Leaders Discuss the Issues, Challenges and Demands

The role of a nurse has expanded and evolved. Today, nurses must undergo more intense, formal education than in years past and, in addition, are expected to take on more patient responsibility.

At the same time, nurses are more specialized than ever - having more advancement opportunities in the medical field due to the number of specialties that have emerged to meet the growing demand for healthcare.

"I've always heard that a nurse is a nurse," said Wendy M. Likes, PhD, dean of the College of Nursing at University of Tennessee Health Science Center (UTHSC).

She was one of four advanced practice registered nurses from the Memphis area who participated in a roundtable discussion concerning the nursing profession. The event was conducted by Pamela Haskins, publisher of the Memphis Medical News.

"A professor at one time said that we need a super nurse, a nurse who can do anything - one who can go from working on the GI tract to delivering babies," Likes said. "We don't expect physicians to do that. It takes a special person to do each job."

Despite these changes, the roundtable participants all agreed one key element has remained the same - nurses are at the forefront of patient care and serve as an advocate for the patient.

Held in conjunction with National Nurses Week, the roundtable included discussion of the high turnover of nurses in the Memphis area, workplace safety issues, the national shortage of nurses in a clinical and academic setting, the need for more nurses at an executive level and the restrictions on nurse practitioners in Tennessee.

Along with Likes, the other three participants in the roundtable discussion were:

• Carla Kirkland, family nurse practitioner, Saint Francis Hospital, , and district 1 president of the Tennessee Nurses Association,
• Blanche F. Petty, women's health nurse practitioner, McDonald Murrman Center for Wellness and Health,
• Cathy Stepter, associate professor and graduate program chair, Baptist College of Health Sciences

High Turnover

According to a recent study by NSI Nursing Solutions, a national nurse placement company, the average hospital nurse turnover rate in 2017 was 18.2 percent. Thirty-three percent of nurses who leave their jobs do so within the first two years.

It was the highest recorded turnover in the healthcare industry in almost a decade.

All four participants agreed that nurse turnover is a big concern. Blanche Petty, of McDonald Murrman, said many nurses are forced to do more because of budget cuts and advancements in technology, and as a result become a product of nurse burnout.

"More and more falls on the nurses," Petty said. "PCAs get cut and nurses have to fill in the gaps. As a result, they get burned out and leave."

She recalled an experience two decades ago when she was a recent graduate from nursing school and became a labor and delivery nurse in a hospital. She was required to attend a six-week, high-risk obstetrics course to learn how to handle certain situations in the hospital. She said this course was a valuable resource, and similar courses could help onboard nurses right out of nursing school.

"It can be an intimidating atmosphere when you get out of school and this course, as well as several charge nurses, helped me understand what to expect working in a high-risk environment," Petty said. "They don't do this anymore, and it was so helpful to me at the time as a nurse right out of school."

Cathy Stepter with Baptist College of Health Sciences said some turnover could be prevented if residency programs were offered for nurses.

"We need to support our nurses in their first year of practice," Stepter said. "These nurses are novices coming in and need to be onboarded correctly. We need nurses ready, and there is a learning curve."

Workplace Safety

Carla Kirkland of the Tennessee Nurses Association (TNA) said a key issue facing nurses in the state is workplace violence, from both patients and co-workers.

Last year a patient was arrested for attacking a nurse practitioner and psychiatric nurse at two different Memphis-area hospitals.

According to Kirkland, this type of violence is on the rise.

Likes said some work is being done on a local level to tackle the issue. Last year, UTHSC was awarded a $16,000 grant from Tennessee Promise, a state scholarship and mentoring program, in collaboration with Regional One Health, to train nurses to handle and defuse crisis situations in hospitals and other healthcare settings. The grant funds crisis management instructor training for six staff members at Regional One Health and two college of nursing faculty members on how to recognize escalating behavior and defuse potentially hostile situations. The training takes place in the classroom and in simulation settings with actors portraying patients in the new UTHSC Center for Healthcare Improvement and Patient Simulation, which opened last year.

"Six hundred nurses have participated in the de-escalation training, which will, hopefully, assist in retention and avoid burnout," Likes said. "The program is still ongoing, and we are in the process of measuring the outcomes."

Nurse Shortage

All nurse participants stressed the need for more nurses in both a clinical and academic setting in the Mid-South. The U.S. Bureau of Labor Statistics predicts that 1.1 million additional nurses are needed to avoid a further nurse shortage nationwide.

"There is a gap in the profession," Likes said. "Many older nurses aren't working in the field anymore. There aren't enough experienced nurses who can onboard a novice nurse."

Stepter said salaries must increase in order to incentivize nurses. She thinks some nurses in the Memphis area choose to leave an employer to become a travel nurse - a nurse hired to work in a specific location for a limited amount of time - and then work locally because the pay is higher. The fact they are travel nurses allows them the opportunity to make additional money when working locally "because of the stipends and perks."
"We need to pay nurses not to travel," she said.
Likes and Stepter said the value of nursing is difficult for hospitals to quantify because nursing isn't a billable profession.
"Nursing is a hidden cost at hospitals," Stepter said. "Many variables demonstrate that we have better outcomes with nurses, and their salaries should reflect that."

Likes and Stepter said there is a need for more nurse faculty at colleges and universities. They agreed that universities are turning away potential nursing students because there aren't enough nurses with advanced degrees nationwide who can teach.

"We are turning nursing students away who are applying," Likes said. "We had 250 applicants for our BSN acceleration program this past year, and we could only accept 60."

Additionally, Likes said nursing salaries are higher in a clinical setting than in an academic one, which can deter some nurses from pursuing advanced degrees.

"We don't expose academia as a career choice for nurses," Stepter said. "Teaching is very different from dealing with patients. The impact of good faculty makes a big difference to students at a time when they are stressed. We need to encourage nurses to look at academia as an option. We need people at all levels."

Likes said it's a common misconception that the academic field isn't a good fit for women and men with families.

"It's a great career choice," Likes said. "The hours are consistent, and it's a good lifestyle for parents. Many women wait until later in life to teach, and they are in an academic setting for only 10 to 15 years before retiring."

More Nurse Executives

Several participants emphasized the need for more nurse executives in area hospitals. Likes said nurses directly impact the health of patients and are advocates for them, so they should be making decisions that impact patients on an executive level.

"Nurses aren't at the table making decisions at organizations," Likes said. "If you look at a hospital's executive board, only one or two nurses are represented. We need more nurses on an executive level."

Advanced Nurse Practitioners

According to the American Association of Nurse Practitioners, 22 U.S. states have approved nurse practitioners to practice independently. This means they are allowed to assess, diagnose, interpret diagnostic tests and prescribe medications independently. Nurse practitioners must practice under the supervision of a licensed physician in Tennessee.

Kirkland, who is the statewide president-elect for the TNA, said there likely will be legislation introduced to the state legislature for nurse practitioners to practice independently in Tennessee in the upcoming year.

"In my experience, nurse practitioners and physicians work together well collaborating," Kirkland said. "There are plenty of patients to go around. We are utilized to fill areas where there are staff shortages."

She emphasized that the Coalition for Access to Care in Tennessee, which is a TNA multiple-advanced practice registered organization, is working to communicate with physicians to come up with a compromise and solution to the many issues facing the healthcare industry in Tennessee.

Stepter said there is sometimes a knowledge gap among physicians regarding an advanced practice registered nurse's duties and understanding all of the new certifications.

"There have been many new certifications in advanced nursing over the years, and not every physician is well versed in them," Stepter said. "Physicians and leadership don't always understand the full scope of the nurse practitioner."

All of the roundtable participants said patients in rural areas in the state don't have quality access to care. Kirkland said the state restrictions on nurse practitioners restrict access to patients in rural areas because they cannot find a collaborating physician to assist them.

"Many rural clinics are closing, and patients from those areas are using the emergency room for their healthcare," Kirkland said. "We can be an asset in those rural areas."

RELATED LINKS:

University of Tennessee Health Science Center

Baptist College of Health Sciences

Regional One Health

McDonald Murrman Center for Wellness and Health

Saint Francis Hospital Memphis

American Association of Nurse Practitioners

Tennessee Nurses Association