|As hospitals struggle to ease the shortage of primary-care doctors, advanced practice nurses could pose an efficient and cost-effective solution. Enabling nurses to perform to the fullest extent of their training and allowing them to act as full partners with other healthcare professionals will help the healthcare industry produce much needed caregivers, and at lower costs, according to an article in the April issue of John Hopkins’ Nursing Magazine.
Health reform will increase the number of Americans who have insurance or require primary care, and advanced practice nurses will play a major role in satisfying that growing demand for care, reports the Oregonian.
“Nursing is absolutely critical to help fill the void,” Michael Bleich, dean of the School of Nursing at Oregon Health & Science University, tells the newspaper.
Before hospitals can utilize nurses in larger, more independent roles in the delivery of care, though, advanced practice nursing laws need to become more consistent, notes Dean Martha N. Hill, PhD, RN, in Nursing Magazine.
So far, 16 states have practice laws in place that allow licensed nurse practitioners to care for patients, order and interpret diagnostic tests and prescribe meds without a physician’s oversight, notes the Oregonian. Other state regulations vary.
Despite the rising need for care–and caregivers–not all healthcare professionals support nurse practitioners taking own expanded roles. The American Medical Association and American Academy of Pediatrics, among others, still maintain that nurse practitioners should only be allowed to practice under physician supervision.
Nursing in America is Changing. Big-time
The Johns Hopkins School of Nursing, May 11, 2011 by Kelly Brooks — While the healthcare industry is simultaneously coping with the aging-patient “silver tsunami,” increasingly complex insurance procedures and loopholes, and implementation of healthcare reform, one thing is clear: healthcare is facing unprecedented challenges, and nurses must play a major role in meeting them.
In a new report, The Future of Nursing: Leading Change, Advancing Health, the Institute of Medicine and the Robert Wood Johnson Foundation examine what it’s going to take – from nurses, hospitals, administrators, government, and other members of the healthcare team – to satisfy future demands for care. Chaired by Donna Shalala, the former Secretary of the U.S. Department of Health and Human Services (see page 3), the report committee offers specific recommendations for the future of the nursing profession.
At Johns Hopkins, Dean Martha N. Hill, PhD, RN, thought “it would be valuable to look at the report recommendations and ask: How do we measure up? What is special about academic health centers in general and about Hopkins in particular? And, what might we do as a step forward?” She invited an interdisciplinary group of university and hospital leaders to do just that.
The report’s recommendations center around four themes: improving and increasing nursing education, supporting nurses in practicing to the fullest extent of their education and training, creating a culture and systems in which nurses act as full partners with other healthcare professionals, and collecting better nursing workforce data.
The Future of Nursing recommendations are “not surprising,” said Steven Wartman, MD, PhD, a Hopkins alumnus and President and CEO of the Association of Academic Health Centers. In a boardroom full of Hopkins VIPs, Wartman’s voice brought a wider perspective to the conversation. “What concerns me is the bigger picture or the context in which these recommendations might or might not be implemented on a national scale.”
Take, for example, the suggestion to increase the proportion of nurses with a baccalaureate degree to 80 percent by 2020. Today, only 50 percent of U.S. nurses meet this criterion. And while it may make sense to increase nurses’ education, says Wartman, “nursing has been described as a fractured profession. If that is still true, the fracture, the fault line, is between the two-year programs and the baccalaureate programs.” In this light, he wondered whether this educational goal is attainable.
Karen Haller, PhD, RN, believes it is – and that the nursing profession is divided no longer. “We’ve well earned our reputation as a fragmented profession, but I don’t want the myth to outlive the reality,” pointed out Haller, who serves as Vice President of Nursing and Patient Care Services at Johns Hopkins Hospital.
“One of the appendices in this report is the consensus model, a model about licensure, accreditation, certification, and education requirements. All of the nursing organizations have signed on to it in addition to the 50 state boards of nursing,” she noted. The support of baccalaureate-level education, she said, is unanimous.
So how does Hopkins measure up? At the Hospital, “we’re at 78 percent of nurses with a bachelor’s,” said Haller. “I’ve got to step that up two percentage points over the next few years here.”
And at the School of Nursing, “the vast majority of our students, more than 80 percent, already have a college degree when they come to us,” added Hill.
The report also recommends doubling the number of nurses with a doctorate degree by 2020 and ensuring that nurses engage in lifelong learning through continuing education and training.
Fulfilling Our Potential
Increased education will only be useful, however, if nurses can fully use their knowledge to improve practice. But nurses often confront government regulations and institutional policies that prohibit them from performing at the top of their ability.
“State regulations that support advanced practice nursing are very uneven across the United States,” explained Hill. The laws permitting (or forbidding) advanced practice nurses to independently examine patients, order and interpret lab tests, prescribe drugs, admit patients in a hospital, or provide other such services vary widely from state to state.
Wartman pointed out that, “dealing with a complex regulatory environment at a time when states’ rights are becoming very powerful and very important presents a serious challenge. How do you transition to a more national framework?”
As we look toward the future, the need for consistent advanced practice nursing laws will be even greater. Hill noted that “as increasing numbers of people have insurance or require primary care, we’re going to need more providers who are qualified in skill that can lead it in practice.”
But not everyone agrees that advanced practice nurses should step up to the role of primary-care providers. Edward Miller, MD, Dean of the School of Medicine, said that the report’s recommendations, taken “to the ultimate,” would be for nurses to conduct independent practice. He asked, “Is that way the right way to go? I’m more partial to the team concept. I think the recommendations go a little too far, to tell you the truth.”
His concern echoes that of other physicians, some of whom wrote to the editor of the New England Journal of Medicine in December. They emphasized that nurses are not interchangeable with physicians and advocated for keeping the traditional, physician-led healthcare team.
Deborah Trautman, PhD, RN, Executive Director of the Johns Hopkins Center for Health Policy, spoke to the issue of whether nurses want to step into leadership roles. “Leadership doesn’t mean they step away from the bedside, necessarily, but in some nurses’ minds that’s what they think. But having nurses continue to do what we support at Hopkins – be involved and participate beyond traditional boundaries – serves not only nursing well but serves some of our other areas equally as well.”
“The advanced practice nurse needs to have more recognition in the Hopkins Health System,” offered Margaret Garrett, Senior Counsel and Director of Risk Management for the Johns Hopkins Health System. “In community positions, we’re getting advanced practice nurses to do more of the primary care, which is excellent because we need that particular level.”
The recommendation to remove scope-of-practice barriers doesnÕt just apply to advanced practice nurses, pointed out Haller. The idea is to allow all nurses, and all levels, to perform to the fullest extent of their training. This would enable nurses to maximize their value to the healthcare teamÑand it can even help lower the cost of healthcare overall.
“The notion I find very attractive in this report is putting the work at the lowest-paid level that is trained to handle it. This means having our aides or our technicians doing certain work rather than our RNs. The report would take that idea all the way up, through every level of healthcare, including advanced practice nurses and our physicians,” said Haller.
Ronald R. Peterson, President of the Johns Hopkins Health System, noted that, “In most compensation models, as long as someone is qualified to do the job, people who are doing the same job should be compensated equally. But if we go the next step of saying that a baccalaureate-trained nurse should be differentiated in terms of scope of work versus someone who has AA, then we have a basis in my opinion for differentiating in terms of compensation.” Hopkins currently gives baccalaureate-prepared RNs more tasks, responsibilities, and compensation at the top tiers of the clinical ladder.
“We need to deliver our services in the most cost-effective way. We have to figure out a way to pay attention to the total cost given the rendering the services,” Peterson added.
Working with Our Colleagues
These kinds of changes – that reach across disciplines and affect the entire healthcare teamÑrequire an enormous amount of respect, collaboration, and communication. The challenge, Wartman pointed out, is that “all the health professions practice within the framework of a guild, and this mentality to a large extent prohibits these kinds of changes that we’d like to see happen. Maybe there are steps within the Hopkins environment that can be taken to reduce that.”
According to Hill, Hopkins is well on the path. “The guild is gone in research. It has become very collegial, very collaborative. I think faculty move that way because they understand that’s going to be the best science,” she said.
The question is how to move that interdisciplinary environment out of the research lab and into the hospital and the classroom. One major obstacle? “We have three schools [nursing, medicine, and public health] with three calendars,” said Hill. Planning interdisciplinary lectures, joint classes, or multi-school student organizations while on different schedules “presents a huge problem and weÕve got challenges there.”
“I think we work pretty well together between the schools of public health and nursing,” added Jim Yager, PhD, Senior Associate Dean for Academic Affairs at the Bloomberg School of Public Health. “But perhaps we could have a bit more sharing of some best practices. But our different academic calendars do create difficulties. I don’t know if Hopkins will ever address that issue. I mean, for us to change our calendar would be revolutionary, but not necessarily bad.”
“I think if we want to do some real good, we need a single schedule among the three schools. That would knock down a couple of barriers,” agreed Miller, speaking for the School of Medicine.
”This is a sword that no one’s been willing to fall on. And who has the authority to make it different?” asked Hill.
The group paused, imagining the possibilities.
“Generally, what’s remarkable about this place is when you get people to come together, anything can happen,” said Hill. “These walls are extremely permeable.”
Lynne Terry/The Oregonian
Karen Butler, 56, hugs her husband Glen Butler at her office in Newport. In late 2009, she developed a British accent after dental surgery. She was later diagnosed with foreign accent syndrome.
By Lynne Terry, The Oregonian.com — When Karen Butler came out of sedation after oral surgery a year and a half ago, her mouth throbbed and her face was puffy. But that’s not all that had changed. When she spoke, the words tumbled out in a thick and foreign accent.
“I sounded like I was from Transylvania,” she said.
Over the next few days, the swelling subsided and the pain vanished, but Butler’s newly acquired accent did not. Though it has softened over time, she’s never again spoken like a native Oregonian from Madras. To most people, she sounds British.
It took months to find an explanation: foreign accent syndrome, a disorder so rare that only about 60 cases have been documented worldwide since the early 1900s.
She’s the first known case in Oregon, said Dr. Ted Lowenkopf, medical director of the statewide Providence Stroke Center.
Karen Butler, who grew up in Madras, now sounds to most people like she’s from Britain, even though she’s never been there and has no British relatives. She developed foreign accent syndrome in late 2009 after dental surgery, one of only about 60 cases worldwide since the 1900s. She’s the only known case in Oregon. Unlike others, who’ve become depressed after their speech pattern changed, she’s having fun with her new accent. “In a scale of one to 100, this doesn’t even rank a one,” she says.
The condition changed Butler’s life, forcing her to answer endless questions about her accent. Most people are incredulous at first. A few insist she’s faking it.
Foreign accent syndrome is usually caused by a stroke, though it also has been associated with multiple sclerosis, head injuries and migraines.
One of the first cases was reported at the turn of the last century by a French neurologist. But the best known case, documented by Norwegian neurologist Georg Herman Monrad-Krohn, was a 30-year-old woman, who was hit by shrapnel from a German air raid over Oslo in 1941. The injury left her with a speech impairment that gradually improved, turning into what sounded like a German accent to her countrymen. Suspecting that she was a collaborator, they ostracized her.
“When it first happened and we didn’t know what it was, all kinds of ideas were handed up as possibilities,” said Butler, a 56-year-old mother of five. Her family joked that she had spun into a past life regression.
She sought help from her dentist and family physician. Both figured the dentures put in during surgery had caused the change.
She felt that wasn’t the case. But in the weeks after the operation at the end of November 2009, she focused on Christmas and then it was January. Manager of an H&R Block office in Newport, she became swamped in work.
In May, when tax season died down, she consulted a neurologist in the Corvallis area. After some research, he came up with the diagnosis.
Lowenkopf, who just met Butler last week, said the syndrome remains much of a mystery. Although he read about it in his neurological training, he had never encountered it before in real life.
“I’m amazed by it, and intrigued by it,” he said.
It’s unclear what caused her speech pattern to change. Dental surgeries do not pose a stroke risk and the drug that Butler says the dentist used to sedate her — Halcion — has not been linked to strokes.
Her dentist, Gregory Herkert, did not want to comment.
Lowenkopf said the syndrome has been linked to injuries in different areas of the brain — the left frontal lobe, the right side and the cerebellum, a “little brain” tucked back on the bottom. The damage is almost always very small, which is why the syndrome is so rare. Strokes usually involve a bigger injury with a bigger impact, depriving a patient of the ability to speak intelligibly, for example, or to understand others.
“What happens with foreign accent syndrome to the best of our understanding is that a very, very small part of the speech area is affected so that the normal intonation of speech gets altered,” he said.
He believes that patients adapt, making them sound to others as if they have an accent.
She would like to have a brain scan — to compare with one she had years ago — but can’t afford it and her insurance won’t shell out the money. Tests show she has no physical problems.
Everything works,” she said, “It just works odd.”
She and her family have taken the change in stride, even delighting in it.
“This is not a tragedy,” said her husband, Glen Butler, a retired Coast Guard official. “The only thing that changed was her voice. She’s still her.”
She doesn’t even hear her new accent — unless she watches herself on a video.
“I’m very lucky it was not something that was devastating,” she said. “On a scale of one to 100 this doesn’t even come up to a one.”
Like many others diagnosed with the condition, she’s never been to the country her accent seems to stem from, though she did study German in eighth-grade and does collect teapots — but from America.
“Although Mrs. Butler has never been to England and has no English relatives as far as we know, I’m sure she’s heard an English accent,” Lowenkopf said.
Other native English language speakers with the syndrome have sounded Russian, Chinese, German, Spanish, Jamaican and Italian. But none of the accents is pure, linguists say. Listen closely and you’ll hear a mix of sounds caused by the way people produce consonants and vowels or emphasize certain syllables, making them sound foreign.
William F. Katz, professor of communication disorders at the University of Texas at Dallas, has studied a number of patients since 1987 in his speech lab.
“We want to understand the circuits that underlie it and what we can do to fix it,” he said. “It’s kind of puzzling. Sometimes patients get very frustrated.”
His lab’s recent attempt to retrain the speech patterns of a Dallas woman who was often mistaken for being Swedish failed, but he said she had other medical issues.
Butler doubts she could be retrained to speak like an Oregonian again. “Others can pretend to talk in different ways,” she said. “I can’t. That’s gone.”
Gone, too, is her shyness. Before the surgery, she was painfully shy.
“Before I was just an ordinary person,” she said. “Now everybody is intrigued. They want to know where you’re from. So I’ve learned in the last year that it’s OK to be social. I like it actually.”