Those were the main take-away messages of yesterday’s nurse practitioner conference at the Washington State Convention Center. There was a lot of mention of the role of nutrition in health, and of individual responsibility for health in some of the sessions I attended—and in the booths at the vendor section. I saw very few obese attendants at this conference—are nurse practitioners skinner on average than their RN counterparts, and if so, why?
The Washington State Dairy Association had free cheese sticks and food pyramids or food Great Walls of China, or whatever architectural wonders they are using now to rank food groups. At a session on health care reform, the speaker spent a lot of time talking about the nutritional content of ‘fast foods’—the winner of the junk-food hall of fame seems to be Baskin Robbins’ Oreo Milkshake at a gazillion calories. As if that is the cause of the dismal health outcomes in our country.
This was at a workshop session by Louise Kaplan, a nurse practitioner who has her doctorate in health policy. She is past president of the Washington State Nurses Association, founder of the first Washington State Nurse Lobby Day in 1984 (in serious need of reform itself–see previous blog post The Nurse Lobby Day That Wasn’t–Feb 15th, 2011), and currently is a Senior Policy Fellow at the American Nurses Association. Besides the information on the Oreo Milkshake, she said we didn’t have health care reform, we had health insurance reform. This statement got applause from the audience, but not from me. This is a profound statement? This is news to anyone? And health insurance in the US is not a significant part of our health care system?
After her talk I asked her if the ANA was looking at reform of the health professions regulatory system in the US. She asked me what I see as the problem with this system—what is in need of reform. I told her in 20 words or less—including that it is not effective in protecting the health of the public, that it drives up health care costs and worsens health inequities. She replied that it was up to each individual state to regulate health professions, and that the ANA would have nothing to say about that—only what the IOM Future of Nursing Report recommended in terms of a consensus on scope of practice for nurses and nurse practitioners. Her response did not surprise me, but I was disappointed in the stock reply.
I loved the vendor area because it was so informative about the role of nurse practitioners in our health care system. Somehow it felt like reading People Magazine—as Paul Farmer says, it is a cultural touchstone. There were many of the major drug company’s represented, including Lilly’s erectile dysfunction “weekend pill” that seemed popular among the ladies. The Washington State Nursing Quality Care Commission had a booth that included a 10-question survey on knowledge of the role/responsibilities of the Commission. There were many booths for local educational programs for nurses, as well as Seattle-area employment agencies/hospitals—and farther afield employment opportunities—the US Navy, the Federal Prisons, Alaska Native American clinics.
But what astounded me was that the most popular booth in the vendor area was a jewelry store. Not fine jewelry, not jewelry for a cause—like for healthcare in Haiti—just glitzy, glittery costume jewelry. Really? There are some things about nursing I am convinced I will never understand.
We just want to be doctors without having to go to medical school. Yes, that’s it. I want to be called Doctor Nurse Ensign—or maybe Ensign Doctor Nurse if I ever work in the Navy and want to really confuse people.
Disclosure: I have a master’s degree preparation for being a Family Nurse Practitioner, with a practice doctorate in public health, a DrPH. The DNP—Doctor of Nursing Practice—the newish practice doctorate in nursing—did not exist when I went to nursing school. I am quite happy with my combination of alphabet-soup letters/degrees given my focus on health policy for marginalized populations. If the DNP had existed when I went to nursing school—and if it had been the only option for becoming a nurse practitioner—I suppose I would have done that but still obtained my MPH—Master of Public Health. The two disciplines complement each other well. In my experience, the MPH provides more uniform, concrete, and useful skills than does any degree in nursing—even the DNP in its current incarnation.
Earlier this month there was a NYT article entitled, “When the Nurse Wants to Be Called ‘Doctor’” (by Gardiner Harris, 10/2/11). It is an excellent, well-balanced article. I also recommend the Well Blog version with interesting reader’s comments/ a longer blog post by Barbara Ficara on the Healthcare Blog.) The NYT journalist discusses how nurse practitioners are moving towards having DNP’s as entry to practice and are asking to be called doctor. Harris writes, “Doctorates are popping up all over the health professions, and the result is a quiet battle over not only the title ‘doctor,’ but also the money, power and prestige that often come with it.” Pharmacists moved to entry-level practice doctorates in 2004, and physical therapists are moving towards it as well. He says that nursing leaders say the push for the DNP has nothing to do with their fight for expanded scope of practice and higher salaries for advanced practice nurses—but rather with the pressures to keep current because “knowledge is exploding.” Not surprisingly, many physicians are fighting back. Physician lobbying groups around the country are pushing for increased state and federal legislation restricting anyone without a MD or DO (doctor of osteopathy) from using the title ‘doctor.’
As Harris points out in his article, there are no data to support the value added of a doctorate over a master’s degree in terms of quality of care provided by nurse practitioners. And it takes one to two years longer to obtain a DNP vs. a master’s degree. Health economists are concerned this can translate into increased costs for patients and longer wait times to access primary care providers. This disturbs me since the nurse practitioner role was developed specifically to help address access to care issues for the poor, the elderly, rural, and other marginalized populations. It is why I chose to become a nurse practitioner.
Facebook, Twitter, blogging, and all the other social media tools, oh my! I have been wading through the realm of social media and health care, specifically as it relates to nurses. Who owns you? Who controls what you can say? I am interested in this topic for many reasons. I am currently writing a book based on my work as a nurse practitioner providing health care to homeless people. Most of my chapters use a specific patient to illustrate larger issues related to homelessness. I have changed patient names, ages and other demographic data—but is that enough to protect identities? In narrative non-fiction, the use of ‘composite’ patients (blending aspects of more that one person in order to hide identities) is frowned upon—at least by purists with a journalistic bent. As a nursing professor, I assign classroom writing assignments relating to narrative medicine/nursing, encouraging students to use a specific health care experience (as patient, provider or family member) and to use that experience to illustrate and examine health care policy issues. I encourage other nurses who are already in practice to speak out about workplace issues as a way of advocating for policy changes. I maintain my own Facebook page, I Twitter and I blog on nursing and health policy, while I maintain my own practice as a family nurse practitioner and as a university professor. What can I say and not say both legally and ethically? What can any nurse say both legally and ethically?
Obviously I am not a lawyer, nor am I an expert on the nuanced legalities of social media, which seem to be amorphous. What I share here is what I have been able to cobble together from a myriad of sources.
Theresa Brown, RN who is a regular contributor to the NYT Well Blog states that HIPAA (Health Insurance Portability and Accountability Act of 1996) rules are easy once you know them: a patient can identify him or herself in whatever you write, but no one else can. (But how can you know that when you are writing it?) Theresa Brown writes about specific patients she works with as a staff nurse on a hospital oncology ward. She also writes about specific interactions she has with other hospital staff, including physicians. For her book Critical Care (harperstudio: 2010) she mixes up the patients by changing race or gender as a way of protecting identity. She can’t do that for her NYT essays for journalistic “truth” reasons, but then she doesn’t disclose a patient’s race, exact age, or physical appearance as a way to protect patient privacy. She states that the hospital she works for tried to get her to have all of her NYT Well Blog essays ‘approved’ by them before publication and she refused, stating that this requirement would not hold up in a court of law. I think that worked in her case because of who she is (for instance, she survived getting tenure at Tufts before becoming a nurse—plus she is writing for the NYT Well Blog). The hospital administration backed down, but they agreed that she would not name the hospital she works for. However, when she was invited to the White House to meet with President Obama during Health Care Reform debates, her hospital was eager to have her identify them as her employer. (see her article, “Nurse as Writer, Writer as Nurse” Clinical Journal of Oncology Nursing, 15(2) April 2011).
Hospitals are risk adverse and tend towards paranoid status. They like tapping into the power of social media for their own benefit, as a way of attracting potential (paying) patients. A rapidly growing number of US hospitals currently have some social media/Web 2.0 presence. Hospital social media staff members also scan other social media sites for any possible negative news items about their hospital, or any infractions of patient privacy by hospital staff that could lead to HIPAA violations and/or lawsuits. Hospital managers and other staff are encouraged to report possible infractions—effectively to rat on their co-workers over their social media use. The recently released 2011 AMA Policy: “Professionalism in the Use of Social Media” encourages physicians to self-police other physicians for unprofessional conduct on social media before resorting to ratting to “appropriate authorities.” The ANA has no policy or guidelines on professional use of social media for nurses.
Many hospitals now have policies restricting use of social media by staff, including residents and physicians. These restrictions range from the concrete/understandable, such as “don’t Tweet from the OR, or add a patient photo on Facebook, or friend a patient on Facebook” to the fuzzy “don’t say anything on social media that you wouldn’t say in a faculty meeting or to a member of the media.” From personal experience, I can say that the latter is highly subjective and not very helpful as a guide. Equally fuzzy is the “elevator rule:” don’t say anything you wouldn’t say on an elevator. That would depend upon the elevator location and whether or not you are on the elevator by yourself… Not a helpful rule.
HIPAA strikes fear into many a health care provider’s heart. The US Department of Health and Human Services (HHS) Office for Civil Rights can levy steep fines on hospitals and individual health care providers for knowingly or unknowingly breeching any of the myriad rules of HIPAA. The University of California at Los Angeles Health System has just agreed to pay a $865,500 fine and add corrective actions in a case where employees viewed electronic medical records of two celebrity patients (for non-patient care reasons). Individual health care providers can be assessed a $50,000 fine and up to a year in jail for knowingly disclosing individually identifiable patient information. Health care providers (mostly nurses and ‘below’) can and have been fired from hospitals and clinics for HIPAA violations.
Just what is individually identifiable patient information? Having read the fine print of HIPAA (available on the HHS website), this includes the obvious date of birth/death, address, Social Security number, fingerprints/other biometric identifiers, and medical record number—to the less obvious age (OK to use an age of a patient up to age 89—after that you need to use ‘age 90 or older’). These unique identifiers have to be removed for individual patients, as well as for “relatives, employers, or household members of the individual.” The HIPAA privacy rule protects all individually identifiable health information “or information for which there is a reasonable basis to believe can be used to identify the individual.” This last stipulation of the privacy rule is where it gets fuzzy and where paranoia can set in.
In 2007 a group of medical bloggers got together to form the Healthcare Blogger Code of Ethics. It acknowledged that bloggers in the medical field have unique legal, ethical and professional challenges to blogging. The code was also developed in response to many medical bloggers being pressured by employers or academic institutions to stop blogging or face consequences, including termination. The code included issues of transparency (limiting anonymous blogging), commercial disclosure, civil discourse/courtesy, reliability of information/citing sources, and patient confidentiality. They developed a system for medical bloggers to apply for membership, be screened for ‘certification’ and then if they passed they could place the Healthcare Blogger Code of Ethics seal on their website to reassure readers (and employers).
I applaud HIPAA and its emphasis on increased patient privacy and security of health care information. I value the privacy of my own health care information. As a health care provider, I honor the trust patients need to have within the health care encounter. Egregious breaches of patient privacy by nurses and others on the health care team are rare, but need to be dealt with quickly and severely. But what concerns me is how HIPAA—as it is broadly interpreted by risk-averse hospital administrators—is further silencing nurses, and hindering their involvement in constructive health policy discourse. We need a more uniform, sane, and concrete guideline on patient privacy and health care providers’ use of social media.
Some resources:
The Healthcare Blogger Code of Ethics seems to be migrating from Blogspot to WordPress, so their website information isn’t currently available or I’d link to it here.
“When Facebook goes to the hospital, patients may suffer: Social networking sites can bolster the image of medical facilities, but privacy standards can easily be violated.” By Molly Hennesey-Fiske. The LA Times, August 8, 2010.
In my previous blog post (Ir)regulation of the Health Professions, I briefly told the story of my run-in with the Virginia Health Regulatory Board, and how I was investigated by them for nine months. They (I think—I still have no written proof) then closed my case due to insufficient evidence. An independent state audit of the Virginia Health Regulatory Boards around the time of my encounter with them revealed that it took the Board of Medicine on average over two and a half years to conclude cases, and the Board of Nursing took over a year. In almost all cases, including ones involving serious violations, the Board of Medicine allowed physicians to continue practicing pending the outcome of the investigation. In contrast, the Board of Nursing usually ordered the nurse to not practice pending their final decision at the conclusion of the investigation. The Board of Nursing was the only health regulatory board to summarily suspend the license of nurses prior to the conclusion of the investigation. In the Virginia audit report, the authors pointed out that such long time delays in processing investigations posed a serious threat to public safety. They also stated that long delays in case processing placed an unfair burden on respondents (providers accused of wrong-doing).
Not having access to any written reports on my own case—including not knowing what I was accused of doing in the first place, I can only go by the notes I took during my meeting with the Attorney General at the time. From what I can gather, the Boards of Medicine and Nursing were disputing scope of practice standards for nurse practitioners and I was a likely test case. I remember testifying at a special hearing of the Virginia legislature about nurse practitioner scope of practice and why reforms in state laws were necessary for the provision of safety net services. Virginia remains one of the worst states in terms of nurse practitioner scope of practice. I don’t plan to practice there anytime soon, but I do hope they get their (nurse practice) act together. I know they are working on it.
This is a cautionary tale about what I have experienced in dealing with the Virginia Department of Health’s Board of Nursing over my own nursing license—and the records they have of my case. It highlights what I believe to be second victim issues stemming from the unfair abuse of power of such health regulatory boards. It is my personal story, based on my own experience. In addition, it is based on research I have conducted, including interviews and an extensive review of public records relating to my own case. From what I know of the Washington State Department of Health’s Health Professions Regulatory Boards, there are similar—if not worse—issues, some of which have come into play in the recent high-profile cases of nurses at Seattle Children’s Hospital. That will be a topic of a follow-up post once I have gathered more information on Washington State.
First, here is some necessary background for people who aren’t familiar with health professions regulation. Each state regulates health professionals licensed to practice in their specific state. The main purpose of health regulatory boards is to ensure safe and competent delivery of health care services. Each health care profession or division is charged with regulating its ‘own kind.’ The health regulatory boards are included in each state’s department of health and are governed by state laws. As in all other states’ rights issues, there is variability in quality and oversight of the health regulatory boards, as well as considerable variation within a state in terms of the different divisions. Thus, the common perception that Boards of Nursing are more likely than Boards of Medicine to be overly strict is backed by independent audits.
In my home state (Commonwealth) of Virginia, a Joint Legislative Audit of the health regulatory boards in 1999 found that “The Board of Medicine does not adequately protect the public from substandard care by physicians. It rarely sanctions physicians for standard of care violations.” The Board of Nursing was twice as likely as the Board of Medicine to suspend licenses or impose other extreme sanctions for the similar practice violations.
This is the highly condensed version of my initial saga with the Virginia Health Regulatory Board. As soon as I graduated/got my nurse practitioner license in the Spring of 1986, I ran the Cross-Over Health Clinic at the Richmond Street Center. This was a multi-service center for Richmond’s burgeoning homeless adult population. I was the sole health care provider, with physician back up by telephone. Several volunteer physicians would also have Saturday morning clinic hours for our more medically complex patients. I had written and co-signed practice protocols in place, which were required for nurse practitioners in Virginia at the time (and still are). By the end of our first year, I had seen over 1,600 patients for 4,000 clinic visits. The clinic’s entire yearly budget–including medications– was $30,000.
In early October 1987, I received a surprise visit by an downtrodden-looking field investigator from the Health Regulatory Board. He said they had received complaints from Richmond physicians about my practice, and specifically about the scope of my practice as a nurse practitioner. At the time there were no other nurse-managed clinics in Virginia, and I soon found out why. Powerful physician groups did not want them. This began an almost nine-month saga of informal hearings with the State Attorney General’s office, times of our clinic being closed by the Regulatory Board, and long stretches of wondering if my license (and livelihood) would be revoked. At the beginning of the investigation I had a six-month old son and my clinic job was my family’s only source of income. To state that this time of being investigated by the Health Regulatory Board was stressful is an understatement. I lost so much weight my doctor advised me to stop breast-feeding my son. My marriage disintegrated. I became disillusioned about nursing in general and took pre-med courses and applied to med school. I became homeless. I seriously contemplated suicide. More than a few times.
But here’s the irony. I’ve gotten past all of that. My son survived early weaning and is in graduate school. I own my home and have a reasonably stable job. I have a happy and rewarding long term relationship. I now like and even love nursing. I have almost completed a book about that time of my life. In researching that specific part of my story I realized I never had any closure on it—as in I never received any documentation about the outcome of their investigation. I knew it had ended, as had my marriage, as had my job. But I had no proof, and I was curious to find the documentation of the investigation into my practice.
So in January of this year I sent an e-mail inquiry to Jay P. Douglas, RN, MSM, CSAC (that means, I believe, that she is a certified substance abuse counselor and a nurse midwife), who is the current Executive Director of the Virginia Board of Nursing. I briefly explained who I was, that I was writing a book and wanted to get copies of the records/documentation of the investigation of my nursing license. I didn’t hear back from her, so after a month I called her office. It was lunchtime, but the woman who answered the phone happened to know about my case, as she had typed up my reports back in 1988 (really—strange things like this have happened to me with this book project.) She said she didn’t see why I couldn’t have copies of my own report, but that she’d have to defer that decision to Jay P. Douglas. She told me that Frank M. Cody was the Assistant Attorney General who had investigated my case, and that they had closed the case in May 1988 without a hearing, for insufficient evidence. She added that they now try to hire more qualified field investigators than what I’d had—that back then they hired former food and/or rat control inspectors.
I got a letter dated 2-4-11 from Jay P. Douglas stating, “Please be aware that according to section 54.1.2400.2 of the Code, any reports, information, or records received and maintained by any health regulatory board in connection with possible disciplinary proceedings, including any material received or developed by a board during an investigation or proceeding, shall be strictly confidential. A board may only disclose such confidential information pursuant to an order of a court or competent jurisdiction for good cause arising from extraordinary circumstances being shown. Therefore, I am unable to comply with your request.”
In a follow-up telephone conversation I had with her (very civil conversation by the way), Ms. Douglas said that she had sought advise on this from the Virginia Attorney General’s Office. I pointed out that I wasn’t asking to know individual identifiers of who said what about my practice, but then she said that since I wasn’t a Virginia State resident now, she couldn’t release any information. So as of this writing I still have no written documentation that my case was ever resolved, much less what the ‘case’ really involved to begin with. It makes me wonder what they have to hide. It makes me wonder who regulates the health regulatory boards in our country.
The health policy journal Health Affairs has a feature entitled “Narrative Matters,” which are personal essays in the voice of patients, their families and caregivers with a health policy aspect. Health Affairs has been running these essays for 10 years and is a popular feature, crossing over to news features on NPR and in the New York Times. In 2006, the editors of Narrative Matters published a book collection of 46 of their best essays. The essays included in the book are all very powerful. They range from a former governor writing about the culture clashes between medicine and public policy, to a physician’s struggle to care for his father with dementia. What struck me as I read these essays, as well as the other more recent ones available online, was the fact that very few were by nurses. In the book version, there are two essays written by nurses. They are both by male nurses and deal with their moral distress, burnout, and decision to leave nursing. This is a common problem in nursing, and rates of burnout and exit from nursing are much higher for male than for female nurses. It’s good to have their perspectives on the issues voiced, but was disappointing that those were the only essays by nurses included. Of the 10 essays published in 2010, seven were by physicians, two were by patients, and one was by a nurse practitioner. The nurse practitioner wrote about her decision not to have mammograms and the negative reactions she gets when she voices her decision and rationale. We need more nurses writing these sorts of essays, and having them published in high profile journals such as Health Affairs. Publishing in nursing-specific journals is all well and good, but I don’t think many nurses ever read them, and the general public most certainly does not.
Next quarter I am teaching a graduate level course in health politics and policy and in lieu of a course paper I am having students write (and submit) policy-level nursing narratives for Narrative Matters. So stay tuned to Narrative Matters for (hopefully) some stronger nursing voices.
