DiversityNursing Blog

Last year the Green Valley Fire District began what is best described as a "mobile urgent care" and next month they will be sharing it in Washington D.C.

The fire district has four nurse practitioners on staff to help respond to medical calls that do not require a trip to the emergency room. They can treat patients in home whether that be giving someone stitches or prescribing antibiotics.

"In essence we are a mobile urgent care," said Battalion Chief Dan Modrzejewski.

He is one of two chiefs with GVFD that will travel to Washington D.C. at the end of March to present their program to the American Society of Aging. They will show how their program works, why they started it, and its success with a group that includes the Centers for Disease Control, the Center for Medicare and Medicaid, among others.

Modrzejewski says he hopes other agencies around the country will adopt their program. Similar programs are already in a handful of jurisdictions.

The Green Valley program, less than a year old, has been a success according to Modrzejewski. He says before they began, a quarter of their 911 calls could have been handled by a nurse.

"They don't necessarily need to go to the emergency room," he said.

Last year, their nurses responded to 170 calls and were able to treat all of them in home instead of transporting them to the emergency room. Modrzejewski says an emergency room transport could cost between $3,000 and $4,000 while their program is much cheaper on the patient.

"The most we charge insurance is going to be $300 or $400," he said.

He says when they began they had one nurse, but now they have four on staff. Additionally, the program has decreased the number of 911 calls they receive because people are calling their appointment line for the nurse. That number is 520-428-0550.

There are undoubtedly a number of myths about the Nursing profession. Being a Nurse is as rewarding spiritually as it is financially, but unfortunately, many qualified individuals overlook the Nurse career path due to any number of possible misconceptions. After debunking some of these Nursing myths, it becomes easier to decide whether a career in Nursing makes sense for anyone considering it.

1. Only females choose the Nursing profession: Perhaps the most commonly believed Nursing myth is that only females become Nurses. From 1970 to 2011 alone, the percentage of male Nurses nearly tripled from 2.7 percent to 9.6 percent. Those figures have only risen since then.

2. Nurses are only found in hospitals: Nurses can work in a variety of settings, hospitals being only one of the more common environments typically thought of by the uninformed public. Among RNs, only 63.2 percent are performing in-patient and out-patient services in hospitals. Among LPN's, the numbers are even less tilted toward hospital work settings, with only 29.3 percent working in hospitals.

3. Nurses want to be doctors: The notion that a Nurse is simply a doctor in training or a doctor that didn't make the cut is both incorrect and disparaging to how unique and important a Nurse's work really is.

4. Due to a Nursing shortage, it's simple to get a job: Nobody would think that because there is a shortage of astronauts, pursuing that career path would be easy. Why use that same logic for the career path of becoming a Nurse? According to professional studies and available data, most Nurses must undergo a period of 2-4 years of training to earn entry into an RN or LPN Nursing role.

5. Nurses are all the same: The work performed by a Nurse is going to vary greatly depending on the specific medical setting the Nurse inhabits. Certainly one of the more common Nursing myths, it is hardly the case that Nurses are just simple clones of one another. Not only are there a wide range of potential services regularly performed by qualified Nurses, but there are a vast set of options in terms of Nursing specializations for those seeking specific types of healthcare work.

6. Continuing Education (CE) is only important if you plan to pursue a management position: More than any other field, the Nursing occupation has stringent requirements for continuing education, even when management positions aren't the goal. The extent to which a Nurse is performing their functions properly is shown in how well the services performed are executed. Continuing Education for Nurses is beyond a requirement -- It's a smart career move.

7. Nurses only work crazy hours and shifts: Too often, a Nurse is thought of as a person who has to work very late into the night, or that Nurses must arrive at their work before the crack of dawn. Frankly and fortunately, this is not always the case.

8. Nurses are doctors' assistants: The tasks required of a Nurse are varied and important. Very rarely are Nurses and doctors actually working on the same efforts and tasks. More commonly, Nurses and doctors are performing their own separate and critical functions within a medical or healthcare environment, but these functions rarely overlap or present themselves in a boss/assistant paradigm.

9. Nurses only take care of patients: One of the most long-standing Nursing myths around is the concept that Nurses are just rushing around taking care of patients' needs. Taking temperatures, writing on charts, fluffing pillows and the like are the type of tasks that are conjured up in the minds of those who frankly don't understand the depth of a Nurse's daily efforts.

10. There is no Diversity in a Nursing job: Continuing on the myth that started this list, the misunderstanding about Nursing diversity extends beyond gender. While the cliché that a Nurse is always a Caucasian female, the numbers are starting to tilt drastically towards an ever-increasing diverse workforce of Nurses. This is definitely in the best interest of the diverse patient populations seeking medical care from Nurses.

Choosing a career in Nursing is a very individual choice, but it does pay to consider these Nursing myths. Simple misunderstandings about what it is to be a Nurse can prevent some potentially excellent Nurses from joining the fold. Not everyone is going to be a perfect match for the job of a Nurse. Once these myths are dispelled, the field opens up to many more individuals with an interest in finding a rewarding occupation and the opportunity to focus their efforts on helping the sick and suffering.

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America is getting old. Not the nation itself, but the average age of the citizens that call America home. According to the US government's census and population board, by 2030 the Baby Boomer generation will be over the age of 65 and as such, the shift in demographics will cause many changes to the USA's way of life and tending to the aged. One such area where these changes will see direct effects is in the palliative care and nursing home care for aging and senior citizens.

Available Beds in Nursing Homes
As the American population sees the shift toward having more senior citizens there is going to be pressure on the available nursing homes in the country to expand and provide more beds and spaces to accommodate the change. This is no small task. The two sides of the coin to this have positive and negative effects on the aging population (and indeed, to those under age 65). The positive side of the coin shows projections illustrating increases in the amount of jobs available in the country, especially in the construction, design and nursing fields.

As the American population ages construction of new facilities and assisted living homes becomes critical. As the construction and expansion takes place there will be a need for qualified laborers and construction specialists such as architects and designers. Economists say this will help push the country's economy forward and will help to keep the unemployment rate down.

The flip side of this coin is while the age demographics shift, there is going to be a demand for laborers and constructions workers, but there will be a dip in available hands to actually do the work. This is going to create a demand for higher wages and benefits which will push the already spiked costs for nursing care and elderly services even higher leaving many in tough situations.

Nurses, Doctors and Trained Medical Professionals
With the growing aged population, there is going to be a huge need for more qualified Nurses, doctors and medical professionals who understand and work with the elderly. When this shift occurs, there will be a strain on available medical services and professionals already in the country. The hope is younger generations will go into the needed fields of medicine and technician professionals.

Everything from radiology techs to physician assistants are going to be in high demand. But with the younger generations not growing as fast as the aging, there are valid concerns about available new medical health practitioners and where to find them.

With the continued strain on Nurses and other medical professionals, there is going to be long waits for basic appointments and services as well as increases in the already high costs of American medical services. For many in the aging population, the fear that even with a pension and health insurance, meeting the basic monthly expenses for needed prescription drugs and doctor's appointments may be out of reach for many. This means the aging population will be at risk as they will not be able to afford their needed medical services and drugs.

Some economists argue that as the demand for such services and professionals increase, there will be a huge opportunity for the younger generations to study, train and enter the medical field. Hopefully this will meet the services needed by the aging population as well as increase the economy and push positive growth forward. This is projected to mean better conditions and services available to the growing and aging population of the USA.

The solutions for the aging population are not easy, but hopefully the country will rise to the challenge to take care of it's elderly. They have already given so much to the country and it is important the country rise to meet their needs as they grow old.

Related Article: Aging Population a Boon for Health Care Workers

In the 1960's colleges in the United States began to develop software that could be used for electronic medical records.  It took until the 1990's before a usable program was initially implemented.  This article will address the major pros and cons.

PROS

• Information available to medical facilities is very complete including demographics, personal information, billing information, diagnoses, surgeries, allergies, lab results, x-rays, smoking status, vitals, medications prescribed and those discontinued.  
• Medications can be renewed or prescribed directly to the pharmacy for pick up by the patient.  Unusual reactions to medications can be noted and avoided in the future.
• Access to any area of the record can be obtained by using a search word and/or using tabs.
• In case of an emergency records are immediately available to the treating medical team for use in treatment.  This alone can save lives. 
• Limited access by insurance companies for preauthorization of procedures.   
• Legibility is a given and it's no longer necessary to try and read medical personnel handwriting. 
• The reduction of paper files has been a real boost to the ecology.  Disuse of paper files has had a major favorable impact. Paper records for over 340 million patients is a lot of paper.
• Patients have access to appointments, lab results, medications and other information through patient portals.

CONS

• Security is somewhat of an issue as there have been thousands of breeches over the years and with HIPPA in effect good security is mandatory. 
• Power outages affecting computer systems could be a major problem if you don't have a backup generator. Loss of the internet due to sun spots or some other issue could be disastrous.
• Records can be accessible to anyone in the facility with a password.
• Start up, maintenance and training costs are very high. Upwards of $30,000 - $50,000 startup and $8,500 per year maintenance per provider. 
• Patients are seen less often which can depersonalize patient-provider interaction. Also, providers spend so much time looking into records on the computer, that it detracts from patient care and attention.
• There are many electronic medical record systems available and they don't necessarily interact. This means the primary provider may have a different system than the local hospital and the necessary information is not available. This results in having to print out the records and fax or email them.  Leading to a major delay in patient treatment which could make the difference in life or death. It can also lead to incorrect treatment because of unknown diseases, allergies or other issues.
•  If lawyers looking for reasons to bring suit can find a medication entered wrong or some other mistake can give them a distinct advantage.

This is just a basic overview of the Pros and Cons of Electronic Medical Records.  Do you have more to add?

Related Article: Complaints About Electronic Medical Records Increase

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Infections borne by mosquitoes are nothing new, however a new virus has recently gained intense global attention because of its potential link to birth defects.  In the vast majority of cases, the Zika Virus is spread by the bite of infected female mosquitoes of the Aedes genus.  The virus was first isolated in 1947, in the Zika forest located in Uganda.  Before 2015, Zika virus outbreaks had been confirmed only in Africa, Asia, and the Pacific Islands.  In May of 2015, Brazil reported an outbreak of the virus, and since then, the virus has rapidly spread across Central and South America.  The virus has currently been identified in at least 33 countries, and the World Health Organization predicts that 3 to 4 million people will be infected by the virus over the next year. 

Symptoms

Four, out of five people, who contract the illness experience no overt symptoms, and never realize that they are carrying the virus.  Those individuals who do become ill, generally have mild symptoms which may include headaches, conjunctivitis, joint and muscle pain, fever, and a skin rash.  Symptoms appear, approximately 3 to 12 days, after being bitten by an infected mosquito, and normally subside within a week’s time.  Few infected individuals need to go to the hospital, and death is extremely rare.

What makes the Zika virus so frightening, however, is that after the huge Zika virus outbreak in Brazil in 2015, Brazilian mothers are giving birth to babies with microcephaly.  Babies born with microcephaly may have smaller heads than normal because the brain is improperly developed or has stopped growing.  The neurological disorder can cause significant developmental delays, impaired cognitive development, and in some cases, death.  Brazil has confirmed 460 cases of microcephaly in newborns since November, and doctors have reported 4,000 suspected cases.  The clusters of increased microcephaly cases appear to significantly overlap with parts of the country where the Zika virus is flourishing.  The Center for Disease Control and Prevention (CDC) is also investigating a possible link between the Zika virus and increased occurrences of Guillain-Barre syndrome, a rare paralysis disorder. 

How to Avoid Getting It

As no vaccine currently exists to eliminate the disease, the best way to avoid getting the Zika virus is to avoid getting bitten.  Generally, mosquitoes responsible for spreading the virus, bite their victims during the daytime.  The CDC recommends taking the following steps when traveling to countries where the Zika virus has been identified:

• Protect your exposure by wearing long pants and shirts with long sleeves.
• Stay inside as much as possible, in areas that have air conditioning or screens that keep mosquitoes outside.
• Use mosquito bed nets when sleeping outside.
• Use insect repellents.  Environmental Protection Agency (EPA) registered repellents are effective, and can safely be used by pregnant or breast-feeding women.
• Spray clothing and trappings with permethrin, a synthetic insecticide, or buy permethrin-treated gear.
• The CDC’s Travelers Health website posts Zika virus health notices for all countries impacted.

The Zika virus is spread almost exclusively by mosquitoes, but recent research confirms that it can also be transmitted through sexual contact and blood transfusions.  Men who have traveled to active Zika virus areas should wear protection consistently, or abstain from sexual activity, if they have a pregnant partner.  It is not yet clear on how long the risk of transmission should be avoided. 

The available evidence indicates that, for the majority of people, the Zika Virus is a rather benign illness.  The greatest risk involves women who are pregnant, or thinking of becoming pregnant.  These women should take every available caution to avoid contracting this virus.

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When Intensive Care Unit (ICU) nurses Kerrie Klepfer, BSN, RN, CNIII, and Jennifer LeBlanc, BSN, RN, CCRN, CNIV, were discussing ways to improve patient care, they had no idea that their efforts would save their hospital 2.9 million dollars and inspire similar initiatives across the globe. They just wanted to see their patients experience a safer, quicker recovery.

Klepfer and LeBlanc are two of four ICU nurses from Duke Raleigh Hospital in Raleigh, N.C., who participated in the American Association of Critical-Care Nurses (AACN) Clinical Scene Investigator (CSI) Academy. Their team developed “Walk This Way: Early Progressive Mobility in the ICU,” a 2013 patient care intervention that encourages mobility in ICU patients.

Nationwide, more than 229 nurses at 68 hospitals have completed or are now participating in the CSI Academy. AACN created the 16-month nursing leadership and innovation training program to empower hospital-based staff nurses as clinical leaders and change agents whose initiatives measurably improve patient outcomes and hospital bottom lines. Participating nurses identify a patient care problem and solution, then work to implement the project to fit the culture of their unit.

“Nurses know what the problems are and they often have ideas for solutions,” said Devin Bowers, RN, MSN, CSI program manager. “Giving them the time to think through their ideas and encouraging their creativity are key aspects of the CSI curriculum.”

At Duke Raleigh Hospital, Klepfer and LeBlanc’s team decided to focus on early progressive mobility.

“In our team’s experience as ICU nurses, the primary practice and standard of care was to keep patients sedated and on bed rest while in the ICU, especially when the patient was intubated,” said Klepfer. “Unfortunately, this extended period of immobility was leading to more extensive rehabilitation and longer hospitalization lengths of stay for patients – and, ultimately, higher costs for hospitals.”

The group produced evidence that increasing mobilization earlier – starting in the ICU – could reduce a wealth of complications, such as muscle atrophy, longer inpatient and outpatient rehab, ventilator associated pneumonia, pressure ulcers, falls, lengthy hospital stays, and cost for patients and hospitals.

The “Walk This Way” project had a tremendous impact within the ICU unit and hospital system. Early progressive mobility is now the standard of care in the Duke Raleigh ICU and is ordered routinely by the team for patients. To date, LeBlanc noted that the program has saved the hospital $2,935,488. Klepfer also noted that at Duke Raleigh Hospital, the protocol was met with excitement from patients and families and even contributed to a significant increase in the ICU’s Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Scores, a national survey that publicly reports patients' perspectives of care. Additionally, “Walk This Way” received national attention. The team and ICU unit were profiled in the media, including by Forbes magazine, and highlighted at the 2014 AACN National Teaching Institute & Critical Care Exposition (NTI) conference.

According to Bowers, the impact of the AACN CSI Academy extends far beyond the nurses who have participated in the program. Projects have spread within hospitals, cities and across states. Klepfer and LeBlanc’s program even had an impact internationally, when Jai Prakash Narayan Apex Trauma Center, a New Delhi, India hospital, patterned its early mobility project on the “Walk This Way” program.

“Creating sustainable change isn’t just about coming up with the idea. In order for the idea to ‘stick,’ it must become part of the cultural norm in a given unit or hospital,” said Bowers. “Frontline nurses are experts when it comes to knowing what will work and what won’t work within the culture of their unit or their organization. This is one of the key reasons that we believe the CSI Academy has been so successful.”

Nurses and other clinical leaders are encouraged to browse the CSI “Innovation Database,” a catalog of past projects completed through the CSI program. With more than 25,000 unique downloads of project materials, including toolkits, presentations and research, the database is a resource for nurses seeking practice-based solutions to improve patient outcomes and reduce costs.

Bowers believes that the long-term impacts of the AACN CSI Academy are positive outcomes for patients, a network of empowered nurses who are active change agents, and organizations that understand the value of frontline nurse-led initiatives by giving them the dedicated time and resources needed to focus on the work.

“The AACN CSI Academy inspires and empowers nurses by demonstrating the connection between their nurse-driven patient care improvements and corresponding financial impact of the professional practice of nursing,” said Bowers. “In the end, this initiative supports nurses in developing a business case for pursuing better quality outcomes for patients.”

For Klepfer and LeBlanc, participation in the program had additional benefits.

“After completing the project, we noticed a significantly stronger bond within our ICU team and were better able to recognize each other’s unique qualities, capabilities and limitations,” said Klepfer. “This bond has become even stronger over time. Even though the specific project has ended and we are now implementing it, our sense of teamwork and motivation remains.” 

“For me,” explained LeBlanc, “involvement in the CSI program meant being a part of leading positive change – and feeling empowered to solve problems in our unit to change standards of care for the better.”

To learn more about the CSI program, visit www.aacn.org.

February 29th is Rare Disease Day- a day celebrated internationally to bring awareness to the 7,000 different types of rare diseases in the world. Globally, 300 million people are affected by a rare disease. Those fighting rare disease face unique struggles.  While there are millions affected by rare diseases- about 50% of rare diseases don't have a disease-specific foundation supporting funds or advocating for the disease. Also, many times common symptoms hide underlying rare diseases, leading to misdiagnosis and uninformed treatment at a later stage. In honor of rare disease day, take a moment to learn more about different rare cancers and diseases such as mesothelioma, a rare cancer caused by exposure to asbestos. 

Nursing is one of the most stressful occupations in America. Nurses have higher rates of illness and psychiatric problems than other professionals. There are things Nurses and other health professionals can do to minimize the stresses of Nursing. The best way to do this is to look at individual stressors and find ways to minimize or cope with them. 

Long Hours and Shift Work 

Long hours are stressful both physically and mentally. According to USA Today, the long hours Nurses work have become such a problem that the American Nurses Association has made recommendations about how many hours Nurses should work. The recommendations include not allowing Nurses to work more than 12 hours a day. Shift work also causes a lot of stress for Nurses, and the AMA has also made the recommendation to minimize night shifts for Nurses working both day and night shifts. 

Insufficient Resources 

Having insufficient resources makes a nurses' job more stressful, and it makes it harder for them to do their job properly. Insufficient resources take on different forms in different settings. Many times it is a shortage of Nursing personnel, which of course means the Nurses that are working have a higher workload. Other times, it is a lack of the material resources that Nurses need to do their job, whether it is due to budget cuts or oversight. Even small items like tape cause a big inconvenience when a Nurse has to search for it before she can draw blood or place an IV.  

Resources can be improved by improving pay for Nurses and making sure there is enough room in the hospital budget for other necessities. Proper inventory keeping is also important. If a Nurse notices a shortage in a particular area, it is important to mention it. Hopefully items are ordered immediately and put in the appropriate paces.

Poor Reward System 

Nurses are essential to the proper functioning of hospitals, and they work very hard. Yet many facilities don't have any kind of reward system in place, nor do they take the time to tell Nurses they are valued and appreciated. Many times Nurses are taken for granted.  

Studies have proven that rewarding employees for good behavior is essential to them being satisfied with their jobs and to retaining employees. Hospitals should have a rewards system in place. Nurses should also recognize each other for their hard work. 

Bullying and Abuse 

No one should have to endure bullying and abuse in the workplace. The ANA found that 17% of Nurses report being the victim of physical abuse at work, and 57% of Nurses reported being verbally abused or threatened. Physical abuse was usually perpetrated by patients or family members. Verbal abuse and bullying was usually at the hands of coworkers. 

Hospitals should hold educational seminars about what constitutes verbal abuse and bullying. Human Resources employees should be available to mediate and help employees solve conflicts. To protect against violence from patients and their family members, it is a good idea to have some type of security presence in the hospital. 

Lack of Communication  

Lack of communication also causes stress for Nurses. Communication between Nurses and doctors is essential to a hospital running smoothly. Daily or weekly meetings are one way to ensure proper communication. A suggestion box can give employees an anonymous way to communicate suggestions. 

Compassion Fatigue and Burnout 

Compassion fatigue happens when a Nurse stops caring about their job and patients. Sustained stress over a long period of time can lead to compassion fatigue. Burnout occurs when a Nurse becomes depressed, withdraws from others, and feels fatigued. 

To prevent compassion fatigue and burnout, try to take time off to relax. Don’t over extend yourself. Hospitals that have a reward system in place and make Nurses feel appreciated helps combat burnout. Everyone wants to feel appreciated in both our personal and professional lives.

Related articles: Dealing With Depressed Patients

6 Tips on Stress and Anxiety Management in Nursing

Nurses’ Survey Results Show ‘Dangerous’ Stress Levels

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In an environment where moments can mean life or death, it is undeniable that communication greatly matters. If the same message can be conveyed without losing meaning in a shorter or more efficient way, then it's a duty of the messenger, especially in a professional medical setting to optimize their communication skills. Speaking is literally only half of the equation, with great listening skills and information retention skills being able to effectively make repeated statements unnecessary. There are some ways to think critically about a healthcare organization to determine where it stands as a team regarding their communication abilities. Taking this closer look at the state of communication at a given facility is the crucial first step towards improving the communication therein. Increased efficiency in communication will result in saved time and increased focus that can be dedicated to the needs of patients, where it ultimately should.

Determining the state of the team's communication skills:

• Turn culture clash into culture strength: If there was no top-down strategy around cultural diversity as a marker of strength, then little petty fights about minor topics could escalate into all-out cultural clashes among a workforce. By the promotion an ideal of strength through unity, the team as a whole has the chance to get in front of any potential culture clash issue rather than chasing the problem, always trying to put out fires.
• Hold group meetings to discuss the overall state of communication at the facility: Management can play a massive role in putting the correct, positive spin on the topic of diversity in the workplace. The larger part of any staff will often be found to be on the same page about the acceptance, curiosity and positive interest in new cultures being integrated into the workplace at all times. By it being an official part of a corporate brand message and identity, the company embraces the diversity perspective even further.

Starting to help create a positive communication culture:

• Create regular workshops to go over basic principles in communications: Different individuals from diverse backgrounds will have unique perspective to share on the same topics, even if they technically speak the same language. Then, of course, there are the actual boundaries that exist between nations and languages that are completely distinct. If the staff of a healthcare facility can say "Hello" in ten distinct languages, that group brings themselves one step closer to the perfect awareness and diversity in their facility. 
• Hold regular cultural show and tell days within the staff: Each staff member, once they share their true selves, are going to have their own special cultural tale to share. If there is an encouraging environment in this way, it becomes natural and easy to leverage this diversity to enrich the staff with increased knowledge and awareness. Patients come from all over the world and there's never any way to predict who will become a patient next. With these principles in mind, a staff trained in cultural sensitivity and awareness will be better prepared to interact with new international cultures.
• Leverage modern and inexpensive tools: Any healthcare facility staff member is going to be all too familiar with the app store on their smartphone, but sadly quite few have downloaded any translation or language-learning app onto their phone. When these powerful and groundbreaking tools are now available and often for no outright cost, it's usually just a matter of pointing this out and creating a culture of support towards adopting these excellent tools to enable a team to begin using them.

Once the realization hits that communication is mostly a function of awareness, effort, empathy and genuine bonding experiences with groups, it becomes much easier to cultivate this environment of abundant and fruitful communication. If the entire healthcare facility can start to treat the state of communication at their facility as a togetherness exercise and a mission dedicated to a better experience for the patients, then the real results can start to be noticed.

Individual differences can make a group stronger and more powerful or they can also tear groups apart. The key to ensuring a positive outcome is to apply conscious effort around fostering excellent communication in any arena or avenue possible.

Related links:

4 nurse communication startups to improve patient outcomes

Three Tips for Better Nurse–Physician Communication In The Digital Age

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By Dr. Melissa DeCapua, DNP, PMHNP via www.bartonassociates.com

This article about “what’s in a name” caught our attention. We’re sharing it with you to find out if you’ve run in to this situation where you work. If you’re an NP or a PA, we know you’ve worked very hard to accomplish your degree requirements. Where you work, is your position sometimes referred to as “mid-level”? If so, read on and then tell us of your experience. Have you pointed out to Human Resources that this is a confusing term?

I had just graduated from nurse practitioner (NP) school and was on the job hunt. Skimming through a few job descriptions the word “mid-level provider” caught my attention. Having never heard that word, I assumed the job wasn’t meant for an NP. The next time it happened, a recruiter called my cell phone telling me there was an open position for a “physician extender” in rural Colorado. A what? It’s interesting how you can be an extension of someone who isn’t even present.

Then, a naive new-graduate, I didn’t quite grasp the scope of the problem. Although I did know one thing, neither of those titles captured who I was or what I did. As I’ve progressed through my career, I’ve heard myself called a “mid-level provider,” “physician extender”, and “non-physician” over and over again. Now-a-days my jaw tightens, and I gauge whether this is an appropriate situation to explain why these terms are offensive.

The time is now. This post will explore the words “mid-level provider,” “physician extender,” and “non-physician”, describing their historical uses and detailing three key reasons why this vocabulary should be eliminated.

Historical Use

These terms were originally created by physicians, and they are perpetuated by physician-led organizations and physician-centric corporations (Hoyt, 2012). The U.S. Department of Justice’s Drug Enforcement Administration uses “ mid-level practitioner” to describe professionals other than physicians, dentists, veterinarians, or podiatrists who dispense controlled substances. The Centers for Medicare and Medicaid have also referred to NPs and PAs as “physician extenders” but has more recently used the term “ non-physician practitioners.”

Why these terms should be eliminated

• Devalues Expertise

Describing NPs or PAs as “mid-level” doesn’t just imply, it asserts that they are providing something less than “high-level” care. However, ample evidence demonstrates that the services offered by these professionals is just as safe and effective as those provided by their physician colleagues.

Both NPs and PAs earn advanced degrees and undergo exhaustive course work, high-tech patient case simulations, and extensive clinical practice hours. Moreover, both clinicians pass national board certification exams and may specialize in any variety of medical specialities. The terms “mid-level provider,” “physician extender,” and “non-physician” undermine the expertise and contributions of NPs and PAs.

• Confuses Patients

Imagine you are a patient and being told, “The mid-level will see you now.” Naturally, you might wonder, “Who?” Using vague, collective vocabulary to describe NPs and PAs can confuse patients. When receiving healthcare services all patients expect and deserve the highest level care no matter who they are seeing. NPs and PAs are held to the same standard of care as physicians, offering the similar services of assessing, diagnosing, and treating medical conditions. By using more accurate terminology (i. e. NP and PA), patients can be assured they are receiving the best care at all times.

• Impedes Teamwork

In their seminal publication, Crossing the Quality Chasm, the Institute of Medicine called for interdisciplinary collaboration to solve the significant problems facing modern healthcare. Using a term like “mid-level” perpetuates a hierarchical healthcare system which impedes this need for teamwork. Most NPs and PAs dislike the terms “mid-level,” “physician-extender,” and non-physician. When they hear themselves described this way, it decreases morale and divides the team.

Take a Stand

To stop the use of these terms, everyone must take a stand. First, recruiters should remove this language from job descriptions, contracts, and business discussions. Employers and administrators specifically need to demonstrate their respect for NPs and PAs expertise by removing this language from the company website. Other healthcare professionals should stand up for their colleagues if someone uses this degrading language. Finally, both NPs and PAs should never allow someone to call them something that undermines their unique contribution to healthcare.

NPs and PAs Weigh In

I recently started a discussion thread about this topic on the American Association of Nurse Practitioners LinkedIn page. The overwhelming majority agreed that these terms should not be used to describe NPs or PAs. Some of the comments that stood out the most to me:

• I will not apply for jobs using mid level provider, or extenders. It’s insulting to my profession and education. – Nurse Practitioner in Florida
 
• It would be nice if nurse practitioners received the respect and recognition they’ve earned through good patient care. -Nurse Practitioner in New Hampshire
 
• I have been truly blessed to work with MDs that actually appreciate, value, and acknowledge what we do and who we are. -Nurse Practitioner in India
 
• How do you extend a physician? It is suggesting that somehow we are not capable of working independent and we must be attached to a physician. I am a Nurse Practitioner of the highest level, and I am an extension of no one. -Nurse Practitioner in Florida 
 
• I am fairly certain they are not referring to us as mid-level providers to degrade us, but rather they’re unaware of how offensive it can be. -Nurse Practitioner in California 
 
• The term “mid-level ” is often used in a denigratory manner, lessening our worth and contribution to health care. This term should be retired and the contribution to healthcare overall made by all professionals should be recognized and validated. Nurse Practitioner in Texas

Barton Associates also conducted a poll on its Facebook page, asking NPs and PAs which term were most offensive. Approximately 1,380 NPs and PAs weighed in on the discussion. Here are the results:

• Mid-level (487 votes)
 
• Noctor (356 votes)
 
• Physician Extender (335 votes)

The poll also asked which term was the preferred term (other than NP or PA). Here are those results:

• Provider (919 votes)
 
• Healthcare Professional (122 votes)
 
• Clinician (115 votes)

Let’s be straight; if there is ever a group of people who are called a name that makes them feel disrespected or devalued, the solution is always to stop. If you’re in doubt as to what you should call an NPor a PA just use “NP” and “PA.” Now let’s get back to patient care.

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