Tag: Robert Wood Johnson Foundation

Back to the Future of Nursing

wierdflightattendantsBack to the Future of Nursing: A Look Ahead Based on a Landmark IOM Report, part of the Rosenthal Lecture Series, was held today at the National Academy of Sciences in Washington, DC. The panel discussion focused on progress made in the past three years since the release of IOM report The Future of Nursing: Leading Change, Advancing Health (FON). The webcast recording of the event will be posted soon. Check out their infographic poster which is quite nicely done.

Some of the highlights that I picked up on during this panel discussion included efforts to increase diversity in nursing as well as career mobility, and national efforts to increase scope-of-practice for nurse practitioners. Currently there are 17 states that allow nurse practitioners to be fully independent and two additional states that allow nurse practitioners to be ‘almost’ fully independent (Maryland and Utah). In the past three years seven states have removed major barriers to practice, and Nevada recently gave nurse practitioners full practice authority. Opposition by state medical organizations blocked passage of similar bills in Connecticut, Kentucky, New York, and most recently in California. But the momentum is growing in favor of independent practice for nurse practitioners across the country. The Federal Trade Commission is challenging limits to nursing scope-of-practice in many of the recalcitrant states (including, I hope, my home state of Virginia).

At the end of today’s lecture there was an excellent televised address by Rissa Lavizzo-Mourey, MD, who is the director of the Robert Wood Johnson Foundation (sponsor the FON report and follow-up efforts). Among other things she spoke of the need to change the “caste system in hospitals” that treats nurses as second-class citizens. That seems to be a daunting task.

I have read the entire IOM FON report several times and think it is an excellent document. (Previous blog post Undoing Nurses as Functional Doers Nov 24, 2010). Of course, being a primary care nurse practitioner myself with previous run-ins with state health regulatory boards over scope-of-practice issues (see To Forgive, Divine blog post), I have been cheering the efforts in this area spurred on by the IOM Future of Nursing report. And being a nurse educator who loves teaching (and who abhors most approaches to nursing education–another nursing care plan anyone?), I applaud the IOM/FON report section on changes needed within nursing education.

So what has changed for me in the past three years since the IOM FON report? Many faculty members invoke the FON report from time-to-time when making various points about needed changes in the curriculum. Not many of our current students have even heard of the report (shame! I need to assign parts of it as required reading). I’ve seen a large uptick in the support for interprofessional educational experiences for students and faculty. And I’ve seen an increased emphasis on adding leadership content as well as political advocacy skill-building activities for students within our various programs (although there’s still a shameful paucity of resources and nursing role models in these areas). The other thing that bugs me in the area of politics and policy education for nurses is the emphasis on self-advocacy for nursing practice. While that’s important, nurses can and should be using their advocacy skills and energies for less self-serving health policy changes.

Back To School Nursing

Children washing their hands before lunch. Tak...
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.

Resources:

Robert Wood Johnson Foundation, Unlocking the Potential of School Nursing: Keeping Children Healthy, In School, Ready to Learn. August 2010

National Association of School Nurses (interview with Linda Davis-Aldritt, President NASN on preparation needed for being a school nurse)

CDC’s Division of Adolescent and School Health

Fun video clip about the work of Vermont school nurse Mandy Mayer, “I am a nurse, I am a leader” (won this year’s ANA award).

Nothing About Me Without Me

An electronic medical record example
Image via Wikipedia

Donald Berwick, recent Administrator of the Centers for Medicare and Medicaid Services, and past President of the Institute for Healthcare Improvement, has some opinions on patient-centered care. One of his maxims for patient-centered care is: nothing about me without me—addressing transparency and patient participation in care. In one of his speeches, “Escape Fire: Lessons for the Future of Health Care” (Commonwealth Fund, 2002), he rails against the difficulties patients have in having access to their own medical information.

Isn’t it ironic that giving patients access to their own medical charts is considered a radical idea? So radical in fact that the Robert Wood Johnson Foundation—that pioneering, cutting edge organization—is funding research on the feasibility and effectiveness of giving patients access to their own medical records. A one-year pilot project called “OpenNotes” was conducted at three hospitals: Harborview Medical Center in Seattle, Beth Israel Deaconess Medical Center in Boston, and the Geisinger Health system in Pennsylvania. Results from the baseline survey data were reported in the Annals of Internal Medicine (12-20-11). Not surprisingly, patients were overwhelmingly (>90%) supportive of the idea of having access to their doctor’s medical notes, saying it would help them remember important health information. In contrast, the majority of the 173 doctors completing baseline surveys expressed reservations over the OpenNote idea. The doctor’s concerns included: 1) worrying/confusing patients with medical chart information, 2) doctors would be less candid in what they charted about patients, 3) it would take up more of their time in having to answer patient questions raised by access to their charts, 4) it could increase the number of lawsuits, and, 5) personal medical information could end up on Facebook.  The yearlong pilot has ended and OpenNote researchers are now analyzing data to see how patients and doctors who participated in the project felt about it. They are also evaluating how often patients accessed their medical charts, how often they shared them with family/other providers, and how often they corrected errors the doctors had made in the charts.

As Carol Ostrom points out in her recent article on the OpenNote project, doctors may need to change some of their charting habits in terms of labeling patients. (“Patients eager to see doctor’s notes; physicians, not so much” Seattle Times, 12-25-11). She includes calling patients SOBs and charting on their BS (bowel signs). I’m not sure I’ve ever read a medical chart where someone called a patient a SOB, but I last worked in a clinic that had ‘slovenly’ as a standard term in a menu for describing patients. My colleagues and I had a debate, with some saying slovenly was a perfectly acceptable term for patients—similar to unkempt or disheveled. I maintained it was much more insulting because it implied a slur on moral character as well as physical appearance. And then there’s the still used FLK (funny looking kid) in pediatrics, used for describing a baby or toddler ‘just doesn’t look quite right and might have a genetic or other disorder but who hasn’t been diagnosed yet.’ Supposedly some pediatricians have been known to use FLP (funny looking parent) in children’s charts—I suppose by way of saying the FLK is genetic in a FLF (funny looking family) sort of way. I don’t think these terms would go over well in OpenNote.

Where have all the nursing professors gone?

Portrait of Florence Nightingale.
Image via Wikipedia

“The Future of Nursing: Leading Change, Advancing Health,” is a weighty tome published/released by the Institute of Medicine and the Robert Wood Johnson Foundation on October 5, 2010, and is written about by Pauline Chen, MD in her NYT article “Nurses’ Role in the Future of Health Care” (Nov 18, 2010). Dr. Chen’s article has been one of the most e-mailed NYT articles since it appeared last week, and at last count it had a total of 91 reader’s comments. It got people’s attention. I find it interesting that in her article, Dr. Chen links to the IOM report ($51 and you can read it), but doesn’t mention that the exact same report is available for free on the RWJ website (also has its own Facebook page). There is a 600 plus page version and a 4 page “Brief Summary” version, both free.

In the 600 page version, Chapter 4 is devoted to nursing education, and among other things, they address “the aging cadre of nursing researchers and educators.” We are dropping like mosquitoes around one of those electrified zapping machines. And there’s no one to replace us. The IOM/RWJ report states there are 5,000-5,500 unfilled nurse educator positions around the US. In my own school of nursing, within three years something close to 70% of our faculty will be 65 or older (disclosure: I’m not even close to being one of those…). Of course, that doesn’t mean they will retire, but that’s another story. That statistic is public information already, as is the fact that many other faculty in major schools of nursing across the country are ‘getting out’ of nursing education–burnt out, put out, or lured out by better opportunities in health care industry of one sort or another. Many of those are people I consider to be the best, brightest, most creative nursing educators we had. The IOM/RWJ report has many excellent recommendations about improving nursing education, but I wonder how they will get done with what’s left of our nursing professor workforce.