Nurses SRQ

Increasingly wanted: Loving, discreet, experienced professional willing to travel the world and work through the night, feeding, cuddling and changing lots of diapers.

The pay is very good — about $350 a day or more — though it includes 24 hours on call.

With a house in Sarasota and roots in Yorkshire, England, Carol Lee is part of a small but growing army of “maternity nurses” (Europe) or “newborn care specialists” (the United States).

While the quaint tradition of a baby nurse who moves into the house to care for newborns around the clock is alive and well in other parts of the world, the phenomenon is relatively new in America, and experienced candidates are in short supply.

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NEW YORK -  The specter of nursing strikes is looming on both coasts, as newly empowered nurses’ unions confront hospitals pressed to cut costs amid changes in health care financing.

In New York, more than 6,000 registered nurses are poised to walk out of three of the city’s most prestigious hospitals before the year’s end, mainly over changes to their health benefits and what they say are strains in staffing. The hospitals — Mount Sinai, Montefiore Medical Center and St. Luke’s-Roosevelt Hospital Center — already are contracting for strike replacements at more than double normal wages.

In California, where 23,000 nurses represented by the California Nurses Association staged a one-day strike in September over similar issues, a new 24-hour walkout is set for Dec. 22 at eight hospitals in the San Francisco Bay area and one in Long Beach. Potential strikes in New Jersey and Minnesota are being advertised on the website of HealthSource Global Staffing, one of the largest strike replacement agencies, which promises “cool locations and hot paychecks” for nurses willing to fill in during a walkout.

In New York, the union, the New York State Nurses’ Association, has not yet given the hospitals a 10-day strike warning, which the law requires, and last-minute settlements are still possible. But their battle with the hospitals reflects common themes across the country.

The nurses, who voted overwhelmingly to authorize a strike, say they are being treated with disrespect by a corporate hospital culture that demands sacrifices from patients and those who provide their care, but pays executives millions of dollars.

Management officials defend executive pay as the price of competition for top leadership, and accuse the nurses of refusing what many other American workers have accepted: paying a share of their health insurance premiums, along with higher co-payments, deductibles and prescription costs.

Though finances differ, all hospitals face cuts in Medicaid and Medicare and uncertainty over budgets under new payment models. Among other changes are new measures on the quality of care: Hospitals will lose money if too many patients are re-admitted within 30 days, or if there are low scores on patient satisfaction surveys — two areas in which nurses play a crucial role.

For patients, the stakes are high, according to a recent study of 50 nurses’ strikes in New York state between 1984 and 2004. The study, for the National Bureau of Economic Research, found that patient mortality was 19.4 percent higher during a strike, or that there was about one extra death for every 280 patients admitted, regardless of whether hospitals hired replacements or tried to manage with a small staff.

The study resonated at a Sutter Health hospital in Oakland, Calif., where the death in September of Judith Ming, 66, a cancer patient, was blamed on a medical error by one of 500 temporary nurses hired to replace those locked out for several days after their 24-hour strike. The death is still under investigation, but The San Francisco Chronicle reported that a dietary supplement was mistakenly fed into the patient’s intravenous line.

In the study, researchers at the Massachusetts Institute of Technology and Carnegie Mellon University found that patients admitted during strikes were no sicker than those admitted at nearby hospitals, but were 6.5 percent more likely to be readmitted within 30 days.

“That would obviously be something a patient might be interested in knowing,” said Samuel Kleiner, one of the study’s authors.

“Nobody wants a strike,” said Bruce McIver, president of the League of Voluntary Hospitals, who is negotiating for Mount Sinai and Montefiore.

Hospitals in New York City have not experienced major nurses strikes for more than a decade.

The contract for the nurses in the city expired last December. Negotiations grew harder, both sides say, after management trustees of the union’s benefit fund won an arbitration decision in June requiring nurses to pay $25 to $400 a month toward premiums previously covered entirely by their employers.

Reduced coverage took effect Sept. 1 at two hospitals. Anger intensified because some nurses, under their health plans, had to pay hundreds of dollars more for medication. For union leaders, elected this year on pledges of more forceful representation, modifying the changes in health benefits became a key goal, despite the arbitrator’s decision.

“They’re making demands at the bargaining table that are out of line with what others have been able to get,” McIver said. “Up and down the line, all health care workers have been asked to make sacrifices.”

Judy Sheridan-Gonzalez, a nurse and union leader at Montefiore, said the strike vote was driven by more than new fees. “As professionals we don’t feel respected,” she said. “We feel this corporate model is being shoved down our throat.”

She said the hospital had hired costly consultants who handed nurses scripts to recite to patients in a bid to boost customer satisfaction scores, even as the nurses were left short-handed with more acutely ill patients, straining the staffing guidelines — one nurse to seven patients — they had negotiated a decade ago.

Jesse Derris, a spokesman for Montefiore, said the hospital routinely hired experts to help employees at every level improve patient care, and that its staffing standards exceeded national guidelines. Montefiore, he added, will continue to “do the best we can for a hospital that relies on Medicaid and Medicare for 80 percent of its funding.”

At Mount Sinai, nurses’ base salaries go from $75,000 to $95,000 after 20 years, and average close to $100,000 with overtime and advanced degrees. Jacklynn Price, president of the bargaining unit, said the sense of disrespect crystallized when a management negotiator told them: “We have the money. We just don’t have the will to give it to you.”

“They go home with bags of money, what I call these nonprofit oligarchs,” said Price, a veteran nurse. She cited a $1.2 million bonus paid last year to the hospital’s chief executive, Kenneth L. Davis, which brought his compensation to $2.6 million. “None of that could they do without nurses.”

In a written response, Mount Sinai said that under the plan nurses would pay about 20 percent of what its other health care professionals pay toward insurance.

“Despite the union’s attempt to mislead,” the hospital wrote, “this is not an issue of respect, but rather an issue of fairness. We have great respect for work done by the nurses, but we also have great respect for the work done by all members of the health care team.”

But a surprise settlement last week by NewYork-Presbyterian, where a strike had been authorized, seemed to undercut that position and to nullify the arbitrator’s decision. The hospital will reimburse its 3,000 nurses for premiums, in exchange for other financial concessions, union leaders said. The trustees of the nurses’ benefit fund, divided between representatives of the union and the hospital, are expected to vote on that arrangement Friday. If they reject it, the nurses could leave the fund, threatening its actuarial health. The settlement also includes 9 percent in raises over three years, and better staffing ratios.

Myrna Manners, a spokeswoman for NewYork-Presbyterian, would not confirm those details. But the settlement’s terms clearly rankled the three hospitals where negotiations are stalled.

“We’re disappointed,” said Rick Pogue, vice president for human relations at Continuum Health Partners, who is at the bargaining table for St. Luke’s-Roosevelt. “But that is not going to change our position.”

“Presbyterian is the wealthy sister up the street, so to speak, that can afford to drive around in a Bentley,” he added. “And we drive a nice Ford, but we still get there.”

Would Mandatory Vaccines Protect Nurses and Patients? | ONS Connect.

NASHVILLE — With pain in her right ear, Sue Cassidy went to a clinic. The doctor, wearing a white lab coat with a stethoscope in one pocket, introduced herself.

“Hi. I’m Dr. Patti McCarver, and I’m your nurse,” she said. And with that, Dr. McCarver stuck a scope in Ms. Cassidy’s ear, noticed a buildup of fluid and prescribed an allergy medicine.

It was something that will become increasingly routine for patients: a someone who is not a physician using the title of doctor.

Dr. McCarver calls herself a doctor because she returned to school to earn a doctorate last year, one of thousands of nurses doing the same recently. 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 comes with it.

As more nurses, pharmacists and physical therapists claim this honorific, physicians are fighting back. For nurses, getting doctorates can help them land a top administrative job at a hospital, improve their standing at a university and win them more respect from colleagues and patients. But so far, the new degrees have not brought higher fees from insurers for seeing patients or greater authority from states to prescribe medicines.

Nursing leaders say that their push to have more nurses earn doctorates has nothing to do with their fight of several decades in state legislatures to give nurses more autonomy, money and prescriptive power.

But many physicians are suspicious and say that once tens of thousands of nurses have doctorates, they will invariably seek more prescribing authority and more money. Otherwise, they ask, what is the point?

Dr. Roland Goertz, the board chairman of the American Academy of Family Physicians, says that physicians are worried that losing control over “doctor,” a word that has defined their profession for centuries, will be followed by the loss of control over the profession itself. He said that patients could be confused about the roles of various health professionals who all call themselves doctors.

“There is real concern that the use of the word ‘doctor’ will not be clear to patients,” he said.

So physicians and their allies are pushing legislative efforts to restrict who gets to use the title of doctor. A bill proposed in the New York State Senate would bar nurses from advertising themselves as doctors, no matter their degree. A law proposed in Congress would bar people from misrepresenting their education or license to practice. And laws already in effect in Arizona, Delaware and other states forbid nurses, pharmacists and others to use the title “doctor” unless they immediately identify their profession.

The deeper battle is over who gets to treat patients first. Pharmacists, physical therapists and nurses largely play secondary roles to physicians, since patients tend to go to them only after a prescription, a referral or instructions from a physician. By requiring doctorates of new entrants, leaders of the pharmacy and physical therapy professions hope their members will be able to treat patients directly and thereby get a larger share of money spent on patient care.

As demand for health care services has grown, physicians have stopped serving as the sole gatekeepers for their patients’ entry into the system. So physicians must increasingly share their patients — not only with one another but also with other professions. Teamwork is the new mantra of medicine, and nurse practitioners and physician assistants (sometimes known as midlevels or physician extenders) have become increasingly important care providers, particularly in rural areas.

But while all physician organizations support the idea of teamwork, not all physicians are willing to surrender the traditional understanding that they should be the ones to lead the team. Their training is so extensive, physicians argue, that they alone should diagnose illnesses. Nurses respond that they are perfectly capable of recognizing a vast majority of patient problems, and they have the studies to prove it. The battle over the title “doctor” is in many ways a proxy for this larger struggle.

For patients, the struggle has brought an increasing array of professionals trained to deal with their day-to-day health woes, but also at times confusion over who is responsible for their care and what sort of training they have.

Six to eight years of collegiate and graduate education generally earn pharmacists, physical therapists and nurses the right to call themselves “doctors,” compared with nearly twice that many years of training for most physicians. For decades, a bachelor’s degree was all that was required to become a pharmacist. That changed in 2004 when a doctorate replaced the bachelor’s degree as the minimum needed to practice. Physical therapists once needed only bachelor’s degrees, too, but the profession will require doctorates of all students by 2015 — the same year that nursing leaders intend to require doctorates of all those becoming nurse practitioners.

Dr. Kathleen Potempa, dean of the University of Michigan School of Nursing and the president of the American Association of Colleges of Nursing, said that the profession’s new doctoral degree, called the doctor of nursing practice, was simply about remaining current. “Knowledge is exploding, and the doctor of nursing practice degree evolved out of a grass-roots recognition that we need to continuously improve our curriculum,” she said.

Last year, 153 nursing schools gave doctor of nursing practice degrees to 7,037 nurses, compared with four schools that gave the degrees to 170 nurses in 2004, when the association of nursing schools voted to embrace the new degree. In 2008, there were 375,794 nurses with master’s degrees and 28,369 with doctorates, according to a recent government survey.
Dr. Potempa said that nurses with master’s degrees were every bit as capable of treating patients as those with doctorates.

Nursing is filled with multiple specialties requiring varying levels of education, from a high school equivalency degree for nursing assistants to a master’s degree for nurse practitioners. Those wishing to become nurse anesthetists will soon be required to earn doctorates, but otherwise there are presently no practical or clinical differences between nurses who earn master’s degrees and those who get doctorates.

Nurse practitioners must generally graduate from college and take an additional 12 to 16 months of classes, which include months of treating patients for both mild and serious illnesses in clinics and hospitals under the watchful eyes of instructors. Those earning doctorates must generally take a further four semesters or 12 to 16 months of additional classes.

While instruction at each school varies, Dr. McCarver took classes in statistics, epidemiology and health care economics to earn her doctor of nursing practice degree. These additional classes, at Vanderbilt University, did not delve into how to treat specific illnesses, but taught Dr. McCarver the scientific and economic underpinnings of the care she was already providing and how they fit into the nation’s health care system. Studies have shown that nurses with master’s level training offer care in many primary care settings that is as good as and sometimes better than care given by physicians, who generally have far more extensive training. And patients often express higher satisfaction with care delivered by nurses, studies show. Physicians say they are better at recognizing rare problems, something studies have trouble measuring.

The benefits to patients of nurses receiving doctorates is unclear, since there is no evidence that nurses with doctoral degrees provide better care than those with master’s degrees do.

Given the proven effectiveness of nurses with master’s degrees, even some nursing leaders have asked why nurses should be required to get doctorates.

“If it ain’t broke, why fix it?” asked Dr. Afaf I. Meleis, dean of the University of Pennsylvania School of Nursing.

Some health care economists say the push for clinical doctorates across health professions could be misguided. They argue that anything requiring students to spend more time and money getting trained will invariably result in longer waits and increased costs for patients, because fewer students will meet the increased requirements and those who do will eventually demand higher compensation.

“Everyone’s talking about improving patients’ access to care, bending the cost curve and creating team-based care,” said Erin Fraher, an assistant professor of surgery and family medicine at the University of North Carolina School of Medicine. “Where’s the evidence that moving to doctorates in pharmacy, physical therapy and nursing achieves any of these?”

Depending on their area of specialty, nurse practitioners earn a median salary of $86,000 to $90,000 annually, according to the Medical Group Management Association — a bit less than half of what primary care physicians earn. Nurses with doctorates generally earn the same salaries as those with master’s degrees since insurers pay the same rates to both. Physician groups fear that the real reason behind the creation of the doctor of nursing practice degree is to persuade more state legislatures to grant nurses the right to treat patients without supervision from doctors.

Twenty-three states allow nurses to practice without a physician’s supervision or collaboration, and most are in the mountain West and northern New England, areas that have trouble attracting enough physicians. Nursing groups have lobbied for years to increase that number. “This degree is just another step toward independent practice,” said Louis J. Goodman, chief executive of the Texas Medical Association.

Not true, Dr. Potempa said — the new degree simply ensures that nurses stay competent. “It’s not like a group of us woke up one day to create a degree as a way to compete with another profession,” she said. “Nurses are very proud of the fact that they’re nurses, and if nurses had wanted to be doctors, they would have gone to medical school.”

Dr. Potempa said that nurses with master’s degrees were every bit as capable of treating patients as those with doctorates.

Nursing is filled with multiple specialties requiring varying levels of education, from a high school equivalency degree for nursing assistants to a master’s degree for nurse practitioners. Those wishing to become nurse anesthetists will soon be required to earn doctorates, but otherwise there are presently no practical or clinical differences between nurses who earn master’s degrees and those who get doctorates.

Nurse practitioners must generally graduate from college and take an additional 12 to 16 months of classes, which include months of treating patients for both mild and serious illnesses in clinics and hospitals under the watchful eyes of instructors. Those earning doctorates must generally take a further four semesters or 12 to 16 months of additional classes.

While instruction at each school varies, Dr. McCarver took classes in statistics, epidemiology and health care economics to earn her doctor of nursing practice degree. These additional classes, at Vanderbilt University, did not delve into how to treat specific illnesses, but taught Dr. McCarver the scientific and economic underpinnings of the care she was already providing and how they fit into the nation’s health care system. Studies have shown that nurses with master’s level training offer care in many primary care settings that is as good as and sometimes better than care given by physicians, who generally have far more extensive training. And patients often express higher satisfaction with care delivered by nurses, studies show. Physicians say they are better at recognizing rare problems, something studies have trouble measuring.

The benefits to patients of nurses receiving doctorates is unclear, since there is no evidence that nurses with doctoral degrees provide better care than those with master’s degrees do.

Given the proven effectiveness of nurses with master’s degrees, even some nursing leaders have asked why nurses should be required to get doctorates.

“If it ain’t broke, why fix it?” asked Dr. Afaf I. Meleis, dean of the University of Pennsylvania School of Nursing.

Some health care economists say the push for clinical doctorates across health professions could be misguided. They argue that anything requiring students to spend more time and money getting trained will invariably result in longer waits and increased costs for patients, because fewer students will meet the increased requirements and those who do will eventually demand higher compensation.

“Everyone’s talking about improving patients’ access to care, bending the cost curve and creating team-based care,” said Erin Fraher, an assistant professor of surgery and family medicine at the University of North Carolina School of Medicine. “Where’s the evidence that moving to doctorates in pharmacy, physical therapy and nursing achieves any of these?”

Depending on their area of specialty, nurse practitioners earn a median salary of $86,000 to $90,000 annually, according to the Medical Group Management Association — a bit less than half of what primary care physicians earn. Nurses with doctorates generally earn the same salaries as those with master’s degrees since insurers pay the same rates to both. Physician groups fear that the real reason behind the creation of the doctor of nursing practice degree is to persuade more state legislatures to grant nurses the right to treat patients without supervision from doctors.

Twenty-three states allow nurses to practice without a physician’s supervision or collaboration, and most are in the mountain West and northern New England, areas that have trouble attracting enough physicians. Nursing groups have lobbied for years to increase that number. “This degree is just another step toward independent practice,” said Louis J. Goodman, chief executive of the Texas Medical Association.

Not true, Dr. Potempa said — the new degree simply ensures that nurses stay competent. “It’s not like a group of us woke up one day to create a degree as a way to compete with another profession,” she said. “Nurses are very proud of the fact that they’re nurses, and if nurses had wanted to be doctors, they would have gone to medical school.”

GARDINER HARRIS

On a flat screen in a corner of the rehab gym, purple grape clusters gently surrender to gravity, while a cartoon fox at the bottom of the screen waits, poised to gobble them. Sitting alertly in her wheelchair, the therapy patient lifts her right hand in a slight beckoning gesture, and in response the grapes scoot to the left so they fall into the fox’s mouth.

She smiles.

After a fall, stroke or surgery, physical therapy for the elderly is painful, arduous and absolutely essential. Studies have shown that getting older patients moving quickly staves off depression and decline. So at Life Care Center of Sarasota, rehab specialists are using a new virtual reality device designed for older patients, helping them take their first steps toward home.

Encouraging older patients to begin the long haul of tedious and repetitive exercises can be a challenge, said Meneth Mazzone, director of rehabilitation for Life Care. After a two-month trial, the center became the first facility in Southwest Florida to lease a system called the OmniVR because she was impressed by how quickly her patients become engaged in the games.

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Any nurse who has practiced in an operating room has likely experienced leg pain. Good shoes and proper hosiery may be the answer, podiatrists say.

Sore feet and tired, achy legs. These are long-standing issues for nurses who must spend hours upon hours on their feet.

No one would know that better or appreciate preventive measures more than Ramona Conner, MSN, RN, a specialist in the Center for Nursing Practice at the Association of Operating Room Nurses headquarters in Aurora, Colorado. She’s been a perioperative nurse for 25 years and once worked a 36-hour shift as part of a transplant team at the University of Colorado.

“I was much younger then,” she confessed.

“Anybody practicing in an operating room at one time or another has experienced leg pain,” Conner said. “Certainly, as we age it’s becoming more common. What I did was wear comfortable shoes,” she said.

Conner also shifted positions frequently. “Support hose are particularly helpful for those long days. Of course, any time you get a break, you put your feet up.”

Good shoes and proper hosiery are the preventive measures that certified wound specialist Julia Overstreet, a doctor of podiatric medicine, recommends. They’re also where treatment begins for problems she sees in practice as a podiatrist and surgeon at Overstreet Health Center in Bellevue, Wash.

“One of the biggest problems I see with the population as a whole, and certainly with my nurse patients, is plantar fasciitis, which is basically heel pain,” Overstreet said.

The plantar fascia is a triangle-shaped band of tissue, widest across the ball of the foot and narrowing to a single point in the heel. The tissue stretches and can tear under the pressure of prolonged walking and standing, particularly on hard surfaces, causing pain. It’s commonly known as a “fallen arch” as opposed to a “flat foot.” The remedy is artificial support.

While some people require custom supports, Overstreet said she first recommends patients use the over-the-counter variety found at sporting goods shoe stores.

The important part of the protocol, she said, is that once arch supports are needed, they always are needed. She said, “Even if someone gets up to go to the bathroom in the middle of the night, they need to have that in their slippers. They can be barefoot in bed and in the shower. That’s it.

“One of the hallmarks of plantar fasciitis is that it hurts worst the first thing in the morning or if you’ve been sitting for a while,” she said. “That’s because while you’re sitting or while you’re sleeping, it starts to heal. Then when you take that first step, it tears that plantar fascia again. It starts all over.”

Supportive shoes from the get-go may prevent or forestall plantar fasciitis. “Tennis shoes, for instance, are great,” Overstreet said, referring to today’s athletic footwear. Flimsy canvas tennis shoes “twist like a towel” and offer no support.

Good nursing shoes
At Birkenstock, the Novato, Calif., shoe manufacturer, brand manager Tim Grimmer ran through qualities common to good nursing shoes. In February, Birkenstock will launch a line based on current models but tailored for physicians and nurses with polyurethane finishes on leather, colors that complement medical uniforms and Velcro enclosures for micro adjustments, he said.

In any shoe brand, Grimmer advises nurses to look for:

• A good toe box so toes can spread out naturally. “Toes are vital in maintaining your balance and carrying your weight. In many shoes, the toes are tightly squeezed and not able to perform this natural function.”
  
• A deep heel cup to hold protective tissue in place. “Our feet were made to walk on the earth, where you have some give to the environment. On hard surfaces, the protective tissue that surrounds your heel bone gets pushed to the side,” she said. The reality, of course, is that nurses spend their shifts on concrete, tile, linoleum and commercial-grade carpeting. A deep heel cup cradles and protects the foot’s natural cushioning.
  
• A neutral or unelevated heel. “This basically allows all the bones in our feet to bear the weight.”
  
• A lightweight, shock-absorbing sole. Grimmer said most people instinctively say that a softer foot bed would be more comfortable, but it needs to be firm for arch support. “Cushioning and shock-absorption come from the sole rather than where your foot actually rests on the foot bed,” he said.

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