Paging Doctor Nurse!

Nurse and Lawyer’s dad sent on an article about the IOM report on the future of nursing. It was also discussed on Talk of the Nation this week. The report talks a lot about education for nurses and how advanced-practice nurses can help address the shortage of health care providers expected to worsen when new health care laws take effect.

Lawyer: Well, Nurse may be on track to be one of those nurses with doctorate degrees that the report says we need! So that’s one way to work for change. Get your boots on the ground.

Nurse: The education issue is huge. And divisive. While I agree that more education is good, and it seems reasonable to move towards a standard of a bachelor’s degree for entry-level nursing, it’s also true that some of the best nurses I know have associates’ degrees.

The article talked briefly about the idea of post-graduate clinical residencies for nurses– and I think that is  a very exciting idea. This is already widely practiced in a very haphazard way by hospitals who have various residencies, preceptorships, and externships for new graduate nurses, but there is no standardized way to do it and a nurse can be lisenced without any experience outside of school. Clinical skills and experience are largely obtained in your first nursing job.

Lawyer: Interestingly and mildly tangentially, that is also true of lawyers — though some (and an increasing number of) law schools have clinical programs where students work on real cases under faculty supervision, it’s still standard practice for newbies to have no practical experience. This (along with the student debt problem) accounts for some of the phenomenon of new graduates going so often into big law firm jobs, rather than working for smaller organizations that could really use the help — big firms have the resources to provide the training that isn’t required as part of the degree.

Nurse: Finally, the standard of education varries greatly. Some places are really pushing for NP’s to require doctorates rather than just masters’ degrees. The DNP degree has been created for this purpose, although a PhD in nursing also exists with a more academic/research focus.
Nurses with advanced degrees tend to be in somewhat different roles than ADN or BSN nurses– they are often educators, or specialists, or managers, serving as resources. They may teach, or do research, or direct nurse-led programs. They may work in primary care or alongside physicians in prescribing and treating. Some (but not many!) work in policy areas.

Lawyer: The Penn program mentioned in the NYT article seems to be getting at caring for people in a way that reduces demand for services. A kind of preventive care that kicks in only after a major incident — preventing relapse, rather than preventing disease to begin with — but still a step in the right direction.  At the risk of getting all econ here, with a shortage of this magnitude, we’ve got to increase supply AND cut demand. It seems to me that nurses could be useful in cutting demand.

Nurse: I agree. readmissions is a huge problem that can be addressed with good follow-up care, and nurses are a great way to do that. Not only will it lessen the burden on the system, but it is good for patients and good for health. This might be one of those situations that needs a very well-designed and executed study to prove that it saves money, since it involves laying out cash upfront. It’s a different way of thinking and those are sometimes hard to sell.

Lawyer: How do we effect change at the cultural level? (If I knew the answer to that. . . jeez.)

Nurse: It’s too bad that there’s so much infighting within the health care professions. Who doesn’t want nurses in expanded roles? What? Physicians? I call shenanigans.

Lawyer:  We need to pay nurses more. There, I said it. Not just to attract more nurses (though that would probably happen), but also because people will then take them more seriously as professionals and be more willing to entrust them with major tasks. (cf. NYT’s discussion of kindergarden teachers a few months ago.)

Nurse: Good point. I have had many people as me, if I’m considering getting my doctorate in nursing, why I don’t just go to medical school since it’s 4 years anyway, and I’d get paid a lot more. And it’s true, I would. My answer is that even nurses practicing in primary care have a different philosophy of care, in general, than physicians do.  But why that pay gap? For education and training, perhaps? Doesn’t hold much water when the nurse is doctorate-prepared. (Another reason to standardize residency programs for nurses– gets rid of that excuse entirely!).

Lawyer: We just need to keep fighting the idea that nurses are inherently less smart, useful, skilled, etc., than are doctors. (I’ll save my feminism rant for another day, but, yeah.) Just because many doctors have significantly more training than many nurses doesn’t mean that it has to stay that way.

Is there a role for law here? The Patient Protection Act is certainly a major force here, and a force for good, but it’s also creating a lot of issues that we need to solve. There are all the traditional answers to what law can do here — malpractice reform to cut costs, various iterations of who pays for which government programs — but could there be something else?

Nurse: Look at nurse practice act– these are different state by state, and the scope of practice varries from state to state. Some states require NP’s to work under physician supervision, some have prescriptive authority, some can function totally independently. Why does it need to be fragmented this way?

Lawyer: California’s is available here: (scroll down to Chapter 6: Nursing). Lots and lots of rules. This is one of those things that really has to be regulated by state law — it’s one of those types of things that seems like a state issue, not a federal issue. (That’s highly technical, I know.) There is an organization that promulgates “Uniform Law” — they very carefully draft laws that make sense to have agreement on and then try to persuade states to adopt them — but they have a really hard time getting enough states to adopt things to make them worthwhile. Still, this seems like the sort of topic where that kind of unity would be useful. (There is a Uniform Healthcare Decisions Act, and a Uniform Healthcare Information.

4 thoughts on “Paging Doctor Nurse!

  1. I’m an Associates level RN. The main differences between my training and that of my friend who just graduated LPN school are 1) her education was quicker and cheaper, 2) I got lots of co-requisite classes required by the state to grant me an associates degree of any kind.

    Sure, you say, “rounded education fuh fuh fuh, important base knowledge fuh fuh fuh”. My co-reqs included such fine topics as Math and English. Fo the Math, I’m not talking statistics or unit conversions or math theory, I’m talking intermediate algebra. 6 semester credits of the kind of class where you have to have the right kind of calculator because with a less powerful one you can’t take the class and with a more powerful one you don’t need the class.

    You might think my 6 semester credits of English would be a little more relevant, but you’d be sadly mistaken. When direct care nurses write, we write short, factual reports of objective assessment data. We write quickly, often by hand, and with no time for editing. My Eng101 essay on the comparative cultural themes of Batman and Superman was entertaining, but it didn’t teach me much about nursing documentation.

    Just for good measure my school failed to offer APA formatted English classes — everything was MLA. That way if I do go on to research or academics in any field even remotely related to health care, I can meet their expectation of being completely inexperienced in APA formatting, and thus need to spend more time and money on required classes that teach me nothing of value. Seriously, my Eng101 professor told us the class existed to create jobs for English majors, but that it was fun so we should make the most of it.

    I can’t help but assume the bulk of the courses required to get a BSN would strike me the same way as my less relevant ASN co-reqs did. I’ve glanced through the course outlines a few times. There’s some good stuff in there, but there’s also a lot of junk advertised as providing a “well rounded” education that hasn’t got a thing to do with working as a nurse.

    All those bells and whistles added in to make bachelors degrees the status symbols that they are are all well and good, but they take time and cost money. I think it’s extremely fortunate to have a more career-training focused, no-nonsense associates degree option available in a field like health care where the base of job specific knowledge is so over the top that you’re devoting years to studying just to get the basics down enough to get started.

    Also, more pragmatically, people have been rattling their sabers about how RN should require a bachelors since what, the 70s? I suspect if it happens, regulation will follow self selection in the field, and that’s not likely to stick any time soon. I’ve had some trouble finding work in the last couple years, and I’ve seen some hospitals that don’t really seem to want to look twice at ADN’s without much experience, but I’ve been looking for work in a town that had a notoriously atrocious job market to begin with, in the middle of a seriously bad recession. In the next 10-20 years the boomers are going to need more and more health care, they’ll probably survive longer than their parents, and those of them who ARE nurses will retire along with the rest. Pragmatically speaking, requiring a bachelors for RNs will happen just as soon as they start reliably being able to find enough BSNs to do all the jobs that need doing. Unless of course they try the pointless method I’ve been expecting for a while now, where they require a BSN to be an RN, make ASN translate to LPN, and then immediately broaden LPN scope to the point where nothing except titles has changed.

    …besides, who needs a bachelors when your associates takes 3 years full time with summer classes?

    I should add, here, that I don’t have the same issues with masters and PhD level study. By then, as far as I can tell, they’re basically done wasting your time rounding your education and weeding out the insufficiently upper-middle-class, and actually seem to focus pretty well on the topics at hand.

    Also, I’m certainly the last to suggest that what’s taught in ASN courses is all you need to know to be a nurse. I’ve been in over my head more times than I care to think about. I do, however, think if we want to have a sufficient number of sufficiently trained staff to do the jobs at hand, it calls for a very direct, to-the-point structure to the required education, and a pragmatic assessment of what knowledge and experience level is required for any given job.

  2. I agree with you that there is a socioeconomic component– bachelor’s programs aren’t cheap– but they are becoming more accessible and cheaper as online options proliferate. I know a lot of nurses who are studying this way and finding it quite doable. And while I really do think that an associate’s degree is adequate education for much RN-level practice (and many of the RN’s I know are associates-prepared and very well prepared at that) we’ll have to agree to disagree about the relevance of some of the bachelor’s components. Sure, it’s easy to see how I use my clinical skills and judgement, but I also need to write persuasively, navigate complex social service system, consider community and lifespan-related effects, and communicate across disciplines. I think taking humanities classes is a great way to hone these skills. I wrote a lot of papers in nursing school– and I think it was a boon to me to have that experience.
    There’s a lot of practical skills to learn in nursing school, but I think that we can improve and broaden our practice by working beyond that level. Every nurse doesn’t have to do that– but some sure do.

  3. I’m currently a master’s student in nursing. I agree with Zack that many classes in bachelor’s and master’s programs seem irrelevant for most areas of direct bedside nursing care. However, I think that the improved communications skills and better understanding of research, public policy, and cultural issues provided by further education are well worth the money. Not to mention that, valid or not, increased education increases one’s credibility. This is important in settings that require other health care professionals to have MD’s, PharmD’s, and doctorates in PT.

  4. Pingback: In Nursing News. . . | Nurse and Lawyer

Leave a Reply

Your email address will not be published. Required fields are marked *


You may use these HTML tags and attributes: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <strike> <strong>