LPN-to-RN -- Does It Take More Than Years of Experience?

According to a story I read recently, there are disgruntled LPNs (also called LVNs in some states) out there who are not happy about the politics of their job. Some feel that they don’t get the respect they deserve and that they are capable of doing more than their scope of practice allows them to do.

Many LPNs are encouraged by their superiors to become RNs but the added expense and time is not something most can afford. One Connecticut nurse has a solution: test out.

Lisa Morell, LPN, thinks that given the chance, she could do the job of an RN. She has developed an online petition to present to her state legislators that would allow any LPN with at least 10 years experience to take the RN exam.

"Even if I don't get anywhere with this, if I can at least make some noise by just speaking my mind as a taxpayer and as a nurse who feels underutilized, I'll be satisfied," said Morell, a 30-year-veteran nurse.

There are plenty who disagree with Morell, including Patricia Bouffard, RN, chairperson of the state nursing board.

"The regulations are clear that an LPN program prepares you to be an LPN and the RN programs prepare you to be an RN," she said. "According to the regulations, the two don't mingle at all. While some skills may overlap from LPN to RN, the education preparation is different.”
Regina Thomson, LPN, president of the Connecticut LPN Association, said Morell’s proposal is like saying that an experienced nurse can be a physician, and thinks the chances of Morell’s proposal passing are “slim to none.”

I can see how the idea of challenging the RN boards would be very attractive to many experienced LPNs. If I recall, back in the late 1960s and early 1970s, many returning men who served as medics in the Vietnam War challenged the LPN exam without further education and earned their licenses that way. They must have put in some book time before taking the boards, though, because their knowledge and skills, while advanced in some areas, did not match to those of an LPN.

I’d say the same about the RN boards. An LPN may be experienced in one area or specialty, but the RN boards test knowledge in many areas. I doubt an LPN’s information bank would contain enough to pass the entire board exam.

This is not to say that LPNs aren’t skilled at what they do and how they do it, and this is not to say that they aren’t needed and valued. Perhaps, though, in-charge RNs don’t recognize LPNs and their contributions enough.

Should experienced LPNs be able to challenge the RN boards?

What do you think?

Nurse's Protest in Pregnancy Pact Case: Is It Sending the Right Message?

People sometimes ask where I get my ideas for this blog and if I have enough things to write about. My answer is that I rarely have to look too far or too long.

I find lots of fodder from conversations with friends, nursing publications, press releases, the Internet, television and newspapers. This morning I came across this New York Times Service story, though lots of variations of it have appeared in numerous publications. It says that at least 17 girls at the public high school in Gloucester, Mass., are pregnant and more than half of them got that way after making a pact to get pregnant and raise their children together.

All of the girls are under 16 and this number of pregnancies is about four times the school’s usual rate (the student body numbers 1,200).

The story notes that Gloucester is a fishing town weathering tough economic times. There have been cuts in school funding for services like after-school programs and some say this has had an adverse social impact. The school district’s superintendent is quoted as saying that economic hardship has devastated families and “many of our young people are growing up directionless.”

The spike in pregnancies has given rise to debates about contraception, a touchy and heated subject in a town that is “heavily Catholic.” In the uproar, the school clinic’s medical director and nurse practitioner have resigned. They disagree with the funding agency’s opposition to making contraception available to students. To add insult to injury, the budget for the health curriculum has been cut, which means there is no sex education available to students. (A committee is now mulling over providing a pregnancy education program and distributing contraceptives.)

I’m not sure the school’s nurse should have resigned. I agree with her stand–that good sex education and contraceptives should be available to students–but she may be the last person standing that can actually help these kids in any way.

One other point of discussion:

It doesn’t sound like having contraceptives available would have helped the girls who made the pact to become pregnant. Apparently they weren’t interested in preventing their pregnancies, but quite the opposite. So what is happening in their world that makes them think that having children will cure all their problems? Where are their dreams for better lives? For higher education? For seeing the world? Would a conversation with a caring school nurse have made any difference?

What do you think? As a health care provider in this situation, what would you have done?

Undercover Patients: Ethical or not?

You could call them secret shoppers in sheets.

They are fake or “undercover” patients, and they are sent to the hospital or medical office where you work to see if you measure up when it comes to competence, caring and customer service.

Some people think the idea is a great one while others don’t.

One of the former is James Loden, M.D., a Nashville, Tennessee, ophthalmologist who commented on the topic in the May edition of Virtual Mentor, the AMA's online ethics journal.

"Employees, including doctors, are paid to do specific tasks,” he wrote. “If they choose to perform at a level that is less than acceptable, they need to improve or find other jobs."

Loden began working with a firm that supplies “sham patients” about two years ago and found that he didn’t provide time for patients to ask questions, and that his staff often failed to introduce themselves or explain the purpose of tests.

"We don't always like what we hear, but it makes us get better and better," said Loden’s chief operating office, Andy Patrick, in a recent Associated Press story.

The payoff for the vision center was a higher referral rate to Loden’s office by his patients.

Others think that using undercover patients may be unethical and could even cause harm to real patients—for instance, in a crowded ER where a real patient must wait while staff cares for the fake patient.

“How could the hospital administration defend this exercise to someone who suffers an adverse outcome while waiting his turn behind the person who is only pretending to be sick?" countered Richard Frederick, M.D., of the University of Illinois College of Medicine in Peoria, on the same online ethics journal.

One thing everyone seems to agree upon, though, is that patients judge their care on more than just the time spent with their doctors. They consider how the nurses, receptionists and other office and hospital staff treat them—all of whom are evaluated when an undercover patient is employed.

The topic will be debated at the American Medical Association’s ethics committee, which meets through June 18 in Washington. D.C.

What do you think about the use of undercover patients?

Is it ethical and is it an effective way of evaluating patient-customer service?

Tell us what you think.

The Media's Image of Nurses

There isn’t much on television these days that I watch, but “Grey’s Anatomy” is my guilty pleasure.

True, the series is over-the-top when it comes to portraying the lives and loves of surgical residents in a Seattle hospital. Writers have even placed this fictitious hospital across the street from the popular Pike’s Market on the waterfront. If you’ve been to Seattle, though, you know that’s about as impossible as some of the story lines.

Nevertheless, I’ve gotten so wrapped up in the minutiae of this medical soap opera that it wasn’t until I read a recent article by freelance writer Jana Hanbury that I realized that the series’ writers have committed a sin. “Grey’s” is guilty of portraying nurses as “handmaidens to the physicians” and “not that bright.”

Perhaps I missed that point because nurses in the series are mostly insignificant characters—and maybe that’s a problem, too.

In her article, Hanbury also recounts the varied images of nurses created by the media throughout the years.

We’ve all seen a comic portrayal of the nurse as rough, tough, gruff and ugly. I usually laugh along with everyone, but it’s odd that there also exists the diametrically opposed sexy image as projected by “Hot Lips” Houlihan in the movie and television series “M*A*S*H.”

And who can forget the devil-incarnate Nurse Ratchet in “One Flew Over the Cuckoo’s Nest”?

We can be thankful for a few movies in which nurses are deemed heroic and hard-working like 2007 Academy Award-nominated film “Atonement” and the 2001 film “Pearl Harbor.”

Hanbury maintains that “the media is a powerful instrument that has an enormous impact on perceptions of life as portrayed on television, movies and the Internet.”

I’m not as sure about that.

I don’t deny the media’s influence, but when it comes to real life, I think most people respect the person who says he or she is a nurse. I believe most of the public can discern the difference between make-believe and the real thing.

What do you think?

Do the media incorrectly portray registered nurses on the big and small screens?

Have you had an experience in which someone clearly has misconstrued the nature of your profession?

Did you read any of the “Cherry Ames” book series about the job-hopping, sleuth/nurse that were so popular between 1940s and the 1970s? If so, did they influence your choice of profession?

What are your favorite or least favorite fictional nurses?

Unions for Nurses: Good or Bad Idea?

There’s a political battle going on in my mailbox and it has nothing to do with John McCain and Barack Obama.

For the past several months, I’ve been bombarded with fliers and pamphlets from the California Nurses Association/National Nurses Organizing Committee (CNA/NNOC) and the Service Employees International Union (SEIU Healthcare). I’m not well versed on this topic, but it appears that the two organizations are dueling it out for members. Their targets are nurses who work in hospitals.

NNOC literature says it is an arm of the CNA that was founded in 2004 to protect nurse-to-patient ratio regulations, pensions and standards after these benefits were challenged by various hospital chains. NNOC has sponsored ratio legislation in Arizona, Illinois, Texas and Maine, and claims 80,000 members in 50 states. It has unions in California, Illinois, Pennsylvania, Maine and Nevada.

SEIU claims its membership consists of 1.9 million “workers” (which include medical and non-medical employees) and 50,000 retirees who are “united to improve services and our communities throughout North America.” Within this large organization is a sub-group of health care workers which claims 900,000 members. They include registered nurses, LPNs and LVNs, doctors, lab technicians, nursing home workers and home care workers.

According to what I read in the fliers, NNOC and SEIU are going head-to-head in some hospitals.

The CNA/NNOC says that, as a nurses-only organization, it can represent the profession much better than a union whose membership is so diversified. Other accusations against SEIU include eroding the strength of nurses at the bargaining table, siding with management, endorsing hospital closures—well, it goes on and on.

The SEIU counters that because it has the numbers, it can better negotiate for hospital workers’ demands. The union accuses the CNA/NNOC of trying to push out all other unions, thus limiting the choices for nurses. SEIU also says the CNA is spending the money it collects from its California members outside of the state. The union’s campaign slogan is “Shame on the CNA.”

And so it goes.

What do you think about unions for nurses?

Are they necessary?

Should everyone have to join?

What’s the situation at your hospital?

Tell us what you think.

Health Coverage Without Profits -- Is It the Answer?

Well, they finally came out and just admitted it; they’re in it for the money and don’t give a damn about subscribers.

I’m talking about the health insurance companies.

Not that we didn’t already know that insurance companies are more concerned about the bottom line than the people who pay the premiums, but I guess I was shocked to see a CEO actually say it out loud.

“We will not sacrifice profitability for membership,” said Angela Braly, WellPoint president and CEO, who was quoted in the May 19 edition of the American Medical News. (WellPoint is the largest private-pay plan in the country.)

Braly, who took the helm in early 2007, most likely will never have to worry about health insurance. Whether she does well by the company or not, she’s still in the money. Her salary alone is $1.1 million, and she’s eligible for generous bonuses. (Her predecessor earned $5.2 million plus $3.1 million in stock awards.)

Braly’s job is to care about nothing other than making money for stockholders—which, of course, means the company will raise premiums, refuse to pay for certain procedures and drop people from the plan.

I have no crystal ball, but these maneuvers have been faithfully and regularly executed by insurance companies for years. The reason for little mystery about WellPoint’s future actions can be found in its 2008 first-quarter report. The company’s net income was $588 million compared to $783 million for the first quarter of 2007.

All of this begs a very basic question: Should health insurance/health care be a for-profit industry?

As long as both are businesses, our premiums will continue to climb, covered services will decrease and more people will be dropped from the rolls.

I know health care is expensive and everyone can’t have everything and shouldn’t have everything. I know that nurses, doctors, dentists and all allied health care professionals must be paid, as well as hospitals, nursing homes, clinics, etc. I’m not implying that these people and institutions should operate like charitable organizations. But I think we can provide a pretty decent level of health care and pay providers what they deserve for a lot less than we’re spending now if we don’t have to worry about paying profits and dividends.

And here’s a final thought: You may not realize it, but you pay for health insurance many times over every year. You pay for it every time you:

• buy homeowners insurance
• buy car insurance
• pay the fees to let your kids play soccer or baseball or join gymnastics
• pay your liability insurance premiums for your business
• pay for workman’s comp
• pay your taxes that cover liability for government-owned facilities like playgrounds, pools, roads and buildings
• buy products made by a company that provides health insurance for its employees
• buy tickets for a movie, airplane, train …

Well, I could go on and on.

If we had some sort of universal, no-fault health insurance, we wouldn’t need to duplicate coverage again and again.

What do you think?

C is for Compliance -- and Can't

I was chatting with a friend, Donna, who is a nurse practitioner in charge of a diabetes clinic and teaching program. She probably knows more than most of the primary care providers in the office because they send her their most difficult patients.

“Difficult” means the patients are newly diagnosed, their disease is out of control and/or they are non-compliant.

And if they are of the non-compliant variety, they must suffer Donna’s wrath. She is a brutally honest, in-your-face East Coast Italian (with a heavy Boston accent) who lays it on the line with these patients.

“I say that if they aren’t going to do what I tell them, they might as well not bother showing up again,” she said.

Well, the truth is, they do come again, even when they aren’t doing all the things diabetics should do, and Donna tells them the same thing again and again. She’s also frustrated because her diabetic patients don’t attend the free classes held on a regular basis—although she knows some of the reasons. Many patients are low-income and don’t have the time because they must work, don’t have transportation or can’t find someone to watch the kids. And they tell her they can’t afford the food they should be eating and sometimes, the medications.

So compliance is a huge problem for Donna and for lots of nurses who see patients that just don’t do what they are told.

If that sounds like your situation, don’t feel bad. You're not alone.

A recent review of many studies over the years (published in The Cochrane Library) concluded that patients often don’t take their medications and that past research has produced no proven way to get them to do it—especially for long periods.

The review authors found that almost all of the more successful long-term strategies were complex combinations of “… more convenient care, information, reminders, self-monitoring, reinforcement, counseling, family therapy, psychological therapy, crisis intervention, manual telephone follow-up and supportive care.”

I certainly can’t think of any other ways to encourage compliance, can you?.

What problems have you had with patient compliance?

Do you have any tricks or methods that work?

What are some of the obstacles you've had to overcome to get patients to do what they are supposed to do?