DiversityNursing Blog

By SABRINA TAVERNISE

www.nytimes.com 

There are just a handful of psychiatrists in all of western Nebraska, a vast expanse of farmland and cattle ranches. So when Murlene Osburn, a cattle rancher turned psychiatric nurse, finished her graduate degree, she thought starting a practice in this tiny village of tumbleweeds and farm equipment dealerships would be easy.

It wasn’t. A state law required nurses like her to get a doctor to sign off before they performed the tasks for which they were nationally certified. But the only willing psychiatrist she could find was seven hours away by car and wanted to charge her $500 a month. Discouraged, she set the idea for a practice aside and returned to work on her ranch.

“Do you see a psychiatrist around here? I don’t!” said Ms. Osburn, who has lived in Wood Lake, population 63, for 11 years. “I am willing to practice here. They aren’t. It just gets down to that.”

But in March the rules changed: Nebraska became the 20th state to adopt a law that makes it possible for nurses in a variety of medical fields with most advanced degrees to practice without a doctor’s oversight. Maryland’s governor signed a similar bill into law this month, and eight more states are considering such legislation, according to the American Association of Nurse Practitioners. Now nurses in Nebraska with a master’s degree or better, known as nurse practitioners, no longer have to get a signed agreement from a doctor to be able to do what their state license allows — order and interpret diagnostic tests, prescribe medications and administer treatments.

“I was like, ‘Oh, my gosh, this is such a wonderful victory,’” said Ms. Osburn, who was delivering a calf when she got the news in a text message.

The laws giving nurse practitioners greater autonomy have been particularly important in rural states like Nebraska, which struggle to recruit doctors to remote areas. About a third of Nebraska’s 1.8 million people live in rural areas, and many go largely unserved as the nearest mental health professional is often hours away.

“The situation could be viewed as an emergency, especially in rural counties,” said Jim P. Stimpson, director of the Center for Health Policy at the University of Nebraska, referring to the shortage.

Groups representing doctors, including the American Medical Association, are fighting the laws. They say nurses lack the knowledge and skills to diagnose complex illnesses by themselves. Dr. Robert M. Wah, the president of the A.M.A., said nurses practicing independently would “further compartmentalize and fragment health care,” which he argued should be collaborative, with “the physician at the head of the team.”

Dr. Richard Blatny, the president of the Nebraska Medical Association, which opposed the state legislation, said nurse practitioners have just 4 percent of the total clinical hours that doctors do when they start out. They are more likely than doctors, he said, to refer patients to specialists and to order diagnostic imaging like X-rays, a pattern that could increase costs.

Nurses say their aim is not to go it alone, which is rarely feasible in the modern age of complex medical care, but to have more freedom to perform the tasks that their licenses allow without getting a permission slip from a doctor — a rule that they argue is more about competition than safety. They say advanced-practice nurses deliver primary care that is as good as that of doctors, and cite research that they say proves it.

What is more, nurses say, they are far less costly to employ and train than doctors and can help provide primary care for the millions of Americans who have become newly insured under the Affordable Care Act in an era of shrinking budgets and shortages of primary care doctors. Three to 14 nurse practitioners can be educated for the same cost as one physician, according to a 2011 report by the Institute of Medicine, a prestigious panel of scientists and other experts that is part of the National Academy of Sciences.

In all, nurse practitioners are about a quarter of the primary care work force, according to the institute, which called on states to lift barriers to their full practice.

There is evidence that the legal tide is turning. Not only are more states passing laws, but a February decision by the Supreme Court found that North Carolina’s dental board did not have the authority to stop dental technicians from whitening teeth in nonclinical settings like shopping malls. The ruling tilted the balance toward more independence for professionals with less training.

“The doctors are fighting a losing battle,” said Uwe E. Reinhardt, a health economist at Princeton University. “The nurses are like insurgents. They are occasionally beaten back, but they’ll win in the long run. They have economics and common sense on their side.”

Nurses acknowledge they need help. Elizabeth Nelson, a nurse practitioner in northern Nebraska, said she was on her own last year when an obese woman with a dislocated hip showed up in the emergency room of her small-town hospital. The hospital’s only doctor came from South Dakota once a month to sign paperwork and see patients.

“I was thinking, ‘I’m not ready for this,’ ” said Ms. Nelson, 35, who has been practicing for three years. “It was such a lonely feeling.”

Ms. Osburn, 55, has been on the plains her whole life, first on a sugar beet farm in eastern Montana and more recently in the Sandhills region of Nebraska, a haunting, lonely landscape of yellow grasses dotted with Black Angus cattle. She has been a nurse since 1982, working in nursing homes, hospitals and a state-run psychiatric facility.

As farming has advanced and required fewer workers, the population has shrunk. In the 1960s, the school in Wood Lake had high school graduating classes. Now it has only four students. Ms. Osburn and her family are the only ones still living on a 14-mile road. Three other farmhouses along it are vacant.

The isolation takes a toll on people with mental illness. And the culture on the plains — self-reliance and fiercely guarded privacy — makes it hard to seek help. Ms. Osburn’s aunt had schizophrenia, and her best friend, a victim of domestic abuse, committed suicide in 2009. She herself suffered through a deep depression after her son died in a farm accident in the late 1990s, with no psychiatrist within hundreds of miles to help her through it.

“The need here is so great,” she said, sitting in her kitchen with windows that look out over the plains. She sometimes uses binoculars to see whether her husband is coming home. “Just finding someone who can listen. That’s what we are missing.”

That conviction drove her to apply to a psychiatric nursing program at the University of Nebraska, which she completed in December 2012. She received her national certification in 2013, giving her the right to act as a therapist, and to diagnose and prescribe medication for patients with mental illness. The new state law still requires some supervision at first, but it can be provided by another psychiatric nurse — help Ms. Osburn said she would gladly accept.

Ms. Nelson, the nurse who treated the obese patient, now works in a different hospital. These days when she is alone on a shift, she has backup. A television monitor beams an emergency medicine doctor and staff into her workstation from an office in Sioux Falls, S.D. They recently helped her insert a breathing tube in a patient.

The doctor shortage remains. The hospital, Brown County Hospital in Ainsworth, Neb., has been searching for a doctor since the spring of 2012. “We have no malls and no Walmart,” Ms. Nelson said. “Recruitment is nearly impossible.”

Ms. Osburn is looking for office space. The law will take effect in September, and she wants to be ready. She has already picked a name: Sandhill Behavioral Services. Three nursing homes have requested her services, and there have been inquiries from a prison.

“I’m planning on getting in this little car and driving everywhere,” she said, smiling, behind the wheel of her 2004 Ford Taurus. “I’m going to drive the wheels off this thing.”

By ALEXANDRA ALTER

Source: www.nytimes.com

It may surprise fans of Johanna Basford’s intricately hand-drawn coloring books that the artist is, by her own admission, “pretty bad” at coloring.

“I can’t stay in the lines,” she said sheepishly.

Not that it matters. Ms. Basford’s coloring book “Secret Garden,” a 96-page collection of elaborate black-and-white ink drawings of flowers, leaves, trees and birds, has become a global best-seller.

Since its release in spring 2013, “Secret Garden” has sold more than 1.4 million copies in 22 languages. It shot to the top of Amazon’s best-seller list this month, overtaking books by authors like Harper Lee, Anthony Doerr and Paula Hawkins. Her follow-up, “Enchanted Forest,” which came out in February, is briskly selling through its first print run of nearly 226,000 copies.

What makes Ms. Basford’s breakout success all the more surprising is her target audience: adults who like coloring books.

There are, it seems, a lot of them. Though it is tempting to describe the market for her books as niche, Ms. Basford, a 31-year-old illustrator in Aberdeenshire, Scotland, has quickly outgrown that label.

Like Play-Doh, jungle gyms and nursery rhymes, coloring books have always seemed best suited for the preschool set. So Ms. Basford and her publisher were surprised to learn that there was a robust — and lucrative — market for coloring books aimed at grown-ups. When they first tested the waters with “Secret Garden” a year ago, they released a cautiously optimistic first printing of 16,000 books.

“I thought my mom was going to have to buy a lot of copies,” Ms. Basford said. “When the sales started to take off, it was a real shock.”

Surging demand caught Ms. Basford and her publisher off guard. Fan mail poured in from busy professionals and parents who confided to Ms. Basford that they found coloring in her books relaxing. More accolades flowed on social media, as people posted images from their coloring books.

Hard-core fans often buy several copies of her books at a time, to experiment with different color combinations. Others have turned it into a social activity. Rebekah Jean Duthie, who lives in Queensland, Australia, and works for the Australian Red Cross, says she regularly gathers with friends for “coloring circles” at cafes and in one another’s homes.

“Each page can transport you back to a gentler time of life,” she said of Ms. Basford’s books in an email.

Ms. Basford has become something of a literary celebrity in South Korea, where “Secret Garden” has sold more than 430,000 copies, she says. The craze was kicked off in part, it seems, by a Korean pop star, Kim Ki-bum, who posted a delicately colored-in floral pattern from Ms. Basford’s book on Instagram, where he has 1.8 million followers.

Part of the apparent appeal is the tactile, interactive nature of the books, which offer respite to the screen-weary. “People are really excited to do something analog and creative, at a time when we’re all so overwhelmed by screens and the Internet,” she said. “And coloring is not as scary as a blank sheet of paper or canvas. It’s a great way to de-stress.”

Ms. Basford started out in fashion, working on silk-screen designs. Then she opened a studio on her parents’ trout and salmon farm in Scotland, and began designing hand-drawn wallpaper for luxury hotels and boutiques. When the financial crisis hit, her business evaporated. She closed the studio and found work as a commercial illustrator for companies like Starbucks, Nike and Sony.

Her publishing break came in 2011, when an editor at Laurence King Publishing discovered her work online. The editor thought her graceful illustrations could work well as a children’s coloring book.

“I came back and said I would like to do a coloring book for grown-ups, and it got a bit quiet for a moment,” Ms. Basford said. “Coloring books for adults weren’t as much of a thing then.”

To convince them that it was a viable market, she drew five sample pages of detailed, mosaic-like illustrations. The publishers were sold.

“When Johanna first approached us with the idea, we knew that people would love her illustrations as much as we did, but could never have predicted just how big the adult coloring trend would be,” said Jo Lightfoot, editorial director of Laurence King Publishing.

Ms. Basford spent the next nine months working on the book at night and freelancing as an illustrator during the day. Occasionally she had doubts. “I was worried that coloring for adults was silly and it was just me that wanted to do it,” she said.

It turns out she was far from alone. Other entries to this small but growing category include Patricia J. Wynne’s lavish, nature-themed Creative Haven coloring books — discreetly described as being “designed for experienced colorists” — and the more explicitly titled “Coloring Books for Grownups,” released by Chiquita Publishing. A subspecies of these books promote the meditative aspects of coloring and doodling, including “Color Me Calm” (subtitle: “A Zen Coloring Book”) and books that promise “Easy Meditation Through Coloring.”

Major publishers are seizing on the trend. This year, Little, Brown will release four illustrated coloring books for adults, all subtitled “Color Your Way to Calm.” The books, “Splendid Cities” by the British artists Rosie Goodwin and Alice Chadwick and three titles by the French illustrator Zoé de Las Cases, feature detailed cityscapes with famous landmarks, cafes and street life. Promotional materials for the books emphasize the health benefits of “mindful coloring,” noting that the activity “has been shown to be a stress reliever for adults.”

Ms. Basford is now working on her third book, after soliciting suggestions for themes from fans. A vocal faction has requested an ocean-themed coloring book. “I’ve been drawing starfish and seahorses this afternoon,” she said.

In the meantime, “Secret Garden” has sold out in many markets, to the consternation of fans. Laurence King is reprinting 75,000 copies for the United States.

This month, Ms. Basford tried to calm her followers with a post on her Facebook page, promising that newly printed books would be shipping in a few weeks: “Don’t panic! New stock of Secret Garden and Enchanted Forest is on its way!”

Some were not placated. “WEEKS?” one frantic follower replied. “I can’t possibly wait WEEKS!”

Jana Kasperkevic

Far from offering patients pennies for their thoughts, mental health therapists often end up billing them hundreds of dollars per month.

The cost is a growing burden as depression among US adolescents and adults rises. The US is suffering a mental health crisis, with a San Diego State University study in October finding that one in 10 Americans is depressed – and more report symptoms of depression.

More Americans are seeking help, and that help can come at a financial sacrifice of thousands of dollars a year. Aside from the cost of often-weekly visits to psychologists – which may or may not be defrayed by insurance – there can be additional costs for psychiatrists and any medicine they prescribe.

The cost of therapy is especially acute for young Americans, many of whom are underemployed and burdened with college debt. This year, a record number of college freshmen reported being depressed. And while many campuses provide free mental health care, affordable help is often harder to find after students leave school.

The Guardian interviewed seven young professionals about their experiences to find out how young Americans manage to pay for therapy – and if they think it’s worth it. To protect their identities, we have kept their surnames anonymous.

Click on the titles below to read their stories: 

‘I just can’t afford to go’

– AK, 27

‘Why do I need to pay someone to listen to me?’

– Matt, 23

Therapy was ‘the best chance I had of feeling OK’

– JE, 29

‘I needed someone to help me find courage to leave [my job]’

– Eve, 33

‘At its best, it’s paying for a friend’

- John, 27

‘Therapy is not a magic wand’

-Jenn, 26 

‘I’d rather be sad’

– Alex, 27

Source: www.theguardian.com