In Nursing News. . .

In nursing news, Centers for Medicare & Medicaid Services made a lot of changes this week, including expanding the definition of “medical staff,” to allow professionals including advanced-practice nurses to practice to the full extent of their training and scope without arbitrary federal rules about physician oversight– state laws already govern scope of practice.

This is a coup on behalf of patient care, healthcare systems, and nurses! CMS is explicitly recognizing that health care is changing, and moving away from a model which is entirely physician-driven.  We had a pretty long discussion   on the issues surrounding advanced practice nurses a while ago. Is this week’s news indicating that the times, they are a changing’?

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.

Nurses in the media?

Theresa Brown, RN, recently wrote a post for NYT’s Well blog about  the image of nursing, especially as it’s shown on TV shows– Grey’s, ER, that sort of thing– and she has a point. Nurses are kind of a foil, they are handmaidens, and doctors are shown doing nurses’ work– but then she gets on to showtime’s new show “nurse jackie.” she dismisses it out of hand because the protagonist is “troubled”– and she is, no question, but hang on. . . was ER’s Carter not troubled? oh, no, no tv doctors ever cheated, took drugs, or broke rules. . . now, “jackie” ain’t perfect, but it’s a much more real picture of nurses than i’ve seen in tv recently. and closer to my job than, say, carla on scrubs– which, i’m afraid, is what more than one old friend brought up when they found out that i’m a nurse now.

what do you say, do nurses get short shrift? do angels, or sexy nurses, undermine what we do?

do lawyers, for that matter, get fair treatment? i never watched law and order. . .