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Nurse Education Key to Scope-of-Care Debate

Cheryl Clark, for HealthLeaders Media, August 15, 2011
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Stone says in those additional two years, nursing students get a wealth of experience that helps them with critical thinking and leadership skills. A nurse with a BSN, she says, will have the skills “to oversee the trajectory of a patient care continuum and give direction to a healthcare coach who would be able to keep folks well in their home, like overseeing a population with a particular health condition.

“One of the things that’s most difficult for a nurse to learn is how to prioritize your workflow,” Stone says. “In school you have a small patient load. When you come out of nursing, you’re trying to balance the care of four or more patients. So it’s very important to learn how to prioritize.”

But nursing education itself has to change, too, by making systemic changes in curriculum.

Patrick Coonan, RN, dean and professor at the Adelphi University School of Nursing in Garden City, NY, agrees that nursing education has to improve.

“There’s been lots of talk, and I think it’s true, that there’s a disconnect between educational programs and the absolute delivery of care in hospitals and the partnerships that lend themselves to nursing students getting a reality education, like how do you organize your day, how do you make things happen?” he says.

“Our focus is to give them a great education so they pass the licensing exam—we’re judged on our first-time pass rate—and make sure they know that stuff. But we may not give them everything that a hospital is expecting them to have. As a nurse, what are the quality and safety indicators, and all the other things that hospitals do that nursing schools are focused on?”

He advocates one of many types of partnership models that allow nurses to work hand in hand with faculty and hospital teams through more residency programs that now exist nationally, to turn out nurses who have a lot more practical acumen as well as an ability to get a good score on a test. 

One major concern that translates into a huge financial cost is the high turnover rate for new nurses, which can be 30% within the first 12 months and 50% or higher in the first 24. Residency programs can make nurses become more familiar with day-to-day practice and effectively reduce two-year turnover rates significantly, Rowe and others point out.

“My sense is that hospital employers expect the RN to walk out of their school and essentially be an expert, when that’s not the expectation we can have of any profession,” says the ANA’s Peterson. The inexperienced nurse gets frustrated and overwhelmed and decides to go into another, less demanding kind of work, perhaps with a home health agency. “We know we’re not doing very well on this. We know there is churn, where graduates spend one or two years at one hospital and then move on to another place. We have to address that and residencies are one way.”

Some nursing programs are adjusting the courses they offer. “Now that we have healthcare reform, we know that there’s a large scope of jobs that we know physicians aren’t going to do, but which nurses are going to do,” Coonan says. Adelphi, for example, is about to launch a master’s program geared to clinicians, especially nurses, to help them understand health information technology systems. “It’s about understanding and analyzing and being able to implement information systems across different venues—hospitals and private offices, for example,” he says. Also on the increase are courses in nursing informatics and case management to train clinicians how to manage large groups of patients.

Colleen Conway-Welch, dean of the school of nursing at Vanderbilt University, says that when nurses gain advanced-degree education and training, there are many more opportunities opening up for them. For example, some acute care nurse practitioners, especially those in rural communities, may be assuming the role of hospitalist. “That’s being looked at more seriously now especially in rural areas that may generally lack physician residents, but that have a need for someone to be in-house,” she says. “This is becoming increasingly important as resident hours are being decreased.”

That’s a good thing, she says, not just for rural hospitals. Even Vanderbilt is looking seriously at the idea, Conway-Welch says.

Some schools are offering nurse practitioners expanded education in pharmacy, in recognition that as nurses gain the ability to prescribe drugs without physician oversight in an increasing number of states, and the fact that medications are so increasingly complex, one can receive dual degrees in pharmacy and nursing. One nursing school with that offering is the University of Hawaii at Hilo, Conway-Welch says. “That’s an example that I think is very creative of beginning to break down the silos.”

George Thibault, MD, president of the Josiah Macy Jr. Foundation, has given 14 grants for interdisciplinary education to medical and nursing schools, between $150,000 and $200,000 per year for each grant, aimed at finding ways to educate nurses, physicians, and other professional providers as teams. “In the past, we have not educated our students in teams, and they have to learn it later. Some do and some don’t. But if we start educating them in teams, they’ll be more effective in taking care of patients.”

Carol Porter, DNP, RN, chief nursing officer and senior vice president for nursing at Mount Sinai Medical Center in New York and associate dean of nursing research and education at Mount Sinai School of Medicine, says there’s one important area for academic improvement in nursing education, and it has to do with quality.

In the classroom and in special courses, nursing students today may tackle a “quality project” dealing with a limited topic such as improving skin care or techniques to prepare discharge instructions properly. But what they often don’t learn well enough, or understand the significance of, she says, is the quality metrics set forth by CMS. Things like “value-based purchasing, patient satisfaction and HCAHPS,” she says.

“They have to have a more in-depth understanding of how the nurse on the unit plays a huge role in a much bigger picture, one that links to our funding,” Porter says referring to the fact that hospitals will be financially penalized if their patient experience scores and quality metrics don’t measure up to their competitors. “I’m bringing it down to the bedside. And I don’t think we’ll ever get the change this country is looking for unless the nurse at the bedside understands it—to treat their patients with respect and dignity not just because it’s the right thing to do, but because that communication impacts the score, and we all play a role in that.”

Asked if she thinks nurses will eventually be doing more of what doctors do, Porter quickly replies that at her facility, which is a Magnet® hospital, “they already do.”

But education needs to support this transformation. “I think there needs to be more collaboration between academic nursing professors and the operational nursing leaders,” Porter says.

Cole Edmonson, vice president of patient care services and chief nursing officer at Texas Health Presbyterian Hospital, a 718-staffed-bed facility in Dallas, says another way that healthcare systems and academia can accomplish that is to increase efforts to offer interdisciplinary practice training, where nurses and medical students take courses together. “Why should they take different classes in anatomy and physiology? Why should they not take them together?” he asks. As an added benefit, they’d learn to work as a team.

Edmonson says that nursing and physician practice have evolved enormously, and will continue to do so. Years ago, he notes, only physicians could take a patient’s blood pressure or insert a needle into a vein. “But over time, nurses proved that they can do that safely and effectively.”

At Texas Health, nurse residency program students learn financial implications of healthcare, “so they understand what the future will look like, what an accountable care organization looks like.”

Rowe of Columbia University says that giving nurses more training and more authority will help their morale and their dignity.

“What they don’t want to have to do is chase after the doctor to get him or her to sign an x-ray requisition. Or have the doctor come in first thing in the morning and sign a thick pad of prescription slips so nurses can fill them out and give them to patients. These are professionally demanding, wasteful of time and energy, and actually demeaning.”

Rowe says that healthcare reform will force physicians and nurses to resolve their issues, without the jealousies and rivalries that distract them today.

He calls it phase two of the Patient Protection and Affordable Care Act, when the government and private payers start reimbursing care providers as teams. It is, he says, “a natural evolution, product, or derivative of healthcare reform. Instead of fee for service, [payers] will be paying ACOs or teams of people and groups for episodes of care. And those global payments will be divided among the providers and the hospital and other facilities.

 “Once we get to that form of payment reform, much of the friction between physician groups and nurse groups will dissipate because they will be in fact put on the same side of the table by the government. It will no longer be a matter of paying the doctor versus the nurse.”


Cheryl Clark is senior quality editor and California correspondent for HealthLeaders Media. She is a member of the Association of Health Care Journalists.
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6 comments on "Nurse Education Key to Scope-of-Care Debate"


D. Andrews, CRNA, MHS (9/27/2011 at 10:05 PM)
Shi Zang, We do carry our own liability insurance at the same limits as physicians. The difference is, our rates have dropped over the past decade due to decreased claims. Do your homework before commenting.

Phyllis Carmichael RN, BSN (9/25/2011 at 3:05 PM)
I enjoyed your article. I am currently in an masters program. A recent discussion centered on nursing skills post graduation. I came from a diploma school in 1998. The hospital was next door to school. Thus, I was confident in my hands-on skills regarding starting IVs, inserting naso-gastric tubes, inserting urinary catheters, performing sterile dressing changes, etc. I wish that I would have gone on to obtain my advanced degree straight away. Now I see how valuable the added education is to my practice. Our discussion turned briefly to nurse residency programs. Little information exists on that subject. Part of the "upheaval" you spoke of? Phyllis

Julia Harris CRNA (9/5/2011 at 3:18 PM)
In response to the previous comment, I do in fact carry my own malpractice insurance and I am very much liable for the outcomes of the patients that I care for. With increased autonomy comes increase in responsibility and I have embraced that as part of my profession.