Monday, November 10, 2014

Our Health Care (Non) System is Chaotic; Can Nurses Help?

By E’Louise Ondash, RN

I’ve been thinking about it a long time, and I just don’t see how our health care nonsystem can survive such as it is for the long run. Many have told us this already, but it’s taken me a while to catch up. The costs are absurdly exorbitant and seem to be increasing, and obtaining the right care—never mind for the right price—can be a task that even health care professionals find difficult and confusing.

I’ve had several recent experiences, or frustrating mishaps, with health care and health insurance—and I’m a nurse who has written fairly extensively about consumer medical matters. If this has been challenging for me, how difficult must it be for those who know little about medicine or how to navigate through the nonsystem?

I use the prefix “non” because there is no system.

Rules vary widely among health plans, and to the consumer, it feels like a free-for-all. Even within the same health plan, the rules are inconsistent, and can be viewed as unfair. Some would even call them unethical.

So many people are finding it so difficult that it’s increased the need for the role of nurse-navigators. These navigators are needed to assist patients in getting the care they need and deciphering the complicated rules and regulations, and of course, it’s an extra expense.

Here’s one problem that seems to be a growing trend: patients are being billed for the services of out-of-network physicians who are working for in-network hospitals. Patients who come to these hospitals for care, as dictated by their insurance plans, are discovering only when the bill comes that the doctors who saw them do not accept their insurance.

This has happened twice this past year to me and my family members, and I’ve read about others having a similar experience. For instance, the New York Times recently ran a story about a man in his mid-30s who needed cervical spine surgery and was billed $117,000 by an assistant surgeon. The patient had no knowledge of this assistant surgeon, had no contact with him, and the surgery was performed in a hospital that is covered by surgical residents, who could have assisted for free.

The patient’s insurance company actually paid the assistant surgeon the full fee, much to the chagrin of the patient. (The surgeon is being investigated for “exorbitant” charges.)

As nurses, I’m not sure what we can do to stop the escalation of health care costs beyond what any consumer would do. I do think nurses should answer honestly any questions that patients have about acquiring care or what their options are if patients have choices.

There is no debate that some of the burden of high costs rests with consumers whose lifestyles promote poor health habits that can become chronic conditions. Nurses should do everything they can to help these patients whose unhealthy lifestyles cost us all. Still, there are many who, like the patient who needed cervical surgery, have no control over their health care expenditures.

Nurses also can report any unethical or illegal actions by individuals, institutions or health insurance companies, and write local and federal legislators about escalating costs and the problems they see within the nonsystem.

Have you experienced or seen instances of over-charging or unethical charges for health care? What did you do? Tell us about it.

Thursday, September 4, 2014

Why Mature Workers Choose Nursing the Second Time Around

By E’Louise Ondash, RN

She talks about how the nursing care she received after a severe trauma was inspirational and never forgotten. He explains that working in home care allows him to know patients much better. She says that her people and organizational skills readily transfer to a nursing career, and he says that his years in a monastery were excellent preparation for helping addicts recover.

These are some of the thoughts of men and women who have chosen to be nurses after other long and successful careers. I read about them – a crime reporter, a judge, a chief of personnel for the New York Fire Department, and a Buddhist monk – in a recent issue of the AARP Bulletin. One of the featured nurses is 50; the other three are in their mid-60s.

They represent, according to the article, the increasing numbers of men and women who are choosing nursing as a second career at a point in their lives when most people are thinking about retirement. Their reasons are both altruistic and financial. Nurses today are compensated much better for their skills than in previous decades, and fast-track programs for those who already have bachelor’s and master’s degrees make the profession attractive to mature and talented people.

Entering a rigorous new career path in one’s fifth or sixth decade is a marked departure from the formerly traditional path to nursing. In decades gone by, most nursing students were young women – teenagers, really – fresh out of high school.

Many veteran nurses tell of how they knew from an even a younger age that they wanted to follow in Florence Nightingale's footsteps. Their motivations were certainly admirable, but at 18 or 19, these young women came to the profession with little life experience.

Second-career nurses have one very big advantage: they bring to their second careers a wealth of experience, knowledge and understanding. They already may have mastered the skills that an 18-year-old won't acquire for years to come. They may have witnessed multiple deaths; endured great loss; chronicled the pain, misery and mistakes of others; learned to work under less-than-ideal situations and with difficult co-workers; mastered balancing family and work; decided the fate of others; made a bad decision or two; learned how to say just the right thing; and even how to be patients themselves.

I have nothing but admiration for those who make the leap into a nursing career when they could easily and deservedly enjoy a life of leisure.

What advice would you give a newly graduated second-career nurse?

At you own graduation, if had known then what you know now, would you have approached your nursing career differently?

Tell us about it.

Monday, August 11, 2014

Paperwork Can Be a Powerful Anti-smoking Tool

By E’Louise Ondash, RN

There are many days when nurses feel like the paperwork never ends, but there is one nurse who makes it her mission to delve into thousands of pages of documents in order to help nurses promote public and individual health.

Ruth Malone, RN, PhD, FAAN, professor and chair in the Department of Social and Behavioral Sciences at the University of California, San Francisco, conducts extensive searches through documents kept by the leading U.S. tobacco companies. She does this to uncover just how they go about promoting smoking and thwarting the efforts of health care professionals to help people quit.

Malone writes that the tobacco industry “actively tries to undo nurses’ efforts at the individual level.”

For instance, the companies know that nurses may encourage patients to quit on New Year’s Day or on their birthdays. “We discovered that tobacco companies sent consumers discount coupons and other promotional offers at these specific times, hoping to weaken people’s resolve to become tobacco-free,” Malone writes.

Malone also points out that, before tobacco companies existed, people became ill from using tobacco, but not to the extent that they have in the last century. Once tobacco companies were created, they aggressively advertised and promoted their products, which were engineered “to increase addictiveness and deep inhalation.”

Somehow, she says, tobacco companies spent the last 100 years trying to convince us that smoking wasn’t harmful, and that it was still acceptable to sell a product that kills half of those who use it.

“Cigarettes would never be allowed on the market if introduced today,” Malone writes. What can nurses do to counteract the tactics of tobacco companies?

Here are some suggestions from Malone:

* Remind patients that they may not want to continue giving money to companies that have lied and deceived users about the deadliness of their products.
* Instruct patients how to recognize industry efforts to discourage them from quitting.
* Remind patients that tobacco companies have purposely engineered their products to contain increasing amounts of addicting substances.
* Tell kids and adolescents that tobacco companies need “replacement smokers” for all those who die each year using tobacco products. The companies do this by promoting tobacco use as cool and edgy.
In the spirit of full disclosure, there is no neutrality on my part when it comes to this subject.

There have been three deaths in my immediate family directly due to tobacco use, and I’ve watched other family members and friends struggle with tobacco addiction. In every case, the smoker started in his/her preteen years because they thought smoking was a “cool” and “mature” thing to do. They all expressed the desire to quit but acknowledged that it was a terribly difficult thing to do.

I’ve also been twice-deposed by a team of lawyers representing a large tobacco company and had my computer and emails “mined” for discussions with my family members about the health hazards of tobacco. Sadly, I’m only one of millions who have lost loved ones or watched them suffer terribly.

I admire Malone and her colleagues for spending hundreds or perhaps even thousands of hours delving into the communications of tobacco companies so that we have a full picture of their tactics to undermine the efforts of nurses and other health care providers.

“Nurses need to learn more about the tobacco industry so that we can all further educate the public,” Malone writes.

Have you had experience in assisting patients, family or friends to quit smoking? What has been the biggest roadblock to success?

Tell us about it.

Monday, June 30, 2014

Nurse-Midwives and Physicians: The Team Approach Is a Win-Win

By E’Louise Ondash, RN

There was a time when C-sections were reserved for mostly emergency situations, but today, 1 in 3 pregnant women undergo a C-section to deliver their babies--a 60 percent rise since 1996. This, according to a report from the Congress of Obstetricians and Gynecologists.

The World Health Organization (WHO) recommends that the C-section rate for any nation not exceed 15 percent.

A cesarean section, or C-section, is often the delivery-method-of-choice for the busy woman who works outside the home, a trend that has escalated as more women enter the workforce. But experts say the health of mother and child can be in jeopardy with the unnecessary surgery.

A new San Francisco Bay Area program aims to encourage women to let nature take its course and to reduce the C-section rate in the area by half. It pairs nurse-midwives with physicians, who will always be available for backup in case of an emergency, according to a recent story in the San Jose Mercury News.

"The philosophy is to trust the body's ability to do that process, and we are the overseer," explained Lin Lee, RN, CNM, in an interview with the newspaper. Lee will direct the program, called Bay Area Maternity, with two physicians.

The program is funded by the Lucina Maternity Foundation, so named for the Roman goddess of childbirth who was believed to keep women in labor safe.  Seed money for the foundation totaling $1 million was donated by two big names in Silicon Valley--Anne Wojcicki, CEO of biotech start-up 23andMe, and Angela Buenning Filo, wife of Yahoo co-founder David Filo. Lee was midwife for both women.

The foundation also will fund a second center at Santa Clara County’s Valley Medical Center. The county is located at the southern end of the San Francisco Bay Area and includes Silicon Valley.

Creating nurse-midwife and physician teams is not new. The idea has been around for some time, and there are practices all over the country; some have up to 10 or 12 midwives and as many doctors working together.

But there are still places where professional rivalries between physicians and these advanced practice nurses exist, as well as divisions in philosophy. These differences can generate tensions and "turf wars," which end up putting patients on the losing side.

It doesn’t have to be that way, according to the American College of Nurse-Midwives, which favors teaming nurse-midwives and doctors.

"Having midwives working in collaboration with physicians, where everyone is using their appropriate skills and the appropriate time, is better for the mother and baby--and is more cost-effective," said Tina Johnson, CNM, MS, director of professional practice and health policy at ACNM, in an interview.

Pairing nurses and physicians in other areas of practice like gerontology and pediatrics can not only be cost effective but result in a higher level of care. The complexity of today’s health care demands a team approach if we are to continue to deliver quality care.

Do you work in an area that pairs nurses and physicians or implements the team care philosophy? Do you think the team approach improves the quality of care?

Tell us about it.

Sunday, June 1, 2014

Can Patients Share Too Much on Social Media?

By E’Louise Ondash, RN

I think social media is wildly out of control.

Don’t get me wrong. I’m all about free speech and the ability of anyone to say whatever they want whenever they want, short of yelling “Fire!” in a crowded theater.

But just because you CAN disseminate an opinion throughout cyberspace doesn’t mean that you SHOULD.  Editorializing via social media can be interesting and informative, but sometimes it can be just TMI (too much information)--especially when it comes to healthcare.

A recent commentary by Bill Saporito in TIME magazine highlights this new reality.

Saporito wrote about sharing the experience of being a long-time cancer patient via blogging and Twitter. He told readers about Lisa Bonchek Adams, a Connecticut mother of three who has breast cancer. In the past seven years, she has posted “more than 165,000 tweets and frequent blog posts” sharing her journey dealing with breast cancer. Her blogs are well written and include details about her care. She even provides links to videos explaining procedures like how patients drain fluid from their lungs at home.

Adams’ latest postings indicate that she has Stage IV cancer (it has metastasized to her bones) and is undergoing chemotherapy. The posts often are quite detailed and contain information that I’d be uncomfortable revealing to thousands of people I don’t know. While reading some of them, it occurred to me how ironic it is that medical professionals must always be on guard about patient privacy, while some of these very patients are sharing intimate details about their illnesses with the whole world.
Apparently there are those who are eager to hear about Adams’ life. She has garnered more than 14,000 followers on Twitter, and one of her most recent blogs prompted more than 120 comments. Here, in her words, are the reasons that she writes so extensively about living with cancer:
 “I think understanding the day to day lives of those of us living with (cancer) is a great way to truly become more aware. It’s one of the reasons I spend so much time writing here. I try to bring you the science, the experience, the thoughts of a mother trying to cope with raising a family and managing an (sic) terminal diagnosis… My posts often give my insights into how to raise children who are resilient and can cope with inevitable hardship. The blog also will be a record of my love and devotion to my children.”

Adams’ arguments for putting her life on a stage are credible and defensible (although I still couldn’t do it). Additionally, blogging and tweeting are two-way streets. Adams has received many messages of support and love, which has to be a boost and a comfort for her and her family. However, while thinking about all of this, I suddenly realized that there is another side to patients sharing so much information; some are also blogging and commenting on social media sites about their caregivers.

This could be a good thing if the patient-caregiver relationship is a good one – and most of the time it is. But what if that relationship turns negative?

Knowing that patients could, at any time, blog or tweet about their caregivers is disturbing.  Being afraid of a “negative review” is no motivation for giving good care, but knowing that patients can tell the world if they are unhappy or dissatisfied puts nurses and other medical professionals on the defensive. It’s a strange place to be.  

Have you ever worried that your patients have commented or will comment via blogging, Facebook or Twitter about you or the care they are receiving?

Tell us about it.

Tuesday, May 6, 2014

When School Nurses Are Absent, It's the Kids Who Lose

By E’Louise Ondash, RN

Most of us are well aware that it is National Nurses Week, but did you know that May 7 is National School Nurse Day? 

It seems fitting to recognize these hard-working colleagues who are continually challenged to do more with less. After all, the days when school nurses were limited to applying Band-Aids and ice packs are pretty much gone.

Today’s school nurses are expected to insert urinary catheters; attend to ventilators; suction tracheotomies; and monitor type-1 diabetics, according to a report by researchers at California State University-Sacramento's School of Nursing.

The report found that an increasing number of California students – currently estimated to be 1.4 million -- have chronic and serious health conditions. The majority of them attend public schools which, the report notes “lack efficiency and effectiveness” when it comes to student health care. 

The nurse investigators reached this conclusion by analyzing data from the 2011–2012 school year and interviewing members of the California School Nurses Association, who reported that their duties and responsibilities are increasing while resources and funding are decreasing.  
Reading about this report reminded me of the time I shadowed a nurse at a middle school for a day.

I was astounded at the breadth of her job as she darted around the campus, never stopping for lunch or the bathroom in seven hours. She cared for kids who ranged from mildly disabled to severely disabled, doing many of the tasks mentioned above.

In between attending the children, she explained that her co-worker recently had been laid off. No one seemed to understand that you can’t double a nurse’s workload and expect him or her to give the same quality of care.

“For the administrators, it’s all about numbers on paper,” I remember her saying, “I just do the best I can.”

Underfunding health care for California students means that 57 percent of public school districts in the state have no certified nurses on staff, according to the report. This means that students often receive care from unlicensed school staff who aren’t properly trained or monitored.

Should parents and guardians expect schools to provide monitoring and care for all children?  If you have school-aged children, do you feel there is adequate health care in their schools?

Tell us about it.  (And then tell a school nurse that you appreciate what he/she does on a daily basis.)

Monday, March 31, 2014

Why Did You Become a Nurse?

By E’Louise Ondash, RN

Why did you become a nurse?

I’m a little embarrassed to reveal how I landed in the profession. While some people know from the time they can walk that they want to be a nurse, my decision was quick and, well, a bit frivolous.

I was a senior in high school and didn’t have a clue as to what I wanted to do the following year. It was distressing; all of my classmates seemed to have their courses charted. Coming from a large family, I was reluctant to ask my parents to finance a college education when I was directionless.

Then my best friend announced she was going to attend nursing school. This was a complete surprise to me, as she had never mentioned it. The thought of a career in medicine had never appeared on my radar, but I began to think about it. Within a week, I had decided to give it a go – mostly because I couldn’t think of anything else to do.

Actually, I had given nursing a very quick glance just a few weeks before.
Another friend, in her last year of nursing school, came home for the weekend and I listened to her describe her life as a student. There were some hilarious stories, some serious ones and some downright scary ones. After she launched into a description of her first urinary catheterization, I couldn’t run away fast enough.

“Never!” I thought. “I will never be a nurse.”

I can’t say how I got from there to announcing that I would be taking the entrance exam for nursing school. My parents were more than surprised, but they supported me. “Besides,” they said, “it’s something that you can always fall back on.”

And so I have – many times.

By the way, my best friend left nursing school after our first year, but we remained close until her death a few years ago.

I thought about my path to and through nursing recently while reading “The Call of Nursing: Stories from the Front Lines of Health Care” by William B. Patrick. It contains the stories of 23 nurses told in the first person. Each nurse explains how he/she arrived at the profession’s door, and tells readers about his/her career, favorite  patients, most memorable moments and what each has learned through the years.

One of the stories that stood out to me was by Rebecca Sweet, a hospice nurse in Albuquerque.

She writes that she knew from the time she was 6 years old that she wanted to be a nurse, but didn’t realize this goal until she was almost 60. She started a two-year RN program in her 20s, but dropped out. Sweet earned a master’s degree in English, a second bachelor’s in geography, and taught at a university. Then life came apart; her marriage failed, she drank too much and she fell into depression.

Sweet believes that, at this point, God called her to return to nursing. 

She had a plan and stuck to it. Sweet first earned her CNA certificate, worked as a hospice aide, which she loved, then graduated from an LPN program. She worked in a jail, a retirement home and several other places before passing the NCLEX for her RN the day before her 60th birthday.

“That was probably the happiest day of my life,” she writes. Today, she coordinates care for hospice patients.

“When you are with people as they are dying,” Sweet writes, “you develop an honest connection with them that I think is pretty rare in our society… Our society focuses more on wealth, on talent, and on ownership of material possessions than on relationships. But hospice offers opportunity for deeper meaning.”

She adds, “That’s what nursing is all about.”

Why did you become a nurse? Do you think this was the right reason or have you changed your mind?

Tell us about it.