By Mary Winter
DENVER – Holli Wiseman remembers when nurses were expected to be seen, not heard.
In the late 1970s, shortly after she’d graduated nursing school and was working at Porter Hospital, Wiseman says a doctor screamed at her: “‘Don’t give the patient any information unless the doctor says to!’”
Wiseman’s faux pas? She’d taken time to explain blood pressure readings to a man in her care.
Wiseman laughs at the memory.
“Today, of course, doctors depend on you to give patients information,” says Wiseman, a clinical nurse specialist with the Visiting Nurse Association in Denver. “Teaching is a major part of our job.”
Wiseman’s anecdote illustrates one of the biggest changes in nursing in the past half century: from the role of doctors’ silent helpmate to that of decision maker, hands-on practitioner and front-line educator, charged with teaching patients how to better manage their own health care in an era of high demand and scarce resources.
Health care tsunami
In fact, that teaching component has become Job 1 for America’s nearly 3 million nurses as the health care system braces for a tsunami of needy patients.
An estimated 10,000 Baby Boomers turn 65 every day. Beset with the illnesses of aging, from chronic toenail fungus to Alzheimer’s Disease, they will demand more and costlier care as they live into their 80s and beyond.
On top of that, the Patient Protection and Affordable Care Act, requiring all Americans to have health coverage, will pour 32 million new patients into the health care pipeline starting in 2014.
Is the system up to the task? Only if it focuses on education, say many experts.
“Our challenge is to learn how to take care of ourselves and to self-manage,” says Laura Reilly, president and CEO of the Visiting Nurse Association in Colorado. “We need to look at how to stay well because our elderly population is growing so rapidly, and our resources will be so thin … Our goal is to teach (patients) to stay independent and out of the hospital, because the days of full-range medical care are over.”
For nurses, the changes also bring opportunities.
Nursing jobs will be plentiful for decades to come. In fact, demand for registered nurses will grow faster than any other job sector through 2020, according to the U.S. Bureau of Labor Statistics. The number of employed nurses is predicted to grow from 2.74 million in 2010 to 3.45 million in 2020, a 26 percent increase.
Additionally, nurses’ roles and responsibilities – and salaries, presumably — will continue to expand; nurses now can specialize in one of 200 different fields, from psychiatry to diabetes management and telemedicine. A range of degrees is available, from licensed practical nurse, which takes as little as nine months of training, to registered nurse with a four-year baccalaureate degree, to advanced-practice nurses with post-graduate degrees. Currently, about a third of U.S. nurses have four-year degrees or above; by 2020, health care leaders recommend that number be 80 percent.
There is a “huge movement” to increase nurses’ education levels, with more baccalaureate, master’s and doctoral degrees, says Rosemarie Polemi,director of nursing practice and emergency management at Kaiser Permanente Colorado.
“More education is definitely the trend and will be the future,” said Polemi. “More skills are needed. With that education comes more independence and less dependence on physicians.”
Role expands for nurse practitioners
Nurse practitioners, who usually have master’s level education and in Colorado can act much like family doctors, are poised to play an especially important role. As the ranks of primary-care doctors shrink across the country, advanced-practice nurses and independent nurse practitioners are stepping in, prescribing medicine and performing jobs that a few years ago only doctors were licensed to do.
But the picture is not all rosy: a nursing shortage, which started in the 1980s, is projected to persist into the next few decades. Although the 2008 recession forced many nurses back to work, temporarily ending the shortage, the long-term prognosis isn’t good. The reasons are complex, but they include a chronic shortage of qualified nursing instructors and an aging nursing population. In Colorado, 32 percent of registered nurses are over 55, according to the Center for Nursing Excellence, which estimates the state will be short at least 6,300 registered nurses by 2018. http://www.coloradonursingcenter.org/sign-up-main
A 2010 benchmark report, “The Future of Nursing: Leading Change, Advancing Health,” by the National Academy of Science’s nonprofit Institute of Medicine and the Robert Wood Johnson Foundation, identifies four traits of a successful health care system: it embraces technology, encourages collaboration with the community, provides continuity of care across settings, and promotes nurse-led and managed health care.
The 600-page report lists four key recommendations for nursing:
- Make state licensing laws more uniform so that nurses are incented to practice to the full extent of their education; enhance and improve nurse residency programs to reduce new nurses’ stress and the resulting high turnover rates.
- Improve nursing education to give students more training in technology, management and specific fields such as geriatrics.
- Create a more efficient system for deploying nurses and monitoring where the biggest needs are.
- Make nurses full partners with doctors and other medical professionals.
If the recommendations become reality, nurses are destined to see more job responsibility, more schooling, greater authority, more professional satisfaction and a much greater diversity of professional duties.
For a glimpse at what some of those new aspects of nursing might look like, Solutions visited two nurses in Denver, one an expert in telemedicine, the other in home health care.
Lana Garner is a nurse, but her appearance doesn’t fit the stereotype. On the job, the 33-year-old wears long hair, designer jeans and a tiny diamond stud in her nose. She looks young, modern and totally at home with technology, which she is.
Garner is the Telehealth clinical manager for Centura Health at Home in Colorado. From her office at 13th Avenue and Speer Boulevard in Denver, Garner oversees three nurses who remotely monitor 200 patients from Canon City to Longmont.
TheTelehealth program uses in-home monitoring stations and live video visits by nurses to spot and treat problems early. The results are substantial reductions in ER visits and re-hospitalizations.
The benefits of the approach are becoming clearer as health care professionals come to understand the costs of re-hospitalizations and frequent ER visits. A recent study in the New England Journal of Medicine found that reducing preventable re-hospitalizations through better follow-up care could save Medicare billions of dollars each year.
The Telehealth monitoring station fits on a dresser or table in the patient’s home, and allows a nurse to collect data on blood pressure, pulse, weight and other vital signs remotely. The nurse reviews the information and provides the patient with feedback and counseling on a daily basis via the station’s videoconferencing feature or by telephone.
The video conferencing feature allows the nurse to visit with the patient in real time, giving feedback, answering and asking questions (Are your ankles swollen? Did you remember to take the new medicine?). The nurse in Denver can immediately dispatch a field nurse to the patient’s home if necessary.
“Telehealth allows the nurse to intervene at the right time, while the home care nurse may not know the status of patient until a home visit is conducted; by the time the home care nurse visits, the patient may already be back in the hospital,” according to a write-up of Centura’s program by the National Academy of Sciences. “The Telehealth nurse can monitor and do video visits on 12 patients a day as opposed to a home care nurse who averages five patients a day,” according to the NAS.
Also impressive is tele-monitoring’s success at reducing hospital re-admissions. Nationally, nearly one in five Medicare patients will return to the hospital within a month of discharge, at a cost of $17.5 billion in additional hospital bills every year, Kaiser Health News reports.
Congestive heart failure patients are emblematic; their national rate of readmission within 30 days is 24.7 percent, Garner says. But among Centura’s Telehealth patients, the rate is less than 1 percent, she says.
Having nurses contact patients shortly after their discharge also has a huge payoff in terms of reduced recidivism, Kaiser Permanente, Rocky Mountain Health Plans of Grand Junction and the University of Pennsylvania have found. Often, nurses short-circuit a trip to the ER.
“Twenty-four to 48 hours after discharge, a nurse communicates with them so they understand discharge orders, medications, etc. These are nurses, not clerks. Nurses act as health coach and are the patients ‘point of contact. It creates a much more efficient system,” says Steve ErkenBrack, CEO of Rocky Mountain Health Plans of Grand Junction.
At the University of Pennsylvania Hospital, nurses are assigned to elderly patients for up to three months after discharge. Nurses visit patients at home, take them to doctor’s appointments if necessary, and generally act as their health advocates and liaisons. Early results show the program has significantly reduced readmissions and costs by as much as $5,000 per patient.
Hospitals that don’t reduce readmissions will pay a price in the future. Tis month the government is penalizing more than 2,200 hospitals for readmitting patients within 30 days of discharge, according to a Kaiser Health News analysis. The hospitals will forfeit about $280 million in Medicare funds over the next year.
Telehealth, launched in 2004, was ahead of its time, Garner says. “It’s definitely the wave of the future. It’s patient-centered and cost effective.” The in-home equipment is user-friendly, even for patients with hearing and sight loss, she says, “and family members, especially those out of state, love it that someone is keeping an eye on them. I’ve been asked, ‘Can we pay you to keep them on (the program)? Can we buy one of those things?’ ”
Centura’s medical records are expected to be computerized by 2013, she adds, making it easier, for example “to keep a patient’s primary-care physician, cardiologist and nurse all connected.”
“For us, being on paper is crazy,” Garner adds. “(Electronic records) are just better for patient care – you’re not looking 10 different places for paperwork.”
At Centura, care increasingly will become more individualized, she believes.
“Before, when you had a patient with congestive heart failure, you put them in a box and said ‘Here is the treatment and the medications you take for this.’ Now, it’s more customized, with much more emphasis on education and preventative care.”
Home health care
Sandra Wood, 48, is a home health nurse who loves her job.
On a recent Friday, she visited a diabetic patient in West Denver. “118 over 78! Wonderful!” Wood says as she takes the woman’s blood pressure, followed by oxygen and blood sugar readings.
A short time later, Wood will inspect the deep, 3-inch-long wound below the woman’s navel. “Where is it sore?” Wood asks. “What’s your pain level, on a scale of one to 10?”
Wood, one of approximately 75 nurses who work for the Visiting Nurse Association in Denver and Colorado Springs, has been checking on the patient three times a week for a month. The woman’s wound is the result of an abscess, which became so painful she had to be hospitalized to have it removed.
Giving her follow-up care at home, Wood points out, is much cheaper than keeping her in the hospital.
Wood is treating the woman with a “wound vac,” a portable, purse-size device that continually removes drainage from the wound, increasing blood flow and stimulating tissue growth. For the next 45 minutes, of new cells. For the next several minutes, Wood will treat the wound, first removing the old sponge fitted that helps keep the area moist. Then, after gingerly cleaning the wound, Wood will cut a new, clean, sponge and insert it, and then cover it all with a layer of skin-like fabric before applying the adhesive draping. Finally, she cuts a hole in the draping and inserts a tube, or track, which hooks up to the vac.
“So my 10-month-old granddaughter took her first steps the other day,” Wood says as she finishes. The patient shares some of her own parenting experiences, and says she’s going out to dinner later that day to celebrate her daughter’s birthday.
Wood, who wears running shoes and blue scrubs, with a stethoscope around her neck and an electronic tablet in her hand, says she enjoys interacting with patients. She previously worked in a hospital, but finds home care more rewarding. “We’re all about teaching people, getting them to take responsibility for their own health care, and you don’t get to do that as much in a hospital setting.”
By helping patients stay independent, Wood believes she’s increasing their quality of life. “They can manage the disease instead of it managing them.”
That philosophy mirrors VNA’s. The 123-year-old nonprofit — whose nurses are famous for inoculating much of America against the flu every season – makes it possible for many elderly to avoid hospitalization.
“Sometimes, it’s that little bit of caring the lets that person stay at home,” says Laura Reilly, Colorado’s VNA’s CEO.
Access to care exploding
The Affordable Care Act, described as the biggest overhaul of the U.S. health care system since the passage of Medicare and Medicaid in 1965, is aimed at increasing health care coverage to all Americans while also cutting costs and improving efficiency of the country’s health care system.
Its success may well depend on nurses.
Marcia Bankirer, president of the Denver School of Nursing, has written that “As the largest, single occupation within health care, Colorado’s 61,000 licensed nurses are a critical element to our healthcare delivery system … Without nurses, the health care system stops in its tracks.”
Bankirer drives home her point with a personal experience. “Last February I was in the hospital for four days. I saw a physician a total of 20 minutes.” Nurses and nurse practitioners, she says, were her primary contacts and care givers.
As the health care law kicks in, the full impact on nurses is still a guess, but signs point in one direction: more education.
“More education for nurses will better prepare them to take on and provide intervention and counseling and direction for patients,” says Kaiser’s Rosemarie Polemi. “We’ll also be utilizing new technology and innovations … I would foresee that nurses will be doing possibly home visits by telemedicine by both phone and interactive computer programs to actually see the patients in their homes.”
The ranks of nurse practitioners are also expected to expand in the new era of expanded health care. Currently, Colorado has 3,173 nurse practitioners, approximately 12 percent of them in communities of less than 25,000. Nationally, 79 percent of NPs are primary care providers, and the percentage is thought to be similar in Colorado, according to the American Academy of Nurse Practitioners.
“In an environment where there is already a shortage of primary care NPs, (the ACA) will increase the need for high quality health care providers, such as NPs,” says Mary Jo Goolsby, director of research and education for the AANP. “There will also be a growing need for specialty care. NPs do also practice in specialty areas such as cardiology, endocrinology, pulmonology, orthopedics, etc. Primary care will likely remain the greatest need, which will likely be the practice area for the largest percentage of NPs.”
Hospitals already rely on NPs and physician assistants to fill in for physicians, especially in rural areas and small towns. Outpatient visits handled by only NPs or PAs jumped 50 percent from 2000 to 2009, from 10 percent to 15 percent, according to a 2011 report from the Centers for Disease Control and Prevention.
Doctors have not uniformly welcomed NPs, and in several states have argued that patient care may be compromised when NPs do the work of doctors. In some states, including Colorado, physicians’ groups have filed lawsuits to keep NPs from performing doctors’ and anesthesiologists’ traditional duties, such as prescribing medicine.
But in July, a Colorado appeals court handed a victory to registered nurse anesthetists when it ruled they could administer anesthesia without a doctor’s supervision.
Dr. Pat Moritz, who recently retired as dean of the School of Nursing at the University of Colorado School of Nursing, says she sides with NPs anesthetists. “I don’t understand (physicians’) issues of safety and concern when there is no evidence of a problem … no reports of poor care or losses,” Moritz says. Nurse anesthetists generally work in small settings, not big-city operating rooms where organs are being transplanted, she adds. “So where this is coming from is much more of a turf issue than it’s about professionalism and competency.”
Kaiser’s Polemi and VNA’s Wiseman say the culture is changing. “More physicians are really coming around to seeing advanced practice nurses as valued colleagues,” says Polemi. “Historically, it was a bit of a concern, and understandably so. Physicians dedicate a huge amount time, energy and money into becoming physicians, and certainly no one wants to misrepresent that by being an APN you are a physician … physicians still hold much more extensive skills.”
But there’s no question that nurses, and nurse practitioners in particular, are well loved.
In a small survey conducted at the University of Michigan, respondents said they prefer NPs over physicians because NPs spend more time with patients, are better listeners, provide more feedback, and show more respect for patients’ opinions.
Nurses also have ranked No. 1 in polls of “most trusted professions in America” for more than 10 years. Despite the unprecedented challenges before them, nurses will likely always be admired because their devotion to others is a calling, and no health care law will change that.