More training, bigger roles for nurse practitioners

(News Observer) In an examining room at the N.C. Cancer Hospital, Matt Feinberg checks for a variety of symptoms common to cancer patients after treatment: skin problems, mouth lesions, nausea.

He also listens carefully to Walter Sane, 70, describe how he returned to work five weeks ago, gained eight pounds and got back to the gym.

“You’re a go-getter,” Feinberg tells Sane, who explains that he was first diagnosed with cancer in 2004. On April Fool’s Day, he jokes.

“I can’t get this caliber of treatment nowhere west of the Yadkin (River),” said Sane, a welder and trucker who made the 225-mile trip from Rutherfordton to Chapel Hill.

For his exam on a recent day, Sane was being seen by a nurse practitioner and Feinberg, a UNC-Chapel Hill student and soon-to-be nurse practitioner who’s about to earn his Master of Science in Nursing degree.

In North Carolina, there are nearly 4,500 nurse practitioners, who are increasingly on the front lines of the American health care system. They can write prescriptions and make diagnoses under the supervision of doctors. Most are nurses who have earned a master’s degree to increase their training in direct patient care.

But starting in the fall, those seeking to be advanced nurses will have the option – and eventually, the requirement – to gain more education. Last month, the UNC system’s Board of Governors approved the Doctor of Nursing Practice, or DNP degree, for six public campuses: East Carolina, UNC-CH, UNC-Charlotte, UNC-Greensboro, Winston-Salem State University and Western Carolina University. Two private universities, Duke and Gardner-Webb, already offer the more advanced degree.

Eventually, the three-year program is expected to replace the two-year Master of Science in nursing for those seeking to be nurse practitioners, clinical nurse specialists, certified nurse midwives and certified registered nurse anesthetists. Current nurse practitioners and other advanced nurses will be allowed to continue practicing with their master’s level education.

The new doctoral degree will add a layer of education on top of the patient care preparation. Students in the program will gain leadership and financial ability, training in deciphering research literature and the capacity to analyze and make changes in health care practice. The idea is to enhance nurses’ decision-making skills and understanding of health care policy and systems, said Kristen Swanson, dean of UNC-CH’s School of Nursing.

That push is causing some tension with doctors. But it’s never been more important than now, Swanson said, at the dawn of the Affordable Care Act, which extends insurance eligibility to an additional 32 million Americans. Those patients are generally poorer and have been without health care access for some time.

“You suddenly have real complex … illness and social problems to put together and address,” Swanson said. “It’s going to take more sophisticated health care providers of just about any flavor you can imagine. It’s going to call for teamwork in ways it never has before.”

A national trend

North Carolina’s move to the advanced nursing degree is part of a national trend to boost education for nurses to meet the growing health care demands of an aging population in an increasingly complicated environment.

A 2010 national report on the future of nursing recommended that nurses be more highly trained and assume leadership roles in redesigning the nation’s health care system. It was issued by the independent Institute of Medicine, the health arm of the National Academy of Sciences, which provides expert analysis and advice on the nation’s health care.

The report recommended that 80 percent of the nation’s nurses be four-year bachelor’s degree holders, as opposed to those with a two-year associate’s degree or diploma. It suggested doubling the number of nurses with doctorates by 2020. Of the North Carolina licensed nurses now practicing, 44 percent have a four-year nursing degree or higher.

Leslie Sharpe, chairwoman of the North Carolina Nurses’ Association Council of Nurse Practitioners, said some who currently practice with the master’s degree may worry that their credential is out of date.

But, she said, “It doesn’t mean that the person who has a doctorate is better. It just prepares us on a different level. It prepares us on a broader level.”

That will be useful as health care evolves, she said. “If we’re going to be there on the front lines, if we’re going to be business owners and things like that, we need to have that knowledge.”

At least 30 students will begin UNC-Chapel Hill’s new advanced nursing program this fall, and the program will expand with time, said Debra Barksdale, director of the program and president of the National Organization of Nurse Practitioner Faculties.

Barksdale points out that there is a shortage of primary care providers, especially in rural areas. Ninety-one of 100 counties in North Carolina are designated as medically underserved.

Nurse practitioners can be instrumental in filling that void and keeping costs down, Barksdale said.

“We can’t just rely on any one profession to meet the needs of 30-plus million people in our population needing care,” she said.

A spat with doctors

The new, higher-level programs may add fuel to arguments of nursing advocates who say the state unnecessarily puts up barriers to advanced nurses. State law requires nurse practitioners to have a supervising physician. The doctor does not have to be on site but bears some responsibility for the care provided.

The Institute of Medicine recommended that “regulatory and institutional obstacles – including limits on nurses’ scope of practice – should be removed so that the health system can reap the full benefit of nurses’ training, skills, and knowledge in patient care.”

That’s not likely to happen without a fight. The N.C. Medical Society, which represents 13,000 doctors statewide, has opposed efforts to loosen regulations on nurse practitioners, anesthetists and midwives.

Early this year at the start of the legislative session, the Medical Society joined with other physician groups calling themselves the NC Coalition to Protect Patients. The groups launched a website that argues that current regulations on advanced nurses should remain in place or be written into law.

A blog post on the site says that every doctor in North Carolina “will tell you that a good nurse is worth his or her weight in gold.”

But, the site says, “While nurses and other mid-level providers are a valuable part of the healthcare team, there is simply no substitute for the extensive education and training of physicians.”

Any effort to weaken the requirements on nurses, the site said, is “a bad idea for a bunch of reasons, but none more important than your safety.”

The new advanced nursing programs have not changed doctors’ minds about the importance of supervision for patient safety, said a spokeswoman for the Medical Society.

“We are completely in favor of more training and education for any provider,” said Elaine Ellis Stone, director of communications for the doctors’ group. But, she added: “Our position has not changed and would not change in light of these new programs.”

Stone said that if physician supervision were eliminated, the legislature would then have to draw up a list of procedures that nurse practitioners would be allowed to do.

Some have characterized the fight over who does what as a turf battle that is increasingly irrelevant as the nation’s health care needs expand.

“There are enough sick and unhealthy people around,” Barksdale said. “We don’t need to be fighting.”

Elaine Harwood, a nursing professor at UNC-CH, said it was natural that nurses want to further their training and education.

“We are always nurses,” said Harwood, who earned her advanced degree from Vanderbilt University a few years ago. “Nursing is our ethic. That’s what we want to be. We are not aspiring to be mini-docs.”

Decisions by nurses

Advances in health care provide ways for nurses to contribute more.

Electronic medical records can be used to track data, for example, on whether patients in a geriatric practice are being properly tested for osteoporosis, or whether diabetes patients are being screened for depression.

Nurse practitioners are in a position to study the data, spot a gap and devise a strategy that could improve care for a practice or population.

“We’re supposed to be moving people toward wellness as opposed to curing of illness,” Harwood said.

Feinberg, the soon-to-be nurse practitioner, likes the idea of acting more decisively. He spent a few years as a hospital floor nurse, then did home health care and most recently worked in long-term care.

“I just felt like I was ready to take the next step, and just have some more autonomy and decision making in managing patients,” he said. “As a nurse, you definitely become very aware of a lot of the gaps in the system and discontinuity of care and you’re constantly thinking of ways to try and improve. You know, how could this be done better? How could this be made more efficient?”

Efficiency will be a key for nurse practitioners who are part of a team providing care and reinventing care, said Swanson, the UNC-CH dean.

Swanson cited an example from a Seattle hospital where she worked as a consultant.

At the suggestion of a local corporate executive, a group of hospital staff went to Japan to observe the Toyota assembly line to see its “lean” model in action. The automaker has been known for its consistency, elimination of waste and fix-it-when-you-find-it approach to problems. The hospital adopted the “lean” model and is training other hospitals to do the same.

The goal isn’t just to save money, Swanson said. It’s to remove the hierarchy among health care providers and put the patient as No. 1.

“When the patient is at the top of the pyramid, it’s all about what will work for that patient,” she said. “It becomes not ‘How can we get you out the door as fast as we possibly can?’”