Nurses prepare for expanded roles

Jim Kaczor and Debbie Micholas spend a day once a week in nursing classes, but they hardly resemble your typical students.

Kaczor has more than two decades of experience as a nurse, while Micholas is newer to the field after working for many years in business offices.

They will earn bachelor’s degrees this May, part of the first class to graduate from an “RN to BSN” program organized by Niagara University and Catholic Health.

The demand for nurses with higher degrees has gained so much in importance that the hospital system is footing the bill for all 23 students in the class — tuition, books and fees. Catholic Health even supplies everyone with a computer.

The program may seem small, but it represents one of many developments in nursing here and across the nation that mark a potential sea change in training and the nature of the work nurses will perform in the future.

Nursing organizations are lobbying for a bill in New York requiring new nurses to earn a bachelor’s within 10 years to keep working in the state.

The proposed legislation coincides with a national campaign, backed by such organizations as AARP, to raise educational standards for all nurses and to gain greater independence for advanced practice nurses.

One of the most contentious initiatives in New York is another bill under consideration — similar to bills in other states — to remove the requirement that nurse practitioners have a written collaborative agreement with a physician to diagnose, treat and prescribe medications or tests for patients.

“What you are seeing is nurses trying to speak with one voice,” said Carol Brewer, a University at Buffalo nursing professor involved in the national Future of Nursing campaign.

The trends in nursing go back many years but received a jolt of momentum with the 2009 release of the Future of Nursing report by the Institute of Medicine, an organization that advises the government.

The report was done in partnership with the Robert Wood Johnson Foundation, which was interested in nursing issues and several years beforehand had given a $10 million grant to the AARP Foundation to start the Center to Champion Nursing in America. AARP advocates on behalf of older people.

The institute concluded that nursing can fill expanded roles as the demand for medical services increases from an aging population and millions more Americans with insurance coverage under health reform.

But to take advantage of these opportunities, the report argued, will require graduating more nurses with higher degrees and giving nurses more caregiving authority.

A handful of paths
The movement to graduate more nurses with bachelor of science degrees exemplifies the changes under way.

For decades, students have been able to follow a handful of paths to become registered nurses, including two-year associate degrees from community colleges, diplomas from hospital programs, and bachelor of science degrees from four-year colleges and universities.

More than 37 percent of nurses in New York State — and 30 percent in Western New York — report the bachelor’s as their highest degree, according to the Center for Health Workforce Studies in Albany.

The institute report recommended the proportion nationwide increase to 80 percent by 2020. Advocates argue that with health care becoming more complex, nurses need more education. They also say the profession needs more people capable of filling administrative jobs, which usually require a bachelor’s, and earning master’s degrees and doctorates so that they can teach.

In New York, a bill under consideration would require new registered nurses to earn a bachelor’s within 10 years to keep working in the state.

Hospitals and schools are already moving in this direction.

The UB School of Nursing, for instance, recently announced it had received state approval to reinstate its 12-month online RN-BS program.

Recruiting tool
Catholic Health — whose hospitals include Mercy, Sisters and Kenmore Mercy — started its tuition-free “RN to BSN” program as a way to retain and recruit nurses. Nurses in the program must agree to stay for at least three years after they graduate and serve as mentors to new nurses.

“We believe the bachelor’s is eventually going to be the basic entry degree for nurses,” said Sandy Spencer, director of clinical education.

Nursing organizations also see the BSN movement as a way to increase the number of nurses capable of teaching, one of the current barriers to graduating more nurses from schools.

For nurses, the developments represent efforts to further professionalize what they do.

Kaczor is a 48-year-old registered nurse with 25 years’ experience who works in the Sisters Hospital emergency room. He wants to be a better nurse and put himself in a position to take on administrative duties.

“I wanted to push myself. There are people coming out of college better prepared than me,” he said. “Nursing is changing, too. You need to be more knowledgeable to educate patients and back up a doctor, and to be considered for management.”

Appropriate training
Micholas is going into her fifth year as a nurse at Kenmore Mercy. Now 46, she got into the profession after working as a billing clerk at a trucking company and then a billing manager for a chiropractor.

“My only regret is that I didn’t do this 20 years ago,” she said.

The students learn about such subjects as statistics in health care, medical ethics and evidence-based medicine.

“It’s the nurse that spends a lot of time by the bedside. We have to educate patients about diet, pain and medications. We need to be appropriately trained to provide that information,” Micholas said.

The “BSN in 10” bill isn’t universally supported, primarily because of concerns that it will exacerbate a potential shortage of nurses over the next decade.

The poor economy has alleviated a national nursing shortage as veteran nurses postponed retirement or returned to work.

In addition, a recent report in the journal Health Affairs indicated that more aggressive steps to make nursing a more attractive career led to a 62 percent increase in the number of younger people entering the field between 2002 and 2009.

Safe, effective care
Eighteen states, as well as the District of Columbia, allow nurse practitioners to treat and prescribe medications without a formal collaborative agreement with a supervising physician. These advance-practice nurses, a level of nursing that also includes nurse anesthetists and nurse midwives, are registered nurses with master’s or doctoral degrees.

Nursing organizations cite studies suggesting that for basic medical services, including the diagnosis and treatment of uncomplicated illnesses, care from nurse practitioners is as safe and effective as from physicians.

Advocates argue that nurses don’t need a requirement for a written agreement to collaborate with physicians because many already work with doctors. They contend that care is not worse in states that don’t require written agreements.

“Nurse practitioners have shown that you don’t need a collaborative agreement to have good care. They know when to collaborate,” Brewer said.

Advocates also say nurse practitioners cost less and can be produced more quickly than doctors. So it makes sense to turn to nurse practitioners to provide primary care to offset a shortage of physicians who provide basic medical services, they argue.

Physician shortages nationwide are projected to reach 62,900 doctors by 2015 and 91,500 by 2020, according to estimates by the Association of American Medical Colleges.

The move toward easing restrictions on nurse practitioners and other advance-practice nurses has received support from many organizations, including AARP. But physician groups oppose it.

“We support the idea of a cadre of health professionals, including nurses, working collaboratively as a team. But the interests of patients are served best by having oversight by their physician,” said Dr. Glen Stream, president of the American Association of Family Physicians.

His organization, as well as others, questions the studies that suggest nurse practitioners can offer care as high quality as doctors. They voice concern over nurse practitioners treating patients on their own and referring to themselves as “Doctor.”

Stream said doctors receive more training. As such, he said, nurse practitioners who practice on their own may be inclined to order more tests and other services, offsetting any cost savings of using nurses instead of doctors.

“The real challenge is dealing with patients who have complex symptoms,” he said. “That’s best done by doctors.”

Nurse practitioners counter that they are appropriately trained to handle basic medical issues and refer to doctors when needed.

“The assertions over quality are disingenuous,” said Seth Gordon, president of the Nurse Practitioner Association of New York State. “You can’t legislate good professional judgment.”