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America’s Nursing Crisis

Many of the nation’s nurses understandably erupted in anger when the co-hosts of ABC’s The View mocked Miss America contestant Kelley Johnson for her pageant-night monologue about being a nurse — and for wearing scrubs and a “doctor’s stethoscope” (their words) in the talent competition. The co-hosts, Joy Behar and Michelle Collins, have since apologized, especially for implying that only doctors use stethoscopes. “I didn’t know what the hell I was talking about,” Behar later said.

It would be easy to attribute this episode solely to the ignorance of some TV personalities, but as most nurses know, the problem goes far deeper. The fact is that much of the nation doesn’t really understand nursing, either.

It’s true that the public rates nursing in Gallup surveys as the most honest and ethical profession. Yet it’s unlikely that most Americans understand the range of critically important roles that nurse’s play across the health care continuum, from health promotion, prevention, and research, to palliative and hospice care.

How many Americans know that patients who obtain organ transplants will have far more contact with – and obtain more hands-on care from – a transplant nurse than a surgeon? Or that two-thirds of all anesthetics given to US patients are delivered by certified registered nurse anesthetists, rather than anesthesiologists with medical degrees?

How many Americans are aware of the role that nurses and nurse practitioners play in advancing the health of communities by addressing some of the root causes of poor health? In Philadelphia, PA, the 11th St. Family Health Services, a nurse-managed clinic, learned through studies that nearly half of the clinic’s adult patients had undergone four or more adverse childhood experiences, such as physical and sexual abuse, that are closely linked to chronic illness later in life.
A resulting focus on preventing and treating the effects of these traumas is now a hallmark of the clinic’s care.

In the end, how many Americans on their own could summon up this description of nursing by Sandy Summers, a master’s degree nurse, and co-author of Saving Lives: Why the Media’s Portrayal of Nursing Puts Us All At Risk: “Nurses practice in high-tech urban trauma centers and in vital health programs for poor mothers in bayou swamps. They work in leading research centers and in disaster zones. Nurses monitor and manage patient conditions, prevent deadly errors, provide skilled emotional support, perform key procedures, and work for better health systems.”

Given the breadth of contributions that nurses make, it’s little wonder that the Institute of Medicine (now the National Academy of Medicine) declared in a seminal 2010 report that nurses should “lead in the improvement and redesign” of the nation’s health care. But the report pointed to several hurdles that would have to be overcome for that to happen. These are hurdles that wouldn’t exist, if the nation truly understood the importance of nursing in health and health care.

Consider the role of advanced practice registered nurses, those with masters or doctoral degrees. These include nurse practitioners, who are trained to take health histories and perform physical exams; diagnose and treat acute and chronic illnesses; prescribe and manage medications and other therapies; order and interpret lab tests and x-rays; and provide health teaching and counseling.

Those are the skills and capabilities that could help redress the lack of care in hundreds of medically under served areas across the country – or alleviate what is frequently couched as a “doctor shortage.” And in fact, under current law, nurse practitioners can practice independently and to the full extent of their training in 21 states and the District of Columbia.

But in more than half of the rest of the states, so-called scope of practice laws limit the breadth of nurse practitioners’ practice,or require them to be linked to, or even supervised, by a physician. There, nurse practitioners cannot prescribe controlled substances, such as medications for attention deficit and hyperactivity disorder, unless they “collaborate” with or are supervised by a physician. In states like Michigan and Oklahoma, nurse practitioners cannot prescribe physical therapy for patients, or sign death certificates. In some states like Alabama, they not only can’t practice independently of physicians, but they also can’t even sign handicap-parking waivers or workers’ compensation claims.

Following the release of the IOM report, a Campaign for Action to address many of these challenges was launched by the Center to Champion Nursing in America, an initiative of AARP, the AARP Foundation and the Robert Wood Johnson Foundation. Under the campaign, 51 state coalitions are tackling issues such as scope-of-practice and advancing the level of training and education of the nation’s nurses. A dashboard on the campaign’s web site shows that the progress has been mixed.

In areas where nurses have their own power to effectuate change, such as advancing their own education, there have been major strides.As of 2013, nearly 15,000 nurses were enrolled in Doctor of Nursing Practice programs, more than double the number in 2010.

But in areas where others are making decisions about nurses’ roles, progress is scant or nonexistent. Although the IOM report recommended that more leadership positions in health systems should be made available to and filled by nurses, only 5percent of hospital board of directors or trustees had nurses on them in 2014, down from 6 percent in 2011.

Complicated dynamics of professional rivalries, gender discrimination (more than 90 percent of nurses are female), and even inertia, clearly lie behind the nation’s inability to make full use of its nursing resources. But another component is surely ignorance, and perhaps even condescension.

Consternation that those forces are still at play clearly motivated the nurses who sent tens of thousands of tweets in protest of The View cohosts’ remarks. Fortunately, patients with first-hand knowledge of the important contributions that nurses make to their health and wellbeing may be better equipped to accord nurses the respect they deserve.

After all, as Kelley Johnson recounted in her pageant monologue, it was one of her grateful patients — an Alzheimer’s sufferer named Joe — who once chastised her for always demurring that she was “just a nurse.” “Although you say it all the time, you are not ‘just a nurse,'” he told her. “You are my nurse, and you have changed my life because you have cared about me.”

“Joe reminded me that day that I’m a lifesaver,” Johnson told the pageant audience. “I’m never going to be ‘just a nurse’.”

Please join the Robert Wood Johnson Foundation on October 2 from 12:15 – 1 p.m. ET for a First Friday Google+ Hangout on Why Nursing is Key to a Culture of Health.  Register here.

Susan Dentzer is the Senior Policy Adviser to the Robert Wood Johnson Foundation.

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Rachel

Hearing that nursing was rated as the “most honest and ethical profession” is very heart-warming and humbling. It reminds me of some of the reasons why I chose nursing.