By SUZANNE BOYD
COVID-19 and should nurses be allowed to practice without physician oversight?
Florence Nightingale may be the world's best-known nurse and since 2020 is the 200th anniversary of her birth, the World Health Organization has declared this the Year of the Nurse. Nightingale's role in healthcare far exceeded that of a nurse because she was a leading reformer of health standards and promoted initiatives such as infection control. She also identified that hospital buildings could affect health outcomes and her ward designs (known as Nightingale Wards) were widely adopted. Ironically, many of the issues close to Nightingale's heart are, once again, in the spotlight during the current pandemic. As such, 2020 may be best remembered as the Year of the Nurse for the role they and other first responders have played in the pandemic.
Each spring, Medical News holds its Nurses' Roundtable to turn the spotlight on nurses across the area and the issues the profession is facing. Obviously, the pandemic has been at the forefront, but there is also state legislation being introduced that could greatly impact the autonomy of Advanced Nurse Practitioners. Medical News gathered four nursing leaders to hear their perspectives on these issues.
As the manager of a dedicated COVID-19 unit at Baptist Memorial Hospital - Memphis, Brett Walker has been on the frontline of the pandemic. The 38-bed inpatient unit treats pending or positive COVID-19 test patients who do not require ICU care. Since it saw its first case on March 7, the unit averaged 20 patients daily through the end of April.
"We learned a lot on the fly using guidelines from the CDC as a roadmap along with what we were learning from China," said Walker. "Collaboration on the unit between nursing, infectious disease and the pulmonologists has been crucial as we had to adapt to the situation as it unfolded. We would try things that had worked in the past but found that often they would not work on the scale we had. For instance, we had a vast number of isolation patients and had to efficiently manage the large amount of clean and dirty Personal Protection Equipment required. We have tables for clean items and those that need cleaning. Our team implemented the use of tables between rooms so that PPE would not be cross-contaminated."
One big lesson learned, said Walker, is that overall, the country was not prepared. This pandemic was a great learning experience for healthcare. "The Ebola scare made us realize that certain areas of the hospital had to have certain things," he said. "This time it was on a much bigger scale and we have learned some valuable lessons. Now, you see more units with negative pressure rooms, and I think that will be integrated into new construction and renovation projects going forward. There will also be better infection control overall, including more screening for visitors and employees."
Having been in a professional role in healthcare since 1975, Methodist North Hospital's president, Florence Jones has seen her share of epidemics but says the COVID-19 pandemic is so different and stressful. "One thing I learned is that I am taking care of the caregivers, and I take that seriously," she said. "When this first started, people looked to me for answers. They were concerned for themselves as well as their families. I had the same emotions but had to stay calm, stay positive and be transparent. I am fortunate to be part of a great system that pulled together to address the needs of those on the frontlines. Our staff feel their needs are being met and I am thankful to them for what they are doing, for without their dedication we could not deliver on our mission."
As the owner of a primary care clinic as well as a Nurse Practitioner, Kathy O'Connor Wray's frontline is a bit different than in the hospital setting. Being both administrator and provider is stressful since she must make sure patients are getting the care they need while the clinic is open, then having to perform on the management side after hours.
"Our practice is primary care and also acute care, so normally we would take all walk-ins. Now, we are technically appointment only due to social distancing. If someone has to be seen urgently, we have to have them wait in the car," said Wray. "Our practice is seeing about half the number of patients we used to because people are waiting to go to the doctor for fear of exposure to COVID-19. Beside a decline in patient revenue, we also run the risk of missing abnormalities and such that would be caught on routine physicals and exams that are now being put on hold."
From an administrative side, Wray said it has been a struggle to keep the doors open. "We have gone to a lot of expense that we would not normally incur. We are having to navigate the financial side of things including cost reporting, lost revenues, etc. as we work with our accountants, as well as with our EHR to get the information needed to apply for stimulus money," she said. "We have had to cut employee hours back, both owners have not taken paychecks so we can pay others and stay open. Our goal is to be able to re-hire workers and get back up to speed as soon as possible."
As an associate professor at Freed Hardeman University as well as president of District 6 of the Tennessee Nursing Association, which includes the Jackson area, Raven Wentworth viewed the frontlines from a distance. Acting as a liaison between the TNA main office and area members, Wentworth's role was to ensure that the concerns of nurses in her area were heard. She said these ranged from reduction in working hours due to decreased censuses that impacted their pay checks, to PPE supply levels and personal safety, which caused the most anxiety among nurses.
On the education front, clinical rotations were impacted immediately and what they will look like in the future is still uncertain. "In March, students were taken out of clinical placements," said Wentworth. "Since we did not know when or if our senior level nursing students would get to complete their clinical rotations, we had to develop simulation case studies that would be acceptable to the Nursing Board. With the future of students in the hospital still uncertain, we are continuing to look at ways we can get them some form of that experiential learning. While we need the students in the hospital setting, we certainly respect the hospital's needs."
Across the panel, having an adequate supply of nurses was a central theme and one that circled back to lessons learned in the midst of the pandemic. Walker expressed his concern for the shortage of nurses at the bedside due to the increasing number of nursing opportunities away from the bedside, which could greatly impact smaller hospitals. He also felt that the comradery developed during the pandemic, especially among nurses, may help keep some at the bedside.
Jones mirrored that concern for a nursing shortage. "In 2022, there is going to be a shortage of seasoned nurses," she said. "I truly believe how we deliver care Post-COVID is going to be different. How that will look, I don't know but I feel there will be an even greater focus on quality care and outcomes as well as ensuring safe care. We will look at simple things, eliminate waste and engage patients to help take care of themselves. I believe nursing will take a prominent role in this evolution because there is evidence that people trust nursing as a profession. My big concern is that nurses are going to need time to deliver on quality care, education and waste prevention but unfortunately our global healthcare system is not set up to accommodate those types of things. As things move forward and evolve, it will be important to engage nurses to take care of those items."
For Wentworth, there was a continuation of common themes such as compassion fatigue and burnout among nurses. "We are also seeing more discussion centering on workplace violence as well as verbal and physical abuse," she said. "Nurses are also concerned about the time devoted to paperwork and charting. While technology is great, a lot of time devoted to EHRs takes nurses away from patients or it has to be done away from or after work hours to stay on top of it."
The sponsors and proponents of this legislation, including the Tennessee Nurses Association, propose to change state law to remove requirements for nurses to maintain a collaborative relationship with a physician that would allow complete independent (unsupervised) practice for advance practice nurses in Tennessee. During the pandemic, Governor Bill Lee suspended collaborative practice rules to allow for access to care in a time of crisis. This has fueled the case in some people's eyes for this legislation to be passed.
Jones pointed out that there is already support from Health and Human Services and government for APN's to work independently. "Advanced Practice Nurses are well received by patients and there is a large body of evidence that supports care given by them is safe, effective, can eliminate waste and reduce costs," said Jones. "It doesn't take much to substantiate that, it just gets emotional. If you put the patient at the center and look at issues such as access to care, affordability and education on chronic disease, allowing access to an APN, makes sense. This issue will evolve over time and we are going to have to work together with both doctors and nurses for what is best for the patient."
Walker saw firsthand the benefit an NP can bring when he worked in an Emergency Department but remains in the middle on the legislation. "Doctors can have up to three to eight additional years of post-graduate training before they practice autonomously," said Walker. "I think ANP's need some transitional phase commensurate with that of a physician to ensure they meet all the requirements to practice on their own. I think NPs can be a great resource, especially for rural areas, there just needs to be some oversight to ensure quality care is provided."
Wray said there has been a lot of commentary from doctors about the difference in education. "I have been to school for 14 years earning my ASN, BSN, MBA, MSN and doctorate. Not everyone does it like I did, but I wanted that knowledge and advancement," she said. "There has been a push for all NPs at the entry level to be like pharmacists and have their doctoral degree. I would wholeheartedly support that."
Wentworth tries not to get discouraged on the issue. "When I graduated from Vanderbilt with my master's, my best friend from Montana left and opened her own practice. Fourteen years later, we cannot do that in that state I live in without oversight," said Wentworth. "Tennessee is 44th in health outcomes. We have to have a plan to improve that because it is unacceptable. I support full practice authority since it can increase access to care, especially in rural areas. As other states work through this issue, I think it is a matter of time before Tennessee does the same."
As a nurse practitioner who owns her own clinic, Wray's perspective on the issue is from firsthand experience. "It really does limit care. If I have an order that needs a doctor's signature and that does not happen in a timely manner, the care is delayed. Also having to pay for a physician to sign off on things takes money away from direct patient care," she said. "We are not going anywhere soon. Research shows that APNs can have great health outcomes and provide quality care to patients without doctor supervision. As the pandemic caused the suspension of collaborative supervision, I hope we can look at the outcomes in our state and see what we have been able to do without doctor oversight and let that guide this legislation."