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.

11:10AM EDT October 5. 2012 -From USAtoday.com

As Baby Boomers age into retirement by the millions each year, their growing health care needs require more people to administer that care.

That makes fields such as nursing one of the fastest-growing occupations, and hospitals are hiring now to prepare for what's to come.

Central Florida Health Alliance has 140 to 170 open positions a week, and almost 90% of them are for jobs that include registered nurses, pharmacists, physical therapists and pharmacy technicians, says Holly Kolozsvary, human resources director.

The two-hospital system based in Leesburg and The Villages is hiring for its peak season from January to April, when many retirees seek winter refuge in the Florida sun. But it's also managing a trend that requires it to employ more people year-round: More retirees aren't leaving at the end of spring, Kolozsvary says.

"It's kind of a domino effect," she says. "They move here, they're well, they get sick, they're left here through their cancer or heart disease, and we have to take care of them."

Job postings on Monster.com for positions including registered nurses, physical therapists and physician assistants rose 13% from June 2011 through June 2012, according to a 2012 health occupational report by the job site.

The additional demand could be due partly to hospitals preparing for the retirements of many older nurses as the economy gets better, increasing the need for new skilled workers. Scripps Health, a group of five hospitals and 23 outpatient facilities in San Diego, plans to hire about 400 nurses a year over the next three years but might need to increase that by 200 annually because of retirements, says Vic Buzachero, senior vice president for human resources. About 30% of the hospitals' nurses are older than 50.

Jamie Malneritch applied for a part-time job as a registered nurse with Scripps in March and heard from the hospital the same day she submitted her application. She started working a month later.

The 31-year-old, who has worked as a nurse for four years, says the job security and growth opportunities were primary drivers in her decision to go to nursing school in 2006.

"It seems like we always need more hands," she says. "Nursing is flourishing."

With an average salary of $64,690 a year, according to 2010 data from the Bureau of Labor Statistics, registered nursing may be the more desired profession, but lower-paid home health aides are actually in higher demand.

An industry shift that puts more emphasis on outpatient care and home health services makes home health and personal care aides two of the fastest-growing occupations in the country. Employment in both positions, which have an average salary of about $20,000 a year, is expected to grow by about 70% by 2020, BLS data show. Registered nursing is expected to grow 26%.

ResCare HomeCare, a national provider and employer of home health and personal care aides, who work primarily with seniors with chronic illnesses or disabilities, has received 32,000 applications this year, a 23.3% jump from last year, and it hired 6,000 of the people who applied, about 5% more than in 2011, says Shelle Womble, senior director of sales.

Home health and personal care aides are generally the same, providing services such as checking vitals, prepping meals and bathing and grooming the patient. But home health aides are funded by Medicare and, in some states, require more training, while personal care aides are funded privately and may require less training, Womble says.

ResCare, where aides make $22,000 to $30,000 a year, is anticipating the need for more workers in the near future.

"Right now, one of our key positions is that we are hiring the talent before we even get the clients so we can be prepared and have the staff available," Womble says of home health and personal care aides. "There's a lot more competition for that type of employee."

By Genevieve M. Clavreul, RN, Ph.D.

By TESS VIGELAND

Published: March 21, 2012

How far would you go for a financial comeback? Heading to North Dakota’s oil boom and other stories of post-recession striving.

IN 2007, Kurt Edwards figured he would be stacking and racking 80-pound boxes of dog food and celery in the back of a grocery store for the rest of his working life. And he was fine with that.

But that June, after nine years on the job, layoff notices arrived on the warehouse floor at the Farmer Jack store in Detroit where he worked. His employer, Great Atlantic and Pacific Tea Company, closed the Farmer Jack chain. Today he still does a lot of lifting, but of people, not boxes. Mr. Edwards joined the ranks of former warehouse, factory and autoworkers trading in their coveralls and job uncertainty for nurses’ scrubs.

At 49, divorced with no children, he now tends to patients on the graveyard shift at Sheffield Manor Nursing and Rehab Center, a two-story, gray brick building in a ramshackle neighborhood on Detroit’s west side. Interviewed last month, he says he is making about $70,000 annually, $20,000 more than he did at the warehouse.

The story of how he made the transition is one that men like him appear to be telling with increasing frequency, and the demand for their services is what is setting so many of them on similar paths.

Hard figures are elusive, but the Michigan Department of Energy, Labor and Economic Growth estimates a shortage of 18,000 nurses in the state by 2015 — and the labor force is adapting.

Oakland University in nearby Rochester, Mich., has established a program specifically to retrain autoworkers in nursing — about 50 a year since 2009. And the College of Nursing at Wayne State University in Detroit is enrolling a wide range of people switching to health careers, including former manufacturing workers, said Barbara Redman, its dean. “They bring age, experience and discipline,” she said.

David Pomerville brings a few more years than Mr. Edwards. A 57-year-old nursing student, he spent most of his career as an automotive vibration engineer, including almost 10 years at General Motors. His pink slip arrived in April 2009.

At the time, Mr. Pomerville was earning almost $110,000 a year at the General Motors Milford Proving Ground in Milford Township, Mich.

But having watched another round of bloodletting at G.M. three years earlier, he had already decided on nursing as his Plan B. “I thought, ‘Well, I worked on cars for this long, now I’m going to work on people for a while,’ ” he said.

A married father of two and grandfather of two, Mr. Pomerville had almost no money saved when he was laid off. But the federal Trade Readjustment Act, which aids workers who lose their jobs as a result of foreign competition, paid for nursing school tuition. His wife is a teacher, and he receives unemployment benefits. He hopes to graduate at the end of this year, and he expects his salary will be about half what he used to make.

Timothy Henk ultimately decided not to try to stick it out as long as Mr. Pomerville did. Mr. Henk, 32, worked for eight years at the Ford Sterling Axle Plant in Sterling Heights, Mich., installing drive shafts in the F-150 truck, and was making about $25 an hour by 2007. With overtime, he earned $70,000 a year.

But as he and his wife contemplated having children, he worried that income would not last. So in 2007, he took a buyout, which included $15,000 a year for four years to put toward education. Two friends in nursing — both women — had suggested he look into joining their profession. He researched the demand for nurses in Michigan and used the buyout money to pay his tuition at Wayne State.

The amount of schooling required to be a nurse depends on the level of nursing a student chooses to pursue. Mr. Henk went through Wayne State’s four-year program to obtain a bachelor of science in nursing and then took a licensing exam to become a registered nurse, or R.N. Other levels of nursing include the C.N.A., or certified nurse’s aide, which can require as little as eight weeks of training plus a certification exam, and L.P.N., or licensed practical nurse, which requires one or two years of schooling and a licensing exam.

All of that assumes acceptance in a nursing program. The American Association of Colleges of Nursing said more than 67,000 applicants were turned away in 2010 for lack of faculty or classroom space — not a good sign with a national nursing shortage projected to be as high as 500,000 by 2025.

Mr. Henk now works in the critical care unit at Beaumont Hospital in Royal Oak, Mich. He makes about $50,000 annually for a 36-hour workweek, though Ford’s health insurance was better.

The choice to make this switch was probably least likely for Mr. Edwards, the former grocery worker. He dropped out of college and spent four years in the Army as a paratrooper with the 82nd Airborne Division. He found his unionized warehouse job after a stint working for his father, an accountant.

“You have this plan, this goal,” he said. “I was going to be at this warehouse; all the guys were retiring with great benefits. I was part of the middle class, and I was going to make it.”

When it became clear that he would not make it to retirement there, someone he was dating suggested nursing.

Though he wrote it off as woman’s work at first, he realized he was getting a bit old for manual labor. So he returned to school, living on unemployment checks and occasional groceries from by his mother. He spent the last four months of his L.P.N. training with no electricity because he could not afford to pay any bills except rent.

Once he finished, the Sheffield Manor administrator, LaKeshia Bell, pretty much hired him on the spot. “They are like a hot commodity,” she said. “A male presence actually helps us in the facility.” At 5 feet 9 inches tall and 220 pounds, Mr. Edwards lifts patients as easily as he stacked boxes.

But he still appears to be a rarity. Just 7 percent of employed registered nurses are men, according to a 2008 Department of Health and Human Services survey. It did not count licensed practical nurses. Still, the percentage of people certified in nursing in some way who are men has risen to 9.6 percent since 2000 from 6.2 percent before, according to the department.

Ms. Bell noted that new nurses coming from manufacturing had unusual adjustments to make. When dealing with parts on the factory floor, she said, repetition is a major part of the job. “These are not parts. They’re people, so you can’t just have a set regimen like in a plant setting,” she said.

That cultural shift goes both ways. Mr. Edwards’s supervisor, Yvonne Gipson, provided an example. “I mean Kurt is not an ugly man, O.K.?” she said. “You got all these female workers, and they’re all looking at him like, ‘Oh! Potential husband!’ So, yes, it does change.” Her voice trailed off, erupting into peals of laughter as Mr. Edwards slipped a $20 bill into her pocket.

While these success stories point to opportunity, Michigan’s unemployment rate is still 9 percent. And Nelson Lichtenstein, director of the Center for the Study of Work, Labor and Democracy at the University of California, Santa Barbara, says history is a cruel taskmaster when it comes to struggling industries.

“When one industry goes in decline and another comes to the fore, you don’t have a one-to-one employment replacement at all,” he said. “It takes a decade, two decades. In the meantime, some people find their careers are ended, ruined, and they never get them back.”

For these new nurses, the advantage is the demand in Michigan. Mr. Edwards knows he is lucky. “You know I wake up every day and I’m very proud,” he said. “I’m looking in the mirror. I’m happy. I’m proud. I’m saying, you know, this turned out great. The lights are on!”

By RICHARD PÉREZ-PEÑA

Published: June 23, 2012

Ms. Matton, a nurse, works at Abington Memorial Hospital, one of hundreds around the country that have started to require that their nurses have at least a bachelor’s degree in nursing. Many more hospitals prefer to hire those with such degrees.

That shift has contributed to a surge in enrollment in nursing courses at four-year colleges, particularly at the more than 600 schools that have opened “R.N. to B.S.N.” programs, for people who are already registered nurses to earn bachelor’s degrees. Fueled by the growth in online courses, enrollment in such programs is almost 90,000, up from fewer than 30,000 a decade ago, according to the American Association of Colleges of Nursing.

The need is so great that nurses without bachelor’s degrees are still in demand. But experts say that may change in years to come, particularly at hospitals, the largest segment of the profession and one of the best paid.

Enrollment in community college programs, the typical path to becoming a nurse, remains strong, but many of those schools are looking for new arrangements, like partnerships with four-year schools, to keep their graduates competitive.

Ms. Matton, 37, first went to college for an associate degree in radio and television broadcasting. By the time she returned to school for an associate’s in nursing, she was a wife and mother — she gave birth to her youngest a few days before taking an exam. Now she is weeks away from her third degree, a bachelor’s in nursing from Drexel University in Philadelphia, with most of the work done online.

“I wanted to get the bachelor’s at the start, but I needed to start earning some money,” said Ms. Matton, whose husband, Joel, is a computer programmer. “Now I need to do this for job security, to have opportunities down the road.”

Schools like Drexel have seized the opportunity. Its online R.N. to B.S.N. program began in the late 1990s with a few dozen students and today has 650. Over all, its College of Nursing and Health Professions has doubled over the last decade, to about 2,400 students, making it one of the nation’s largest.

“There are several hospitals in our region, like Abington, that will hire nonbaccalaureate nurses but give you a certain number of years to finish the baccalaureate, and some that won’t even interview you without it,” said Gloria Donnelly, dean of the nursing college.

Such policies are limited to a small fraction of the nation’s more than 5,000 hospitals — while no definitive count exists, they tend to be teaching hospitals in major metropolitan areas — but the number is rising fast. Hospital and nursing school officials say most hospitals insisting on bachelor’s degrees began doing so in the last five years, like Abington, a suburban hospital north of Philadelphia, which adopted its policy in 2010.

Surveys show that most hospitals prefer to hire nurses with bachelor’s degrees, though they often cannot find enough. Lawmakers in several states, including New York, have introduced bills that would require at least some hospital staff nurses to have bachelor’s degrees within 10 years, though none have become law.

No matter the type of nursing school, a graduate who passes a national licensing exam becomes an R.N., and for decades, that was the only credential that mattered to hospitals. (Licensed practical nurses, or L.P.N.’s, who take a different version of the exam, can perform fewer functions and are being phased out of hospitals.)

Not long ago, most nurses did not go to college at all, but to nursing schools run by hospitals — including one still run by Abington — that do not confer degrees. As recently as the mid-1980s, half of the country’s registered nurses had started that way. But by then, hospital-based schools were closing in droves, and community college education was becoming the norm.

Still, professional groups and employers continue to push for more education, citing studies linking better-educated nurses to better patient care. Where traditional nursing education focuses on practical skills, students in four-year programs learn more about theory, public health and research.

An added incentive for hospitals is the coveted “magnet” designation, awarded by the American Nurses Association to about 400 hospitals and sometimes featured in their advertising. Among the association’s criteria for magnet status is the nursing staff’s level of education.

A 2008 federal government survey showed that among newly minted nurses, only 3 percent had graduated from nondegree programs, 58 percent from community colleges, and 39 percent from four-year colleges. With more of them returning to school, half of the nation’s 3 million registered nurses had a bachelor’s or master’s degree in nursing.

In 2010, the Institute of Medicine called for raising that figure to 80 percent by 2020, but that is a tall order.

“The baccalaureate programs can’t find enough qualified instructors, so they turn away tens of thousands of qualified applicants every year,” said Geraldine Bednash, chief executive of the American Association of Colleges of Nursing. “There’s going to be a big need for community-college-educated nurses for a long time, but they may be increasingly limited to nonhospital settings.”

But many community colleges are finding ways to appeal to students who want more than an associate degree. A handful of community colleges have won permission to offer bachelor’s degrees in nursing — notably Miami Dade College, one of the nation’s largest, which started its bachelor’s program in 2008 — and other schools have petitioned state regulators and accreditation agencies to do the same.

Many more junior colleges have made arrangements with four-year colleges to help nursing students move more readily from one to the other. In Oregon, eight community colleges and the state’s Health and Science University have shared a nursing curriculum since 2006, an approach since adopted by others around the country.

“I really don’t foresee a day when the nursing pipeline can continue without community colleges, but we have to take steps to ensure our graduates remain marketable, and some programs may not survive in the long run,” said Nell Ard, director of nursing at Collin College, a community college outside Dallas. Each Collin nursing student is enrolled simultaneously in one of two four-year state schools, allowing for a seamless transfer.

But a bachelor’s program sets a high a bar for many would-be nurses and working nurses, who are older than their counterparts of a generation ago and are more likely to have family obligations. It is, increasingly, a second career; the typical starting age is around 30.

“My school puts more pressure on us, no question, and more household stuff falls to the wayside,” said Ms. Matton, 37, sitting in her kitchen and eating a hamburger her husband had waiting when she got home. She shifted a few years ago to working part time.

Yet she endorses the bachelor’s requirement, pointing to the high stakes of her job, working in the emergency room. On a recent day that she described as slow, she had treated, among others, a middle-aged man who fainted in the heat and needed a cardiac work-up, a young woman in withdrawal from an opiate addiction, a pregnant woman with abdominal pain who spoke no English, an elderly woman with a badly infected thumbnail, an elderly man with gastrointestinal bleeding who had an adverse reaction to a plasma transfusion, and a young man whose tingling hands, head pain and elevated blood pressure persuaded a doctor to order a CT scan.

“It blows me away how much influence nurses have on serious treatment decisions,” Ms. Matton said. “After going back to school, I think more critically about what we’re doing, and I have a better understanding of why we’re doing it.”

By Shantelle Coe RN BSN - Diversity and Inclusion Consultant

Creating an environment that embraces diversity and equality not only attracts the most qualified nursing candidates, but an inclusive environment also helps to assure that the standards of nursing care include “cultural competency.”  Cultural differences can affect patient assessment, teaching and patient outcomes, as well as overall patient compliance.

Lack of cultural competence is oftentimes a barrier to effective communication amongst interdisciplinary teams, which can often trickle down to patients and their families.

With the increase in global mobility of people, the patient population has become more ethnically diverse, while the nursing forces remain virtually unchanged.  Nursing staff work with patients from different cultural backgrounds.  Consequently, one of the challenges facing nurses is the provision of care to culturally diverse patients.  Hospitals and healthcare agencies must accommodate these needs by initiating diversity management and leadership practices.

According to Cross, T., Bazron, B., Dennis, K., and Isaacs, M. (1989); these are the 5 essential elements that contribute to an institutions ability to become more culturally competent:

• Valuing diversity

• Having the capacity for cultural self-assessment.

• Being conscious of the dynamics inherent when cultures interact.

• Having institutionalized cultural knowledge.

• Having developed adaptations of service delivery reflecting an understanding of  cultural diversity. 

A culturally competent organization incorporates these elements in the structures, policies and services it provides, and should be a part of its overall vision.

From all levels, the nursing workforce should reflect the diversity of the population that it serves.  A more diverse workforce will push for better care of underserved groups.  It’s important to note that that diversity, inclusion, and cultural awareness isn't just about race or ethnicity.  We must always keep in mind socioeconomic status, gender, and disability in our awareness.

Becoming more inclusive is a shared responsibility between nurses and healthcare agencies.  Becoming an “agent of change” within your facility can inspire awareness and affect attitudes and perceptions amongst your peers. 

Nurses and healthcare workers must not rely fully on the hospital and healthcare systems to institute an environment of cultural awareness.   

Nurses can increase their own cultural competencies by following a few guidelines:                                   

• Recognizing cultural differences and the diversity in our population.

• Building your own self-awareness and examining your own belief systems.

• Describing and making assessments based on facts and direct observation.

• Soliciting the advice of team members with experience in diverse backgrounds.

• Sharing your experiences honestly with other team members or staff to keep communication lines open.  Acknowledging any discomfort, hesitation, or concern.

• Practicing politically correct communication at all times –  avoid making assumptions or stereotypical remarks.

• Creating a universal rule to give your time and attention when communicating.

• Refraining from making a judgment based on a personal experience or limited interaction.

• Signing up for diversity and inclusions seminars.

• Becoming involved in your agencies diversity programs – find out what your resources are - most institutions have something in place.

By incorporating a few of these steps into your daily nursing practice, you are taking steps towards becoming culturally competent.

Inclusive nurses demonstrate that we are not only clinically proficient and culturally competent, but are the essence and spirit of the patients that we care for.

By Christina Orlovsky, senior writer, and Karen Siroky, RN, MSN, contributor

As the nation’s population becomes more diverse, so do the needs of the patient population that enters U.S. hospitals. As caregivers with direct contact with patients from a wide spectrum of races, ethnicities and religions, nurses need to be aware and respectful of the varying needs and beliefs of all of their patients.

In its position statement on cultural diversity in nursing practice, the American Nurses Association (ANA) states that: “Knowledge of cultural diversity is vital at all levels of nursing practice…nurses need to understand: how cultural groups understand life processes; how cultural groups define health and illness; what cultural groups do to maintain wellness; what cultural groups believe to be the causes of illness; how healers cure and care for members of cultural groups; and how the cultural background of the nurse influences the way in which care is delivered.”

Additionally, the Joint Commission requires that all patients have the right to care that is sensitive to, respectful of and responsive to their cultural and religious/spiritual beliefs and values. Assessment of patients includes cultural and religious practices in order to provide appropriate care to meet their special needs and to assist in determining their response to illness, treatment and participation in their health care.

There are a number of ways to comply with the requirements for providing culturally diverse care.

First, be self-aware; know how your views and behavior is affected by culture. Appreciate the dynamics of cultural differences to anticipate and respond to miscommunications. Seek understanding of your patients cultural and religious beliefs and values systems. Determine their degree of compliance with their religion/culture, and do not assume.

Furthermore, respond to patients’ special needs, which may include food preferences, visitors, gender of health care workers, medical care preferences, rituals, gender roles, eye contact and communication style, authority and decision making, alternative therapies, prayer practices and beliefs about organ or tissue donation.

Kathleen Hanson, Ph.D., MN, associate professor and interim executive associate dean for academic affairs at the University of Iowa, summarized the importance of learning cultural diversity in nursing education.

“Cultural competency is threaded throughout the nursing school curriculum. We teach every course with the idea that there’s content that may need to be explained for a diverse student group,” Hanson said. “In nursing, cultural competency has been around for a long time. I think that’s probably something that the nursing profession recognized maybe a bit before some other disciplines. We’ve always worked in public health, so we have always seen the diversity of America.”

Hanson concluded: “We need to be able to care for diverse populations because our country is growing increasingly diverse. Oftentimes persons who are in minority groups or who are underrepresented have different health care needs. It’s important for us to have a student population that is as equally diverse as our client; we need to prepare a workforce that not only knows how to work with diverse peoples, but also represents them.”

by Lynda Lampert

If you have an iPhone, iPad or other mobile device, you likely have a ton of apps taking up space. While some of those apps are likely tailored for fun (Angry Birds, Words with Friends), there’s no question that you can use your smartphone to serve your nursing career.

Of course, when you’re in your scrubs and ready to tackle the shift, using mobile apps to get information on drugs to anatomy to conditions is a no-brainer way to better treat your patients and keep reference materials easily accessible. Here’s a look at 20 top clinical apps for nurses in 2012!

Not all of these apps are free, but when you think about the great services they provide—such as keeping you on top of ever-changing medical data—it’s well worth the money.