The scope of nurse practitioner (NP) practice is regulated by the state government. Currently, 21 states and Washington, D.C have passed legislation allowing nurse practitioners full practice authority. This permits NPs in these states to independently diagnose, make treatment decisions, order and interpret diagnostic tests, and prescribe medications without the oversight of a physician. Research unequivocally supports the safety, effectiveness and quality of the care provided by nurse practitioners as a safe alternate to physician care (Horrocks et al. 2002, Mundinger et al. 2000). Furthermore, this model for nurse practitioner care is endorsed by the groundbreaking 2010 Institute of Medicine report titled, The Future of Nursing: Leading Change, Advancing Health
. This document comprehensively analyzed ways to expand access to quality care for persons in the United States and supports NPs practicing to the full extent of their license and education. This movement is gaining momentum as NPs have made great strides in lobbying for full practice authority.
A recent article in the New York Times,
“Doctoring without the Doctor
” tells the story of a nurse practitioner in rural Nebraska who, upon graduation, was unable to practice in her field because she was unable to find a collaborating physician to work with for a reasonable cost and within a reasonable distance. The article goes on to describe the recent legislation in Nebraska, which, in April 2015, became the 20th state to pass legislation allowing nurse practitioners to practice without a collaborating physician. While the overall tone of the article was supportive and brought to light the issues of access to healthcare in rural America, the title insinuates an effort for NPs to take on duties and responsibilities that they were not trained to perform (i.e. providing the services of a doctor with no doctor). In reality, the legislation has little to do with the nurse practitioner practicing without “the Doctor;” the impetus for full practice authority lies in a goal to eliminate barriers to healthcare access rooted in old, outdated laws and regulatory barriers that prevent nurse practitioners from practicing to the full degree and providing the full scope of services for which we were educated for. Furthermore, nurse practitioners do not wish to eliminate collegial collaboration with physicians or any members of the healthcare team. We all understand that true quality care takes a team of healthcare providers from multiple disciplines. Nurse practitioners are not lobbying to “doctor” without a “doctor” as the title implies. In essence, the NP movement to expand legislation to support scope of practice will provide increased patient access to proven high quality care,expanding the healthcare work force to allow access to care in geographic regions where patients have limited access to quality care.
As nurses, we must continue to support legislation and promote our profession, as well as continue to educate the public on misconceptions about the profession. There were over 400 comments in response to the New York Times
article. Reading through them brings to light an abundance of support from the public and healthcare community, but, unfortunately, also highlights continued misconceptions of the public and healthcare providers on the role and scope of NP practice in the U.S., as well as misconceptions as to the goal of full practice authority. One comment from a physician is as follows, “I may be biased, but I am yet to encounter a nurse practitioner with the competence, (I believe) intelligence and with the sense of responsibility of my physician.” Another physician writes, “If NPs want independent practice, so be it. Just make them get their own malpractice insurance and not be tied in any way to any physician, supervising or not. Take full responsibility and liability for all their own medical decisions and see how it plays out. It's only fair.”(Tavernase, 2015). These type of comments shade the topic to appear as a turf battle, when in reality, the majority of NPs and physicians work together seamlessly in our healthcare system.
The American Association of Nurse Practitioners (AANP) has been a main supporter of removing barriers to NP practice. In an issues brief
they summarize the goals best as to “remove barriers and obsolete legislation and regulations that do not recognize NPs’ advanced education and clinical preparation to furnish the full range of services that they are licensed to provide.”
Recently, the Pennsylvania Coalition of Nurse Practitioners (PCNP) organized a lobby day in support of a house and senate bill to support full practice authority. PCNP has dedicated significant time and effort to ensure PA laws are udated. To date, PA has yet to pass this legislation. What types of struggles have you encountered in your state for full practice authority? Do you have full practice authority in your state and if so, has there been any noticeable changes in your day to day practice? Have the physicians, patients, and other nurses in your life supported this work? Please share your thoughts in the comment below.
Megan Doble, MSN, RN, CRNP
AANP Issues Brief: Remove Barriers to Nurse Practitioners’ Ability To Practice.Retrieved from:
Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine. The future of nursing: leading change, advancing health. Washington, DC: National Academies Press; 2011
Horrocks, S., Anderson, E. & Salisbury, C. (2002). Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. BMJ, 324, 819
Mundinger, M.O., Kane, R.L., Lenz, E.R., Totten, A. M., Tsai, W., Cleary, P.D., Friedewald, W.T., Siu, A.L. &Shelanski, M.L. (2000). Primary Care Outcomes in Patients Treated by Nurse Practitioners or Physicians: A Randomized Trial. The Journal of the American Medical Association. 283(1), 59-68
Tavernise, S. (2015). Doctoring, without the doctor. New York Times. May 25, 2015.Retreived from: http://www.nytimes.com/2015/05/26/health/rural-nebraska-offers-stark-view-of-nursing-autonomy-debate.html
The Maternal Mortality Rate (MMR) is an issue in many countries that are often regarded to have the most advanced healthcare systems. In fact, the rate at which mothers are dying as a result of pregnancy or childbirth in the United States continues to rise despite the U.S. spending more money than any other country in the world in regards to pregnancy hospitalization and childbirth.
Nursing@Georgetown prepared a useful infographic on the topic of Maternal Health around the World in hope to explore not only the cause of these deaths but also how they may be prevented in the future. The infographic dives into some of the most important statistics such as leading causes, MMR across the world, the midwifery model, and more.
Brought to you by Nursing@Georgetown: Nurse Midwife programs
Middle East Respiratory Syndrome (MERS) has been making headlines since 2012 when it was first discovered in Saudi Arabia. A recent outbreak of MERS has occurred in the Republic of Korea affecting 150 people and claiming the lives of over a dozen to date. Close to 3,000 people in South Korea are under quarantine. Two unrelated cases of MERS were diagnosed in the United States in 2014 and both patients have made a full recovery.
While not considered a public health emergency by the World Health Organization, viruses can mutate and could cause a global pandemic. As a healthcare provider, it is important that you have an understanding of MERS and appropriate infection control practices in order to identify and prevent its further spread. As an educator, you play a critical role in informing patients about the signs and symptoms of MERS and strategies to avoid contracting this highly contagious disease.
What is MERS?
MERS is caused by a coronavirus (CoV), a group of viruses that are responsible for illnesses ranging from the common cold to Severe Acute Respiratory Syndrome (SARS). Almost 1,200 cases of human MERS-CoV infection have been reported and over 440 deaths (35% mortality rate) have been attributed to it. The origin of the virus is unknown but is suspected to have come from an animal source. MERS-CoV is thought to spread from an infected person’s respiratory secretions, such as through coughing. The incubation period for MERS (time from exposure to MERS-CoV to symptoms) is typically five to six days but can range from two to 14 days. There are no specific treatments for patients aside from supportive therapy to relieve the symptoms. Patients with mild to no symptoms have made a full recovery.
- Fever, cough, shortness of breath, runny nose, severe acute respiratory disease
- Chills, chest pain, body aches, sore throat, malaise, headache
- Diarrhea, nausea, vomiting, abdominal pain
Severe complications include:
Who’s susceptible or at high risk?
- People with pre-existing medical conditions such as diabetes, kidney failure, chronic lung disease
- People with weakened immune systems such as cancer patients receiving chemotherapy or organ transplant patients receiving immunosuppressive drugs
Need-to-know information for nurses
- If your patient exhibits fever and symptoms of respiratory illness, assess if he or she has
- traveled to a country in or near the Arabian Peninsula within 14 days of symptoms onset.
- been in contact with someone who has traveled to the Arabian Peninsula within 14 days of symptoms onset.
- a history of being in a healthcare facility (as a patient, worker or visitor) in the Republic of Korea within 14 days of symptom onset.
- been in close contact with a confirmed MERS patient while the patient was ill.
- MERS is a reportable disease and local health departments should be notified of any suspected MERS cases.
- Strict infection-control measures should be used while managing suspected and confirmed cases of MERS, including hand hygiene; contact, droplet and airborne precautions along with full personal protective equipment – gown, gloves, mask and eye protection (goggles or face shield). MERS patients should be placed in a negative pressure room.
Please visit the Centers for Disease Control and Prevention (CDC) for complete recommendations and Interim Guidance for Healthcare Professionals
in the detection, evaluation and care of MERS patients.
Myrna B. Schnur, RN, MSN
A recent Quick Quiz on our Facebook page
resulted in a mix of responses. Do you know what word is used to describe the amount of stretch on the myocardium at the end of diastole? The responses were split between preload and afterload.
Let’s take a closer look at what these terms mean.
Preload, also known as the left ventricular end-diastolic pressure (LVEDP), is the amount of ventricular stretch at the end of diastole. Think of it as the heart loading up for the next big squeeze of the ventricles during systole. Some people remember this by using an analogy of a balloon – blow air into the balloon and it stretches; the more air you blow in, the greater the stretch.
Afterload, also known as the systemic vascular resistance (SVR), is the amount of resistance the heart must overcome to open the aortic valve and push the blood volume out into the systemic circulation. If you think about the balloon analogy, afterload is represented by the knot at the end of the balloon. To get the air out, the balloon must work against that knot.
Cardiac Output & Cardiac Index
Cardiac output is the volume of blood the heart pumps per minute. Cardiac output is calculated by multiplying the stroke volume by the heart rate; normal cardiac output is about 4 to 8 L/min, but varies depending on the body’s metabolic needs. Cardiac index is a calculation of the cardiac output divided by the person’s body surface area (BSA).
So, if you answered ‘D’ to the quiz above, you’re right!
I didn’t have to travel too far this year to attend the National Conference for Nurse Practitioners! Held at the Philadelphia Downtown Marriott in historic Philadelphia, Pa., there was plenty to see and do within the venue and out in the city. My days were filled with conference sessions, fun in the exhibit hall, and dinners out with colleagues.
There was so much to see, do, and learn. The opening session celebrated the 50 year mark of the NP profession, while the conference honored 40 years of the Nurse Practitioner
journal and Nurses Week. The conference sessions focused on clinical updates and professional issues; I was able to meet both my CE needs as a Women’s Health NP and learn about the latest developments in acute care so that I can stay up-to-date in the world of critical care.
Here are highlights from some of the sessions I attended:
- According to the U.S. News & World Report of 100 Best Jobs, nurse practitioner ranks #2!
- Fifty percent of insurance plans now cover obesity medications. (New Drug Update 2015: What’s Hot and What’s Not, presented by Wendy Wright, MS, RN, ARNP, FNP, FAANP)
- In terms of radiation exposure, one chest CT is equal to 750 chest xrays. (5 Things I Wish I Knew Last Year, presented by Louis Kuritzky, MD)
- Research has shown that interactions that occur during a student’s education will shape his or her professional image. (Lateral Violence: Bullying in the Workplace, presented by Monica N. Tombasco, MS, MSNA, FNP-BC, CRNA)
- When the GFR is < 30 mL/min, thiazide diuretics are not as effective; use loop diuretics instead. (Hypertension Update: The Latest Treatment Recommendations from JNC-8, presented by Margaret A. Fitzgerald, DNP, FNP-BC, NP-C, FAANP, CSP, FAAN, DCC)
- Many states now have ‘breast density notification laws’ and several have legislation in progress. (Breast Evaluation: Screening to Diagnosis, presented by Constance A. Roche, MSN, CNP, APNG)
- Pneumonia and aspiration are the most common direct lung injury causes of ARDS. (Acute Care Track: Diagnosis and Management of Acute Respiratory Distress Syndrome, presented by Sophia Chu Rodgers, ACNP, FNP, FAANP, FCCM)
The Exhibit Hall (and other fun!)
Food, fun, and learning happened during all of the exhibit hall hours! Exhibitors educated attendees on their latest products, and handed out samples and fun ‘giveaways’. Attendees also got to view the poster presentations.
Meals were served, prizes were awarded and there was even a band one evening! Bonus morning sessions included Yoga for the Nurse Practitioner: A Gentle Practice with Techniques for Clinical Practice
with Tom Bartol, NP and Rhythm and Funk: Low Impact, High Energy Workout
with Jessica Clark.
If you attended the conference this year, don’t forget to complete your CE (and view sessions online)
! Hope to see you at NCNP 2016!
It seems odd to end Nurses Week with a post about bullying – after all, when thinking about celebrating our week, why be a “downer?” Hasn’t there been enough talk and articles about this ugly side of nursing?
But like other problems, raising awareness is usually the first step towards change. The sentinel event alert
from JCAHCO in 2008 on the dangers to patients from intimidating and disruptive behaviors spurred many organizations to look seriously at the behaviors of their staff. We saw several research reports and reviews about the phenomena of bullying among nurses, nurses and physicians, nurses and ancillary staff and students. We can’t just point fingers at the clinical setting. Cynthia Clark and colleagues reported their research
on faculty-to-faculty incivility in the April 2013 issue of the Journal of Nursing Education
. In a study of 588 educators from 40 states, they found that faculty perceived this to be a “moderate to severe problem” and that it persisted because of “fear of retaliation, lack of administrative support, and lack of clear policies addressing the problem.”
But, maybe there are a few subtle signs that we’re starting to deal with bullying.
One piece of good news is that since it was first published in January 2009, Cheryl Dellasega’s article, “Bullying Among Nurses,”
always ranked among AJN
’s top 20 most viewed and most emailed articles, which to me, meant it was all too relevant. I’ve heard from more than a few nurses in the clinical setting that people are getting tired of the sniping and are confronting those responsible. Articles moved from describing the problem to reporting on dealing with it, like:
Organizations, too, are helping members with resources, such as the American Association of Critical Care Nurses, which developed standards
for a health work environment. The ANA has a list of resources
addressing bullying and incivility.
Later this year, look for an article in the American Journal of Nursing
on how one hospital successfully rallied staff to deal with bullying behavior.
Perhaps people are getting the message that we’re losing too many nurses because of the untenable work environment – the “toxic workplace” – that this can create. As I noted in a message I wrote in a 2011 editorial
for Nurses Week, “Our work is too important; we can’t afford to be sidetracked by bullying and other forms of relational aggression. Use this Nurses Week as a catalyst for focusing on all that we share and accomplish as colleagues.”
Maureen Shawn Kennedy, MA, RN, FAAN
Editor in Chief, American Journal of Nursing
In today’s society, we have seen many great advances in medicine, science, and technology that have resulted in an aging population with chronic illnesses. Often times, these issues require frequent or prolonged acute care admissions. With this in mind, choices need to be made that involve discussing end-of-life care goals with patients and their families. As nurses, we must work hard to provide high value end-of-life care for these patients in the acute care setting when death is near.
Although many patients would prefer to die at home, the truth is a majority will die in acute care settings and other healthcare institutions. Over the years, end-of-life care in acute care settings has taken great stride in the implementation of specialty practices such as palliative care.1 However, in a healthcare organization that does not benefit from such a specialty, how is end-of-life care provided?
The first step in being able to plan and provide good end-of-life care is for the patient, family, and nursing staff to accept that death is the outcome.1 Next, all active life sustaining medications should be discontinued. These medications would include but not limited to: intravenous fluids, antibiotics, insulin, steroids, and blood pressure medications, but intravenous access should be maintained in order to administer end-of-life medications. Typically, in the acute care setting before transition to hospice is made, or if the patient is awaiting a hospice bed, the standard appropriate medical procedure for transitioning a patient to end-of-life care is started. A morphine bolus and/or relaxant such as Ativan is administered. These medications are given in end-of-life cases in order to decrease anxiety that the patient may experience as well as ease any feeling of breathlessness. It is very important to remember that the administration of these medications is not to promote death, but to aid the patient with the symptoms that often accompany dying.
Next, a continuous morphine drip which should be titrated for patient comfort is initiated. Often times, medications to aid with the patient’s secretions (such as levsin) is administered. Basic nursing care such as mouth care, turning, and repositioning of the patient should also be continued.
With life, comes death. As good as a healthcare professional may be, we, as a profession have yet to keep anyone from dying. We have kept people alive longer, but everyone dies at some point. Much of this understanding should not be when, but how. As a profession, when a patient’s care transitions to end-of-life care, we are not failing them. We often times begin to fail the dying patient when the health care team does not provide what the patient needs. If the outcome of the disease process or admission is death, then as a health care system, we are failing that patient by not providing a death for them that is good. Curing everyone is simply impossible, but what we can do as a profession and as patient advocates, is to provide a death that is comfortable for the patient’s final life journey.
Bloomer, M., Moss, C., & Cross, W. (2011). End of life care in acute hospitals: an integrative literature review. Journal of Nursing and Healthcare of Chronic Illnesses, 3(3), 165-173.
William Pezzotti, MSN, RN, CRNP, AGACNP-BC, CEN
Acute Care NP at Penn Medicine Chester County Hospital
Adjunct faculty at Drexel University, College of Nursing and Health Sciences
When I think about moral distress, I’d describe it as a gnawing, distraught feeling born of perceived injustice. The underlying catalysts are highly variable and include lack of essential resources necessary to provide the standard of care to patients, interpersonal or inter-professional conflict, especially involving ethically challenging situations with patients, families, providers, or co-workers, as well as errors and disturbing treatment decisions. It encompasses a constellation of emotions that nurses have likely felt since the dawn of our profession. If left to fester without effective intervention, moral distress can lead to disillusionment, disenchantment, and even disengagement with the nursing profession.
Over 30 plus years of practice, I’ve not only observed moral distress in colleagues, but have experienced it personally on several occasions. Until relatively recently, I didn’t have a name for it. My earliest memories of what I’d now term moral distress typically stemmed from being a party to treatment decisions that I simply couldn’t fathom -- they involved care that was either too aggressive (and seemingly abusive) for patients who simply had no hope for any type of recovery, or care that was not aggressive enough in patients who did. These were the days before evidence-based care pathways or palliative care services existed. I felt outraged that the hospital I worked for at that time didn’t seem to address these issues with the medical staff. A nurse, seasonedand hardened by her own years of enduring ethically challenging assignments, brushed off my distress as reality shock. “Just do what’s ordered; that’s our job,” she advised. But my own professional framework wouldn’t allow me to be satisfied with that advice since I felt the patients deserved so much more. As this situation recurred repeatedly, I felt something had to change, but I didn’t know how to affect change at that point in time. Simply being mad wasn’t constructive.
Sadly, the way many nurses, especially ones in their formative years, handle this type of challenge is by jumping ship in their search for calmer seas or greener pastures. The true reality shock, in my opinion, is that no sea is always calm or pasture always greener. The secret is learning how to cope with resilience and fortitude, and at the same time, derive strategies to tackle the root causes of the situations that lead to moral distress in an effective manner.
Mentoring and supportive relationships are essential among colleagues, nursing educators, and leaders to help individuals in the throes of moral distress to sort out their feelings, identify the causative factors, plan the resolution, and regain their own healthy emotional balance. Sometimes employee assistance programs are the best options to help nurses deal with the emotional toll in highly sensitive and confidential matters when discussions with colleagues or leaders wouldn’t be conducive to the open dialogue needed to sort out feelings and develop potential solutions.
For nurse leaders, listening and observation skills are key to identify problem situations and the impact they have on the staff. Ongoing vigilance and diligence are necessary to deal with the issues in our healthcare facilities that cause moral distress in nurses. Frankly, these issues should be very visible in the priority scheme of all healthcare leaders. The solutions aren’t always straightforward, quick or easy, but they are essential to preserving quality and safety in patient care, as well as nursing itself as a long-term career choice.
Linda Laskowski-Jones, RN, MS, ACNS-BC, CEN, FAWM
Nurses have a duty to report and to protect vulnerable populations including older adults. Yet it can be difficult for nurses to intervene successfully or to feel that they have made a difference in clients’ lives when older adults choose to stay in abusive situations. Abuse in the family and intimate partner abuse are often complicated because older adults are struggling with conflicting social, cultural, religious, or other pressures to continue living with their abusers (Finfgeld-Connett, D. 2014). In order to prevent harm to your clients at risk for abuse, nurses must carefully assess the ethical implications from the perspective of older adults, and then develop the best plan to intervene.
Social and Cultural
When deeply rooted cultural stigma about broken families exists, women may endure decades of abuse to portray an image of family unity rather than taking assistance to ensure their own personal safety (Finfgeld-Connett, D. 2014). As most abuse occurs in families, some older adults feel shame, guilt, or fear over reporting their relatives to the authorities (Olson & Hoglund, 2014).
Think about the dilemma of having a client with a lifelong religious devotion and a deep commitment to his/her marital vows when the relationship is abusive. There are reports of elders whose spiritual advisors have encouraged them to remain in abusive relationships rather than to leave (Finfgeld-Connett, D. 2014).
Low income contributes to the risk of abuse (Dong & Simon, 2014) and complexity of assisting elders who are abused. Some elders who have been abused feel trapped and unable to leave the relationship because of guilt over dependency of their spouse for shared income or fear for their own ability to provide for themselves (Finfgeld-Connett, D. 2014).
Nurses Role in Suspected Abuse
- “provide an accurate assessment of abuse and risk factors for abuse;
- clearly and objectively document assessment findings;
- report suspected incidents of abuse and participate in investigation as appropriate;
- provide support and referrals for clients experiencing potential or actual abuse; and
- implement strategies to prevent elder abuse.” (Olson & Hoglund, 2014)
Just remember that safety comes first. If there is a situation when a client is in eminent danger or has been injured, there should be immediate action to obtain treatment and to remove weak or disabled individual to a safe location. In non-urgent situations, nurses should take steps to help their clients to seek support from the community including counseling services, religious organizations, senior centers, or support groups to reduce their risk for being abused.
For more information, on risk factors and protective factors related to elder abuse, go to http://www.cdc.gov/violenceprevention/elderabuse/riskprotectivefactors.html
Elder Abuse: Speaking Out for Justice
Dong, X. & Simon, M.A. (2014). Vulnerability Risk Index Profile for Elder Abuse in a Community-Dwelling Population. Journal of the American Geriatric Society,
62:10–15, doi: 10.1111/jgs.12621
Finfgeld-Connett, D. (2014). Intimate partner abuse among older women: Qualitative systematic review. Clinical Nursing Research,
Olson, J.M. & Hoglund, B.A. (2014). Elder Abuse: Speaking out for justice. Journal of Christian Nursing, 31(1):14-21
Karen Innocent, DNP, RN, CRNP, ANP-BC, CMSRN
Executive Director, Lippincott Continuing Education
Wolters Kluwer, Health Learning Research & Practice