DiversityNursing Blog

By Bobby Shuttleworth

At Calhoun Community College, nursing students are looking forward to the day they get their certification, degree and begin in the work force. While some will end up in a traditional role, others may look forward to adventure.

Brian Soloman is ready to get into a career and be with his children. 

"I would like to go on to possibly UAH and consider even pursuing a nurse practitioner," said Soloman.

Takicha Barrett said her goals revolve around the very young. 

"My plan is to successfully obtain a job, hopefully in the pediatrics department. I love kids," she said.

Soloman said he's heard of exotic locations, but he wants to stay home with his children.   He said those locations are everywhere. 

"...On oil rigs, people that are offshore. And there's even contractors that are in the Middle East or in the theatre in Afghanistan and that were in Iraq; some of the companies have also hired out nurses," he said.

Bret McGill is the Dean of the Health Sciences Division at Calhoun Community College. He said the options are almost limitless.   

"A couple of jobs that come to mind, one is a school nurse and just about every school has an LPN or an RN that works to take care of children and administer medications," said McGill.

One of the areas people may not be familiar with is in the industrial setting.

Candy Fall is an occupational nurse at BP. She's worked at several industries before honing her skills here with a focus on wellness. She writes articles for the corporate newsletter, an internal TV station, and much more.  

"This particular plant, I'm responsible for medical surveillance for each employee that's here," Fall said.

She said BP is big into wellness programs to keep their employees healthy, like flu shots and more.  

"We have a fitness center reimbursement program. We have fruit of the day, where we have fruit delivered to the plant three times a week and our employees and our contract employees can have a piece of fruit to keep them from going to the vending machines," she added.

The program at Calhoun is giving nurses an opportunity to pursue a rewarding job, while helping to keep employees healthy.

Copyright 2013 WAFF. All rights reserved.

By COURTNEY PERKES 

Two Orange County nurses seeded their dreams of a Rose Parade float to honor their profession with donations as small as a dollar.

Pat Spongberg, 79, of Mission Viejo and Judy Dahle, 68, of Costa Mesa spent five years working to raise money for a nature-themed float designed to embody the healing traits of nurses.

The women are among five operating-room nurses who in 2007 formed a nonprofit, Bare Root Inc., that will present a one-time entry at Tuesday's parade in Pasadena.

"In our mind, that's how roses start – from a bare root," Spongberg said.

Click here to watch the nurses decorate their Rose Parade float.

Dahle added, "We were starting from a seed. We had some moments where we'd go, 'What are we doing?' We're finally in the blossoming stage."

The float, titled "A Healing Place," will carry 6,000 roses as well as 10 nurses and nursing students.

"The Rose Parade is seen by millions around the world," Dahle said. "It is an opportunity to showcase nursing internationally. The people that watch it, probably every one, have been touched by a nurse in one way or another."

GRASS-ROOTS START

The idea came about at an operating-room nursing conference where they learned that their colleague, Sally Bixby, would serve as president of the Tournament of Roses for the 2013 parade.

"I'm totally honored by it," said Bixby, who spent 38 years as a nurse. "I can't believe they did it. When they called me originally a few years ago to tell me they were going to take this on, it gave me chills."

In the beginning, fundraising went slowly. The board members started by seeking donations at nursing conferences.

"We'd literally have a little box out at the table, and people threw in $1 or $5 or maybe a 20," said Dahle, who is a consultant after years of working at Hoag Hospital.

The economy plunged into recession, and when pitching their project, 2013 sounded very far away to prospective donors.

Still, the group persisted, spending its own money to travel to conferences across the country.

Members created a website, where supporters could buy a rose to honor a nurse or make a credit card donation. Several hospitals gave the largest gifts of $30,000 each.

"I think we all feel a sense of pride of accomplishment," said Spongberg, who retired from Mission Hospital.

PAYING TRIBUTE

Hundreds of nurses have volunteered to decorate the float, which showcases animals that symbolize the traits of a good nurse. Three nightingales on a branch pay tribute to Florence Nightingale, the founder of modern nursing. Owls stand for wisdom. (Nightingale also had a pet owl.) The raccoon represents intelligence and the nurses who work all night. The mother deer symbolizes caring.

The lanterns are replicas of the kind Nightingale used to visit her patients at night.

"That was our one touch of sentimental nursing," Dahle said.

Words along the bottom include: compassionate, gentle, leader, conscientious and confident.

The 55-foot-long float cost $215,000. In all, the nurses raised $400,000. After accounting for other administrative and technical expenses, the nonprofit will donate the remaining funds for nursing scholarships and then dissolve.

"We don't have the fundraising background to go through it again," Dahle said. "People don't realize the business behind it."

Nurse Cherie Fox, 41, was scheduled to work in the cardiac intensive care unit at Mission Hospital on New Year's Day, but her plans changed after she was selected to ride on the float.

"I think it's amazing that they have taken it on to truly highlight the nursing profession," said Fox, who lives in Huntington Beach. "Most nurses go into nursing because they have a desire to give back and make connections with families and patients. Nurses learn to work in whatever they're put into. We all try to do it with grace and dignity."

Some nurses will travel from other states to attend the parade. Dahle last watched in person 40 years ago. Spongberg will attend the parade for the first time ever with her husband.

"I am very excited. This is the culmination of all we've worked for," Spongberg said. "To see the finished product going down Colorado Boulevard is going to be awesome."

BY LYNDA LAMPERT

You’re the kind of person who’s in the right place at the right time.

No, I mean it.

Look at yourself. You’re a nurse when it’s a great time to be a nurse. Plus, you’re obviously thinking about your future (You’re reading this article, right?). You want to know where you need to be in 2013 in order to make the most money –– and be in the most demand.

I’ve pulled together the numbers to help you plan your next steps (and determine where your competition lies). These stats from the Bureau of Labor Statistics (BLS) may surprise you with some interesting projections.

Where the Jobs Are

If you love med-surg, get ready for some good news. According to the BLS, nurses can expect to find a variety of employment opportunities in privately owned, general medical surgical hospitals. This includes physician’s offices, local medical surgical hospitals, home health care agencies and nursing care homes. Job seeking nurses may also want to consider government agencies, nursing education and administrative roles in hospitals and insurance companies.

Salary Forecast

Although it may not seem like it sometimes, nursing is among the higher paid professions. In May 2010, the average annual median salary for nurses was $64,690 per year (the top 10 percent earned more than $95,130). So how will your salary stack up in the near distant future?

Nurses in private medical surgical hospitals can expect to earn $66,650 per year. Those who work in doctor’s offices, local medical surgical hospitals and home health agencies can all expect a salary just above $60,000.

Where the Competion Will Be

Although anecdotal evidence in the nursing community doesn’t necessarily point to a nursing shortage, statistics show that growth for the nursing profession is expected to increase exponentially by the year 2020. In fact, growth is projected to increase by 26 percent, while all other professions are only expected to grow by 14 percent.

That isn’t to say that some venues aren’t more competitive than others. Hospital nursing is a good place to find a job due to the relatively high turnover of nurses and the progressive aging of retirement-eligible nurses. The competition is expected to be much higher for positions in doctor’s offices and outpatient care centers as well due to the family-friendly shifts and relatively lower patient care demands.

Should You Beef Up Your Credentials?

The demand for nurses with at least a BSN is expected to rise in the US. Additionally, all advanced practice registered nurses, such as certified registered nurse practitioners, nurse midwives and nurse anesthetists are expected to be in higher demand. If you’re looking for the hot jobs in this profession, you would do well to advance your education as far as possible.

References:

Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, 2012-13 Edition, Registered Nurses.

The American Nurse Project-- 60 second trailer from American Nurse Project on Vimeo.

This is a videon trailer you will want to see.

By ANEMONA HARTOCOLLIS and NINA BERNSTEIN

Published: November 1, 2012

Officials rushed to move the most critically ill patients closer to an emergency generator. After midnight, doctors heard shouts in the hallway. The basement fuel pumps had stopped working, and medical residents, nurses and administrators formed a bucket brigade to ferry fuel up 13 flights to the main backup generators.

By Tuesday, the elevator shafts at Bellevue, the country’s oldest public hospital, had flooded, so all 32 elevators stopped working. There was limited compressed air to run ventilators, so oxygen tanks were placed next to the beds of patients who needed them. Water faucets went dry, food ran low, and buckets of water had to be carried up to flush toilets.

Some doctors began urging evacuations, and on Tuesday, at least two dozen ambulances lined up around the block to pick up many of the 725 patients housed there. People carried babies down flights of stairs. The National Guard was called in to help. On Thursday afternoon, the last two patients were waiting to be taken out.

The evacuation went quickly only because Bellevue had planned for such a possibility before Hurricane Irene hit last year, several doctors said. But the city, which had evacuated two nearby hospitals before that storm, decided not to clear out Bellevue. In the wake of Hurricane Sandy, the consequences of bad calls, bad luck and equipment failures cascaded through the region’s health care system, as sleep-deprived health care workers and patients were confronted by a new kind of disarray.

A patient recovering from a triple bypass operation at Bellevue walked down 10 flights of stairs to a waiting ambulance, one of the dozens provided through the Federal Emergency Management Agency to speed patients across the metropolitan region.

Mount Sinai Medical Center, already dealing with the 2 a.m. arrival of a dozen psychiatric patients who spoke only Chinese, was struggling to identify the relatives of brain-injured traffic victims from Bellevue who arrived three hours later with only rudimentary medical records.

Maimonides Medical Center in Brooklyn was straining to meet a rising need for emergency dialysis for hundreds of people shut out of storm-crippled private dialysis centers. Patients who would normally get three hours of dialysis were getting only two, to ensure the maximum number of people received at least a minimal amount of care.

“The catastrophe is growing by the minute,” said Eileen Tynion, a Maimonides spokeswoman. “Here we thought we’d reached a quiet point after the storm.”

Every hospital maintains an elaborate disaster plan, but after Hurricane Sandy, the fact that many health care facilities are in low-lying areas proved to be something of an Achilles’ heel. Bellevue became the third hospital in the city to evacuate after the storm’s landfall, after NYU Langone Medical Center, just north of Bellevue, and Coney Island Hospital, another public hospital.

New York Downtown Hospital, the only hospital south of 14th Street in Manhattan, and the Veterans Affairs Hospital, just below Bellevue, had evacuated before the storm.

Hospital executives were reluctant to criticize their colleagues or city officials. But the sequence of events left them with many questions.

“All hospitals are required to do disaster planning and disaster drills,” Pamela Brier, the chief executive of Maimonides, noted. “All hospitals are required as a condition of being accredited, to have generators, backup generators.”

City health department and emergency officials have been particularly fervent about citywide disaster drills, she added, but “as prepared as we think we are we’ve never had a mock disaster drill where we carried patients downstairs. I’m shocked that we didn’t do that. Now we’re going to.”

The city’s health commissioner, Dr. Thomas Farley, defended the decision not to require evacuations of Bellevue, Coney Island and NYU Langone hospitals before the storm, which he said had been made in consultation with the state health commissioner, Dr. Nirav Shah.

Dr. Farley said they based the decision on their experience with Hurricane Irene, when they ordered the evacuation of hundreds of patients from six hospitals, including NYU Langone, and a psychiatric center, as well as of thousands of residents of nursing and adult homes.

“We saw there was definitely risks to patients from evacuations,” Dr. Farley said.

He added that, “As the storm got worse on Sunday, we did recognize that there would be some risk to health care facilities, so we took some steps to make sure that they were aware of that.”

But he said he considered the decision to wait a success overall: “There was no loss of life as a result of those evacuations.”

He said the city was still assessing what to do differently next time. “We certainly are seeing many more severe weather events in this city than we’ve seen in the past, that does mean we have to rethink the vulnerability of our health care facilities,” Dr. Farley said.

A major concern for hospitals is that traditionally, generators, fuel tanks and fuel pumps have been located in their basements. Both NYU Langone and Bellevue had actually shored up their defenses after Hurricane Irene, according to executives of both hospitals. Among other changes, both built flood-resistant housings for their fuel pumps.

But some circuitry, as well as tanks and pumps, remain on low floors, making backup systems vulnerable. The equipment is enormously heavy, so putting them on higher floors would require a great deal of reconstruction and possibly changes in building codes, said Dr. Steven J. Corwin, the chief executive officer of NewYork-Presbyterian Hospital, which has been taking on extra patients and bringing in extra staff.

Another serious issue is how long a hospital should expect to rely on a generator if the power fails.

“Heretofore, it was felt that generator power would be for a self-limited time, not more than a day — two, three at the outside,” Dr. Corwin said. “Now we’re looking at events where it could be a week.”

Alan Aviles, president of the Health and Hospitals Corporation, which runs the city’s public hospitals, said that all signs pointed against a storm emergency. “Up until an hour before the storm made landfall, the National Hurricane Center was saying that there was only a 5 percent probability of a storm surge over 11 feet in the area that would impact Coney Island, and they weren’t even showing a 5 percent probability on the East River,” Mr. Aviles said.

When the main power went off about 9 p.m. Monday, doctors and nurses were initially told not to worry, because the backup generators were working fine, people there at the time said. But by about 10 p.m., the basement was completely flooded, the pumps were flooded, and doctors were warned that they could lose backup power very shortly.

Critical-care doctors and nurses immediately began moving their patients to the area served by a lower-floor generator. Everyone moved quickly to disconnect patients from respiratory machines and then reconnect them.

A Bellevue doctor said midlevel administrators began begging their bosses to evacuate the hospital Monday night, when water could be heard pouring through the elevators, “like Niagara running through the hospital.”

“The phones didn’t work,” he said, speaking on the condition of anonymity for fear of being fired. “We lost all communication between floors. We were in the dark all night. No water to wash hands — I mean, we’re doctors!”

When the evacuation began, patients were bundled into red and orange sleds and dragged down as many as 13 or 15 flights of stairs. “If they were ventilated, someone was dragging them with a bag” of hand-pumped oxygen, one doctor said. “It was a herculean effort.”

Despite the power problems, Bellevue was able to print out some medical records or get summaries from doctors to send with patients. But landlines and cellphones were affected, and doctors and nurses said they wished some other form of communication, like walkie-talkies, had been available.

It was not until Wednesday, Mr. Aviles said, that everyone realized the situation was beyond repair and the final decision to evacuate everyone was made. “It was at that point that it was clear that it was just not tenable to keep patients for a longer term in the hospital,” he said. “We know that all these patients were successfully transferred to safety and are doing well, and I think that’s what’s important.”

By ABIGAIL ZUGER, M.D.
NYTimes.com

 
When a book is heavy with glossy photographs, you seldom expect too much from its words. In “The American Nurse,” though, it’s the narrative that hits you in the solar plexus.

Take the comments of Jason Short, a hospice nurse in rural Kentucky. Mr. Short started out as an auto mechanic, then became a commercial trucker. “When the economy went under,” he says, “I thought it would be a good idea to get into health care.” But a purely pragmatic decision became a mission: Mr. Short found his calling among the desperately ill of Appalachia and will not be changing careers again.

“Once you get a taste for helping people, it’s kind of addictive,” he says, dodging the inspirational verbiage that often smothers the healing professions in favor of a single incontrovertible point.
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Some of the 75 nurses who tell their stories in this coffee-table book headed into the work with adolescent passion; others backed in reluctantly just to pay the bills. But all of them speak of their difficult, exhilarating job with the same surprised gratitude: “It’s a privilege and honor to do what I do,” says one. “I walk on sacred ground every day.”

They hail from a few dozen health care settings around the country, ranging from large academic institutions like Johns Hopkins in Baltimore to tiny facilities like the Villa Loretto Nursing Home in Mount Calvary, Wis., home to 50 patients and a collection of goats, sheep and other animals on a therapeutic farm. Some nurses are administrators, some staff wards or emergency rooms, some visit patients at home. Many are deeply religious, a few are members of the military, and a handful of immigrants were doctors in their home countries.

All describe unique professional paths in short first-person essays culled from video interviews conducted by the photographer Carolyn Jones. Their faces beam out from the book in Ms. Jones’s black-and-white headshots, a few posing with a favorite patient or with their work tools — a medevac helicopter, a stack of prosthetic limbs or a couple of goats.

But even the best photographs are too static to capture people who never stop moving once they get to work. For a real idea of what goes on in their lives, you have to listen to them talk.

Here is Mary Helen Barletti, an intensive care nurse in the Bronx: “My whole life I’ve marched to a the beat of a different drummer. I used to have purple hair, which I’d blow-dry straight up. I wore tight jeans, high heels and — God forgive me — fur (now I am an animal rights activist). My patients loved it. They said I was like sunshine coming into their room.”

Says Judy Ramsay, a pediatric nurse in Chicago: “For twelve years I took care of children who would never get better. People ask how I could do it, but it was the most fulfilling job of my life. We couldn’t cure these kids, but we could give them a better hour or even a better minute of life. All we wanted to do was make their day a little brighter.”

Says Brad Henderson, a nursing student in Wyoming: “I decided to be a nurse because taking care of patients interested me. Once I started, nursing just grabbed me and made me grow up.”

Says Amanda Owen, a wound care nurse at Johns Hopkins: “My nickname here is ‘Pus Princess.’ I don’t talk about my work at cocktail parties.”

John Barbe, a hospice nurse in Florida, sums it up: “When I am out in the community and get asked what I do for a living, I say that I work at Tidewell Hospice, and there’s complete silence. You can hear the crickets chirping. It doesn’t matter because I love what I do; I can’t stay away from this place.”

The volume is not entirely about selfless service: It was underwritten by Fresenius-Kabi, a German health care corporation and leading supplier of intravenous drugs in the United States. Presumably, crass public relations motives lurk somewhere in the background. But that’s no real reason to be meanspirited about the result, a compelling advertisement for an honorable profession.

Young people with kind hearts and uncertain futures might just sit themselves down with the book, or wander through the Web site featuring its video interviews, www.americannurseproject.com, and see what happens.

By DAN FROSCH

The debate pits nurse anesthetists, who specialize in administering anesthesia and maintain that they are well equipped to treat patients on their own, against anesthesiologists, who are physicians and say nurses lack the necessary training.

The dispute dates to a 2001 change in Medicare and Medicaid regulations, allowing states to opt out of a requirement that nurse anesthetists be supervised. And it is part of a broader turf war over how much power nurses should have in treating patients.

“With the removal of the requirement, it actually increases access to health care for citizens in rural Colorado,” said Scott K. Shaffer, president of the nurse anesthetists association in Colorado, one of 17 states that have chosen to allow nurses to deliver anesthesia without supervision.

Since Colorado’s rural hospitals were exempted from the supervision regulation in 2010, Mr. Shaffer said, some medical facilities that may not have employed anesthesiologists have been able to attract specialists because there is no longer a concern about who would administer anesthesia or supervise.

“Now patients don’t have to turn around and go to Colorado Springs or Denver when they can be taken care of in their hometown,” he said.

In Colorado, however, the issue has prompted a legal battle. In 2010, anesthesiologist and medical societies filed a lawsuit in state court asserting that allowing nurse anesthetists to deliver anesthesia without supervision was not consistent with state law, a requirement for opting out of the federal rule.

But a judge dismissed the case, ruling that the legislature had indeed intended for the practice to be permitted. The medical groups appealed last May.

“There is a very different background between nurses and physicians in both education and training,” said Dr. Randall Clark, a spokesman for the Colorado Society of Anesthesiologists. “Anesthesia is a very complex and technically demanding area of medicine that, at its core, needs to be either performed by a physician or supervised by one.”

Dr. Clark said that despite concerns about health care access, his group believed that there were more anesthesiologists than nurse anesthetists currently working in the nearly 50 rural Colorado hospitals affected by the opt-out decision. And in those instances when a hospital does not have a staff anesthesiologist, he said, it is still safer to have a physician on hand to supervise lest complications arise.

At a state appeals court hearing in Denver on Tuesday, Assistant Attorney General LeeAnn Morrill argued that Colorado law clearly permitted doctors to delegate medical functions to advanced practice nurses. Joseph J. Bronesky, a lawyer for the anesthesiologist society, said the law was murkier.

The case is being watched closely by national nursing and anesthesiologist groups, for whom the debate has become increasingly contentious. Each side has promoted studies backing its perspective.

The American Society of Anesthesiologists cited a 2000 study financed by the federal Agency for Healthcare Research and Quality, which found that the presence of an anesthesiologist helped prevent deaths in cases where an anesthesia or surgical complication had occurred.

Conversely, the American Association of Nurse Anesthetists referred to a study it financed that was published in Health Affairs in 2010. It examined Medicare data from 1999 to 2005 and found no evidence that opting out of the supervision requirement resulted in increased inpatient deaths or complications.

“When it comes to giving anesthesia, certified registered nurse anesthetists and anesthesiologists are identical,” said Christopher Bettin, a spokesman for the nurse anesthetists group. “There are no differences in what they learn, the drugs and equipment they use and the standards of care they follow.”

Colorado is not the only state where the dispute over nurse anesthetists has ended up in the courts. Last month, the California Society of Anesthesiologists petitioned the State Supreme Court to review its lawsuit over California’s 2009 decision to opt out of the supervision requirement. The group’s suit, initially filed in 2010, has so far been unsuccessful.

“Our concern is patient safety,” said Dr. Kenneth Y. Pauker, president of the California group. “Is an independent nurse able to tender the same quality of care as an anesthesiologist or an anesthesia care team? What happens when things get really complex and you have to call upon all your years of medicine?”

Jana Du Bois, chief counsel for the California Hospital Association — which has sided with the nurses, as has its Colorado counterpart — said that rural areas in California continued to struggle to recruit and retain specialists.

“If there aren’t enough physicians and a woman in labor comes in, you can’t say, ‘We have to wait until next week to get an anesthesiologist,’ ” she said.

The Family Health Clinic of Carroll County, in Delphi, Ind., and its smaller sibling about 40 minutes away in Monon provide full-service health care for about 10,000 people a year, most of them farmers or employees of the local pork production plant. About half the patients are Hispanic but there are also many German Baptist Brethren. Most of the patients are uninsured, and pay according to their income — the vast majority paying the $20 minimum charge for an appointment. About 30 percent are on Medicaid. The clinics, which are part of Purdue University’s School of Nursing, offer family care, pediatrics, mental health and pregnancy care. Many patients come in for chronic problems: obesity, diabetes, hypertension, depression, alcoholism.

What these clinics don’t offer are doctors. They are two of around 250 health clinics across America run completely by nurse practitioners: nurses with a master’s degree that includes two or three years of advanced training in diagnosing and treating disease. By 2015, nurse practitioners will be required to have a doctorate of nursing practice, which means two or three more years of study. Nurse practitioners do everything primary care doctors do, including prescribing, although some states require that a physician provide review. Like doctors, of course, nurse practitioners refer patients to specialists or a hospital when needed.

America has a serious shortage of primary care physicians, and the deficit is growing. The population is aging — and getting sicker, with chronic disease ever more prevalent. Obamacare will bring 32 million uninsured people into the health system — and these newbies will need a lot of medical care. According to the American Association of Medical Colleges, the United States will be short some 45,000 primary care physicians by 2020.

The primary care physicians who do exist are badly distributed — 90 percent of internal medicine physicians, for example, work in urban areas. Some doctors go to work in rural areas or the poor parts of major cities, treating people who have Medicaid or no insurance. But they are few.

In part it’s the money. Primary care doctors make less than specialists anywhere, but they take an even larger financial hit to treat the poor. Particularly in the countryside — even with programs that offer partial loan forgiveness, it’s very hard to pay off medical school debt treating Medicaid patients, much less those with no insurance at all.

And the job of a primary care doctor today is largely managing chronic disease — coordinating the patient’s care with specialists, convincing him to exercise or eat better. Poor patients can be a frustrating struggle. Compared with wealthier patients, they tend to have more serious diseases and fewer resources for getting better. They are less educated, take worse care of themselves and have lower levels of compliance with doctors’ orders. Very few people start medical school hoping to do this kind of work. Those who do it may burn out quickly.

It might seem that offering the rural poor a clinic staffed only by nurses is to give them second-class primary care. It is not. The alternative for residents of Carroll County was not first-class primary care, but none. Before the clinic opened in 1996, the area had some family physicians, but very few accepted Medicaid or uninsured patients. When people got sick, they went to the emergency room. Or they waited it out — and then often landed in the emergency room anyway, now much sicker.

Just as important, while nurses take a different approach to patient care than doctors, it has proven just as effective. It might be particularly useful for treating chronic diseases, where so much depends on the patients’ behavioral choices.

Doctors are trained to focus on a disease — what is it? How do we make it go away?

Nurses are trained to think more holistically. The medical profession is trying to get doctors to ask about their patients’ lives, listen more, coach more and lecture less — being “patient-centered” is the term — in order to better understand what ails them.

“I’ve been out of nursing school since 1972 and I still remember that when faculty members finished talking about the scientific parts of the disease they would talk about the psycho-social part,” said Donna Torrisi, the executive director of the Family Practice and Counseling Network, which has three clinics in Philadelphia. “It’s not about the disease, it’s about the person who has the disease. While in the hospital you’ll often hear doctors refer to a patient as ‘the cardiac down the hall.’”

Younger doctors are no doubt better at this than their older peers. But the system conspires against them. The 15-minute appointment standard in fee-for-service medicine — which pays doctors according to how many patients they see and treatments they provide — makes it unlikely that doctors will spend time discussing a patient’s life in any detail. Physician reimbursement places a zero value on talking to the patient. But nurse practitioners are salaried, giving them the luxury of time. At the Family Health clinics, appointments last half an hour — an hour for a new diabetic or pregnant patient.

Jennifer Coddington, a pediatric nurse practitioner who is a co-clinical director of Family Health Clinics, said that she spends a lot of time teaching patients and their families about their diseases and how to manage it. “We want to know socially and economically what’s going on in their life — their educational level, how are they making it financially,” she said. “You can’t teach patients if you’re not at their educational level. And if a patient can’t afford something, what’s the point of trying to prescribe it? He’s going to be non-compliant.”

A physician might suggest that a patient lose weight and hand him a diet plan — or refer him to a nutritionist. At the Family Health clinics, nutrition counselors — graduate students at Purdue — will sit down with patients to talk about the specific consequence of their diet, and suggest good foods and how to cook them, Coddington said. “When you don’t have enough money to buy fruits and vegetables, so you go to the dollar menu at McDonald’s — we help those people put planners together for the week.”

Data has shown that nurse practitioners provide good health care. A review of 118 published studies over 18 years comparing health outcomes and patient satisfaction at doctor-led and nurse practioner-led clinics found the two groups to be equivalent on most outcomes. The nurses did better at controlling blood glucose and lipid levels, and on many aspects of birthing. There were no measures on which the nurses did worse.

Nurse-led clinics can save money — but not always in the obvious way. Many are cheaper than comparable physician-led clinics. Suzan Overholser, the business manager of the Family Health clinics, said that their cost per patient was $453 per year — lower than the Indiana average for similarly federally qualified clinics (all the others physician-led) of $549. But nurse-led clinics aren’t always cheaper. Coddington examined published studies of clinic costs and found that in some cases, nurse-managed clinics had slightly higher per-patient costs than traditional clinics.

Although nurses are paid less than doctors (Medicare reimburses them at 85 percent of what it pays doctors,) nurse-led clinics are often very small, and so don’t have the variety of practitioners necessary to keep a clinic running at full capacity. They also serve the most difficult and expensive patients.

The biggest financial benefit, however, likely comes from offering patients an alternative to the emergency room. Coddington’s review cites studies showing large savings in paramedic, police, emergency room and hospital use. A traditional clinic in an underserved area would do that, too, of course — it’s just that nurses tend to go where doctors won’t.

There are about 150,000 nurse practitioners in America today. The vast majority practice in traditional settings — only about a thousand are in nurse-managed clinics. One reason these clinics are rare is that they may equal traditional clinics in health care, but not in business success.

Nurse-managed clinics have to overcome regulatory and financial obstacles that traditional clinics don’t face. Powerful physicians’ groups such as the American Academy of Family Physicians oppose allowing nurses to practice independently. “Granting independent practice to nurse practitioners would be creating two classes of care: one run by a physician-led team and one run by less-qualified health professionals,” says a paper from the A.A.F.P., citing the fact that doctors get more years of education and training. “Americans should not be forced into this two-tier scenario. Everyone deserves to be under the care of a doctor.”

Only 16 states and Washington, D.C., allow nurses complete independence. In other states, some of the restrictions are bizarre — in Indiana, for example, nurse practitioners may do everything doctors do, with two exceptions: they can’t prescribe physical therapy or do physicals for high school sports.

Jim Layman, the executive director of the Family Health clinics, said he thought that nurse practitioners cared for the majority of Medicaid patients in Indiana. But if you look through Medicaid records, you’ll find only doctors — nurses are not allowed to be the primary caregiver of record. So the Family Health clinics, like others, employ a physician off-site from 4 to 6 hours a week who uses electronic health records to examine a sample of cases and consult when necessary. Medicaid is billed in his name.

It is not easy for nurse-run clinics to win status as a Federally Qualified Community Health clinic, which would allow them to get federal grants. This is largely because most come out of universities, and most universities don’t want to cede control to the community — a requirement for this status. Purdue decided it would, and the Family Health clinics qualified in 2009. Before that, they received some money from the state, and raised the rest from local March of Dimes, United Way and Chamber of Commerce donations, plus fund-raising dinners and auctions. This was enough to support just one full-time provider at each clinic. Getting F.Q.C.H. status allowed them to hire more staff and move the Carroll County clinic into a modern new building — and probably saved them from collapse. “It would have been very difficult for us had we not gotten F.Q.C.H. status,” said Coddington. The Affordable Care Act — Obamacare — did authorize $50 million for five years for nurse-managed clinics. So far 10 clinics have gotten a total of $15 million.

In some ways, the nurse practitioner-managed clinic is a throwback to the small-town family practice, when your doctor asked about the schoolyard bully and your dad’s unemployment. Among the many changes needed in how America values and reimburses health care, it’s important to encourage and support these clinics. They may be old-fashioned, but that doesn’t mean they should be financed with bake sales.

By limiting our understanding of diversity in nursing to matters of race and religion, we risk excluding other cultural groups, warns Arabella Sinclair-Penwarden

Issues of diversity enjoy a high profile in nursing today, from the RCN’s continuing emphasis on the importance of valuing diversity, to training in this area in both pre- and post-graduate contexts. Defined as ‘the state or quality of being different or varied’ in Collins English Dictionary, the word has accumulated various different interpretations, not all true to the original.

I asked several colleagues what ‘diversity’ meant to them. ‘Respecting people of different races,’ said one. ‘Being aware of other people’s religions and faiths,’ said another. Still another commented that it was ‘to do with treating each patient as an individual’.

These are examples of applying the term constructively and, typically of nursing, in a wholly practical manner. Yet by restricting our definition to matters of race or creed, we risk isolating the term and omitting cultural groups that fall under neither heading.
When I was asked to take on the role of diversity link nurse in my department, I was intrigued by the potential of the role. You see, there was no precedent, no shoes to fill. The role was entirely new.

Our trust had a comprehensive policy relating to the different spiritual beliefs of patients, and I had no desire to replicate what had been written. But I had read about Deaf culture – and there did not seem to be a great deal of awareness about it.

Deaf people are not always perceived as a specific cultural group. Indeed, there is confusion about the terms related to an absence of hearing. What, for example, is the difference between a patient being deaf and Deaf? Between being deafened and hard of hearing? Information is both scarce and sparse. Terms may be used interchangeably and research can be confusing.

It is common practice to capitalise the ‘D’ in ‘Deaf’ when writing about the culture and the children and adults that make up its members. The term ‘deafened’, or ‘deaf’ with a small ‘d’, or ‘hard of hearing’ is frequently used to describe someone who has acquired hearing loss. This may also be referred to as being ‘post-lingually deaf’, meaning those whose loss developed after the acquisition of spoken language.

Anecdotally it has been noted that terms can be used inconsistently, and sometimes incorrectly, even by healthcare workers.

Yet, when such a lack of clarity exists, it is unsurprising that confusion regarding dealing with patients with hearing loss should follow.

The term ‘Deaf community’ has demographic, linguistic, psychological and sociological dimensions, and this is underlined by the description of sign language as ‘a minority language’. It therefore seems wholly appropriate to include the needs of people who identify themselves as culturally Deaf when discussing diversity issues.

As nurses and midwives we are bound by the code of conduct set down by the NMC. Thus, we are – or should be – aware not only of the need to respect each person within our care as an individual but also to be wary of discriminating against them. Yet discrimination can take many forms. Direct discrimination is defined by the government as when a person is treated ‘less favourably because of, for example, their gender or race’. Indirect discrimination is when ‘a condition that disadvantages one group more than another is applied’.

By being ignorant of the discrete needs of culturally Deaf patients we risk indirectly discriminating against our own patients, whether by not providing an interpreter when one is required, or by assuming that a pre-lingually Deaf patient will be able to lip-read fluently.

We are not expected to be fluent in British sign language, nor to be fully au fait with the finer nuances of Deaf culture. But, in view of a 2004 RNID statistic suggesting that 35% of Deaf and hard of hearing people have been left unclear about their condition because of communication problems with a GP or nurse, neither can we afford to be lackadaisical. Awareness of these issues is the key to individualising care – and that is something that we are required to do.