Children washing their hands before lunch. Taken at the Penasco school in Taos County, New Mexico, United States. (Photo credit: Wikipedia)
School nurses are an important—and often overlooked—part of our health care safety net. RNs at our nation’s schools handle medical emergencies, provide episodic and chronic care (including for the increasing number of children with Type II diabetes), track communicable diseases, connect children with needed insurance and health care providers, promote healthy behaviors, and screen for conditions that negatively affect learning—such as poor vision. They do all of these things mostly independently, while juggling sometimes competing and conflicting demands, rules, and laws of the educational and health care worlds. And now that Michelle Obama and the USDA have successfully added fruits and vegetables to school lunches, our school nurses are extra busy encouraging millions of school children to eat them. Some nurses must be responding to skeptical and creative students with, “No, you are probably not allergic to broccoli—only Justice Scalia is allergic to broccoli.” Given that the average school nurse in the U.S. is responsible for 1,151 students at 2.2 schools, school nurses are an important, overlooked, and overworked workforce.
Lina Rogers Struthers was the nation’s first school nurse. Part of Lillian Wald’s community nursing group, Struthers was employed by the school system of New York City in 1903. The year before she was hired a total of 10,567 children were excluded from NYC schools due to health reasons. The year after the introduction of the school nurse program only 1,101 students were excluded from school for health reasons.
On April 23, 2009 school nurse Mary Pappas in Queens, NY altered the local health department of an unusual outbreak of flu-like illness in her school. The CDC was called in to investigate and it was found to be the first documented outbreak of H1N1 influenza in the U.S., triggering a national response. This past spring in my home state of Washington, school nurse Becky Neff alerted state health officials of an outbreak of pertussis (whooping cough) in Skagit County, north of Seattle. Ms. Neff is the only registered nurse in her 3,700 student school district. (see NYT article “Cutbacks Hurt a State’s Response to Whooping Cough” 5-12-12, by Kirk Johnson) School nurses don’t just help keep students healthy: they help keep entire communities healthy. We need more of them.
British nurse in nurses’ station. (Photo credit: Wikipedia)
Theresa Brown, RN has a new NYT monthly opinion piece column called “Bedside.” In a recent e-mail, Theresa describes her column as, “…a nurse’s eye view on ways to make health care better and more humane.” In her debut piece “Money or Your Life” (6-23-12/print version 6-24-12 in Sunday Week in Review section), she argues for the Affordable Care Act (ACA) based on her work as a hospital-based oncology nurse. She describes working with an uninsured male patient with leukemia who asked her about death panels, hoping they existed. It seemed he wanted to be put out of his misery, while avoiding bankrupting his family. Ms. Brown then does a good job of describing some of the complexities of–and the argument for–the individual mandate component of the ACA. This, of course, is a key element of the ACA, and one before the US Supreme Court as to its constitutionality. Their decision is due out this week.
Congratulations Theresa Brown! And thanks NYT editors for recognizing and including a nursing perspective on the continuing health care debate in our country.
Since this is a blog, and since Theresa Brown asked for feedback on her new column, I offer a few reflections. The name “Bedside,” as in bedside nursing, implies direct patient care in an inpatient hospital setting. As such, it is descriptive of the type of nursing Theresa Brown is involved with. But bedside nursing is a term often used as code for “real nursing,” as if community/public health, home health, school and occupational health, and nursing home nurses are somehow not real nurses. The name “Bedside” also perpetuates the notion that nurses spend the most time with patients of any health care team member, and are, therefore, in the best position to advocate for patient’s needs. This belief undermines patient care and safety by working against good health care team communication. It is a paternalistic (maternalistic?) belief that undermines the patient autonomy and agency central to patient-centered care. The belief is also not supported by facts.
Recent studies indicate that hospital-based nurses consistently (and significantly) overestimate the amount of time they spend on direct patient care. Whereas many nurses ‘guesstimate’ they spend over half their time during a given shift on direct patient care, national studies (sophisticated versions of time/motion studies) indicate that hospital nurses spend just 15% of their time in direct patient care. (see RWJ study by Hendrich, et al, “A 36-hospital time and motion study: how do medical-surgical nurses spend their time?” The Permanente Journal, Summer 2008) The largest percentage of their time was spent on charting and other administrative tasks. And a recent study found that physician hospitalists also spent 15% of their time in direct patient care (“Hospitalist time useage and cyclicality: opportunities to improve efficiency” Kim, et al. Journal of Hospital Medicine, July/Aug 2010). So nurses’ time-honored claim to spending the most time at a patient’s bedside is no longer true.
The One Slide: End of Life Questions (Photo credit: stevegarfield)
It’s official: they have a research scale for everything, including God’s Will. In dealing with my elderly father’s illness and end-of-life (EOL) decision-making/interface with the health care system, I kept remembering research I’d read about religiosity and EOL choices. Higher religiosity is associated with preference for life-prolonging medical treatments. This may seem counterintuitive at first, but perhaps people with higher religiosity are less likely to doubt the limits of medical science and our health care system. Researchers developed the Gods’ Will Scale to measure degree of religiosity (Winter, et al, 2009, Preferences for life-prolonging medical treatments and deference to the Will of God, J. Relig Health. 48: 418-430) The New York Times today has an interesting Opinion piece related to this topic: Why Do Americans Balk at Euthanasia Laws? Contributors to this article point to the fact that the US population scores much higher on religiosity scales than do our peer nations. I should mention again that my father is a retired Presbyterian minister living in the conservative and highly religious state of Virginia.
I praise God and every other possible Higher Being that I live in a relatively enlightened state—that state being Washington State, which joined Oregon in the Death with Dignity Act. We also have a relatively active and from what I hear effective POLST Paradigm program: Physician Orders for Life-Sustaining Treatment Paradigm. POLST Paradigm program is designed to improve the quality of care people receive at the end of life. As they describe the program “It is based on effective communication of patient wishes, documentation of medical orders on a brightly colored form and a promise by health care professionals to honor these wishes.” From what I understand, POLST was started in response to complaints from patients that their EOL wishes as declared on Living Wills/Advance Directives were not being honored within the health care system. There have been cases of patients tattooing “DNR” (Do Not Resuscitate) on their chests in an attempt to have their wishes honored. Supposedly this works as long as rescue personnel bother to read their tattoo.
On the POLST website they describe patient-centered end-of-life care as, “Effective communication between the patient or legally designated decision-maker and health care professionals ensures decisions are sound and based on the patient’s understanding their medical condition, their prognosis, the benefits and burdens of the life-sustaining treatment and their personal goals for care.”
All people over the age of 18 are advised to have a Living Will/Advance Directives. In addition, people with a life-limiting illness should have a POLST. In Washington State POLST forms can be signed by physicians, nurse practitioners or physician assistants–that, of course, varies state to state according to their scope of practice regulations. Virginia has not yet adopted the POLST Paradigm.
In my opinion, my father has not received patient-centered end-of-life care. Instead, he received costly life-sustaining medical treatment and remains hospitalized in ICU. But at the same time, he is up and walking with help, complaining about the hospital food, and ready to get back to his work of taking communion to people in nursing homes. So, maybe it’s God’s will?
To continue the baby theme and to remind myself–and all of you–about the good stuff of life and of nursing, I want to highlight the Nurse-Family Partnership Program. As they state on their website, the Nurse-Family Partnership Program “is an evidence-based community healthcare program that empowers low-income, first-time mothers to become confident parents and strong women by partnering with nurse home visits.” Based on independent research, for every public health dollar a community invests in the Nurse-Family Partnership Program, the community gets at least five dollars in return from savings in social services, criminal justice and healthcare costs. The program has now been adopted by over 400 countries and 29 states in the US–and is growing due to its wide-spread appeal and proven cost-effectiveness.
I have the good fortune of working with two local nurses involved with the Nurse Family Partnership in Seattle–King County. It should come as no surprise that they are some of the happiest and seemingly healthiest most grounded of all nurses. They always make my day and remind me of the good stuff of nursing.
Here’s a link to my favorite video of the Nurse-Family Partnership–from New York City. Healthy happy babies and moms and nurses! What’s not to like?
OK–the puppies snuck in here and the kittens are close behind….
I love nurse midwives and tried to have one deliver my son a quarter century ago. But since I lived in the south—and did I mention it was a quarter century ago?—and had an extremely benign heart arrhythmia and maybe had been exposed to TB by a homeless patient, I was deemed too high risk to rate a midwife. In labor, I went to a birthing center to have my son and was doing just fine with the nurses there and with no real medical intervention—until some uptight female OB/GYN who I’d never met came clicking down the hallway in insanely high heels, yelled at me not to push until she returned—she had to go park her car—and clicked back down the hallway. I wanted to kick her or at least fire her. I’m sure it would have been a better birthing experience if I’d had a nurse midwife.
I’ve worked with nurse midwives in a variety of community-based health settings and they provide wonderful women-centric primary care. It will be interesting to see what emerges in the continuing—hopefully public—debate over the fate of nurse midwives at the University of Washington.
Nurses did it again: topped Gallop’s annual Honesty and Ethics of professions survey for the twelfth straight year. In fact, nursing has topped the Gallop survey every year except one since nursing was added to the list in 1999. Nursing was eclipsed by firefighters in the 2001 poll, which was conducted two months after 911. It is interesting to note that Gallop started the Honesty and Ethics survey in 1976, and nursing wasn’t included until 1999. Prior to 1999 pharmacists or clergy were rated #1.
The 2011 Gallop Honesty and Ethics poll was based on a telephone (landline and cell) survey conducted November 28-December 1st from a random sample of 1,012 adults representing all 50 states and Washington, DC. The survey question was, “Please tell me how you would rate the honesty and ethical standards of people in these different fields—very high, high, average, low, or very low?” Rankings of the professions by overall results are done based on the percentage of respondents answering either ‘very high’ or ‘high.’ This year 84% of those surveyed rated nurses as very high/high (and only 1% rated nurses ‘very low/low). Pharmacists were the next highest medical profession in the ranking, 73%, very high/high, followed by medical doctors at 70%. Military officers and high school teachers rank higher than doctors.
The phrase, “nursing is the most trusted profession in the US” is inserted into many public speeches—by nursing leaders ,of course—but also by politicians pandering to the nursing vote. It is almost taken for granted that nurses are trusted. But why are we so trusted?
First, you can’t trust nursing leaders for the full answer to this question. They have a vested interest in positive spin, such as this recent statement by ANA’s President Karen Daley: “The public’s continued trust in nurses is well-placed, and reflects appreciation for the many ways nurses provide expert care and advocacy.” Well, yes, but isn’t there more to it than that?
If you dig into analysis by the Gallop researchers, they point out that the medical professions as a whole are generally highly trusted in our society, and that stability is the norm in American’s rating of professions. However, American’s opinions do shift in response to real-world events (e.g.: 911 and firefighters), and mostly to large scandals that reflect poorly on a profession. For instance, the clergy took a tumble in ratings in the wake of the Catholic priest sex abuse scandals (as well as the Evangelical sex scandals such as Jim Bakker/closets, etc). For whatever reason (relative low-profile/low power and prestige perhaps?) nurses and pharmacists have been able to avoid widespread scandals.
Sandy Summers (a nurse) on her The Truth About Nursing website states, “The reason the ‘most trusted’ poll results don’t do too much for us is that this public view often goes hand in hand with the prevailing vision of nurses as devoted, angelic handmaidens.” And Suzanne Gordon (a journalist/not a nurse, but rather a die-hard nurse advocate) goes even further, writing on her blog last year, “I am getting tired of these polls that try to assuage nurses and stroke them and make them feel better.” Both Sally and Suzanne point out that trust does not equal respect, and that many people may trust nurses but have little idea what they really do. But I’m not convinced that you have to understand what someone does to be able to trust them.
I find it intriguing that the four most highly trusted professions (listed in order) are nurses, military officers, pharmacists, and grade school teachers. All four have strict codes of ethics and standards of practice, and all—for the most part—work within rigid hierarchies for ‘the man’ or ‘the woman.’ They don’t typically work on their own as physicians can and often do. They all, in various ways, take orders. And they aren’t exactly the highest paid professions around—although the average pharmacist salary now tops six figures. So—taking orders within a rigid hierarchy and not profiting in a huge way would seem to be related to high public trust. The lowest ranked professions on the trust survey are members of congress, car salespeople, telemarketers, and lobbyists. The lesson here for our country? Perhaps more nurses should become members of congress?
I am writing this post with a newly hennaed hand, given to me today by a talented Somali woman at Harborview’s Daryel Project. Daryel roughly translates as “Wellness” in Somali. Bria Chakofsky-Lewey, a community health nurse at Harborview Medical Center’s Community House Calls Program, started the project several years ago. The Community House Calls Program provides interpreters and cultural mediators for the different immigrant/refugee populations in the Seattle area.
In her work with Somali women, Bria was noticing that many of the women had complaints of pain that doctors were unable to treat through medication or physical therapy. She suspected that massage would be more culturally acceptable and effective for addressing the women’s pain—but it needed to be massage adapted to the women’s religious beliefs and cultural practices. She couldn’t just send the Somali women off to some hippy-dippy massage practice and expect it to work. Bria also knew from her work with the women that they suffered from isolation in this strange new country and big city of Seattle. Many had also experienced multiple traumas in their homeland, and the psychic effects of these traumas could be expressed as body pain. So she started Daryel with the help of female Somali interpreters/cultural brokers.
The Daryel program is offered every Sunday afternoon at a community center/senior center in Rainier Valley/ south Seattle. Today there were about a dozen Somali women who brought traditional food to share. They usually have group yoga sessions as well as individual/private massage, mixed in with wellness/health information.
This past summer I attended one of their yoga group sessions, and found them refreshingly raucous—the women really enjoy talking to each other and laughing as they try out yoga poses. Happy yoga instead of the usual overly serious yoga usually experienced. (For wonderful photo documentation of Daryel—and visual proof of happy yoga–check out Seattle Times photographer Erika Schultz’s photos here). Today, one of the Somali women commented that when Bria had first introduced the idea of yoga, she had been skeptical—but now she looked forward to it and felt refreshed afterwards. Another Somali woman at today’s session told everyone that she was there because her doctor referred her to the program.
Daryel is always on the lookout for additional volunteer female massage therapists. On the Sundays when they can’t get a massage therapist, the women sit in a circle and give each other backrubs. It is an amazingly uplifting program and a fine example of what
All nurses should be required to take college-level micro/macro economics. Trying to teach nursing students the basics of health policy is almost impossible if they are not comfortable with economic terms and concepts.
I was reminded of this recently, when in a fit of fall office cleaning, I finally gave away my copy of Samuelson’s economics textbook. It was stuffed full of class notes, health economic diagrams and highlighted paragraphs. Two quarters of economics were required for my public health degree, and both were taught by a passionate German economist who waved dollar bills around his head for effect. I begrudgingly signed up for his course, found it—and him—fascinating, and it has been the single most useful class I’ve ever taken in any of my health care programs. That and a water and sanitation class: the basics of health care.
Economics of health care finds its way into my mailbox. My home mail these days mainly consists of utility bills and glossy medical newsletters by local hospitals. The cover of the latest one (photographed here) is oh so Seattle, showing two smiling but scary looking roller derby women. I’ve met one of the women (off rink thankfully) and she is quite nice in person. Inside the hospital newsletter/magazine is a two page article about the women’s roller derby team, the various sports injuries team members have endured, their team orthopedist and the orthopedic surgical ‘cures’ performed at the hospital. I get similar hospital newsletters from two other local hospitals I’ve been a patient at. All three highlight the hospital cash cows of cardiac surgery, cancer care, and orthopedic surgery (none of which I’ve been there for). I’ve been successful getting off the mailing lists of most all major catalog/merchandise companies, but have not been able to stop getting these hospital newsletter/magazines. It is oh so NOT Seattle, being decidedly un-green and tree/salmon-killing.
I know that I am bombarded with these hospital newsletters because: 1) I have decent health insurance, 2) I’m getting towards the age when cardiac/cancer/ortho surgeries may be needed, 3) I might be crazy enough and able to afford to make a monetary donation to a certain hospital unit/program, and 4) perhaps because I am a health care provider and can recommend certain hospitals to my friends and relatives.
Most experts on hospital advertising agree that the main purpose of such advertising is brand recognition—and that hospital advertising increases (as do the costs obviously) as competition increases for insured/affluent/paying customer-patients. If you ask hospital PR people (I have), they will say their newsletters are an important patient education/health literacy effort—a public service of sorts. But when you analyze the content of articles and print ads, this claim doesn’t hold up. Most are not written or reviewed by clinically-knowledgeable people, they play up emotional content (her heart was fixed and she can now play with puppies and kittens and grandchildren!), and they exaggerate benefits/leave out adverse effects of surgeries and other treatments. Hardly real health education. Most industrialized countries ban or severely restrict health care advertising.
A fascinating underlying reason for hospital/physician advertising (as I learned from Paul Levy’s blog post on this topic), is that it strokes the egos of physicians and senior executives of hospitals. The doctor egos need stroking because they make money for the hospitals and doctors are free agents and can move to a different/higher paying hospital. Funny how there aren’t too many hospital ads or newsletter articles highlighting nurses.
The final reason that health care economics is on my mind is the excellent article in today’s Seattle Times by health reporter Carol Ostrom: “ERBuilding Boom is Wrong Prescription, Experts Say.” In this article she discusses the economic and regulatory issues behind our Seattle-area resort-spa-emergency department craziness—a problem not unique to our region. If you want to understand health care, take or review Economics 101.
The following is an essay I recently wrote about the health professions regulatory system in the US. It is written in the format for Narrative Matter’s “narrative policy” essay, and as such is longer than my typical blog posts. Please share widely, with proper attribution, of course…. I want to thank Morris M. Kleiner for reviewing drafts of the essay for accuracy.
One evening this past April, I was sitting on the floor of O’Hare airport, near a packed gate, waiting to board my flight back home to Seattle. Headphones on, working on my laptop, I clicked on the Seattle Times news site. “Nurses’ Death Follows Tragedy,” was the title of the lead story, with the byline summary, “The suicide of Kimberly Hiatt, a nurse who accidentally gave an infant a fatal overdose last year at Seattle Children’s hospital, has closed an investigation but opened wounds for her friends and family members.” (Carol Ostrom, The Seattle Times, 21 April 2011)
I read the brief article, and then stared at the ubiquitous overhead TV screens in the waiting area, wondering why her death wasn’t included in the endless loop of news. Kim’s story seemed weighty—national in scope. Kim was 50 when she died from hanging herself. She had miscalculated a medication dosage for a medically fragile infant, and immediately reported her mistake. This was the first serious medical error Kim had made in her 25-year career. An official medical report stated it was unclear that the medication error contributed to the infant’s death. But the hospital fired Kim. And the Washington State Nursing Quality Assurance Commission—the sate nurse licensing unit—fined her $3,000 and placed such severe restrictions on her nursing license that she could no longer find employment as a nurse.
In the weeks following news of Kim’s death, I was left wondering how this could have happened—not the medical error—but the cascade of negative consequences for Kim. I thought I knew how health systems worked; I had a doctorate in health policy. And I was convinced that Washington State had a progressive health professions regulatory system—that things like this couldn’t happen here—or now.
The week after Kim’s death hit the news, the topic of my health policy class was quality of care. I planned to talk about just culture: having open, fair, and just organizational cultures supportive of patient safety. There is strong evidence indicating that just cultures are more effective at ensuring patient safety than are traditional punitive health care work climates. Kim was an alumnus of the nursing school where I taught. Most of my nursing students were graduating in a month and would obtain their Washington State nursing license. Our class discussion was no longer at the theoretical level.
But I had a more personal connection with the news of Kim’s death: I was seeking closure to an investigation of my own nursing license by a health regulatory board. I was seeking both emotional and literal closure. For the past year, I had been writing a book about my work as a nurse practitioner providing health care to homeless people in the 1980s. Back then, my life and my career had been derailed by a collision with a state licensing system.
Early in my career as a nurse practitioner, I had my nursing license investigated by the Virginia Health Regulatory Boards of Medicine and Nursing. At the time, I was the sole provider at a clinic for Richmond’s homeless population. I was working within written protocols with a supervising physician available for telephone consultation. This was in compliance with the practice regulations in Virginia. In my second year of working at the clinic, I had an unannounced visit by an investigator for the Health Regulatory Board. I remember the day—and him—vividly.
I noticed an older man walk into the waiting room of the clinic. His shoes were what I noticed first: beige puffy comfort shoes with Velcro straps. He pulled out a business card and handed it to me.
“ I’m doing an investigation of a complaint made to the Boards of Medicine and Nursing about your practice.”
I was stunned. My mind raced through worst-case scenarios: had I killed a patient?
“What complaint? And where did it come from?” I asked.
“I can’t tell you that information. It was requested to remain anonymous. I’m just gathering information for my supervisors.”
He asked to see my patient files and medication dispensary. He stayed for several hours, interrupting clinic.
The health regulatory board investigation of my nursing license sent destructive tentacles—like mold hyphae—throughout my life. The process of the investigation remained unclear to me. I was told they were investigating my scope of practice, including prescribing of medications. Fear was the first thing I felt: fear verging on terror. The most immediate threat was the potential loss of my nursing license. This would have devastating effects on my family since my salary supported all of us. My husband was still in seminary, and I was paying for childcare for our then five-month-old son so I could work and my husband could finish school. An additional threat was the loss of my professional reputation: people assume there are valid reasons for an investigation.
For several months after the investigator’s initial visit, I couldn’t sleep well. I lost so much weight that I had to stop nursing my baby before he was six months old, and that made me feel even more guilt as a working mother. My husband and I got in spats. Due to the ongoing investigation, I was forced to work at the clinic in reduced capacity. The Health Regulatory Board kept threatening to close the clinic, and they finally did for several weeks in the eighth month of the investigation.
The Board of Directors for the clinic where I worked responded to the investigation by increasing their efforts to hire a full-time physician. No physicians were clamoring to do this work. The clinic Executive Director enlisted the help of a volunteer lawyer who talked with lawyers at the Virginia Office of the Attorney General, who advised the Health Regulatory Board. No one seemed to know what nurse practitioners could and couldn’t do. I was told it was a contested area of state law, and that they had never had a nurse practitioner as the only health care provider for a clinic. Even at the time, I knew I was a pawn in the grand political game of professional turf battles.
I was treated as if I were guilty until proven innocent. Investigators and lawyers told me not to talk to anyone about the situation or it could make the outcome worse—effectively issuing a gag order and isolating me from seeking help. More recently, I’ve asked myself why I didn’t get my own lawyer back then. No one advised me to and I couldn’t afford one. There were large gaps of time of not hearing anything about the investigation, but I was always aware that it was unresolved, like a large noose dangling above my head that could come down around my neck at any time.
The stress of the investigation contributed to the dissolution of my marriage, loss of my job, and my own spiral into homelessness. I seriously contemplated suicide on several occasions during the investigation. It was such a painful chapter of my life that I had not been able to look at it before—or talk about it.
Twenty-five years later, as I was writing a book about my work with people experiencing homelessness, I wanted to include the investigation of my license. I realized I had no documentation on it. When I read the news of Kim’s death in April of this year, I was awaiting a reply from the Virginia Board of Nursing to my written request for a copy of my case file. I had expected some resistance, but was confident I would eventually see copies of the investigation. I asked for redacted records: I was not interested in knowing who had ratted on me.
Jay Douglas, the Executive Director of the Virginia Board of Nursing, refused my request. In a telephone conversation with me in late February, she stated that they were confidential records, “Board property, and besides, Virginia’s Freedom of Information Act doesn’t apply to people who are not state residents.” This made me angry: confidential records on me by a government agency that I wasn’t allowed to see? This wasn’t a matter of national security; I wasn’t a terrorist. And freedom of information—the right to a transparent and accountable government—only applies to certain citizens? I studied the relevant laws and wrote a polite rebuttal based on the Code of Virginia. While I waited for her reply, I began to do more research on health care workforce regulatory systems. Between my own experience and that of Kim Hiatt, I wanted a better understanding of how these systems worked.
Health Care Workforce Regulation
All states in the US license health care professionals, as well as an increasing number of other occupations ranging from architects to wrestlers, and even frog farmers. These are labor market institutions, administrative agencies with executive, legislative and judicial powers, ostensibly under public mandate to protect public health and safety. According to economist Morris M. Kleiner in Licensing Occupations: Ensuring Quality or Restricting Competition? (Upjohn Institute Press, 2006), they are self-policing, self-regulating bodies, and have been identified as state-sanctioned monopolies. The most autonomous units of state health care licensing systems—medical boards—have been formed by powerful professional associations and their lobbying arms which make large campaign contributions to state legislators. Many state legislators who serve on health subcommittees, which make the health care workforce regulations, are themselves health care providers and members of the professional organizations “funding” state regulatory systems.
But do these state health regulatory systems really protect public health? While there may be the perception of protection from ‘charlatans, quacks, sexual predators and drug abusers,’ it is not supported by data. Kleiner points out that there are no data to support improvement in overall quality of health care by state health regulatory systems. There is some indication that higher-income people gain from stricter health professions licensing, but there is no measurable impact on overall quality of health care for the population as a whole. There is robust evidence that by effectively limiting supply, licensing of health professions increases overall health care costs, and creates longer wait times for health care services. This worsens health inequities in the US. In addition, licensing laws that standardize health care services effectively restrict innovation and improvements in the health care system. Health care workforce regulatory systems in all states are notoriously inefficient, with many taking over two years to investigate and resolve even the most serious of cases. There are wide inconsistencies between the different health professions licensing boards in how they discipline individual health care providers for similar infractions, as well as inconsistencies between states.
The Pew Health Professions Commission Taskforce on Health Care Workforce Regulation—a national, nonpartisan panel of experts—issued a series of reports in the late 1990s’. They called this a significant public health policy issue that flies under the radar. They stated there is a lack of oversight and accountability of the state regulatory systems, as well as a lack of effort to provide consumers access to information on health care providers’ practice histories. They called for national scope-of-practice standards, as well as consideration of changing from licensure to certification of health care providers, which is more likely to improve overall quality of care while not driving up health care costs. According to the reports, the next best alternative to a certification system would be to appoint more neutral parties as the decision makers on licensing boards, with members of the profession available to advise board members on technical issues.
None of the major Pew Commission recommended changes have been made. Instead, there have been incremental reforms, including improved websites, and uniform sanctioning guidelines, which sound good in theory, but have not proven to be effective in practice. According to Kleiner and the Pew Commission experts, powerful professional associations that helped create the licensing system in the first place, benefit from its continued existence. Higher income health professionals benefit from limiting supply by restricting competition, thus boosting their own salaries. Administrators at universities and technical schools support its continuance, since their institutions benefit financially from licensing requirements tied to entry and continuing education. And the current state licensing system continues because the risk-averse voting public has been repeatedly told it is an effective system protecting them from harm by sorting out the “bad apples” of incompetent, impaired, immoral health care providers.
______________________________
Ms. Douglas informed me that without a court order she refused to provide a redacted copy of my individual case file. It took hiring a lawyer to convince her to provide a copy of the Case Decision Memorandum for the investigation of my nursing license. Dated February 13, 1989, the memo stated that if I continued consulting with my supervising physician as reported, no further action would be taken. It concluded, “There have been no further complaints or problems and the case is closed with no violation and no sanctions.” The memo confirmed that it had been a scope of practice issue, and that the Medical Board had wanted tighter reign on my nursing practice. What surprised me though was the date of the memo. While I had remembered the investigation as being a painfully long process, I hadn’t realized it took 16 months. My husband and I had separated a few days before the official closure of my case. And by that time I was disillusioned with nursing and with our health care system.
Ironically, the same week I received the one-page Case Decision Memorandum, I received 1,500 pages of redacted, detailed information on the case of Kimberly Hiatt from the Washington State Health Department. I requested Kim’s files in order to better understand the current decision-making process of the Nursing Commission in a state where I am responsible for teaching nursing students health policy. And in a state where I maintain nurse and nurse practitioner licenses. Reading through Kim’s records only deepened my distrust of the health professions regulatory system. The Washington State Nursing Commission refused the request by Kim’s lawyer for copies of their investigative reports in order to adequately advise his client.
I remind myself that Ms. Douglas and others in the health regulatory system are well-intentioned people who believe their work promotes public health and safety. But the system they work within is not part of a just culture. The current regulatory system is not working to protect public health and safety. It is not working for the majority of health care providers, who justifiably view it as capricious, punitive, and with little oversight or accountability. If we are to have a higher quality and more equitable health care system in our country, it is essential that we reform the byzantine health professions licensing system.
Image by Sacred Heart Rehabilitation Center via Flickr
This week I attended the John R. Hogness Symposium on Health Care at the University of Washington. This year’s speaker was Daniel R. Williams, PhD, Professor of Public Health/African and African-American Studies/Sociology at Harvard University. Dr. Williams is a sociologist who studies the social determinants of health, including racial and socio-economic health disparities. He is prominently featured on the excellent PBS series, Unnatural Causes, being interviewed on a variety of topics related to his research.
The title of Dr. William’s talk was, “Making America Healthier: Surprising Steps for Every Health Professional.” While Dr. Williams is an excellent public speaker and delivered a cohesive lecture, most all of the information he covered was the same/similar to what is in Unnatural Causes—so it wasn’t really surprising. I suppose though that it is surprising that the information is surprising to health professionals in the US. He was mostly preaching to the choir here in Seattle. I was also surprised (and bemused) by the pre-lecture conversational content of a group of young students sitting beside me. While looking around at the increasing crowd, one student exclaimed, “Wow! So this is like a big deal!” OK, so we have work to do in our educational system.
Dr. William’s main talking points were as follows: 1) the US ranks near the bottom of all industrialized countries on most all health measures—and we are losing ground; 2) immigrants to the US become less healthy the longer they live in the US (“life in the US is bad for your health”); 3) the racial gap for blacks/whites in health is larger for higher educational levels; and, 4) racial segregation in large US cities in the 2000 census was close to the level of racial segregation in South Africa in 1991 under Apartheid. He stated that health care reform is crucial but insufficient—that we also need to address the social determinants of health in order to make America healthier. He included health behaviors/individual lifestyle choices as something we all need to work on—we are now supposed to eat at least nine servings/day of fruits and vegetables and not just five—while acknowledging how poverty and lack of access to healthy choices makes it more difficult for some to ‘do what’s right’ health-wise.
What can we as health professionals do to make America healthier? Of note is that Dr. Williams is not a health care professional, and that fact was reflected in some of his recommendations. He gave examples of successful programs that incorporate social determinants of health into mainstream health care. Heading his list (yeah!) was the Nurse Family Partnership. Then he talked about the Boston Medical Center’s Medical Legal Partnership, which links low-income families with lawyers—for instance to pressure landlords to remedy asthma-inducing mold and cockroach problems in apartments. The third program he mentioned was Health Leads, started by a Harvard undergrad. This is a service-learning project training college students to staff waiting rooms of safety net clinics, linking patients and families with needed social services.
I was left thinking, “Yes-but?” This all sounds good, but what can individual health care providers such as nurses really do to change things in the health care system? How can we include any of Dr. William’s suggested programs? For instance, our local Odessa Brown Clinic, a safety net clinic in a traditionally African-American Seattle Community, had a grant to include legal services for patients. But once the grant ended, the program ended. Our Washington State Maternity Support Services are on the chopping block in the upcoming legislative session. I suppose we could try to replicate the Health Leads program locally, but with food banks and other basic services being cut, it is hard to know what the students would be linking patients to.
I try to maintain healthy skepticism as opposed to unhealthy cynicism in terms of health policy in general, and the social determinants of health in particular. But Dr. William’s talk left me with the vivid impression of all of us health care progressives spitting into the wind. Even the authors of the Biology of Disadvantage report have somewhat similar sentiments, “…thus we face with humility the task of identifying appropriate poverty-reducing strategies that improve health.” (p.247)
