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Messing with Texas

Mess with TexasSeptember 11, 2009 -- Recently veteran Texas nurses have published powerful op-eds advocating legislative changes to improve nurses' practice environments--and public health. On August 22, the Houston Chronicle ran an op-ed by Linda Record Srungaram arguing that the recent indictment of two West Texas nurses after they filed a complaint about a physician with the state medical board showed the need for better whistle-blower protections for nurses, who must be able to engage in such advocacy to protect patients. And today, the Austin Statesman published Toni Inglis's piece arguing that primary care shortages require the removal of legislative barriers that still inhibit the work of advanced practice nurses. These op-eds show the importance of nurses speaking up to protect patients and to show the public that nurses are critical thinkers with thoughtful perspectives on health policy. We thank those responsible for the op-eds.

Prosecuted for advocacy

Building a future

Prosecuted for advocacy

Srungaram's August op-ed in the Houston Chronicle is "When nurses are prosecuted for advocacy, we all lose." Srungaram, an emergency and critical care nurse, begins by stressing that nurses have "an ethical and professional obligation to serve as patient advocates at all times." However, she notes, that duty has been hard for Anne Mitchell and Vicki Galle, the Winkler County Memorial Hospital nurses who complained that a physician had "improperly encouraged patients to buy herbal medicines from him and had wanted to use hospital supplies to perform a procedure at a patient's home." The physician went to the Winkler County D.A., who actually indicted the nurses for "misuse of official information," apparently on the grounds that they "improperly accessed information that was not public 'with intent to harm' the doctor for 'a nongovernmental purpose.'"

Srungaram argues that this case should never have been brought. She notes that the executive director of the Texas Medical Board said she had never seen a criminal prosecution brought against someone for giving information to the board. Srungaram also argues the nurses were actually doing what their profession and the public interest requires--alerting authorities when they believe patients are in danger--and that this kind of advocacy has saved lives.

But the case, Srungaram says, could create a chill that would discourage nurses from advocating to protect patients, especially since Texas nurses lack good whistle-blower protection. They have the "much-derided 'Safe Harbor Law,'" but Srungaram says that this law is ineffective because it requires nurses to pursue an "internal peer review process" in order to receive protection, which leaves nurses in a Catch-22 situation, caught in internal workplace politics. She notes that the Safe Harbor law has the support of the Texas Nurses Association, "a group largely composed of nurse managers who usually don't provide hands-on care."

Srungaram includes some examples of the existing barriers to Texas nurses speaking out:

An RN working at a San Antonio dialysis center was fired after she voiced concerns about being assigned too many patients per nurse to provide proper care;

a nurse in a South Texas hospital reported that her manager told the RNs working in the intensive care unit there that they have no business invoking Safe Harbor because they are ICU nurses who "should be able to handle it";

another San Antonio RN worked in a hospital where a notice was posted on the employee bulletin board stating that anyone who claimed Safe Harbor would be investigated and could face discipline, even termination.

Srungaram concludes by arguing that "there is hope" because the

National Nurses Organizing Committee-Texas, a network of activist RNs, supports legislation to bring our state up to national standards for whistle-blower protection. The state bill is modeled after NNOC's national bill, the National Nursing Shortage Reform and Patient Advocacy Act.

Srungaram quotes a Texas state legislator who supports the bill, and urges nurses to "demand that nurses who report unsafe care be protected from legal retribution for their advocacy."

This strong, well-written op-ed identifies a serious problem in the nursing care environment and proposes a specific measure to address it. Whatever the merits of the specific case involving the two nurses who complained, nurses are indeed required to advocate for patients, and they cannot do that effectively if they lack sufficient power and are subject to retribution from vested interests that would rather not have their power questioned. The op-ed also shows the public that nurses are spirited patient advocates with informed views on health policy.

Of course, it seems unlikely that this op-ed was entirely home-grown. On June 22, the Philadelphia Daily News published a similarly powerful op-ed by veteran nurse and union leader Patricia Eakin arguing that deadly nurse short-staffing required state and national legislation to set minimum nurse-patient ratios. Like the Houston Chronicle piece, the Daily News op-ed described a serious problem in the nursing practice environment, then offered a legislative solution proposed by the National Nurses Organizing Committee (NNOC), the growing national nurses' union spearheaded by the California Nurses Association. It seems likely that these op-eds are part of a coordinated national effort to increase the visibility and influence of NNOC. In any case, they address issues of genuine importance to nurses, and they engage nurse readers in the kinds of policy discussion that should be a key part of their professional lives.

Building a future

Inglis's op-ed in today's Austin Statesman is headlined "Health reform must address primary care's shortcomings." She first highlights the "senseless paradox" that those in the U.S. have access to the "finest high-technology care in the world," yet the uninsured have trouble getting primary care, including vital preventative care. Inglis, a NICU nurse, cites data illustrating the value of primary care, and the magnitude of the primary care shortage that has developed as physicians have increasingly chosen more lucrative specialties:

How much healthier would we be and how much more efficiently would we spend health care dollars if everyone could get the care they need when they need it? A recent study reported in the American Journal of Medicine found that in an average-size metropolitan area, each 1 percent increase in the number of primary care physicians led to a decrease of 503 hospital visits, 2,968 emergency room visits and 512 surgeries. ... Counterintuitively, primary care -- arguably the most complex specialty -- is one of the most poorly reimbursed.

Inglis argues that President Barack Obama's health financing reform plan "more fairly reimburses primary care providers," but that we must also stop relying solely on physicians:

A more sensible, rational way to deliver primary care is through large collaborative practices staffed with physicians, nurse practitioners and physician assistants who are salaried. Nurse practitioners and physician assistants begin careers with far less debt than physicians and are eminently qualified and prepared to offer primary care. They do not hesitate to refer to physician specialists as necessary.

Inglis says that she has seen this "collaborative" model work in the NICU and elsewhere, noting in passing that the participating providers are "salaried," i.e., that their compensation is not tied to the amount or nature of health services they provide. This subtle point may elude some readers.

Finally, Inglis argues directly that legislative barriers to APRN practice must be removed if we are to reap the full benefits of collaborative primary care:

Antiquated regulations constraining nurses' practice date back to the 1930s when nurses, who were mainly women, were seen as assistants to physicians, who were mostly men. Such constraints include limits on scope of practice, direct reimbursement and prescriptive authority.

Inglis urges states to continue removing these barriers to advanced nursing practice, noting that other "evolved democracies" have made primary care a national priority and now enjoy emergency rooms that are "empty" except for true emergencies like trauma and strokes. She closes with a quote from Obama urging us to not just "clean up crises," but also "build a future."

Although Inglis curiously makes no specific reference to Texas legislation, her op-ed is a persuasive call for a more sensible approach to primary care in general and the role of advanced practice nurses in particular. Like Srungaram's piece, this op-ed highlights the importance of nursing to modern health care, both directly in its discussion and by implication, since an articulate, informed nurse is making the argument.

This kind of advocacy can help nursing build its future.

We urge all nurses to consider writing op-eds for newspapers or other media outlets. Or see our action page to learn how you can get involved in remaking nursing's image. Thank you!


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