H1N1: Creating Dilemma On All Sides

The swine flu and vaccine are presenting some problems for nurses.

In New York state, nurses are threatened with job termination if they don’t get vaccinated against H1N1. The state health department is telling all people who work directly with patients and those with whom they come in contact that they must be vaccinated for both the seasonal flu and the H1N1 virus.

At least one nurse doesn’t like being told that the vaccine is mandatory.

“It's just that we're being forced to take this against our will, without proof that the vaccine will even be effective," Sara L. Rombough, RN, told the Watertown Daily Times. Rombough is a 25-year veteran nurse who works at Massena Memorial Hospital in Massena, N.Y. She says she’ll lose her job in November if she refuses to get vaccinated.

The New York State Nurses Association is taking her side. A spokesman said the association encourages nurses to get the vaccine, but doesn’t think it should be mandatory.

According to the Watertown Daily Times, smaller rural hospitals in New York state may not be able to fire nurses who don’t want the vaccine because dismissing them will cause staff shortages.

The state health department defends its stand on mandatory immunization, saying it wants “herd immunity,” and to achieve that, 95 percent of populations need to be vaccinated. Officials also say that hospital patients need to be protected.

Out West, 16,000 union nurses in 39 hospitals in California and Nevada plan to strike because they say that their employers are not providing enough protections against the swine flu.

The union contends that hospitals should supply disposable N95 respirators to nurses who care for people with swine flu, but there is debate about whether this should happen. One view is that because N95 respirators must be custom-fitted, they are impractical. The Society for Healthcare Epidemiology of America says the masks are not necessary.

The other opinion, fostered by the Centers for Disease Control and Prevention, is that giving N95s to health care workers should be a priority.

A spokeswoman for the California Association of Hospitals said most hospitals would be glad to give N95s to their staff, but the masks are in short supply and many hospitals can’t get them.

In August, a California nurse died of H1N1 because of a severe respiratory infection, according to the California Department of Health Services. The department also reports that more than 3,000 people have been hospitalized in the state because of swine flu; 200 have died.

Should nurses and other health care workers who care for patients with H1N1 be forced to receive the vaccine?

Are nurses who refuse to take the vaccine doing the right thing?

Should hospitals do whatever it takes to protect their medical staff, regardless of cost?

Tell us what you think.

Cancer Screenings: What Should Nurses Say?

I know that, because I’m a nurse, I’m going to be asked by more than one person what I think of the American Cancer Society’s new stand on the benefits and problems of screening for some cancers.

According to a story by the New York Times, the society is “quietly” preparing a statement that will say that the benefits of screening for prostate and breast cancers may have been overrated. I suppose the “quietly” part is an effort not to cause a major public uproar or freak-out. After all, we Americans have had it drilled into our heads the importance of screening for breast and prostate cancers and catching these diseases early. We consider screening a right.

However, the statistics on cancer outcomes make the experts not-so-sure anymore about the wisdom of screening.

According to an analysis recently published in The Journal of the American Medical Association, there has there been a 40 percent increase in the diagnosis of breast cancer, but only a 10 percent decrease in the breast cancers that metastasize. A large increase in early cancers should be balanced by an equal decrease in late-stage cancers, which is what has occurred with screening for colon and cervical cancers.

“The issue here is, as we look at cancer medicine over the last 35 or 40 years, we have always worked to treat cancer or to find cancer early,” Dr. Otis Brawley, chief medical officer of the cancer society, told the Times. “We never sat back and actually thought, ‘Are we treating the cancers that need to be treated?’ ”

The hard and scary reality is that medical science still doesn’t know which types of cancer have the ability to invade aggressively and which types could or should be left alone. Treating slow-growing cancers can cause more harm than good, but when we hear the word “cancer,” we want to shout, “Take it out!”

We know that many men who have been diagnosed with prostate cancer choose the “watchful waiting” option, and rightly so. They often die of some other cause before the prostate cancer becomes a problem. In addition, the PSA test is far from the exact science we once thought it to be.

When it comes to breast cancer, though, I’ve never heard of a “watch and wait” option. Imagine the outrage at any physician who advised a woman to “watch the lump” for awhile. It’s fair to say that many women consider getting yearly mammograms as routine and important as preventive visits to the dentist or taking a daily vitamin.

I often have to remind myself and others that there is still a lot we don’t know about the body, cancer and treating disease. There are so many stories every week about new discoveries, research and promising drugs and other treatments that it’s easy to get caught up in the hype and jump to conclusions. But as nurses, we need to remind patients and anyone who asks that there are no magic bullets or one-size-fits all when it comes to conquering disease.

What will I say when asked about continuing with screenings for prostate cancer and breast cancer?

I’ll encourage women to continue to get those mammograms, and for men, the digital exams and PSA (with the caveat that the numbers can be deceiving) until somebody really proves that the harm done really outweighs the good.

What do you think?

Multi-State Licensure Compact - Is It Time?

When I graduated from nursing school oh-so-many years ago, there was no National Council Licensing Exam.

Every state devised its own nursing boards, and states differed on what were passing grades. I sat for my boards in Missouri – a multiple choice test for which we used a pencil to fill in those little bubbles. The exam was a five-parter, taken over two days, and students had to travel to the state capital, Jefferson City, to take the exam.

We drove from St. Louis – four and five senior nursing students per car – and quadrupled-up in motel rooms to save money. We got little sleep the night before the first test. We had studied for weeks for the boards, but still stayed up way too late, quizzing each other for Part I, II and III. The rest of the process is a bit of a blur, but I remember returning home and dreading the three-to-four-month wait for the results.

Finally, the letter from Missouri’s board of nursing arrived; I had passed all parts. Most of my classmates were as successful, but a few had to re-test on one or two parts, and they had to wait another few months before returning to Jeff City. In the meantime, they couldn’t collect that boost in pay that we “full-fledged” nurses received as soon as we recorded our notice of passing with our employers.

A year later, I was off to California, which recognized Missouri licenses, but only if the nurse’s passing scores met a certain minimum, which was higher than Missouri’s minimum scores.

Fortunately, I qualified. I gratefully paid what was a hefty fee for those days because it saved me from taking the California boards.

Then along came the NCLEX, which was a really good idea. Physicians take national exams; why not nurses? I’m all for simplifying, and shouldn’t nurses be held to a uniform standard of skills throughout the United States?

I think the obvious next step should be license reciprocation among all of the states – or multi-state licensure – but politics, power and money are the big stumbling blocks.

In some cases, the problem lies with the state boards of nursing, and sometimes it’s the state nursing associations that are holding out joining the Nursing Licensure Compact (NLC). These organizations don’t want to relinquish control and/or the income that license applications generate. And some state nursing organizations feel that multistate licensure will make it much easier to replace striking nurses.

So far, 23 states (and one pending) have joined the NLC.

For those nurses who obtain their original licenses in compact states and who want to work in another compact state, life is easy; no applications and no waiting to practice. This can be pretty important when nurses are needed at a disaster site, and certainly removes the dilemma for telehealth nurses who work in one state and advise patients who live in another.

But for nurses who take their boards in non-compact states, there is waiting and expense. And for telehealth nurses, there is confusion about the law. It’s bound to get even murkier as technology makes patient care from a distance a more common occurrence.

One expert I spoke with had what I think is an excellent model of practice: the driver’s license.

Drivers with valid licenses can operate a vehicle in any other state without charge, but they are expected to observe the laws of each state. When drivers establish residency in another states, they must apply for a new license.

We are a mobile society and our technology takes us to places electronically that we never envisioned going. How do you feel about multi-state licensure? Is now the time for nurses to get in the driver’s seat and push for multi-state licensure? Please, share your thoughts.

Survey Shows the Changing Face of Nursing

California is often called a bellwether state because trends are likely to begin here and that’s important because it has more than 10 percent of the country’s population. So it was with great interest that I read the results of the recently published California Board of Registered Nursing 2008 Survey of Registered Nurses.

There’s a lot of interesting information in this 218-page report, which contains lot of easy-to-understand tables and graphs. (I confess; I didn’t read the entire thing, but if you’re interested, visit http://www.rn.ca.gov/pdfs/forms/survey2008.pdf.

This is the sixth time the survey has been conducted – the previous one was conducted just two years ago – and about 56 percent of California’s nurses responded to the survey. That’s a huge response rate in a pollster’s world.

Like the 2004 & 2006 surveys, the 2008 survey targeted two populations:
• RNs with active California licenses living in and outside California.
• RNs with inactive status since 2006.

The survey found that there have been some major changes within the California nursing community since that first survey in 1990.

• In the last 18 years, the average age of working RNs rose from 42.9 to 47.1 years.
• More than 14 percent of nurses are men.
• In 1990, more than three-fourths of nurses were white; now that number is about 58 percent. Filipinos represent 18 percent of the RN workforce and Hispanics 7.5 percent . About 4 percent are Black/African American. The remaining 12 percent are non-Filipino/Indian Asian, Pacific Islander, American Indian and mixed ethnicity.
• In 1990, about a third of all nurses received their initial education in a diploma program; that has dropped to about 14 percent.
• Nurses new to the job with baccalaureate or master’s degrees rose from about 29 percent in 1990 to 39 percent in 2008.
• Nurses today average 27 years old at graduation and 12 percent have earned a master’s or doctoral degree.

What about the money?

It’s better. Incomes for nurses in California have risen dramatically in the last 18 years. In 1990, the average annual income was $31,504. By 2008, it was $81,428. A fifth of respondents reported earnings of more than $100,000.

Most working nurses get benefits, too. Nearly 85 percent of nurses received retirement benefits and health insurance, and nearly 9 out of 10 received dental insurance.

Why do nurses do what they do?

The survey found that it’s because they like the interactions with patients, feel that their work is meaningful and that they have job security. Most also are happy with their work schedule.

What gets under nurses’ skin?

Definitely the paperwork and other non-nursing tasks. Many also are not happy with administration and management decisions – complaints that have not changed much since the 2006 survey.

Technology: Can't Live With It; Can't Live Without It

Nurses must embrace technology every day. If they don’t embrace it, they at least must deal with it, so it bodes well to stay on its good side. Pretend technology is your friend.

Until the late 1960s, hospital technology was pretty basic. I remember how excited I was in 1968 to learn how to read EKGs, and I worked in one of the first telemetry units in the country. What a great idea, I thought, but as it turned out, we nurses in this new step-down unit spent most of our time dealing with problems that ate up untold hours.

Things have vastly improved since then, but every time one thing is perfected, something else appears on the scene that demands de-bugging and a large learning curve.

I was dragged kicking and screaming into the computer age, and now, of course, I can hardly live without one. Heck – I’ve got a computer on my phone now, but some days I think my brain is going to explode. Technology seems to be getting away from me regardless of how fast I peddle.

How did we get here?

At the risk of sounding like one of those irksome “remember-the-days” emails, I,m going to ask the question anyway: Remember the days when all we had to know was how to use the telephone (it was attached to the wall), a typewriter and an electric can opener?

Remember the days before you had to take a course on how to use a microwave and program a clock?

Remember the days when it took only one knob to turn on the TV?

OK, I admit; I’m not sorry that someone invented the remote, nor do I regret having email. I’m excited about the prospect of online, Internet-based medical records, and most nurses would never give up their PDAs.

But it’s scary to think about how much we depend on technology.

For instance, I recently took my computer into one of those big-box tech stores for diagnosis and treatment last week. Nine days later, I was told that no one had even looked at it. I drove to the store, pulled my tower out of the clinic and went to the Internet (on my backup laptop) to find a compassionate geek who makes house calls.

I found Gregory. He arrived at the door with a Bluetooth on his ear, talking to his father.

“I’m helping him set up his Blackberry,” he whispered as he entered the house.

Eureka! I had purchased a Blackberry the week before and needed help with that, too.

While I watched and tried to learn something, Gregory discovered my computer had contracted 46 viruses. With his right hand on the keyboard, he fixed the problem. With his left hand, he set up email and Internet access on my Blackberry – all while instructing his father on how to do the same.

Glory be. Could I bottle this guy’s DNA and sell it?

When it comes to fixing tech problems, I do what I can, then search for someone like Gregory. Every nurse could use a miracle worker like him close at hand – or at least a phone call away.

Now if I can just quit trying to turn on the television with our portable phone…

Death Panels...Nonsense!

I don’t like talking about death, especially my own, but when all the rumors about government death panels were flying, I was hoping that the National Hospice and Palliative Care Association would use the opportunity to discuss the wisdom of life/death planning. Perhaps they did and I missed it; if not, what I wanted to see was hospice nurses speaking loudly and clearly to dispel the ridiculous notion that, under the evolving health care plan, the government will decide who should live and who should die.

During the furor, I was surprised to see how many intelligent people are under the misconception about end-of-life care.

They think there is no middle ground between bringing out all the big guns of extraordinary care and doing nothing when dealing with life-threatening illnesses. I found myself explaining the philosophy of palliative care, which can include a lot of care, and that patients can change their minds as time progresses.

The other concept is the importance of telling your physician and family which medical measures you want and don’t want and when. Too many people seem to have the notion that if a patient decides to forego extreme measures, they’ll get no care at all – that they’ll be abandoned by their medical providers.

I also learned that people are outraged at what they perceive to be a new incentive for “expediting death” – a provision that provides for reimbursement to physicians for discussing end-of-life care with their patients. Nurses and doctors to whom I’ve spoken don’t understand why this is even in the legislation except perhaps to create a new billing code. Physicians and hospice nurses already have these discussions during office and hospital visits.

The booklet on end-of-life decisions created and published by the Veterans Administration was soundly criticized, too. I’ve seen it and I think it provides veterans and anyone else who might want to use it with a systematic, sensible and sensitive way of considering all the possibilities around end-of-life care.

Maybe the big picture here is that, as our country grows more diverse, nurses must be aware of all the cultural differences that exist when it comes to facing our mortality, including the belief that life should be sustained at any cost.

Disclaimer: The opinions expressed here are the views of the writer and do not necessarily reflect the views and opinions of AMN Healthcare or its employees.