Tuesday, November 27, 2012

Look!! Nurses blogging! 

Take a look here for a list of nurse-authored blogs compiled by the editors of the American Journal of Nursing, an evidence-based, peer-reviewed journal that has been published since the year 1900. AJN calls itself the "oldest and most honored broad-based nursing journal in the world," and  believe it.

Happy reading!

-  Florid

Thursday, September 6, 2012

Nursing's Long, Rough Road to (Some) Recognition

I slept 12 hours last night, groggily emerging from my rest at 11:30 a.m. I never do this and I don't know why. Maybe simple fatigue from rushing for 12 1/2 hours yesterday in the Trauma ICU, coupled with my advancing age suffices, but something about this fatigue feels more than physical. I process when I sleep, often awakening with new insight into an old problem, or at least a clear awareness that the problem exists. That's what happened during those 12 hours last night.

I awakened thinking it's time for a new career, frustrated by the many defeats of our profession, and the numerous insults and slights I've suffered as a nurse. A smattering: in the 1980s, when I started nursing, our profession was just beginning to emerge from subservience and acknowledge our specialized knowledge and unique contributions to health care. On my first nursing job, the head nurse, Sue, proved to a skeptical cardiologist that she could, indeed, define hysteresis with regard to pacemakers. She was a beacon. Others, not so much. Like Diana who informed new orientees that Dr. Baker preferred a glass of orange juice in the morning. It made him less likely to yell at you. And there was the outright lechery. The urologist who called me a ripe cherry ready for picking, with a leer. The senior resident who ogled me on the day he left, saying, "Oh, I sure hope I'll see YOU again," with a creepy smile. The hematologist who DEMANDED my phone number upon meeting me. (Great pickup line, jerk.)  Even after I got my PhD, the surgeon who paid no attention to my credentials or experience, (or even my name), as he delivered a diatribe against nurses who manage feeding tubes incorrectly, never thinking that a nurse who had done research in this area might be the subject of his invective.  The pulmonologist who complained that the nurses in my hospital "won't do anything for you," right to my face. The assumption that nurses are not persons that is embedded in every one of these incidents gave me reason to feel discouraged, and ready to leave my profession of 30 years. Still groggy, I continued to muse on the rough road taken by the nursing profession over the course of my career.

The 1990s were important. In 1989, the American Journal of Nursing published a questionnaire, asking nurses to report the physician-billed services that they actually perform. This was the first of several studies on the theme of nurses doing work that physicians bill, and get paid, for.  These articles, and other movements of the time such second-wave feminism, questioned medical supremacy and risked breaking down the scaffolding upon which health care had so long rested. ("Doctors know everything, nurses know nothing. Doctors give orders, nurses follow orders...and so on.") The larger problem with the practice of physician billing for services rendered by nurses is that nurses and physicians are paid under different systems: the physician bills insurers directly, and is paid directly. Nursing care was (and is) paid by insurers to employers as part of "room rate", so if physicians billed for things actually done by nurses they did not employ, they were being paid for work done by employees whose costs they did not absorb. (This has since been remedied by Medicare, which requires attestation by the physician of his/her presence during the "critical" aspects of the procedure now.)  Further research in the 90s showed that nursing taxonomies were far superior to CPT codes (a system owned by the AMA) for describing, and potentially billing for, nursing services. Sadly, capturing nursing care for billing purposes never caught on, and the CPT system remains supreme. Nursing care is still not valued by the health care system, which puts nursing in the "cost" column and medical care in the "revenue" column, for reasons that probably have to do with medical hegemony, misunderstandings on the part of health care administrators, and good old fashioned sexism.(See above.)

It was in the late '90s that nurses tried to gain reimbursement parity for identical services rendered by physicians and were shot down in the Balanced Budget Act of 1997 (see page 2 in linked pdf). The rationale for the lack of parity was that, because physicians practices and education cost more to run, they should be paid more. This was called "resource-based relative value," and it made nurses lower-cost providers for services which advanced practice registered nurses (APRNs) had the right to bill Medicare. It also codified the current policy of 100% reimbursement for services rendered by non-physician providers while working under the direct supervision of a physician, but only 85% reimbursement for independently-provided services, again on the rationale that physicians cost more, so they should make more money.  (I can't name another profession that gets to decide how much they should make based on the cost of their overhead, but that is another topic.) There was hope, however, that the failure to gain parity could work in favor of nurses and patients by increasing public access to more cost-effective nurse-provided services.  This might have happened if the laws of economics held.

So, where was the outcry for more nurse practitioners, certified registered nurse anesthetists, clinical nurse specialists, and nurse midwives?  APRN practice could save money, because we took fewer "resources" to render identical services, but nursing organizations continued to fight for small amounts of funding for nurse education, research and quality improvement. I, and doubtless many other nurses, wrote to my legislators imploring them: support the education of APRNs, and save our health care system money! No-brainer!  But it fell on deaf ears, even in the time of Clinton-era health care reform. Even though the president's mother was a CRNA. Perhaps the status of the American Hospital Association and the AMA as the country's 2nd and 7th biggest-spending lobbyists in 1999 played a role.

Now, after 30 years in watching my profession struggle, my heart is all aflutter with the glimmer of hope  demonstrated in the publication, in 2010, of the Institute of Medicine (IOM) report The Future of Nursing: Leading Change, Advancing Health.  The report includes in its major recommendations furthering nurse education, removing barriers to practice for APRNs, and listening to nurses when health policy is made.

When it was published in 2010, it was tempting to view the IOM report cynically. For decades, nurses have decried our powerlessness in advancing our education (which, believe it or not, some other health care providers still oppose) and changing health policy. Countless white papers, position statements and studies have confirmed that disempowering nurses is not good for the health of our nation. But nurses have been figuratively patted on the head and told to go fluff a pillow so many times one really can't blame a nurse for demonstrating skepticism toward yet another official report.

The reason I decided, in that blurry waking moment, to go on hoping is that in the 2 years since the publication of the IOM report, a sliver of light has begun shining through the locked doors of policymaking halls. The IOM report brought about the creation of Regional Action Coalitions, thanks to the Robert Wood Johnson Foundation, intended "to move key nursing-related issues forward at the local, state and national levels."  Now, nearly two years into the RWJF initiative, 15 states have formed RACs and put forth innovative projects with lofty goals, such as doubling the number of nurses with doctoral preparation by 2020. Jumping on the nursing bandwagon with its Center to Champion Nursing in America is AARP, with its powerful lobbying engine and huge membership.  This year, The Centers for Medicare and Medicaid devoted $200 million to training APRNs, as policymakers recognize the impact that the "silver tsunami" will have on the future healthcare needs of Americans.

Make no mistake: nurses don't have much chance of matching the political clout of the AMA or AHA anytime soon.  There is only one nurse in Modern Healthcare's 2012 "100 Most Influential People in Healthcare." (Although I may have missed them, because only physicians are indicated by their titles.)  There are finally three nurses on the board of commissioners of The Joint Commission, the accrediting agency that is the de facto controller of much of nursing practice. (Founded in 1910 by the American College of Surgeons, The Joint Commission did not have a nurse member on its board until 1992.)

Nurses don't have the money or political gravitas required to be the AMA, ACS or AHA, but the reason I haven't followed my drowsy urge to leave the profession is this: I am proud that nursing has slowly gained some recognition and a certain degree of power by doing the right thing: educating cost-effective, excellent health care providers, carrying out the rigorous research to prove it, and staying true to our primary mission to do the right thing for people who need health care.  So I'll hang around a few more years, at least until retirement.

Saturday, March 31, 2012

Naive, Childlike, and Wholly Unrealistic

Let's take a trip together to a hypothetical United States of the future where the health care industry's* prime interest lies in prevention versus treatment of illness.

In this election year, with my irrational hope of meaningful health care reform under the Affordable Care Act, I've been thinking a lot about what health care would look like if health promotion (a skill not usually emphasized by the leaders of our medical-industrial complex) were as highly valued as illness treatment.

I realize my fictional health promotion system will never come to pass. I know that heroic fire-quenching action with its swift, tangible gratification is usually chosen by human beings over the weak satisfaction of making something not happen. But, then again, fantasies help us set goals. So here's my dreamy, wacky, silly, naive, childlike, unrealistic list of what would happen in a reformed U.S. health promotion system, in no particular order, all drawn from what I have myself observed in my 30 years in health care:

  • No one would wait until after their coronary artery bypass graft operation or their heart attack to get a referral to cardiac rehabilitation. Ditto for pulmonary and post-cancer rehabilitation.  And how about we start a rehabilitation program for everyone, not just those with certain diseases?  These programs work for people who benefit from social interaction paired with healthy lifestyle education and exercise. These programs also relieve the fears of people with certain diseases about exercise (in other words, people with heart and lung disease learn that exercise is safe for them.) 
  • People undergoing chemotherapy would not be surprised to find that hair loss is the least of the side effects they will experience. Disabling fatigue is the most common and troublesome cancer symptom, but people do not know this before they start chemo. Other side effects are infertility, depression and instant menopause for even young women. Everyone, in my fantasy health care system, would understand the benefits and risks of their own treatment regimen before one molecule of chemo enters their body. This would mean skilled educators explaining, demonstrating and showing patients what to expect as many times as it takes, for as long as it takes, using many different methods. 
  • Ditto for surgery. Relying on surgeons to do the explanation of risks and side effects is the fox guarding the henhouse. 
  • Just as my mail-in pharmacy phones me to remind me when it's refill time, people would be reminded by phone and email when their children need vaccinations, when they need that regular screening physical or colonoscopy, when to visit the dentist, when to get an eye exam, and so forth. We are overcome by information and demands on our time - the health care system must help people put priority on health maintenance, or it is easily forgotten.
  • Vitamin deficiencies are entirely preventable. A once-daily multivitamin for every citizen should be covered by the health care system. Calcium for women, too.  Both of these are cheap. 
  • Not-for-profit public exercise clubs with group classes would be available to every citizen for a small fee per visit. For personal trainers we would pay out-of-pocket. 
  • Every person could call a single toll-free number to get health coaching by a nurse or person with a degree in health education (i.e., the people who are educated to do this well). The program would not be linked to their employer in any way. Because I suspect assurances of confidentiality from employers who dole out discounts for taking part in insurance company-run health improvement programs do not convince everyone. The baccalaureate-prepared registered nurses and healht educators who answer the lines would perform a focused health interview and use evidence-based strategies to help people live healthier lifestyles. No guilt; no shame; no overwhelming demands to fix everything at once. No idiotic "You should lose weight" to someone who has struggled their entire life with obesity. (I kid you not -  I hear this all the time from physicians; they do not know how to do health coaching, world.)  
So that's my short list. Add your own health care plan improvements in the comments. And thanks. 

* Industry may not be the most apt noun because most of our health care costs are paid in public systems, primarily Medicare and Medicaid. I prefer industry vs. system because there really is no system; we have more of a mish-mash of systems.

News Flash: "Trickle-Down" Does Not Save Lives

This week the New England Journal of Medicine published an evaluation of Premier HQID, a Medicare pay-for-performance program that provides monetary incentives to hospitals to improve quality of care. Hospitals that perform well on certain measures get 1-2% bonuses and hospitals that underperform are penalized by the same amount. 
In the study, a huge number of hospitals, 252 in the Premier program and 3363 not, submitted data to Medicare on 33 quality indicators for common conditions such as heart failure, pneumonia and joint replacement.  Data from over 6 million patients  went into the analysis. 
The headline-making conclusion went like this:
"Tying financial incentives to performance, often referred to as pay for performance, has gained broad acceptance as an approach to improving the quality of health care....We found no evidence that the largest hospital-based pay-for-performance program led to a decrease in 30-day mortality. Expectations of improved outcomes for programs modeled after Premier HQID should therefore remain modest."
To me, and I imagine others who were not consulted when this program was planned, this finding comes as little surprise.  Let me explain why:
  •  Financial incentives in the program did not necessarily go to the people who prevent hospital deaths. They went to hospital administrators who had the freedom to use the dollars as they wished.  So our tax dollars - make no mistake -  might have paid for nurse education or better staffing, and they might have bought a fancy new office suite for the CEO, the benefits of which would presumably trickle down to the little people.
  • Almost all of the Medicare quality indicators concern processes of care, not patient outcomes.  Processes (like which drugs are given and when) are only thinly linked to patient outcomes because of the complexity of human beings (whether patient or health care provider) and big organizations like hospitals.  If the right antibiotic is given at the right interval before surgery, is there certainty that the patient will not have an infection post-operatively? Of course not. It helps, but the maddening and wonderful complexity of humans and organizations means the process can only boost the odds in the patient's favor, not ensure the desired outcome. In short, there are no guarantees.
All the hospitals in the study report their data on Medicare's Hospital Compare website; this characteristic was equalized because public reporting is widely understood as a way to improve hospital quality. However, this understanding is based upon assumption, not fact, and some emerging data suggest otherwise.
This new study's findings about pay-for-performance are not unique.  I did find some evidence of success of the Premier program on (surprise!) Premier's website, where one also finds the list of Premier and other health care executives as well as the cadre of physicians who comprise the Premier board of directors.  Again excluding the largest group of health care providersin the country.
Lest this post appear as a rant from a burned-out nurse, I will add that nearly 1 in 5 older adults discharged from a hospital is re-admitted within 30 days. About half of these patients saw a physician in the interim, so it appears doctor visits did not prevent readmission.  Moreover, errors in health care are deadly - to nearly 200,000 people a year. And studies from across the globe show that nursing care saves lives. We understand the scope o the problem, and we know at least part of the solution. When will we stop making up voodoo quality strategies and start implementing what works?