It is now the beginning of July, the month Margie Dorman-O’Donnell, RN assumes the presidency of Texas Nurses Association.  It has been a great pleasure to be the TNA president for the last four years, and to share news and thoughts with you this past year via this Nurses-at-Work blog.  

The themes we’ve discussed – the nursing legislative agenda, nursing education, the IOM report on the Future of Nursing,  the collaboration between TNA and other professional nursing groups, the results of the “Winkler County nurses’’ trial, the role of the nurse in health and illness,  and various initiatives of TNA – continue to be important for nurses.  Although I won’t be writing this blog every week or so, I will read it faithfully to learn via your comments what you have to say. 

Thank you for your dialogue and for your concern for nursing and nurses in Texas.  I am confident that we will continue to make progress to make the health care environment safe for patients and for nurses.

There are many important reasons to belong to Texas Nurses Association and American Nurses Association, but I recently received an email which provided a new reason to be linked to other nurses through TNA/ANA. Dr. Karen Daley, president of ANA, sent me an email because of my membership. She wanted to encourage members to participate in the third evolution of the Nurses’ Health Study.

The original Nurses’ Health Study began in 1976 with the participation of more than 121,000 nurses. An additional 116,000 female RNs were enrolled in Nurses’ Health Study II in 1989. Nurses were chosen as subjects for this study because researchers felt their education prepared them to accurately answer the technically-worded questionnaires and that they would be motivated to participate in a long-term study. The original researchers were right about nurses’ commitment to understanding health and illness. The response rates to questionnaires are at 90% for each two-year cycle.

Every two years since the beginning of the original study, cohort members received a follow-up questionnaire with questions about diseases and health-related topics including smoking, hormone use, and menopausal status. Ultimately, questions about diet, exercise and quality of life issues were added. These two studies were among the largest investigations ever conducted into risk factors for major chronic disease in women.

Despite the results of these studies, there is still a great deal about women’s health, especially among women from diverse ethnic backgrounds, that we don’t know. So, the goal of the Nurses’ Health Study 3 is to investigate how women’s lifestyles (including diet, exercise, birth control, pregnancy, work exposures, etc.) during their 20s, 30s and 40s can influence their health and disease risk later in life. Enrollment for this study began in the summer of 2010 and will continue until 100,000 nurses aged 22 to 45 are recruited. To make it more convenient, this study will be conducted entirely over the Internet via online questionnaires.

Unfortunately, I am not between the ages of 22and 45 and cannot participate but I can encourage those of you who are in that age group to participate. Just go to www.NHS3.org and sign up. Nurses make a difference in the health of our patients in many, many ways. This study is another example – and an example of why a connection with TNA/ANA helps us all.

Our voices do make a difference!  In the closing days of the 82^nd Texas Legislative Session, nurses have once again proved that, led by the TNA staff, nurses’ opinions do influence our legislators.  Let me give you an example. 

Senate Bill 794 proposed the dedication to nursing of certain tobacco lawsuit settlement funds.  For a number of years, the Texas Higher Education Coordinating Board has used these tobacco funds for Nursing Innovative Grant Programs which provide funding to nursing schools that “propose to address the shortage of RNs by developing innovative educational strategies for initial licensure nursing students and of faculty who would teach in initial RN licensure programs.”  The dedication of these funds for nursing education was set to expire on August 31, which would result in nursing education losing at least $3 million in potential state funding. 

On Monday, May 9, TNA sent out an alert indicating that SB 794 could not pass without a hearing by the House Higher Education Committee.  With only two hearings left in this legislative session, TNA members and stakeholders were asked to communicate with the members of this committee requesting a hearing of this bill.  As a result of the ground swell of communication, on May 10, the chairman of the committee, Dan Branch, had the House rules suspended so that SB 794 could be added to the Committee Hearing on May 11.  The chairman of the TNA Education Committee, Beth Mancini, testified on behalf of TNA regarding the importance of the continued dedication of these funds to nursing.  The committee voted the bill out of the committee and recommended that it be set on the Local and Consent Calendar – exactly the results we wanted.  As Clair Jordan, TNA executive director says, “While something can always go wrong in the legislative process, the chances of this bill passing are very good.” 

This example illustrates how important TNA’s lobbying efforts are for nursing.  I encourage you to connect with the Governmental Affairs efforts.   You can make a difference in the future of nursing. 

P.S.  At the end of Beth Mancini’s testimony before the House Higher Education Committee, the Committee chairman asked her a number of questions about the nursing shortage and nursing education.  If you want to listen to that exchange, it can be found at:

http://www.house.state.tx.us/video-audio/committee-bradcasts/committee-archives/player/?session=82&committee=290&ram=11051108290

SB 794 starts at tape position 31:55 and Chairman Branch’s questioning begins at 36:40.

Most of you who have followed nursing news from TNA or read my blog are aware of the ordeal that the two “Winkler County nurses” experienced after reporting a physician to the Texas Medical Board.  Their complaint was anonymous.  In their complaint letter, the nurses wrote:

Due to the “economic climate,” the fact that I am over 50, female and have been employed by this facility since the 1980s, I am hesitant to place a signature on this information.  Administration has made it clear that there will be no reporting of any problems without Administrative, Medical Staff and Board notification.  This would certainly create an opportunity for the administrator to remove me from employment.

The fact that the nurses could report this situation anonymously made it possible for them to do so, even when the administration of the hospital where they were employed  were unwilling to act to protect patients.  Unfortunately in this situation, even though the report was anonymous, the Winkler County Sheriff was able to identify them.  Not only were they fired, they were also criminally indicted and arrested. 

The anonymous reporting of physician misconduct to the Texas Medical Board supports the nurses’ ability to act to protect their patients, even when their own professional career is at risk.  Unfortunately, House Bill 1013, currently in the House Calendar Committee waiting to be set on the House Calendar for a vote by the full house, requires that the Texas Medical Board disclose to the physician  the identity of anyone who reports that physician unless it is the patient or the patient’s parents.   

It is a nurse’s ethical duty to protect patients—and this may include reporting unsafe practices to appropriate bodies.  Unfortunately, we have seen what can happen when people in positions of power, including physicians and hospital administrators, wish to hide unsafe practices from public scrutiny.  While we might wish that providers of all disciplines who speak up for patient safety would be protected from retribution, we know that retribution of one kind or another may occur.  This bill may have been developed with the best of intentions; however, we have recent and dramatic evidence that confidentiality for reporting unsafe practices must be preserved.  TNA will be sending an alert asking constituents to contact their representatives to vote against this bill.  Please visit the TNA website often this week for further information.  TNA continues to protect the practice of nursing!

The IOM report, The Future of Nursing, has received a lot of attention since its release in October of 2010.  The four key messages of the report are designed to improve the quality of health care by enhancement of nursing in this country.  

As a strategy to support implementation of the report throughout the country, the Robert Wood Johnson Foundation and AARP Foundation created the Future of Nursing: Campaign for Action, a collaboration to ensure that all Americans have access to high quality, patient-centered care in which nurses contribute as essential partners in system-wide transformation.  A major mechanism is to develop Regional Action Coalitions (RAC) to drive these recommendations throughout state, regional and local areas. 

Texas is applying to become a recognized RAC to be known as Texas Team:  Leading Change and Advancing Health Initiative on the Future of Texas. The effort is under the direction of Dr. Alexia Green, professor and dean emerita of the Anita Thigpen Perry School of Nursing, Texas Tech University Health Sciences Center and former TNA president.  At the recent Texas Nurses Association House of Delegates, the delegates approved TNA’s role as the lead nursing organization in this RAC.  Blue Cross Blue Shield of Texas will serve as the lead non-nursing organization.  

This coalition brings a wide range of organizations (advocacy groups, businesses, foundations, health care organizations, nursing organizations, schools of nursing, universities and community colleges) together with individuals to address the IOM recommendations in Texas.  This work will be accomplished through several teams with state-wide representation, including the Advancing Nursing Education and Advancing Nursing Practice Teams, as well as Executive Committee, Strategic Advisory Committee, and Tactical Support and Operations.  

TNA believes this initiative is important for the nurses of Texas and we are delighted to be a leader of this effort.  Many TNA members are actively involved and we hope that you will be as well.  Please go to www.dshs.state.tx.us/chs/cnws and click on Texas Team for more information.  Inaugural meetings of the various state teams will be held in the next several weeks.  Stay tuned to this blog for more information of plans to move this initiative to Texas regional and local areas, as well as opportunities for individuals to be involved.

How often do you provide nursing care without any interaction with others?   How often does your care of the patient depend only on your intervention and the individual patient’s response?  My guess is this rarely happens.  Instead, you must interact not only with the patient and his/her significant others, but also with a wide range of health professionals (physicians, allied health professionals, administrators, and even insurers).  Your ability to collaborate with a variety of health professionals is critical for a successful outcome.

In nursing, we have been talking about the need for interdisciplinary or interprofessional collaboration as long as I have been a nurse (which is a LONG time!).  Yet for a variety of reasons, in most work places, we rarely get it right.  Today, as care becomes more complex and the need to reduce costs points us toward improved coordination across the care continuum, the need for REAL collaboration among the patient and a wide range of health professionals becomes critical.  One of the goals of the IOM Future of Nursing report is to foster interprofessional collaboration.  In February, the Interprofessional Education Collaborative (IPEC), sponsored by a number of organizations representing health professions education, proposed “Core Competencies for Interprofessional Collaborative Practice”.  The notion behind these competencies is that if students are taught to work with other disciplines, they are more likely to effectively work together in the work place after graduation.  These core competencies are:

• Work with individuals of other professions to maintain a climate of mutual respect and shared values.
• Use the knowledge of one’s own role and the roles of those professions to appropriately assess and address the health care needs of the patients and populations served.
• Communicate with patients, families, communities and other health professionals in a responsive and responsible manner that supports a team approach to maintaining health and treatment of disease.
• Apply relationship-building values and principles of team dynamics to perform effectively in different team roles to plan and deliver patient/population-centered care that is safe, timely, efficient, effective, and equitable. 

What has been your experience in interprofessional collaboration?  Do you believe, in general, nurses have the skills to collaborate effectively with other professions?  How about other groups?  What can be done to improve interprofessional collaboration in general and in your work place?  What initiatives do you believe Texas Nurses Association should engage in to enhance interprofessional collaboration to improve care in Texas?  I look forward to hearing from you.

TNA’s work with various coalitions has been a favored topic in my previous blogs, but attending several nursing meetings in the last two weeks has re-emphasized for me the importance of collaboration in formal and informal coalitions to improving the practice of nursing and the quality of patient care.  For example, I had the opportunity to hear Dr. Donna Shalala, chair of the Institute of Medicine Future of Nursing Committee, speak about the formation of that committee.  Dr. Shalala acknowledged there are only 5 nurses on the committee of 18 members; the remaining members being drawn from business, non-profit organizations, law, political science, academia, social work and medicine.  She noted that when the committee was formed, many nurses were concerned that there was an insufficient number of nurses on it to really define the future of nursing.  However, Dr. Shalala countered that having other stakeholders heavily involved in the process has provided a broad base of support for the final committee recommendations, thus, increasing the likelihood that action will be taken to achieve the recommendations.  This is the value of coalitions.

Over the last five months since the Future of Nursing report came out, Dr. Shalala – and other spokespersons involved in the implementation of the recommendations – have emphasized that similar coalitions made up of groups with a variety of perspectives must now work together at state, regional, and local areas to accomplish the broad recommendations of the report. 

True to our tradition, TNA is involved in the state-wide coalition to make the Future of Nursing recommendations a reality in Texas.  TNA is serving as one of two lead organizations in the Texas Team:  Advancing Health through Nursing Initiative.  The other lead organization is Blue Cross Blue Shield of Texas.  I’ll tell you more about the work of this coalition in the future as TNA continues its commitment to collaborate with all stakeholders who also seek to improve the practice of nursing and the quality of patient care.  Are there any groups you’d recommend for collaboration with TNA?  Please share your thoughts.

Imagine the impact when 200 nurses convene upon the Texas Legislature to talk to their legislators about nursing and health care!  I had the pleasure of participating in the 2011 Nurse Day at the Capital on March 7 and 8, and saw the impact on both the nurses who came to the event and the legislators and their staffs who heard nursing’s issues.  The two-day event began with an orientation presented by Joe Gagen, legislative grass roots trainer.  Jim Willmann and the TNA Governmental Affairs Committee also gave the participants an overview of the bills that could affect nursing and health care that are currently somewhere within the legislative process. 

You can follow nursing’s bills on TNA’s website.  Look for Priority Bills for Nursing.   

On the second day of Nurse Day at the Capital, nurses had the opportunity to visit with their legislators (or their staffs) in meetings set up by the TNA Governmental Affairs Committee (GAC).  This gave those new to the advocacy process an opportunity to participate in these visits with more experienced nurses and gave everyone an opportunity to learn from their colleagues.  In addition, everyone was able to observe the proceedings in both the Texas House and Senate.  Sen. Jane Nelson and Rep. Donna Howard both put forward a resolution honoring nurses in the Senate and House respectively. 

After the morning’s legislative session, those in attendance heard testimony presented before the Texas Senate Committee on Health and Human Services.  I was privileged to be able to testify on behalf of TNA during this committee session. 

In short, it was a great day and I would encourage you all to stay tuned to the impact of the legislative process on your practice during this legislative session.  Please feel free to provide me with comments, questions and opinions about the legislative process.  I look forward to hearing from you.

A major contribution that Texas Nurses Association brings to nursing in this state is the organization’s involvement in issues important to nursing and its connections to other groups that influence the education and practice of nurses.  Here’s a perfect example of this influence: For years, a barrier to nurses’ continued formal education is the lack of flexibility in transferring earned credits from one school to another.  Fifteen years ago, TNA took the lead to develop the TNA Articulation Agreement, which allowed university nursing programs to accept the successful completion of the NCLEX exam as evidence of competence in various entry-level nursing courses, such as med-surg, OB, and Pediatrics.  This resulted in a much easier transition from an associate degree or diploma to a BSN program.

When the IOM report, The Future of Nursing, recommended that 80% of practicing RNs should hold BSNs by 2020, the TNA Education Committee recognized that there was more work to be done.  The general education courses, some of which are required by state mandates and some by university mission and policy, are cumbersome to negotiate for those who want to enroll in RN-to-BSN/MSN programs or who want to transfer schools prior to their professional course work.  In order to address this issue, the TNA Education Committee under the leadership of Beth Mancini, is developing a survey of ADN and BSN faculty.  The purpose of the survey is to determine what general education courses these experts in nursing education believe are CRITICAL for successful practice as an ADN/Diploma- or BSN-prepared nurse and which are “nice to know”.  The results of the survey, to be completed during March, will provide us with information which nursing education administrators can negotiate within their own colleges/universities, possible exceptions to general education requirements.

This work, important in its own right, is particularly timely because, on Wednesday, February 16^th, staff from the Texas Board of Nursing testified before the House Appropriations Committee.  One of the legislators expressed great concern about the lack of seamless transition between nursing programs, primarily related to prerequisite courses.  Since the nursing community is well connected, in large measure because of the ongoing work of TNA (and others), organized nursing was able to communicate its concerns about this issue—-and what we are doing to resolve the problem.

Problems related to nursing and health care will not go away in this state.  Yet, because of TNA and its connections around the state, we can be in front of the possible solutions, not behind them.  I would be interested in hearing other stories that represent TNA’s connections—or areas in which you think we should focus.  Together, we can make a difference in nursing education and practice.

A couple of weeks ago, I mentioned the exciting work of the TNA/TONE Health Information Technology (HIT) Task Force.  Because I realize how important HIT will be to health care delivery—and because I recognize my lack of expertise in this area, I spent a cold, snowy day in Wichita Falls, reviewing what the IOM’s “The Future of Nursing: Leading Change, Advancing Health” had to say about the impact of technology in health care today and tomorrow.

The report indicates that the 2009 American Recovery and Reinvestment Act (ARRA) authorized CMS to provide incentives to encourage eligible hospitals and health professionals to become “meaningful users” of certified electronic health records.  (Incidentally, meaningful use is currently defined as “use by providers to achieve improvements in care.”) Currently, this data includes patient demographics, vital signs, diagnoses, allergies, and active medications, but in the future, many other types of data may be included in the definition.  The report states that nurses must be integral to proper collection of meaningful use data. 

Since implementation of the ARRA in 2009, the use of HIT has expanded throughout the care delivery system. I am sure that many of you have been involved in the integration of EHRs into your practice. The integration of HIT into practice settings will likely fundamentally change the way nurses plan and document care (IOM, 2010).   The limited available research regarding the use of HIT to document care finds that quality and accessibility generally improve after implementation of an EHR system (IOM, 2010).  In addition, medication errors are almost always reduced after implementation of bar codes as part of medication administration (Waneka & Spetz, 2009).  Even more importantly, over the next several decades, the expanding use of HIT will also change the way we deliver care.  For example, patient history and examination data may be collected by devices, such as an automatic BP cuff that interact with a patient’s body and then automatically stream the results into the EHR.

Despite the progress that has been made in integrating information technology into health care, a survey at 25 leading acute care facilities across the U.S. indicated nurses find that the existing HIT systems are often splintered, unable to interface, and require multiple log-on access to enter data (Bolton, 2008). The results of this study suggest that there is work to be done to reach the vision for HIT.  The technological systems must be improved AND providers must become competent in managing information technology.  The IOM report suggests that the transition from the health care we know today to the health care of the future is based, at least in part, on the technological literacy of the providers.   How will nurses in Texas achieve this literacy?  How can TNA and other nursing organizations, such as TONE, help in this development?  The HIT Task Force is working to develop priorities for our next steps in this arena.   I would love to hear your ideas on this important initiative.

 References

Bolton, L., Gassert, C., Cipriano, P.  (2008)  Smart technology, enduring solutions:  Technology solutions can make nursing care safer and more efficient.  Journal of Healthcare Information Management.  22 (4) 24-30.

IOM (2010) The Future of Nursing:  Leading Change, Advancing Health.  Institute of Medicine of the National Academies of Sciences

Waneka, R., Spetz, J. (2009) 2007-2008 Annual school report:  Data summary and historical trend analysis.  Sacramento, CA:  California Board of Registered Nursing.