nurses Minimum Wage.” Carissa writes:

“Dear Mr. Angry, I just wanted to take a moment to express my sincere disappointment. Yep, I’m a nurse. Yep, I got it, you were trying to be funny, with some witty satire. Yep, I see that you were trying to point out how backwards it is to pass legislation “outsourcing” nursing. But, by making a funny funny post, what you did was perpetuate the ongoing misconception of what a nurse does. You describe nurses as a group of butt wiping, overpaid babysitters with skills the equivalent of retail clerks. And while yes, in my 13 years of nursing experience I have done my fair share of butt wiping and babysitting, my daily work involves so very much more than the public understands. So let me clarify my job description for you and for the American public that you have misinformed. In my career I have: Sat by a patient as the only person in the room while they met their maker, and provided dignified post mortem care for them; Given a 40 year old wife the news that her husband had suffered a massive heart attack and was recovering from a cardiac cath procedure that saved his life for the third time; Told a hospitalist the orders that she needed to write for a patient suffering from Diabetic Ketoacidosis; Helped countless doctors sort through the diagnostics on their patients and helped make critical decisions in their patients’ care; Provided critical information to doctors during their patients’ sudden onset of cardiac dysrhythmias; Run countless codes; Prayed with families and patients prior to some very frightening surgeries; Packed countless gaping abdomenal wounds; Given countless doses of Morphine, Zofran and Insulin; Spotted critical errors and omissions in care and brought them to the attention of the doctor responsible for immediate correction; Informed families of impending brain death of their loved ones; Continue reading “Commentology: Dear Mr. Angry”

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MASTHEAD


Matthew Holt
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Vikram Khanna
Editor-At-Large, Wellness

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Michael Millenson
Contributing Editor










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