Retail Clinics: Do They Help or Hinder Health Care Delivery?

We used to call it “doc-in-the-box”—a free-standing clinic where you could get seen without appointments and for less than it would cost to go to an emergency room.

These clinics more recently are known as urgent care centers and they’ve continued to evolve. The latest nomenclature is “retail clinics.” They’re popping up in grocery stores, pharmacies and Wal-Marts in urban and suburban settings, and they are staffed almost exclusively by nurse practitioners.

There are many pros and cons to these retail clinics, which are discussed in a new report by the California Health Care Foundation. It is co-authored by Mary Takach, RN, MPH, a policy specialist at the National Academy of State Health Policy.

According to the report, these clinics are proliferating. Currently, there are more than 1,000 in 37 states, and the nurse practitioners mostly see people with sore throats, earaches, rashes, upper respiratory infections, urinary tract infections and other minor health problems.

Employing nurse practitioners who see patients outside a hospital setting means that the cost of these visits is lower than if patients received care from a physician in an emergency room. That’s a plus for everyone, but especially for underinsured patients who have high deductibles.

On the other hand, these clinics are sometimes still too expensive for underserved, uninsured consumers. Some also fear that continuity of care becomes a problem when patients forego visits to their regular doctors for an appointment with a nurse at a retail clinic.

According to the report, every state has different rules and regulations for retail clinics and each state differs in the policies that regulate physician oversight for the nurse practitioners. Only Massachusetts treats the retail clinic as a new and separate entity with its own set of regulations tailored for this type of health care delivery.

The study concludes that there appears to be little continuity from state to state on how these clinics operate.

What do you think are the pluses and minuses of retail clinics?

Do they help bring down the cost of health care or just complicate and fragment health care?

Tell us what you think.

Nurses -1; California Department of Education - 0

The idea of a non-nurse, non-medical, non-parent person giving insulin to a young diabetic strikes horror in the heart of most nurses, but until the end of 2008, “health technicians” in various California school districts were allowed to do so.

These non-nurse school personnel were given the mandate/permission to do this because of a measure enacted by the California Department of Education in 2007. But now a state court has said otherwise and ended the practice. The judge ruled that the board of education cannot supersede California’s Nursing Practice Act.

Not everyone is happy about the nurse-only policy because it limits the number and type of people who can administer insulin to school children.

One of those is Oak Park Unified School district, northwest of Los Angeles. Like many districts, its nurses are spread pretty thinly. Oak Park has only two nurses to care for about 3,700 students, according to the assistant superintendent of educational services. (The nurses are contracted, not school district employees.) The district previously had trained “technicians” who were allowed to give insulin, and now some parents and the district are concerned about a situation in which a nurse is not available.

“Many of our parents are opposed to this (court ruling),” Cliff Moore, assistant superintendent of educational services, told the Ventura County Star. “They feel it limits services. If a credentialed school nurse or registered nurse was not available for immediate access, it can cause some problems. The court mandate really ties everyone’s hands.”

Of course, nurses know that administering insulin is more than just giving a shot. There is a lot of information and knowledge that backs up that procedure.

“It’s about assessing the whole situation and what’s going on with the child,” Sheila Raives, a school nurse in Ventura for 12 years, told the newspaper. For now, if there’s an emergency situation, school staff is instructed to call 911.

That suits some of the non-medical staff just fine. They are happy the responsibility of caring for diabetic kids is no longer theirs.

Do you think non-medical school employees are capable of being trained to care for diabetic children?

Or should the responsibility be restricted to nurses?

Tell us what you think.

Taking Care of Yourself in a Tough Economy

I mused a few weeks ago about how this national economic downturn might be affecting nurses.

Past recessions have had few repercussions for nurses. There always seems to be a shortage—except during those years when managed care made its entry and many experienced hospital nurses were laid off to cut costs. And the experts say there is still a shortage, and that it will increase as boomers age, older nurses retire and older populations need more care.

So, in the past, nurses have had to worry little about finding work or keeping it, but this recession seems to be different.

From what I hear, it’s making inroads into the job/financial security of nurses in various ways. Certainly it’s not because there is a shortage of patients; there are plenty of those but fewer who can pay. Their health coverage has disappeared with their jobs. COBRA may be nice in theory, but who can afford the premiums without that contribution from the employer?

The number of elective surgeries is down because—again—the loss of health care insurance. And in some states, Medicaid payments are getting smaller. Here in California, hospitals are looking at huge state-mandated costs for retrofitting for earthquake safety, so some nursing jobs may be sacrificed.

This all adds up to problems for nurses and job security.

Some are losing their jobs as units shrink or close; others have had their hours cut. For some, a partner or spouse has lost his/her job, so the family is reduced to one income instead of two. If there are no nurse-to-patient ratios, hospitals stretch their staffs to the limit and beyond, so that those who are left work even harder and longer and feel the stress.

I spoke to a few nurses who have been affected one way or another, and I was surprised to hear about their coping mechanisms, which seem so sensible.

After being laid off, one nurses said she and her friends look to other friends, co-workers and family for support—a good choice, since nurses are known to be martyrs and are reluctant to ask for help.

Another nurse told me that she is educating herself on what’s happening in Congress with the stimulus package and other legislation that is supposed to improve the economy. Her research goes a long way in relieving anxiety about what the future holds, she said.

Another nurse who likes to shop has put the brakes on that, as well as cutting back on other pleasures. Her frugality goes a long way to maintaining her sanity when it’s time to pay bills.

The one thing that these nurses have in common is their proactive stance. Instead of letting the chips fall where they may, they are making the first move and controlling the nature of their lives and personal finances.

What is your situation?

Have you been affected by this economy?

If so, what are you doing about it—and what coping mechanisms have worked best for you?

Tell us about it.

What Nurses Want

It ain’t rocket science—figuring out what makes nurses happy.

There have been surveys ad infinitum and some studies, but many employers still don’t seem to get it. (All they have to do is ask.) I still hear how unhappy many nurses are with their employment situations. Their gripes include lousy scheduling, no input on decisions, inadequate staffing, mandatory overtime and too much paperwork, among other things.

I rarely hear complaints about pay, except by nursing instructors and educators.

There are some nurses who praise their employers and seem ecstatic with their job situations. They are the ones who work at Planetree hospitals. The Planetree philosophy is that care is patient-centered and holistic, and in implementing the measures that meet this creed, the nurses get a good deal, too.

Administrations at these hospitals ask their nurses what they need to make work easier and more effective. They provide perks like free and/or inexpensive massages. Planetree nurses also attend occasional on- and off-campus conferences where they brainstorm and meet other employees. Some Planetree hospitals even have volunteers regularly baking cookies for patients, their families and staff.

You know there’s something good about the Planetree philosophy because staff turnover in many of these hospitals runs at 2 percent to 3 percent.

A recent study done by nurse-researchers at the Orvis School of Nursing at the University of Nevada, Reno, found that nurses leave the bedside because of stress and burnout caused by the physical demands, inadequate staffing and inconvenient scheduling.

Many former bedside nurses have found work in both health-related and non-health related areas. According to a story that appeared on www.nursezone.com, the study found that nurses who work outside of nursing cited these reasons: needed a change of career (65.8 percent); experienced burnout/stressful work environment (41.3 percent); had scheduling challenges or were working too many hours (38.7 percent); there is better pay in non-nursing employment (31.4 percent); there was inadequate staffing (30.8 percent); and the physical demands were high (25.8 percent).

In a perfect work world, what do you need or want at your workplace?

Do you feel your employer is responsive to your needs?

Would you recommend your place of work to a job-seeker?

What ideas do you have for making the workplace better?

Don't Blame Us

We have a three-ring circus going on at the hospital about three miles from my house and the nurses there want people to know that it’s not their fault and it won’t affect patient care.

In a story that appeared this past week in the local newspaper, two nurses and 300 compatriots signed a "love letter to the community." It assured residents that the nurses are separate from all the craziness, controversies and clouds that hang over the hospital’s board.

"We love this hospital dearly and we believe in the care we give," G.G. Salvatierra, RN, told a reporter. "We feel like the behavior of the board has humiliated the people who show up every day to give their very best. We want the community to know they don't represent us. We're still here doing our jobs.”

Salvatierra could be referring to the hospital’s CEO and eight administrators who were dismissed (with pay) several weeks ago by a new board, which then installed their people as interim administrators. There are unanswered questions about the legality of this grand sweep, although many hospital employees are glad to see the old guard gone. One reason: the previous board kept approving increased salaries, perks and bonuses for the CEO. Many said he didn’t earn them and doesn’t deserve them…but that’s another story.

The new board is seen as pro-union. The CEO-on-leave, of course, is not. The union was voted in months ago but has yet to become a visible force.

There’s more to this soap opera.

In the past, the board has been laughably dysfunctional. One female member physically assaulted other members and was forbidden to enter the hospital without an escort. A guard was assigned to stand watch during board meetings to help guarantee some order and safety.

The CEO has led two failed campaigns to get the public’s permission to issue bonds that would finance expensive (state-mandated) earthquake retrofitting. The voters axed the measures because the cost would be borne by only some of the residents who use the hospital.

Two recent blows: The state has denied an extension for earthquake retrofitting, and a recent report on death rates at California hospitals shows this on had higher-than-average death rates for acute stroke, gastrointestinal hemorrhage and craniotomies.

Those of us who live in the hospital district have grown accustomed to seeing startling headlines about the hospital once or twice a week. The ongoing saga has become a bit of a joke and we’re always waiting for the next fiasco. I can’t blame the nurses for wanting to distance themselves from the circus—for declaring that those who have the misfortune to enter the tent at least don’t have to worry that the nurses will take good care of them.

Do you think the nurses were right in distancing themselves from the business of running the hospital?

Do you think the public can discern between the work of nurses and the craziness and politics that can go on with hospital boards and administration?

Tell us what you think.