nursing

What Is-Or Should Be- the Future of Nursing?

nancyvalko conscience rights, end-of-life, medical ethics, nursing

In a recent Medscape News article “Back to the Future of Nursing: What Progress Have We Made?” , Laura A. Stokowski, RN, MS reported on the results five years after the national Institutes of Medicine (IOM) issued a 2010 report titled “The Future of Nursing: Leading Change, Advancing Health” that was designed to be:

“a wake-up call that exposed the many barriers that prevented the nursing profession from contributing fully to the healthcare system: an aging workforce, regulatory restrictions on nursing practice, fragmentation of healthcare, limited capacity of the nursing education system, and lack of workforce data. It was also a catalyst for finding solutions to these problems.”

The followup report titled “Assessing Progress on the Institute of Medicine Report The Future of Nursing” came out in December 2015 and reported only some progress in their key questions:

  -Have scope-of-practice barricades been pushed aside? Are nurses being permitted to practice to the full extent of their education and licensure?

-Are more nurses earning baccalaureate, master’s, and doctoral degrees?

-Are new graduate nurses being transitioned to the profession more safely and effectively through nurse residency programs?

-Does the ethnic composition of the nursing workforce more closely match the level of diversity in the general population?

-Have opportunities expanded for leadership and interprofessional collaboration in healthcare?

If you are a nurse and were unaware of all this, you are not alone. As a full-time ICU nurse, neither I nor my fellow nurses were aware of this study at that time. The only change we noticed was when our hospital suddenly announced  that every RN must have a BSN by 2021 or be terminated.

I wish we had been asked for our input!

WILL MORE DEGREES, DIVERSITY AND EXPANDED RESPONSIBILITIES REALLY HELP NURSING?

Instead of the IOM focus on these issues, I would propose  at least four measures to really help the majority of us who work in health care institutions to provide the quality care we want for our patients as well as to reduce the stresses of nurses that often lead to burnout and quitting the profession.

 1. Consider bringing back the head nurse

When I started nursing over 47 years ago, we had head nurses who knew the patients, doctors and staff by working with them daily to make sure care was coordinated, staffing was adequate,  and problems were addressed quickly.

Now we have managers and other administrators who often are not RNs and who are often rarely seen or available because of endless meetings. The formerly close working relationships with head nurses have now become almost adversarial relationships with managers as cost containment measures, endless new policies based on legal risk, mandated government regulations, inadequate staffing etc., grind down nurses.

 2. Try retention incentives instead of signup bonuses

Years ago when there was a nursing shortage, signup bonuses were offered to potential nurse employees. I was asked by a director of nurses if I thought the bonuses were high enough.

I told this director that it might be better to try retention bonuses since the newly employed nurses we trained often left after the required year of service to get a signup bonus at another hospital. This wasted the money and time used to assign a precepting nurse to support the temporary new nurse during the weeks-long orientation to our hospital policies and procedures.

A retention bonus would help keep our good, experienced nurses who were already familiar with the doctors, other staff, departments and hospital policies. Such nurses are also often excellent resources for the rest of the staff. This could help prevent some mistakes caused by inexperience or unfamiliarity. In addition, such bonuses could also save money  and increase staff morale by reducing a high turnover rate.

3. Don’t automatically force nurses to get a BSN (bachelor’s degree in nursing)

As I wrote in my March blog “Is it Time for a Two-Track Nursing Education System?”, there is a lack of openings in many BSN programs, not to mention the time stresses and money involved in trying to coordinate full-time 12 hour hospital shifts while  caring for a family and taking classes on a deadline.

Yet there will always a need for excellent bedside nurses who strive to improve their skills, whether or not they decide to pursue a BSN. I believe that it should be a choice, not a requirement, to seek an advanced degree only in nursing.

In the meantime, I believe we should improve basic nursing education, especially by increasing clinical experience and providing mentoring to new graduates.

4. Good nurses deserve to have both conscience and whistle blower rights respected

An April, 2016  Medscape News article “Two Nurses Who Spoke Up, Lost Their Jobs, and Sued”  chronicled the years-long battle of 2 nurses who discovered and reported patient safety problems at their hospitals and lost their jobs as a result of their patient advocacy efforts. Unfortunately, being a good nurse does not automatically provide job security or protection.

Good nurses need both conscience and whistle blower rights protected. Despite rapid changes in historic ethical  and legal principles involving life-termination and abortion issues, most nurses still don’t want to actively participate. Neither do most nurses want to be intimidated from reporting medical incompetence or serious violations of standards involving patient safety.

However, good nurses often find themselves  at risk of harassment or even termination if they refuse to participate in deliberate life-ending decisions or refuse to ignore actual or potential harms to their patients.

Unfortunately, the American Nurses Association and state boards of nursing do not offer much help to nurses in such difficult situations. As the Medscape News article states, even though one nurse cited documents from the American Nurses Association (ANA) code of ethics  which say that nurses have a professional responsibility to protect patient safety:

 “The tricky part—and this is where an experienced attorney is helpful—is understanding the ins and outs of state laws that describe the exceptions to “at will” employment. If an employee reports a patient safety problem and/or is a member of a protected class (older, or a minority), the employer will probably try to prove that the employee was fired for another reason—poor performance, for example. A court will weigh the evidence and decide whether the public policy at issue is more important than upholding the doctrine of at-will employment.”

CONCLUSION

Nurses share a special bond and I am proud to be part of a truly noble profession.  But we need to be able to speak out without fear to insist on the highest standards to improve our healthcare system for both ourselves and especially our patients’ sake.

Is it Time for a Two-Track Nursing Education System?

nancyvalko education, nursing

In what may be news to most people, a March 6, 2016 Wall Street article “Colleges Lock Horns Over Nursing Programs-Four-year institutions try to prevent community colleges from offering advanced programs” states:

The Institute of Medicine, now part of the nonprofit National Academy of Sciences, in 2010 recommended that 80% of nurses hold bachelor’s degrees by 2020, up from about 50% at the time.

Spurred by the report, as well as incentives in the Affordable Care Act to use more highly credentialed nurses, hospitals are scrambling to bring on new staff with bachelor of science degrees in nursing, or push nurses with associate degrees to upgrade to a BSN. That means additional coursework emphasizing community health, critical thinking and evaluating research, in addition to liberal-arts or general-education classes….

That means nurses like Kristina Spaete, who landed a job as a surgical nurse at Scripps Mercy Hospital in San Diego after completing her associate degree in nursing at a community college last May, could soon find herself back in school.

“I feel selfish if I were to go back and pay a ton of money for school,” said the 35-year-old mother of three, who is hoping she can get a BSN at a community college.
For now, getting into any program is tough. U.S. schools turned away 68,938 qualified applicants from bachelor’s and graduate nursing programs in 2014, according to the American Association of Colleges of Nursing, citing a dearth of faculty, clinical sites and classroom space.

Leaders at community colleges, which now train nurses to the associate-degree level, argue they can help fill a hole in the nursing labor market at a low price. Administrators at four-year colleges counter that community colleges aren’t equipped to teach upper-level nursing courses and say there aren’t enough qualified faculty to go around.

“We have to be responsible in terms of how many students realistically can complete these programs, and how many can get jobs,” said Christine Mallon, assistant vice chancellor of academic programs and faculty development at the California State University System.

Here is the letter to the editor I sent to the Wall Street Journal about the crisis in nursing education.

In 1969, I graduated from one of the first associate degree nursing programs due to limited funds and an intense desire to start my nursing career. Some of my high school classmates chose a 4 year BSN degree but the vast majority of nurses then were three year hospital diploma nurses. Now there are almost no diploma programs which were then considered the “gold standard” for nursing education.

At the time, I felt I received a great nursing education but I also felt I needed more clinical experience so I went to the only hospital in my area to offer a nursing internship. I spent the next year in different divisions: 3 months each on medical and surgical divisions including ICUs, 3 months in operating rooms and 3 months as an elective in the cardiac ICU.

By the end of that year, not only did I gain an enormous amount of knowledge and confidence but I also was able to make the decision that I wanted to be an ICU nurse able to work in any type of ICU. I did achieve my dream and more.

A few years after working, I decided I wanted to learn more and I signed up for a BSN completion course at my own expense since scholarships were few and far between. However, I was disappointed that the program seemed geared to producing administrative nurses rather than clinical nurses. I wanted to be a great bedside nurse so instead, I took courses in music and considered pursuing an economics degree to give me more options.

But now, only a BSN will protect many fine nurses from termination or even finding employment at the beginning of their careers. In addition, the shortage of good, reasonably priced BSN completion programs will probably deter many people from even considering a nursing career.

I propose a 2 track nursing education system.

Those who want to be a great bedside nurse could obtain an associate degree and complete a year of internship as a kind of apprenticeship. This plan would not only give new nurses the support to take on the challenges of a bedside nursing career but also help them discover what kind of nursing fit their capabilities best. Such nurses could advance by becoming certified in their chosen specialties. A BSN completion course would always be available if wanted but not required as it is in many health care institutions today.

Some students would choose a BSN program from the beginning but might also want access to the support of an internship when they begin their nursing careers.
I believe this would produce the dedicated nurses we need both at the bedside and in administrative roles.

And after almost 47 years in nursing after following this plan, I would still choose this career again.

I would like to hear what you think or what ideas you have, especially if you are a nurse yourself!

Germany Legalizes Assisted Suicide-As Long As It Is “Free”

nancyvalko assisted suicide, euthanasia, medical ethics, nursing

While the UK Parliament overwhelmingly defeated a physician-assisted suicide bill in September 2015, less than two months later the German parliament has passed a law legalizing some assisted suicides. As Reuters News reported:

“The bill, which was upheld with 360 out of 602 votes, criminalizes organizations that assist patients in terminating their own lives for profit. It is meant to prevent the commercialization of the procedure as a “suicide business.”

However, single instances of suicide assistance – by a doctor or relative – do not contradict the new law. A husband who helps his terminally ill wife to die would not be prosecuted.

“Commercial” assisted suicide would be punished by up to three years imprisonment, even if doctors allegedly perform the procedure to relieve suffering.

Why Germany?

The law is a surprise to many, especially since Germany has long been sensitive to the issue of euthanasia following its’ history in World War II when the Nazis used the practice to kill over 200,000 people with mental and physical disabilities as well as millions of Holocaust victims.

Actually, the 1945 Hadamar Trial involving euthanasia by healthcare professionals at the Hadamar psychiatric clinic was the first mass atrocity trial in the US zone of Germany following World War II. As a nurse, I was particularly horrified when I first read about the famous study of the willing participation of nurses titled “Killing while caring: the nurses of Hadamar”

What can we expect?

Former Justice Minister Brigitte Zypries said the new German assisted suicide law “will open an era of great legal uncertainty” and will certainly be appealed to the Federal Constitutional Court.

But If efforts to stop the German law fail, the law will doubtless be expanded in the future as other countries in Europe have done.

Although ignored or dismissed in the US, the expansion and problems of euthanasia/assisted suicide in European countries like the Netherlands, Belgium, Luxembourg and Switzerland show the danger of first accepting a supposedly “limited” assisted suicide law.

For example, the Netherlands now uses lethal injections to dispatch infants with disabilities and adults of any age even without physical illness or consent. Belgium has done planned organ donation after euthanasia by lethal injection with the Ethics Committee of Eurotransplant even formulating recommendations for organ donation after euthanasia.  And Switzerland has a booming business with assisted suicide organizations like Exit and Dignitas even though a study showed that 16% of assisted suicide deaths in Switzerland are of people who have no underlying illness.

Conclusion

As the late Richard John Neuhaus wisely said ” I believe in the slippery slope the same way I believe in the Hudson River. It’s there.”

But until we are ready to recognize the potent logic about the disastrous and unintended consequences when we legalize “just a little bit” of legalized medical killing, we may find that the slippery slope has no bottom.

Physician-assisted Suicide: Nurses in the Line of Fire

nancyvalko assisted suicide, conscience rights, medical ethics, nursing

Years ago, the newly legalized Oregon physician-assisted suicide law caused much discussion at my St. Louis hospital. Some of my fellow nurses said that they supported such a law but when I asked them if they would participate, they were shocked. “No, of course, the doctor would have to do it!”, one exclaimed. Some nurses, like perhaps most people,  thought assisted suicide would only occur at a patient’s home with his or her family sitting with the patient watching the drinking of the lethal overdose.

I explained that in hospitals or hospices, would we expect the assisting doctors to be present when the patient ingested the lethal overdose, not to mention staying with the patient and family during the time it could take for the patient to die? My colleague agreed that nurses, not doctors, would probably bear the brunt of the “dirty work” of assisted suicide.

Back in 2000 and three years after Oregon legalized physician-assisted suicide, I saw an article from Nursing Spectrum magazine titled “Assisted Suicide: What Role for Nurses?” that stated:

Initially, when the law was designed, the assumption was that physicians would be the first ones to explore PAS with patients,” says Pam Matthews, RN, BSN, administrator for Evergreen Hospice, Albany, OR, “but in reality, nurses are usually the ones in the line of fire…. Much of nurses’ roles lies behind the scenes long before the drama of PAS unfolds. Home care and hospice nurses actively help patients understand their rights, acting as advocates for those who are considering PAS.” (emphasis added)

How many nurses are really willing to “advocate” for physician-assisted suicide? The article states:

“Before PAS became law, it was publicly debated, and we performed surveys of our hospice teams’ feelings on the issue,” Matthews says. “We found that most nurses felt strongly that patients should have the choice of PAS, although most said they would not participate in the event.” (emphasis added)

Recently, I spoke to a nurse in Washington State who is against physician-assisted suicide law about nurses’ experience with physician-assisted suicide in her state. She referred me to a 2014 study in the Journal of Pain and Symptom Management titled “Dignity, Death, and Dilemmas: A Study of Washington Hospices and Physician-Assisted Death”. (click on link and click PDF to read the full text)

While 21% of the Washington hospices in this study, mostly religiously-affiliated, refused any involvement in assisted suicide, this study sadly confirms the how legalization has affected both hospices’ and nurses’ role in assisted suicide.

Here are some excerpts:

First of all, the study notes that:

(T)he primary patient rights organization that facilitates arrangements for physician-assisted death, Compassion & Choices, refers terminally ill patients to hospice programs as a first resort for end-of-life caregiving. (emphasis added)
And admits that:
The authorizing legal statutes in both states (Oregon and Washington) make no reference to the experience of severe pain or intolerable suffering as an indication for a patient to make a request for physician-assisted death but rely entirely on the entitlement due a patient in respect of their personal dignity. (emphasis added)
However, the study rationalizes the upwards of 90% of physician-assisted suicide victims being enrolled in hospice:

The designation of a ‘‘physician’’ as the primary professional resource for patients allows hospice programs to maintain fidelity to the norm that ‘‘hospice neither prolongs nor hastens dying’’ (our emphasis). In short, although most patients who use the Death with Dignity rights are enrolled in hospice, hospice programs want to stress that this is a ‘‘physician-directed’’ process, not ‘‘hospice-assisted’’ death.” (emphasis added)

The study provides further dubious rationalization:

Although the phrase (“hastening death”) is descriptively accurate about what typically happens when a patient ingests the medication, describing the process in this manner appears to compromise a central hospice precept that dying or death is not to be hastened. It thus raises a broader question about an evolving hospice identity and integrity in which, in contrast to historical tradition and practice, hospice programs are willing to incorporate practices that hasten death. Insofar as several hospices in both Oregon and Washington have policies with respect to palliative sedation, in which pain relief is the primary goal even if death is hastened as a secondary consequence, it may be that some hospice programs could legitimately claim that the issue has already been resolved, and physician-assisted death is the moral equivalent for hospice of palliative sedation.” (emphasis added)

As far as allowing the hospice nurse to exercise his or her conscience rights:

In every circumstance in which personal, moral, or ethical values are cited as a basis for a caregiver to request they withdraw from being the responsible caregiver for a patient that makes a request, another staff member must be available to assure continuity of care and avoid violating the hospice value of non-abandonment.” Two traditional tenets of hospice philosophy-non-abandonment and refraining from ‘‘hastening death’’-remain prevalent values but create their own complications. (emphasis added)

One obvious complication is that it may not always be possible to find another nurse willing to be involved in the assisted suicide and if not enough willing nurses can be found, this “right” to withdraw may result in workplace discrimination against such nurses or even rejection of some potential hospice nurses before employment.

The article also cites a surprising reason, denied or unmentioned in news stories, for some hospice policies restricting nurses from actually attending the assisted suicide:

This may be particularly compelling in circumstances where the patient experiences complications with the medication (e.g., when the patient aspirates the medication), and some further medical treatment is needed by the patient for death to occur. In this context, the restriction on hospice staff presence serves as a further check against physician-assisted death becoming hospice-assisted death.
(emphasis added)

In the conclusion, the study refers to a 2011 Hastings Center Report by ethicist Bruce Jennings, MA:

Jennings contends that legalized physician-assisted death presents a defining moral choice for hospice identity because ‘‘legalization(of physician-assisted death) would liberate dying people from what hospice had been teaching could be a meaningful and valuable time of life. On the other hand, a major part of that quality of living while dying that hospice champions is autonomy, respect, and dignity. How could hospice stand against that?”  (emphasis added.)

For the sake of ourselves, our patients and our profession, how can we nurses NOT make a stand against physician-assisted suicide?