Nursing Notes

October 5, 2011

Nurses Don’t Want To Be Doctors

Here is an interesting article about the discord between nurses with graduate degrees and physicians.  This is a “hot topic” right now as the ANA encourages more and more nurses to pursue higher education as a means of advancing the practice of nursing.
Physicians have a point, I guess.  But mostly I think that they have missed the point. Nurses do not want to BE physicians, they want to be nurses.  But they want to be the best nurses they can be.  Receiving your doctorate in nursing only means that you value the profession and you want to pass on to your patients the benefit of you learning.  Nurses are much more global thinkers than physicians.  We are trained to look at the whole picture and then figure out the way the symptoms are affecting the persons health.  Doctors are symptom driven and deal with specifics.  Have you ever gone to the doctor with a complaint of, “I just don’t feel right” and gotten a concerned and interested response.  The usual response would be to send you for a million tests to rule out things.  Nurses will get inquisitive and ask lots and lots of personal questions until they have an “ah-ha” moment.
This article is from HealthLeadersmedia, which I have used before.  I really love this site and hope that you will click over to finish reading this great article.  Leave us both a comment about your take on this issue, won’t you?
Rebecca Hendren, for HealthLeaders Media, October 4, 2011

As a child addressing thank you notes for birthday gifts, I was perplexed by the one relative whose address began “Dr. and Mrs. John Doe.” I knew he was not a Doctor and yet he was called doctor. My mother explained he was a doctor, but not a “Doctor,” and you can imagine the emphasis on the second doctor.

This was my first introduction to the confusing world of honorifics and it hasn’t become any simpler since.

We all know that the title “doctor” refers both to physicians with medical degrees and to people who have been awarded a doctorate in a certain subject. These days patients often visit “the doctor” and are seen by a nurse who has an advanced practice degree and whose title includes the right to use the honorific term doctor.

Physician groups have been voicing concerns that the growing numbers of nurses who are also doctors are confusing for patients. Nurses are concerned that advanced practice professionals who have received doctorates in their field are afforded the proper respect and receive the designation that advanced study and knowledge is usually afforded in other fields.

Patients are left in the middle. Most patients grasp the differences between a physician and a nurse practitioner (or a physician assistant). Where many patients become confused is when the advanced practice nurse is referred to as doctor. As in, “Hello Mr. Green, I’m your nurse, Dr. Blue.”

Nurse practitioners who use the title with patients in care settings makes some physicians apoplectic. Their reaction leaves advanced practice nurses fuming. It leaves me perplexed. Why would any nurse want patients to think he or she was a medical doctor?

Nurses don’t want to be doctors. Advanced practice nurses could have chosen medical school if they wanted to become doctors. Instead, they chose to expand their study of nursing through advanced practice programs such as anesthesia, nurse practitioners, or the rapidly expanding doctorate in nursing practice.

Choosing further study in the nursing profession is a commitment to the nursing model, which emphasizes holistic patient care. Nurses approach their profession in a very different manner than physicians approach theirs and both are valuable and necessary to the overall provision of care in this country. Indeed, given the physician shortage, particularly in rural areas, the only way to meet the country’s needs for primary care is through advanced practice nurses.

So advanced practice nurses are necessary, vital, and supported by the public. Study after study has shown equal, or in some cases better, outcomes in patient care from advanced practice nurses. A study in the northwest last year revealed patients found nurse practitioner care just as good as physician care and the nurse…[read more]

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April 28, 2011

Residential Health’s med monitoring pilot slashes readmissions

HELP Telemedicine clinic 1

Image via Wikipedia

Here is an article that describes another way that telemedicine can be utilized to prevent readmission.  In reading this article, I was confused by the physicians who did not want to participate in this study.  Why?  If this is a way to maintain a patient’s health while out of the hospital, what is the problem?

Please read the entire article and come back here to tell me what you think, okay?  I really would like to hear from you on this topic.  It seems that telemedicine is the wave of the future and we need to be prepared to use it as nurses.  I think it is a great tool for health.  That’s just my opinion.  What’s yours?


By Jay Greene

Crain’s Detroit Business

A pilot project by Madison Heights-based Residential Home Health LLC that uses remote medical monitoring held hospital readmissions to 3 percent last year for 239 patients with congestive heart failure and chronic obstructive pulmonary disease.

National data show that 20 percent of all Medicare patients are readmitted to hospitals within 30 days, and 33 percent are readmitted within 90 days, costing Medicare more than $17 billion annually, according to a 2009 study in the New England Journal of Medicine.

In similar patients who did not participate in Residential’s Cardiopulmonary Hospital Admit Management Program, called CHAMP, during the last six months of 2010, the readmission rate was 25 percent, said David Curtis, Residential’s president.

But remote monitoring isn’t universally popular.

“Not every patient wants to use telemonitoring, and some physicians don’t want it,” Curtis said. “In order to drive down readmissions, we need better alignment (with patients and physicians).”

Curtis said the reduction in readmissions comes by focusing on three areas: educating patients within 24 to 48 hours after going home from the hospital, preventing medication errors, and having patients take vital signs with the devices daily.

Residential uses remote medical monitoring devices provided by Philips Telehealth Solutions including wireless weight scales, blood pressure cuffs and blood glucose meters.

Residential nurses and therapists teach patients to use the Philips devices. The data is transmitted daily to Residential, where nurses monitor it and contact physicians if warranted.

But the use of remote medical monitoring devices to reduce readmissions is still in its infancy and studies have shown mixed results.

For example, a study published November in the New England Journal of Medicine showed no reduction in readmissions from use of telemedicine in heart failure patients. However, the study concluded that many of the patients didn’t take daily readings from the instruments.

Curtis is familiar with the studies and says the effectiveness of the remote monitoring devices is only as good as nurses and therapists following up with patients to make sure they are compliant.

“If we don’t hear from our patients by 11 a.m., we are calling to remind them,” Curtis said. “The value of telemedicine is not in the equipment, it is in the process and patient education we use to prevent readmissions.”

Christopher Kim, M.D., a hospitalist at the University of Michigan Hospitals in Ann Arbor and a readmission reduction expert, said some technology vendors are aggressively promoting the use of telemedicine devices to reduce hospital readmissions.

“I am not sure it is completely justified yet,” he said. “The technology can help, but we have to look at our workflow and make sure we coordinate care with post-acute providers to keep patients out of the hospital.”

Besides the program saving Medicare money and improving patient care, Curtis said demonstrating low readmission rates will help bring more patient referrals to Residential from physicians.

“If we have the best outcomes, we can generate new business,” said Curtis, a health care and manufacturing consultant who acquired Residential six years ago with three other partners, including Chairman and CEO Mike Lewis, a lawyer who was a senior partner at Troy-based Dean & Fulkerson.

The company is already one of the state’s largest non-hospital-based agencies with more than 2,200 patients, according to the Michigan Home Health Association.

Annual revenue for 2010 for Residential and its affiliates totaled $48 million, down from $53 million in 2009, Lewis said. The revenue slide came from rising costs and flat Medicare payments, a shortage of nurses and therapists that limited census, and costs associated with expanding into Illinois, he said.

“We had staffing issues last year because of the nursing shortage, but this year we have hired one clinician every other day (more than 50 nurses and therapists),” Lewis said.

Of Residential’s 473 employees in Michigan, 255 are nurses and therapists and 17 employees are part of the company’s marketing and community liaison team, Curtis said.

In Michigan, Residential averages 1,500 patient home care visits per day, a 20 percent increase from last year. The company also has an agency in Illinois that averages about 300 patient visits per day.

Jerry Wilborn, M.D., a pulmonary critical care specialist and hospitalist who refers some patients from Botsford Hospital to Residential, said he uses data collected by Residential to determine…[read the rest here]

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January 31, 2011

Update on the fiasco in Winkler County–By Toni Inglis

Map of Texas highlighting Winkler County
Image via Wikipedia

Imaging my surprise when I opened the website for my hospital and discovered this article prominently displayed there.  Toni Inglis writes for both our hospital newspaper as well as for the Austin newspaper and she has been keeping tabs on this ongoing saga since the beginning.  I had to repost her article here in case other hospitals are not as forcoming about informing nurses across the country about these events.  Enjoy!



I’m a nurse. Fortunately, I’ve never worked with an incompetent doctor. But if I worked alongside one who sutured a rubber scissor tip to a patient’s broken thumb; gave three enemas to a 10-year-old boy and misdiagnosed his appendicitis; and examined the genitals of patients presenting with stomach distress, headache and sinus, blood pressure and jaw problems, I assure you I would report that doctor to the Texas Medical Board in a flash.

Back in April 2009, Anne Mitchell and Vickilyn Galle, nurses in dusty Winkler County in the Permian Basin, and others reported to the board that Dr. Rolando Arafiles Jr. delivered the inept care described above. The board investigated the reports and issued formal charges against the doctor.

Upon receiving notification of the complaint, the doctor turned to his buddy, the sheriff. Winkler County Sheriff Robert L. Roberts Jr. launched an investigation aimed at finding who had reported his buddy, the doctor, to the medical board. The administrator of the Winkler County Memorial Hospital in Kermit fired the nurses. That was only the beginning of their troubles.

In June 2009, the nurses were indicted on charges of misusing official information — a third-degree felony punishable by up to 10 years in prison and a $10,000 fine.

Mitchell and Galle filed a federal civil lawsuit in August 2009 against the hospital administrator, physician, sheriff, county attorney, District Attorney Mike Fostel as well as the hospital and the county. They charged that their constitutional right to free speech and due process was violated. They further accused the defendants of violating laws intended to protect whistle-blowers.

A year later, the civil suit was settled when Winkler County officials agreed to pay them $750,000 for past and future earnings, an amount they will share with their attorneys. Taxpayers are responsible for the bill.

The criminal charges against Galle were dropped. National headlines were made when a jury acquitted Mitchell in less than an hour in February 2010.

Last month, Arafiles was arrested and charged but continued his $200,000 job at the hospital.

After Mitchell’s acquittal, Attorney General Greg Abbott opened an investigation of the case. Lawyers from the attorney general’s office presented their case to a grand jury, which on Jan. 13 returned indictments against the doctor, sheriff, county attorney and hospital administrator on charges of retaliation against the nurses.

Roberts and County Attorney Scott M. Tidwell each face six counts — two counts each of misuse of official information and retaliation (third-degree felonies) and official oppression (class A misdemeanor).

Stan Wiley, the hospital administrator who hired Arafiles and fired the nurses, was indicted on two counts of retaliation. He has since resigned.

Arafiles faces two counts each of misuse of official information and retaliation against the nurses. How rich an irony that those involved were indicted on the same charge as the nurses — misuse of official information.

Two brilliant nursing careers were ended; the county became divided as its reputation suffered. The rural hospital was left in turmoil, and medical providers left, leaving people with few options for care — a burden disproportionately shared by the elderly.

Ultimately, after the medical board’s official charges were challenged by Arafiles, the case went to an administrative law judge.

Arafiles and medical board staff reached an agreed settlement. The terms have not been disclosed. The medical board has final say on the agreement and is scheduled to consider it at its February meeting.

The whole tawdry affair was unnecessary and should send a message that stunning displays of good ol’ boy idiocy and abuse of prosecutorial discretion in a small, far-off county will not be tolerated.

Turning a case around 180 degrees and prosecuting the prosecutors is a judicial anomaly. The judicial system functioned as it should.

We await the final disposition of the case, when the doctor and officials might or might not be convicted. Like the nurses before them, they are presumed innocent. But their indictments alone prove that justice was served, at least so far.


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April 19, 2010

Nursing our way out of a doctor shortage

Here’s an article that talks about the physician shortage currently looming and the way nursing can help fill the empty spaces to provide basic care and free up the physicians to see the patients that really need them.  Nurses could care for simple things like colds, fever, stomach upset, check-ups and send seriously ill patients to the physicians.  Just thought I’d post this article here to see what you think about this topic.


Give non-physicians more freedom to help patients.

Steve ChapmanApril 18, 2010

Thanks to health care reform, millions of previously uninsured Americans will have policies enabling them to go to the doctor when necessary without financial fear. But it’s a bit like giving everyone a plane ticket to fly tomorrow. If the planes are all full, you won’t be going anywhere.

There are not a lot of doctors sitting in their offices like the Maytag repairman, playing solitaire and wishing a patient would drop by. Most of them manage to stay plenty busy. Nor is there a tidal wave of young physicians about to roll in to quench this new thirst for medical care.

On the contrary. The Association of American Medical Colleges says that by 2025, the nation could be 150,000 doctors short of the number we need. Meanwhile, the number of med students entering primary care, the area of greatest need, is on the decline.

It’s hard to quickly boost the supply of physicians, since the necessary training usually takes at least seven years beyond college. The result, as an AAMC official told The Wall Street Journal: “It will probably take 10 years to even make a dent into the number of doctors that we need out there.”

That, of course, is assuming that the new health insurance system doesn’t drive aspiring or existing doctors out of medicine, which is entirely possible. Regardless, there seems to be no doubt that it will get harder to find someone to treat you, it may cost more and you’ll spend two hours in the waiting room instead of one.

Or maybe not. What people with medical problems need is medical care, but you don’t always need a physician to get treatment. You might also see a different sort of trained professional — say, a nurse practitioner, physician’s assistant, nurse or physical therapist.

Not every ailment demands Dr. McDreamy, any more than every car trip requires a Lexus. If you have a sore throat, earache or runny nose, you probably don’t absolutely require a board-certified internist to conduct an exam and dispense a remedy.

But it may not be up to you to decide who is suited to provide the care you want. Different states have different rules on what these clinicians may do. In many places, a nurse practitioner has to be under the supervision of a doctor. In others, she may not prescribe medicines or use the title “Dr.” even if she has a doctorate (as many do).

Medicare typically reimburses nurse practitioners at a lower rate than physicians. In Chicago, an office visit that would bring $70 to a doctor is worth only $60 to a nurse practitioner.

But the need for more primary care is forcing a welcome reassessment of these policies. So 28 states are reportedly considering loosening the regulations for nurse practitioners, on the novel theory that any competent professional health care is better than none.

Private enterprise is already responding to what consumers want. Walgreens, for example, has established more than 700 retail health clinics staffed by nurses, nurse practitioners and other non-doctor professionals. CVS has its own version. The number of these facilities is expected to soar in the next few years.

You might fear that this sort of treatment is inferior to what you’d get from your personal doctor. Your doctor might agree. The American Medical Association, reports The Associated Press, warns that “a doctor shortage is no reason to put nurses in charge and endanger patients.”

But put your mind at ease. A 2000 study published in the Journal of the American Medical Association found that where nurse practitioners have full latitude to do their jobs, their patients did just as well as patients sent to physicians. Other research confirms that finding, while noting that retail clinics provide their services for far less money than doctors’ offices and emergency rooms.

Obviously, if you wake up with crushing pain in your chest or fall out of a second-story window, you’d be well-advised to see a specialist. But for common ailments that are mainly a nuisance, a physician may be a superfluous luxury.

Obama’s health care reform rests on the assumption that expanding access demands a bigger government role. But even its supporters should be able to see that sometimes, it helps to get the government out of the way.

Steve Chapman is a member of the Tribune’s editorial board and blogs at

Here’s the link to the original article

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March 31, 2010

Calling the Doc-Nurse educators teach new grad nurses how to better communicate with physicians to improve patient care.

SBAR has just come to my hospital and I am sure it will be helpful in the nurse’s dealings with the on-call residents.  Most of the time they are first year residents and know absolutely nothing about giving orders, so they need the help of experienced nurses to help them make the transition to being the “doctor”.  Working in a  teaching facility has its drawbacks, communication between nurses and residents is usually at the top of the list.

I read this article and I fully enjoyed seeing the difference between the different approaches and I loved that there was even a bit of whimsy mixed in with the educational stew.  It’s not only new graduates who sometimes need to have this information; experienced nurses who are stressed and worried about their patients can sometimes forget to get themselves organized and prepared before calling the doctor, so we all benefit from this improved way to communicate.


By Sandy Keefe, MSN, RN

New staff nurses Amanda Alarcon, RN (standing), and Joanne Lukaszewicz, RN, present some patient data to endocrinologist Joseph Rosa, MD, in a chart room on the med/surg unit of St. Vincent’s Medical Center, Bridgeport, CT. Photo courtesy St. Vincent’s Medical Center

When Sheryl Hollyday, MSN, RN, cardiovascular service line educator, and Diane Sheehan, BSN, RN, orientation coordinator, performed a tongue-in-cheek skit that highlighted what not to do when calling a physician, new graduate nurses at St. Vincent’s Medical Center, Bridgeport, CT, were intrigued and wanted to learn more.

“It served as an icebreaker that led to a productive discussion about communication,” Sheehan noted.

The exercise was part of a roundtable of volunteer physicians and newly graduated nurses. The physicians spoke without scripts, sharing examples and tips about how to deal with challenging behavior from doctors.

The physicians “emphasized that if the nurse believes there is an area of concern and communicates that clearly, most physicians will welcome the call and appreciate what’s being done for their patients,” Hollyday said.

Experiential Learning
The idea for the roundtable came from past new graduates.

“Every year we have a staff education retreat, and we invite several new nurses,” said Nina Fausty, MSN, APRN, assistant vice president of patient care services. “We solicit their feedback and ask for recommendations about how we can better meet their needs. Anxiety about physician communications was one of their greatest concerns.”

New grads emphasized their preference for experiential learning over didactic classroom sessions during the roundtable. “As a result, we have made many changes, such as role playing, shadowing experiences in relevant departments and fostering communication, critical thinking and clinical skills through the use of simulation,” Sheehan said.

The roundtable has been a resounding success, she added. “Many [new grads] were apprehensive about asking questions like when to call, what’s important to convey and how to prepare themselves for those phone calls,” Sheehan said. “After we had the open forum meeting with the attending physicians, they were more comfortable and confident on this topic.”

Communication Becomes Curriculum
Marion Smith, MA, RN, AOCN, BC, nurse educator and coordinator of the Nurse Residency Program at NYU Langone Medical Center, New York, NY, believes today’s new grads are more comfortable with communication than their predecessors. “They are coming out of school with more of a sense of their identity, and that allows them to communicate more assertively,” she said. “They expect people to respect them as professionals.”

NYU’s new-grad program builds upon that foundation. “One of our first seminars is on communication in general,” Smith explained. “We talk about assertive communication and active listening. Our new grads write [and share] clinical narratives about communication issues as a way of looking at their practice, and if physician communications come up in one of those narratives we discuss the topic.”

Communication is a theme throughout the first year of the residency program at NYU. During the seminar about handling emergencies, the group discusses the nurse’s role in communicating about the patient’s status in an escalating situation, while an advanced pain management seminar includes advice from an advanced practice nurse.

“The nurse might say, ‘Mrs. Smith seems to be in a lot of pain and doesn’t want to get out of bed today. I’m concerned she won’t be able to go home tomorrow,'” Smith said. “That’s an assertive communication that highlights issues of concern to the physician.”

Facing the Challenge
Anne Walker, MEd, RN, shares a similar perspective in Facing the Challenge: Difficult Conversations, a seminar she teaches for the Vermont Nurses in Partnership.

“New grads face a shock coming into the workforce with an average of less than 450 hours of clinical time,” she explained. “They’re not well-prepared to interact with colleagues and physicians at the professional level. We teach them to voice their needs and to articulate them well.”

Walker recommends reflective practice, staying in the moment, having a common purpose and asking questions to understand the other’s point of view. She uses a process known as MRI (mental, rehearsal and intermission) that allows new grads to identify communication barriers, prepare for the conversation and be proactive rather than reactive.

“The rehearsal part of the process involves ‘what if’ scenarios,” she said. “Most of the time, the ‘what ifs’ don’t happen, but if they do, how will you handle it? What if the physician yells at you at 3 a.m.?”

Andi Churchill-Boutwell, RN-BC, ONC, clinical educator in the surgical care unit at Rutland Regional Medical Center, Rutland, VT, found Walker’s approach very helpful.

“As a result of the workshop, we will be better able to use the reflective-listening process to have effective conversations,” between nurses and physicians, she said. “As preceptors, we must be good role models for our new nurses. When we are in a difficult situation or conversation, we must treat the other person with respect and truly ‘hear’ the person.”

SBAR Communication
Donna Cill, DNP, FNP-BC, director of continuing education and clinical faculty for the nurse practitioner program at the University of Medicine & Dentistry of New Jersey (UMDNJ) -School of Nursing, Newark, teaches a communication module based on the SBAR (situation, background, assessment, and recommendations) model.

“The only way for a nurse to be confident in communications with a physician is to be competent,” she emphasized. “Are we organized enough?  Do we know enough to give the physician the information needed for good decision-making? The SBAR model helps ensure the nurse can answer those questions appropriately.”

Cill emphasized that attitude matters. “Our nurse residency and nurse refresher programs consistently teach that nurses are the physicians’ colleagues,” she said. “They need us to be advocates for patients, to be insightful and competent clinicians, and to give them the information they need to provide excellent patient care.”

During the program, new grads complete a case study using the SBAR format. “We need to be direct and confident in the way we speak,” Cill emphasized. “The ‘R’ in SBAR refers to recommendation. As nurses, we are the experts on our patients, and we need to make those recommendations. Many times physicians, especially new residents, need those recommendations.”

Overcoming Intimidation
While most SBAR communications do a great job of getting the point across, the nurse has a duty and responsibility to follow through. “If the physician doesn’t seem to take the nurse’s communication seriously, it’s important to think about the patient first,” Cill said. “What would happen if the nurse doesn’t communicate and advocate effectively on the patient’s behalf?”

New grads need guidance to go up the chain of command. “I encourage nurses to work with their preceptors to get used to calling physicians,” Sheehan said. “Instead of calling blindly, we help them prepare by doing a quick head-to-toe assessment that we’ve practiced in our simulation lab. If the physician’s answer sounds totally off the wall, we suggest the new grad say, ‘I’m new and I just want to learn, so could you explain why this is the plan of care?'”

Preparation is the key to successful communication, Hollyday concluded. “Yes, there will be physicians who are grouchy at 2 a.m.,” she said, “but we encourage the new grads to let the doctor know they’re new; hopefully that will cut them some slack.”

Sandy Keefe is a frequent contributor to ADVANCE.

Here’s the link to the original article

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March 13, 2010

Nursing covering more health care

Here is a great article about the future of nurse practitioners.  With the looming physician shortage and the lack of properly available medical care in rural areas, this seems like a good compromise.  I don’t believe that nurse practitioners want to be doctors; I do believe that they want to provide care to the under served and help people keep their medical expenditures down.

Let me know what you think on this topic.  Are you for or against letting nurse practitioners practice all over with less supervision?

By Deborah Yetter and Jessie Halladay, USA TODAY
FRANKFORT, Ky. — Each year, Wendy Fletcher says, she and two partners see more than 5,000 patients at their practice in Morehead, Ky.

They are not doctors, but rather registered nurse practitioners who say they are able to increase access to health care and make it more affordable.

“None of us are trying to play doctor,” she said.

“If we’d wanted to be doctors, we would have gone to medical school,” added nurse practitioner Melinda Staten of Louisville.

The Kentucky Medical Association claims otherwise and is fighting proposed legislation that would lift some limits on the ability of about 3,700 nurse practitioners in Kentucky to prescribe medication and perform other, mostly routine tasks such as signing a child’s immunization certificate or certifying the need for employee sick leave.

Greg Cooper, a former Kentucky Medical Association president and family physician from Cynthiana, Ky., who testified against the Kentucky bill, said he objects to what he said “is this constant push by nurse practitioners to be physicians.”

“It’s a little bit frustrating, the way this has evolved,” he said. “The family physician is the foundation of health care.”

That argument has been echoed nationally by the American Medical Association, which issued a report last fall critical of the training that nurse practitioners receive.

Dealing with doctor shortage

As the debate over health care legislation continues in Washington, advocates for nurse practitioners say it is these primary care nurses who will make up for the shortage of primary care physicians and at the same time keep costs down.

According to the American Nurses Association, as of November, the median expected salary for a typical nurse practitioner in the United States was $83,293, while the median expected salary for a typical family practice physician was $160,586.

Rebecca Patton, president of the American Nurses Association, said that each year, state legislatures are seeing measures proposed that seek to increase the capabilities of nurse practitioners and in many cases eliminate a level of supervision from physicians.

Among recent examples she cited:

• In January, Ohio’s Democratic Gov. Ted Strickland signed a bill that did away with the need for nurse practitioners moving to Ohio to repeat training with an Ohio physician as long as they have had prescribing privileges in another state at least one of the prior three years.

• In July 2009, Hawaii enacted a bill that gave nurse practitioners broader prescription authority that includes controlled substances.

In addition, the association cited several additional states that have bills pending that would either broaden or restrict prescription writing ability for nurse practitioners, including bills in Alabama, Colorado, Washington and West Virginia. And Alabama, Connecticut, Mississippi, Nebraska and New York have bills pending related to removing requirements for physician supervision or collaboration agreements.

‘Don’t see a big difference’

Nurse practitioners are “gaining traction because people are seeing how cost-effective they are,” Patton said. “The primary care physician shortage is going to drive it.”

Judi James, 56, who lives in Morehead, Ky., said she gets her basic medical care from a nurse practitioner and has no qualms about going to see a nurse rather than a doctor.

“I really just don’t see a big difference,” James said. “The nurses are the ones who take care of you anyway, not always the doctor. If I need a specialist, she’ll send me there.”

Each state sets up regulations for nurse practitioners. In Kentucky, for example, nurse practitioners are able to practice independently without being supervised by a physician. But in order to prescribe medicine they must obtain a signed agreement from a physician, even though that physician may not work directly with or consult with the nurse.

The Kentucky bill would allow nurses to forgo the agreement when it comes to certain medications, such as antibiotics and blood-pressure medication. Prescribing controlled drugs, such as narcotic painkillers and sedatives, would still require the physician agreement.

The Kentucky bill passed out of committee and could come to the full house for consideration as soon as Monday, said its sponsor, Rep. Mary Lou Marzian, a Louisville Democrat. Marzian said she’s not sure the bill can make it through the Senate.

Twelve states, including Alaska, New Mexico, Montana, Wisconsin and Wyoming, and the District of Columbia allow nurse practitioners to prescribe independently, including controlled substances, according to the American Nurses Association. In 29 states, laws require physician collaboration for prescribing controlled substances.

Some states have limits on which controlled substances can be prescribed by nurse practitioners. Laws in Florida and Alabama prohibit nurse practitioners from prescribing any controlled substances.

Yetter and Halladay report for The (Louisville) Courier-Journal

Here’s the link to the original article

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February 11, 2010

Whistleblower Trial Update Galle’s Case Dismissed; Mitchell’s Trial Proceedings Begin

Here’s another article on the two West Texas nurses facing felony charges.  I know that I keep posting about this but this is a serious precedent and one we nurses should all be following closely.  This article is from Advance for Nurses, which is  a nursing magazine distributed to registered and licensed nurses.  The scope of the damage this incident can cause for nurses is unimaginable.  On the one hand, you will be held accountable to your licensing board for your efforts or lack of efforts to advocate for your patients.  On the other, you can be held legally liable and can be prosecuted for being a patient advocate if in doing so you happen to step on the toes of someone with more power than you.  You will not be protected by the Whistle-blower laws that protect others who come forward with proof of dangerous actions by persons and businesses.

I can see that there may be some type of history between this nurse, Ann Mitchell, and the doctor, Dr. Arafiles.  That may be playing a part in this scenario, but is bad blood a felony?  When this was reported to the Medical Board, was the information taken seriously and investigated by that board?  Did they take any action?  Aren’t there federal laws that prevent doctors from steering patients to some other business in which the doctor has involvement and stands to make monetary gains?

I am still very worried about this outcome and I hope you are too.


By Amy McGuire

Last updated on: February 9, 2010 | Posted on: February 5, 2010

In what may be considered a surprise move, prosecutors filed a motion Feb. 1 to dismiss the criminal case against Vicki Galle, RN, in the Winkler County nurse whistleblower trial. “Prosecutor’s discretion” was the sole reason given for the dismissal.

At press time, the other defendant, Anne Mitchell, RN, continued to face felony charges. Her trial proceedings began on Feb. 8.

Mitchell is being tried by the state for “misusing official information” by allegedly obtaining details as a Winkler County Hospital employee to jointly report, with Galle, what they considered to be sub-standard care provided by hospital physician Rolando Arafiles, MD. They filed the report to the Texas Medical Board April 7. In June, both nurses were indicted on the criminal charge, a third-degree felony that carries potential penalties of 2-10 years’ imprisonment and a maximum fine of $10,000. Mitchell and Galle, both long-time nurses at the hospital, were subsequently fired from their positions.

Nursing Community Responds
The case has brought the attention of both the Texas Nurses Association and the American Nurses Association officials who claim the nurses had a duty to act in the best interests of their patients. The groups are concerned that the case will set a legal precedent regarding nurse whistleblowers, sending a message to healthcare practitioners that there are adverse affects to reporting improper care.

TNA general counsel Jim Willmann, JD, told ADVANCE the dismissal of Galle’s case was a positive step.

“It appears the county attorney finally agreed that Galle’s duty as a nurse required her to report the physician and by doing so, she was fulfilling her duty,” said Willmann, who also serves as TNA director of governmental affairs. “It’s unfortunate that it took him 8 months to make that decision.

Still, Willmann is unsure why the prosecution thinks they can convince a jury that Mitchell acted with bad motives.

“I do not understand why [the prosecution] believes Texas courts would ever hold that a nurse who uses information in fulfilling her or his duty to patients by reporting a physician for substandard care to the Texas Medical Board is committing the crime of ‘misuse of official information,'” he said. “Whether the county attorney has ‘non-legal’ reasons for continuing against Mitchell is open to speculation.”

At the Oct. 21 pretrial hearing, the county attorney described the state’s position: “It doesn’t matter whether the underlying care was good, bad or indifferent. If the motive for reporting was something other than good faith, then they’re guilty of the crime.”

Depending on the state’s case, Willmann believes the nurses’ attorneys may decide to: 1) not put on a defense and call no witnesses because they believe the state has not proved its case beyond a reasonable doubt, 2) put on a limited case and call only the witnesses needed to refute specific evidence put on by the state, or 3) put on a full case.

Federal Civil Suit Mediation Failed
Despite her case’s dismissal, Galle will have a felony indictment on her record, an issue that Willmann called “outrageous.”

“For Galle, it means the state criminal case is over. Unfortunately, the indictment will probably stay on her record. Her federal civil suit against the county, county attorney, hospital, et al. remains alive.”

The court-ordered mediation in the federal civil suit was held Dec. 17, but failed to produce any agreement by the parties, said Willmann.

“Consequently, the federal civil case filed by the nurses will proceed,” he said.

The nurses’ federal suit alleges not only illegal retaliation for patient advocacy activities, but also civil rights and due process violations. The suit names a number of defendants, including Winkler County Memorial Hospital, the hospital administrator, the physician, Winkler County, the district and county attorneys, and the county sheriff.

A change of venue was court-ordered in October to move the criminal trial from Winkler County to Andrews in Andrews County.Willmann told ADVANCE he plans to attend the trial and provide updates on a daily basis through the TNA Web site at

Amy McGuire is regional editor at ADVANCE.

Here’s the link to the original posted article

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February 8, 2010

The continuing saga of doctor against nurses in West Texas

Here’s another short follow-up article about the nurses in Kermit, Tx and the pending criminal charges.  Please read the comments section on the original post as there is a YouTube link to see this doctor in action.
Don’t you wonder why they would drop the charges against one nurse but not the other?  Do you think someone has an axe to grind?  These nurses have been fired and had to hire legal representation.  How is that okay?  Where are the medical organizations in this fiasco?  All questions I’d like answers to.
February 7th, 2010

Dr Rolando Arafiles & His Nurses Tit for Tat Charges


Winkler County Rural Health ClinicWinkler County Rural Health Clinic

Doctor Rolando Arafiles accused two nurses, Anne Mitchell and Vicki Galle of revealing confidential patient information. Charges were suddenly dropped against Ms. Galle’s but Ms. Mitchell is headed to trial next week. Dr. Arafiles has expertise in emergency physician, family practice, and pain medicine and is affiliated with the Winkler County Rural Health Clinic.

Now for the background, in April, Anne Mitchell and Vicki Galle filed an anonymous complaint to  the Texas Medical board against Doctor Rolando Arafiles.  Subsequently, the doctor took filed filing harassment charges and accused the duo of revealing confidential patient information. It gets better, the nurses fought back, filing a civil suit against the county, the hospital and the doctor. Stay tuned….

Go here for the original post

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January 21, 2010

Doctors and Nurses, Still Learning

This is a well written and well thought out article about the actual events on a medical floor in Any Hospital, USA.  These types of events happen all day and all night on any unit anywhere.

I work on a teaching floor at my hospital and regularly interact with new residents, staff physicians, and attendings.  Because I work in psychiatry, where teamwork is the norm and not the exception, I don’t really have problems asking my doctors about patient care issues.  I find most of them to be patient-centered and available to nurses.

There are times, when dealing with a doctor, that you must stand your ground and speak your mind about treatment issues.  Maybe, as this nurse was, you will be shown to be wrong; but you’ll never know unless you ask.  In her case, asking saved a patient irrepairable harm.

In the field of medicine, things change daily.  Research results are released that can cause you to feel as if you have been in an earthquake.  Changes are fast and furious, so it is absolutely necessary that we all work together and spend our time learning and teaching each other as well as our patients if we are to stay abreast of the current information.

Please read this excellent article and let me know what you think about this topic.


Oncology nurse Theresa Brown is a regular contributor to Well. INSERT DESCRIPTION

By Theresa Brown, R.N.

My patient was a young woman struggling with aggressive lymphoma who needed around-the-clock pain control. Because of her youth, and the hope that she might be cured, the attending physician was thinking of her future. He worried a patient-controlled analgesia pump could lead to a psychological dependence on narcotics..

For my part, it was hard to watch her struggle against the pain. “What about a fentanyl patch?” I suggested to the doctor, a “fellow’’ who was second in command to the attending physician. Fentanyl patches are the pain-control version of nicotine patches for smokers, and they’re a great way to treat chronic pain in cancer patients. It seemed like a good idea. A patch would give the patient more consistent pain relief and would obviate the doctor’s concerns about overuse.

The fellow looked at me. “That’s a terrible idea,” he said, “to put a fentanyl patch on a patient who is having fevers.” He didn’t say it aggressively, or meanly. But he was very clear, and he was right. My idea was really, really terrible, even dangerous.

The doctor was referring to the fact that heat can interfere with the patch’s slow-release mechanism, causing it to “dump” a large dose of fentanyl all at once. Some patients wearing the patches have died, and some of those deaths were likely caused by a patient applying a heating pad, or because a patient had a fever.

I knew about these risks because about six months earlier a flurry of e-mails went out to staff nurses alerting us to the dangers of combining fentanyl patches and heat. Stories about patient deaths were posted in the break room, and fentanyl patches became a hot topic of conversation among the nurses on the floor. Remembering those discussions, I couldn’t believe what I had just suggested. Everything I knew about fentanyl patches and fevers rushed to the front of my mind as a reproach, and nine months later the memory of this experience still fills me with shame.

A few weeks later I was caring for another patient who had been having fevers on and off. It was about 10 in the morning, three hours into my shift, and the time of day when we usually get our first chance to catch our breath, when it clicked in my head that my patient with the fevers was wearing a fentanyl patch for pain.

I paged the intern, the doctor-in-training who had my patient for the day, and half-asked, half-explained, “I’m wondering if you want to remove that fentanyl patch since the patient keeps spiking temps?”

The intern paused for a moment. I’m sure he was in the middle of morning rounds and busy, possibly even waiting to present a different patient, on another floor, to the attending physician. “No,” he said, “It’s a low dose — it’ll be O.K.”

Was there some condescension in his voice? I wasn’t sure, but I decided to leave the question of what to do about the patch unanswered for the moment. Twenty minutes seemed like an acceptable amount of time to wait before repaging the intern. After all, he was right, it was a low dose. I had a few meds to give to my other patients, and afterwards I could flag down the charge nurse and ask her whether it was safe to leave the fentanyl patch on the patient.

The 20 minutes was almost up when my phone rang. It was the intern, calling to tell me he had checked with pharmacy about the fentanyl patch and the feverish patient. “They said it would be a good idea to remove it,’’ he told me.

This time I wondered if he sounded embarrassed, but I didn’t linger, just told him I’d remove the patch. “I feel better about that,” I said.

I walked through the double doors that separate one part of my floor from another, on my way to remove the patch, when the intern himself came through the door from the other side. I had not met him before, but I recognized him by the name stitched on his long white coat.

We stopped in the doorway, he and I, for the briefest of conversations. I realized he definitely was embarrassed. I tried to reassure him. “That news about fevers and fentanyl came out maybe a year ago,” I told him, trying to be neutral, to keep any flavor of judgment out of my voice. I knew from experience how bad it felt to make that particular mistake, and I didn’t want to aggravate any bad feelings he already had.

He nodded at me and gave a small smile. I smiled back. Then he hurried through the doors to finish morning rounds, and I went back through the doors in the opposite direction, toward the patient whose patch needed to be removed.

In the book “Complications,” the surgeon Atul Gawande described the difficulties inherent in medicine being learned on the job: “The moral burden of practicing on people is always with us, but for the most part unspoken.” He explained that part of what blunts that moral burden is the supervision interns and residents get from more senior residents and attending physicians, who guide and instruct as needed. What Dr. Gawande did not say, and in my experience what also remains unspoken among nurses and doctors, is that floor nurses do some of that guiding and instructing, too. It’s an ad hoc, unsystematic part of medical education, but it can make a difference in patient care.

We all get emails, read journals and take classes, but still sometimes, in the hurly-burly of the modern hospital, crucial information can fall through individual mental cracks. At those times information gets passed on person to person: doctor to doctor, nurse to nurse, doctor to nurse, and sometimes even nurse to doctor.

Having doctors who are willing to educate nurses makes a difference, too. The fellow who took my suggestion about the fentanyl patch seriously enough to tell me it was a “terrible idea” cemented the information in my brain. When the issue came up again, I could raise it as a question for the intern, who then went to the pharmacy to complete his education.

There’s always more to learn, and no matter how hard any of us try, there’s rarely enough time for one person to learn it all.

Please click here to go to the original article and read the comments

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November 27, 2009

Six Best Practice Elements of ThedaCare’s Collaborative Care Model

Illustration of w:Florence Nightingale
Image via Wikipedia

This is an interesting article that discusses the way a hospital system decided to change the way it provided care and establish a goal for the future by addressing patient care and patient perceptions.  That is unique in this field, but what really caught my eye was the fact that the model was developed mainly on the input from nurses who were actually giving that care.  That is unheard of!

It is very nice to see an article that gives credit to the nursing staff and actually has nice things to say about their collective abilities to facilitate changes that make things better.  In this instance, the patients themselves gave the model a good response.

Anyway, read the article here or visit the original and read some of the other articles found there.  It is worth your time, I think, to read and think about this process.  Maybe you can initiate something similar in your own system?  It’s not impossible, but I agree change is always hard.


By Lindsey Dunn October 23, 2009

ThedaCare, a four hospital community health system based in Appleton, Wisc., is a leading healthcare delivery system and is nationally recognized for its continual process improvement efforts. The hospital recently implemented one of its widest-ranging improvement efforts — a truly integrated, collaborative model to guide all inpatient care. The collaborative model has been widely successful in improving the quality of patient care and making that care more efficient, according to Kathryn Correia, senior vice president of ThedaCare and president of Appleton Medical Center and ThedaClark Medical Center in Neenah, Wisc.

“Lean” process improvement
In 2003, ThedaCare executives searched for a way to accelerate the health system’s process improvement efforts and stumbled upon lean management — a management and process improvement method that is focused on eliminating activities that do not add value to the organization’s end product. Executives from the health system found a company in their own backyard that had successfully implemented lean processes to the manufacturing of outdoor equipment and set forward in implementing these same processes in their hospitals.

“We knew there was a lot we didn’t know, but we decided to get our hands dirty and jump right in,” says Ms. Correia. “We brought in facilitators and held week-long rapid improvement events where groups of employees examined various processes and recommended improvements. We looked at the various results from these events and selected a few areas to work on first.”

The hospitals started with improving administrative aspects of hospital processes, and then moved to examining enterprise value streams. Eventually, hospital leaders began to focus on improving inpatient care in order to differentiate ThedaCare’s inpatient services from its competitors, and put an improvement group to work to figure out a way to meet this goal.

“We decided that our vision for the future was creating a unique inpatient and ER experience, which relates back to the mission of our hospitals, and this became part of our strategic plan,” says Ms. Correia. “What resulted from about 18 months of process improvement events examining this was a total redesign of our inpatient care — a truly breakthrough and innovative model for collaborative care.”

Model of success
After a year of trialing the new, employee-developed collaborative-care model, ThedaCare began implementing it system-wide — a process which is expected to be completed by 2012. The model has proven extremely effective so far, reducing costs associated with inpatient stays by 25 percent, patients’ length of stay by 25 percent and various error margins to nearly zero and significantly increasing patient satisfaction scores.

According to Ms. Correia, the model’s effectiveness is due to the input of front-line employees in developing the model. “Innovation happens synergistically. We knew we had to figure out what our differentiator would be in the future for inpatient care, but we weren’t quite sure what it would be,” she says. “Nurses had a good concept of what they wanted collaborative care to look like, but we needed lean processes to really develop something we could implement.”

ThedaCare’s collaborative care model is truly groundbreaking and will likely serve as a model for many other hospitals as they look to integrate their services and provide more collaborative care. The model is composed of six critical elements, all of which encourage the collaboration of caregivers and the removal of non-value added activity in the provision of inpatient care. The six elements are:

1. Collaborative rounding upon admission.
Within 90 minutes of admission, a nurse, physician and pharmacist round on a patient and his or her family and collaboratively develop a care plan specific to the patient. The three-way rounding ensures that all providers understand and agree upon a patient’s course of care, and the presence of the pharmacist additionally reduces the possibility of harmful drug interactions, says Ms. Correia.

2. Evidence-based plans of care. Each patient receives his or her own evidence-based single plan of care, which integrates services from various departments within the hospital. The care plans are developed using care guidelines from Milliman Care Guidelines, a Milliman Company, and all disciplines combine to form a single integrated plan.

3. Nurse as manager of care.
In ThedaCare’s collaborative model, the nurse is the navigator of patient care and is supported by ancillary paraprofessionals. The nurse is responsible for guiding the patient from one phase of care to the next and makes sure that all quality criteria are met during each phase of care. Nurses often suggest options to physicians in order to advance care at a more optimum rate, says Ms. Correia.

4. Tollgates.
As patients move through their care plans, nurses ensure that the patients do not move forward unless they meet certain requirements of their last phase of care. These “tollgates” are based largely on care guidelines and time, and serve stopping points along the path of care. When a patient reaches a tollgate, the nurse will only allow the patient through to the next phase of care if it is documented that the patient has undergone certain measures of quality required in the previous phase of care.

For example, evidence-based medicine suggests that pneumonia patient should receive an antibiotic within four hours of admission. Thus, a ThedaCare nurse is responsible for ensuring that all pneumonia patients receive an antibiotic in this time frame, and if this doesn’t occur, the nurse must stop the care pathway and fix the issue before advancing the patient.

5. Electronic medical record.
Thedacare uses electronic medical records to track the progress of a patient’s care along his or her pathway and share health information among providers from different service areas within the hospitals. The EMRs also include notifications for tollgates, alerting nurses of the need to evaluate a phase of care.

6. Purposeful design of physical space.
Finally, ThedaCare redesigned its inpatient floors in order to make care more efficient. Each patient room includes approximately 80 percent of supplies a nurse would need to care for a patient; this reduces the time a nurse would spend traveling from the room to the central supply location, says Ms. Correia. Additionally, the rooms are designed to reduce the steps staff members take to perform various tasks, thereby making care more efficient.

Learn more about this model here

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