Worcester District Medical Society

Central Massachusetts has a rich nursing heritage. In the Fall 2000 issue of Worcester Medicine, Anne Lawson, RN highlighted the history of nursing in our community. In the current issue, Pam Guillotte, RN takes us further back in time to summarize the evolution of the nursing profession. It is clear from these reviews that nursing and medicine have experienced a long-standing complementary relationship. As our health care system adjusts to the increasing demands for safe, accessible, quality care for all, it is timely that nursing and medicine understand each other, especially in light of the critical issues that cross disciplinary lines, such as the nurse-to-bed ratio debate.

There is no greater time to be a nurse. We are challenged by an aging population that needs competent, compassionate care. We are energized by the opportunities that continue to re-define the practice of nursing. And we are committed to providing nursing care in a collegial multidisciplinary environment. So what are the barriers that need to be overcome in Worcester and beyond?

First, as Dr. Harper discusses in her article, there is a shortage of nursing faculty to educate the next generation of nurses (and to keep pace with the need for greater numbers of RNs at the bedside). Nursing faculty are retiring at an alarming rate. It is important to note that there was a decline in the number of nurses who moved into nursing faculty roles during the 1990s. In my opinion, much of this decline was due to the emergence ~ beginning in the late 1970s ~ of new and exciting roles for advanced practice nurses. But now we need to “play catch-up” and make educating the next generation of nurses more appealing to our clinically skilled, educated, nursing workforce.

Second, we have the active debate over staffing levels. Sandy Ellis, RN and Janet Madigan, RN present a lively discourse on this issue. It is clear from both articles that the ultimate goal is patient safety. What remains to be seen is how nursing, medicine, and health care administration can best work together to achieve this goal.

Lastly, we need to support nurses who work tirelessly on the front-line of patient care. It is especially important that we learn to nurture the careers of new nurses and honor those who serve in the military and respond to disaster situations. We clearly have a cadre of these nurses among us in the Worcester community (see the article by Lt. Col Sean Collins and In My View ~ Challenges and Rewards of the Nursing Profession.) It is our hope that this issue, which is devoted to nursing, will enhance the collegiality between nursing and medicine and will elicit debate about concerns important to all disciplines involved in patient care.

Point Counter Point
By Janet M. Madigan, RN, MS, CNAA
President, Massachusetts Organization of Nurse Executives

Let’s stipulate a few facts about the nurse staffing issue. First, our hospitals need more nurses and our state needs more faculty to teach the students currently on waiting lists to get into college nursing programs. Second, nurses are integral and important members of the caregiving team. And third, there’s not a single shred of evidence ~ nothing ~ that supports a specific and ideal nurse-to-patient ratio for our hospitals.

In response to the nursing shortage and because hospitals want to keep the public informed about the care they receive, the Massachusetts Hospital Association and the Massachusetts Organization of Nurse Executives unveiled on January 27 the first-in-the-nation voluntary posting of nurse staffing levels for every hospital in the state. Patients can log on to www.patientsfirstma.org and see how many RNs and other nurses are assigned to each unit for each shift throughout the day. The site also lists other professionals ~ from Rapid Response Team members to Intensivists ~ that hospitals assign to patients. Hospitals check off which of these professionals are available in each unit so that patients can get an absolutely transparent assessment of who will be at their bedside in each hospital.

The Patients First website also lists “Worked hours per patient day” for each unit ~ that’s the nationally recognized standard for assessing the number of hours of direct care a patient can expect to receive from an RN, along with LPNs and nursing assistants, in a 24-hour period.

Explaining staffing to patients ~ and vowing to undertake by year’s end the public reporting of nurse-sensitive performance measures for each hospital ~ is information the public needs to assess our state’s health care system. National leaders in the patient safety field, such as the Institute for Healthcare Improvement’s Don Berwick and Harvard’s Lucian Leape, M.D., have praised the Patients First staffing website. According to Berwick, “This program is a national model.”

We believe that Patients First addresses in a concrete way nurse staffing issues, ensuring that our hospitals continue to provide the safest, highest quality care in the nation. But, this issue is also being debated at the State House.

A bill now pending ~ SB 1260, The Patient Safety Act from Senator Richard Moore ~ would codify many elements of Patients First and build upon the initiative. Among other things, the Patient Safety Act establishes the Clara Barton Nursing Excellence Program to fund nursing student loan repayment assistance, a nursing scholarship program, a matching grant program with hospitals to promote more clinical settings, nursing faculty bonuses, and stipends for experienced nurses to mentor new nurses.

While there are stringent reporting requirements, the Patient Safety Act does not include ratios. That’s because ratios handcuff caregivers, robbing nurse managers ~ in consultation with RNs ~ of the flexibility they need to address individual patient needs. Doctors know that all patients are different, that two patients with the same diagnosis may have differing conditions that require different levels of care. Nurse managers know that a patient in one bed may require a level of attention that is entirely different from another patient in the same room. Nurses know how their workdays and workloads vary. Patients also understand that they are unique.

Numerous studies are frequently cited ~ perhaps none more than the 2002 JAMA article by Linda Aiken ~ to show that more nurses equal better patient outcomes. Hospitals agree with the need for more nurses. But neither the Aiken study, nor any other, recommends an etched-in-stone ratio that all hospitals should follow. It’s an important point to remember given that a nursing union representing just 20 percent of our Massachusetts RNs is currently trying to impose ratios on our state’s health care system. The well-financed union has decried ratio opponents ~ no matter how reasoned their concerns ~ as profit-driven and callous.

Throughout this too-long and too-contentious staffing debate, the nursing union supporting ratios has argued, “Impose ratios and the state’s supply of non-practicing nurses will flock back to their jobs.” It’s a specious argument that isn’t supported by the facts. According to the U.S. Department of Health and Human Services (HHS), approximately 4,820 RN vacancies in Massachusetts hospitals were expected in 2005. HHS projects that the deficit of registered nurses in Massachusetts will reach 9,100 by 2010 and grow to more than 25,000 in the following decade. The employment rate of RNs older than age 50 is growing faster than any other age group among nurses. These RNs are fast approaching retirement age. Their exodus will occur at a faster rate than the entrance of new nurses into the nursing field, thereby increasing the gap between supply and demand of nurses. Hospitals, the state’s Board of Higher Education, and other stakeholders recognize that and all are committed to expanding the “nursing pipeline.” The ratio bill does nothing to address the nursing shortage; it merely demands that more RNs be hired from a non-existing supply.

The only independent analysis of both the ratio bill and Senator Moore’s compromise legislation came from the University of Massachusetts Medical School in Worcester and states that “Mandated ratios do not take into consideration patient acuity, nursing skill levels, or the availability of other licensed and non-licensed caregivers,” and “At present, there is no scientific evidence in the literature that would establish optimal nurse staffing ratios.” The Massachusetts Medical Society has also come out against government-mandated RN staffing ratios.

So the choice seems to be clear. We can get behind the Patients First initiative and the Patient Safety Act to bring more nurses into the system, to make hospital staffing plans and outcome measures available to the public, and to work cooperatively to advance patient safety and high-quality care. The principle is to provide the right care, not the same care. Or we can embrace ratios, which are unsupported by science, are prohibitively expensive, and which treat people admitted into hospitals more like numbers than like the patients they are.

We have a disturbing crisis in Massachusetts: nurses are being forced to care for too many patients at once and patients are suffering the consequences in the form of preventable medical errors, avoidable complications, increased lengths of stay and readmissions. To make matters worse, nurses “burned out” from high patient loads are leaving the bedside.

Nurses are not the only ones who are concerned about this crisis. Last April, Opinion Dynamics Corporation, a leading polling and research firm, released the results of a landmark statewide survey of Massachusetts physicians with hospital admitting privileges. The survey confirmed that chronic understaffing of registered nurses is having a devastating impact on the quality and safety of patient care. The survey found that 78 percent of physicians believe RN staffing levels are too low; 82 percent report the quality of care is being compromised; 54 percent report an increase in medication errors; 42 percent report longer stays; 37 percent report injury or harm to a patient; and an alarming 19 percent (one in five) report patient deaths directly attributable to nurses having too many patients.

To address this patient safety crisis, Massachusetts nurses and the 105-member Coalition to Protect Massachusetts Patients have filed H. 2663. This bill sets a safe limit to the number of patients a nurse may be assigned to at one time. The bill also calls for the adoption of an acuity-based system that measures the severity of a patient’s illness in order to adjust the level of nursing care needed beyond the minimum safety standard.

An overwhelming body of medical research has unequivocally proven the relationship between RN staffing levels and patient outcomes:

A Harvard School of Public Health study published in the New England Journal of Medicine found a “strong and consistent” link between RN staffing levels and patient outcomes (e.g., improved RN-to-patient ratios reduce rates of pneumonia, urinary infections, shock, cardiac arrest, gastrointestinal bleeding, and other adverse outcomes).

JCAHO found that inadequate nurse staffing precipitated one-fourth of all occurrences that led to patient deaths, injuries, or permanent loss of function.

The Institute of Medicine reported that “Nurse staffing levels affect patient outcomes and safety…” and that understaffing of RNs is responsible for nearly 20 percent of all medical errors.

A groundbreaking study published in the Journal of the American Medical Association went beyond linking RN staffing to patient outcomes. This study quantified the morbidity and mortality risks according to staffing level and found that, on a typical medical/surgical floor, if an RN is caring for more than four patients, the risk of morbidity and mortality increases by 7 percent, compounded for each patient. Thus, an RN’s assignment of eight patients carries with it a 31 percent increase in risk of injury/harm, including death, to each of these eight patients. Still, today, if you are a patient in a Massachusetts hospital your nurse may have eight, 10 or 12 other patients ~ there is no limit.

A number of experts are making a financial argument for limiting the number of patients a nurse is assigned to at one time. Safe minimum RN staffing levels reduce complications and preventable medical errors and curb extended length of stays and readmissions, saving precious health care dollars as a result.

The journal, Medical Care, finds that minimum RN staffing levels are more cost-effective than common lifesaving practices such as cancer screenings and clot-busting medications for heart attack and stroke.

The journal, Health Affairs, reports that an “unequivocal business case” can be made for increasing the level of registered nurse staffing in hospitals ~ a move that could pay for itself in fewer patient deaths, shorter hospital stays, and decreased rates of costly medical complications.

One of the biggest misconceptions surrounding this issue is the contention that RN understaffing is being caused by a shortage of nurses in Massachusetts. The fact is that there is no shortage of nurses in our state. We have more nurses per capita than any state in the nation. What we do have is a shortage of nurses willing to work in hospitals because of the conditions created by hospital administrators. The good news is that more than 65 percent of those nurses currently not working in hospitals say they are likely to return if the H. 2663 is passed. That’s a pool of 35,000 nurses.

The state’s hospital industry has ample resources to solve this crisis. Massachusetts hospitals reported nearly $1 billion in profits in 2005. Hospitals in Central Massachusetts reported more than $100 million in profits last year, and Massachusetts hospitals have completed and/or are working on expansion projects totaling another half billion dollars.

It appears that no profit margin is big enough to persuade hospitals to fix a crisis they have created. The industry’s own legislative proposal to deal with this crisis places no limit on how many patients a nurse is assigned to and creates a website that purports to provide consumers with access to hospital staffing “plans” online.

The website provides only a sampling of hospital units, and the information provided is deliberately misleading, not to mention totally incomprehensible to the public. Physicians are well aware of the pitfalls of posting online health care data as a patient safety initiative.

There is no disputing that under the current staffing conditions we are putting patients at risk daily. Nurses provide a 24-hour surveillance system in hospitals to protect patients. Medical research and surveys of the state’s physicians show that poor RN-to-patient ratios compromise the health and safety of hospital patients. It’s time to join the nurses and to support H. 2663 in order to ensure that there is a minimum, safe standard of care in place for all patients.

Lt. Col Sean Collins serves as Medical Group Commander, 104th FW, Barnes Air National Guard Base, Westfield, MA.

A common question that I get asked when people know I served an Active Duty tour in Iraq is “What was it like?” How can I do justice to giving an accurate answer and not keep someone there for hours? I usually sum it up by saying, “It was a unique experience.” It is hard to believe that it has been one year since I returned from a four-month tour in the combat zone in Iraq. To say the least, it was a real learning experience.

As a Nurse Practitioner, I have been preparing and deploying our troops since September 11, 2001 to join Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), not knowing first hand the issues that they would face once they were on the ground. I now have a deep appreciation for all the efforts that our Airmen, Soldiers, Sailors and Marines have endured to maintain peace in a hostile and ever-changing environment. The risks are real and the consequences of working in a dangerous environment can be catastrophic.

There have recently been some high profile discussions regarding the Air Force’s Expeditionary Medical Support system (EMEDS) and our seamless integration of Active Duty, Guard and Reserve in the combat setting. I certainly can attest to the success of the system, having participated in the trauma treatment and support with rapid evacuation to more definitive care in an expeditious and professional manner. Transitioning care over to our Guard Critical Care Air Transport Teams (CCAT) was an awesome sight.

I had a rewarding experience while deployed to Tallil Air Base in Iraq, a coalition base with more than 10,000 troops. I was stationed at an EMEDS that was the trauma center for southern Iraq. We had the capabilities of a trauma center with a lab, X-ray department, a two bed operating room, an ICU and medical beds. The Medical Group from the Active Duty base in Elmendorf, Alaska staffed the EMEDS during my tour; we arrived and departed on the same rotation. From Alaska to Iraq ~ is there justice there? There were only four Guards and one Reservist who augmented this Active Duty deployment team of 100. I was the only clinical member of the “augmentee package.” Joining a group who all knew each other, worked with each other, and practiced field exercises together was a little intimidating. However, I am glad to report that I made a seamless transition into their provider staff without missing a beat. Working out of the ER, I had a great opportunity to interact with all components of the EMEDS team. Functioning out of a coalition compound gave me an opportunity to work with our Italian, Dutch, Romanian and Portuguese counterparts. We had the ability to train together and share valuable resources.

It did not take us long after arrival to be exposed to our first (real world) mass casualty. A Blackhawk helicopter crashed on the flight line at approximately 10pm and the number of injured and types of injuries were not known so we prepared for the worst. It was amazing to see everyone come together so quickly; everyone stepped into a role to make things happen. Triage officers, treatment teams, work areas and supplies were all readied for the incoming wounded. It was inspiring to see the team pull together ~ everyone maximizing their skills to get the job done ~ and provide outstanding and life-saving treatment for our fellow soldiers. Everyone had a role, no matter how small, in these mini resuscitation teams. It was so encouraging to see our young “medics” (EMTs) provide a level of compassionate and competent care which is hard to teach in any environment. This scene would be played many times over during my four-month tour. The ER could be transformed from a four-bed evaluation station to an open bay trauma room in minutes to meet the actual demands.

Working out of the EMEDS, which, by the way, is a series of tents, offered a great deal of variety in the daily routine. Providing care for Air Force, Army, Marine, and Naval members was our core mission. However, we also provided care for third country nationals (TCNs), local nationals, contract employees and DOD employees deployed. You can imagine that this brought about a tremendous diversity to the ER.

I was able to use my diabetes specialization ~ who would have thought? We cared for contractors with diabetes and soldiers newly diagnosed with diabetes. We also cared for local nationals with life threatening illnesses that required treatment at our facility (they showed up at our gate). One interesting case was a little girl who was bitten by a venomous snake and was dying when she was brought to our facility. Her father was an Iraqi policeman. Using antivenom (several doses) along with a terrific orthopedic surgeon and great nursing care, her “life and limb” were saved. She became a real celebrity in the EMEDS and made a great number of new friends. It was amazing to see how their community supported them ~ and us. Their town sent the EMEDS staff a wonderful letter of thanks.

The environment was always a challenge. With the heat, wind-blown sand, and insects, we always had something to lavage, extract or rehydrate! Tallil can be considered the Leishmaniasis (caused by insect bite) capital of the world, and I became king of the skin biopsies! You could predict based on the clinical history and the look of the lesion if the biopsy would come back positive. The importance of physical fitness was also noted. When I stepped off the plane it was 126 degrees Fahrenheit ~ and believe me, that is hot! Wearing more than 25 pounds of body armor everywhere you go can stress out even the fittest individual.

The sights and sounds of the EMEDS ER may be familiar to any busy trauma center, but it was what lay outside our perimeter that made it different. The constant sound of “dust off” choppers that went into harm’s way to retrieve the injured have a distinctive sound to their rotary blades. The rewards were plentiful; knowing we were there to provide the care that our troops deserved made the sacrifice of being in an uninviting environment more palatable.

Educating Nurses to Improve Quality Care
By Doreen C. Harper, PhD, RN, FAAN, Dean and Professor, University of Alabama at Birmingham School of Nursing, Birmingham, AL
Former Dean and Professor, University of Massachusetts Worcester, Graduate School of Nursing, Worcester, MA

Contemporary health care demands high quality, patient-centered care with every health team member focused on improving quality care. Professional and advanced practice nurses translate evidenced-based practice to patients across hospital and community-based settings as members of interdisciplinary teams. With changing and increasingly complex practice environments and health delivery systems driven by rising health care costs, nursing education and practice have begun to incorporate knowledge and specialized activities focused on improving quality and enhancing safety for all patients while remaining mindful of costs (Donley, 2005; AACN, 2004; IOM, 2004).

Recent studies have shown that more and better educated nurses improve patient safety and the quality of care. Several studies (Aiken, et al, 2002; Needleman et al, 2002, Unruh, 2003) have shown that increased nursing staffing in hospitals is associated with better patient outcomes, reduced length of stay, decreased errors, and fewer complications (ulcers, falls, urinary tract infections, atelectasis) and a net reduction in costs (Needleman et al, 2006). Aiken and associates (2003) found a relationship between nursing education and patient outcomes in a study of surgical patients in Pennsylvania hospitals. This study found that the higher the proportion of nurses with baccalaureate degrees and higher, the lower the rates of morbidity and mortality experienced by the patients.

A 2003 Institute of Medicine Report on Health Professions Education: A Bridge to Quality recommended that “…all health professionals should be educated to deliver patient-centered care as members of interdisciplinary teams, emphasizing evidenced based practice, quality improvement approaches, and informatics.” (IOM, 2003)

As new health care demands have emerged, nursing education and practice have incorporated new curriculum and specialized knowledge to prepare professional and advanced practice nurses in the areas of evidenced-based practice, informatics, quality improvement and team care.

Current and predicted shortages of nurses and faculty have generated academic/service partnerships among schools of nursing, hospitals, and community-based clinical agencies. Partnership opportunities have emerged from the nursing shortage, enabling academic nursing to develop new models of nursing education for professional and advanced practice nurses. This article describes nursing workforce challenges and innovative education/service strategies that are being used to build nursing capacity nationally and in Massachusetts to ensure patient safety and high quality care.

National and state nursing workforce data projects an escalating shortage from 2010 through 2040. Nationwide demand for nursing services continues to rise with the growth of the population, an increase in the number of persons living with chronic illnesses, aging demographics, and bio-medical advances. While the supply of nurses has recently begun to show modest growth (AACN, 2005; National Sample Survey of Registered Nurses, 2006), the faculty shortage and accelerated retirements among aging registered nurses obscure these gains. A national shortage of 29% is predicted nationally by 2020 if current supply and demand nursing workforce trends continue (U.S. Department of Health and Human Services Administration, 2002).

The National Sample Survey of Registered Nurses (NSSRN; 2006), a series of national studies of registered nurses that has been conducted every four years since 1980, reported its 2004 preliminary findings. These findings estimate that there is a total of 2.9 million nurses in the United States and that 83.2% (2.42 million) are employed. The survey estimated that in Massachusetts there is a total of 89,358 registered nurses of whom 84.4% are employed. Among employed nurses, an estimated 75,398 are working; 43,384 (57%) are working full-time. The estimated number of RNs has grown nationally by 7.9 percent since the last sample survey; despite this growth, state estimates in 2004 fell 1.53 percent short of the Registered Nurses in the state in 1995, well below the projected demands for registered nurses in Massachusetts.

Nursing schools in Massachusetts have been producing new registered nurses at record numbers since 2002. Massachusetts has 41 nursing programs in baccalaureate and higher degree institutions, hospitals and community colleges. These 41 programs offer entry-level Masters, Baccalaureate, diploma and Associate Degree programs to prepare registered nurses. In 2004, these programs enrolled 7,854 students and graduated 2,031 students. Over the past four years, registered nurse educational programs in Massachusetts have grown on average 5.25% annually without additional state funding (MBRN, 2005). However, similar to the national trend, only 1886 entry- level RNs took the RN licensure exam (NCLEX-RN) for the first time in 2004, remaining well below the 1996 number of 2821 entry-level RNs (MBRN, 2005).

Nationally, enrollment in entry-level Baccalaureate nursing programs increased by 13.0 percent from 2004 to 2005, while 32,617 qualified applicants were rejected due to faculty vacancies and inadequate clinical resources (AACN, 2005). At a time when enrollment capacity needs to increase, the faculty vacancy rate for nursing programs in Massachusetts was estimated at 8% in 2005, limiting enrollments in the state’s nursing programs. These programs graduated 2,031 nursing students in 2004, an increase of 16% over 2003, but well below the 2,821 students who graduated in 1996 XE from the state’s programs (MBRN, 2005). Among the 41 state-approved registered nursing education programs, 13 offer Masters Degree programs and four offer PhDs in nursing programs. These graduate programs prepare nurses for leadership roles as nursing faculty, advanced practice nurses (clinical specialists, nurse practitioners and nurse anesthetists), case managers, administrators, executives, clinical trial coordinators and researchers (MACN, 2005).

Despite the growth in overall nursing school enrollments for 2004, 78% of Massachusetts RN nursing schools reported that a total of 1,814 qualified nursing applicants were turned away. The Massachusetts Board of Registration in Nursing (BORN) conducted a Faculty Vacancy Survey in 2004 and found that over 20% of basic nursing education programs in Massachusetts listed faculty vacancies as the primary reason they were unable to increase enrollments. Among the reasons noted for these vacancies were retirement and non-competitive salaries with clinical agencies and other academic programs. Lastly, a comparison of salaries among practicing nurses and faculty showed that Masters-prepared nursing faculty salaries on average range between 37 and 46% less than practicing Masters-prepared nurses and 24% less than the practicing registered nurses (University of Massachusetts Worcester, 2005).

Educational programs in nursing require nursing faculty with different educational backgrounds. Four year colleges and university nursing education programs must comply with university standards for faculty prepared at the doctoral level, while community colleges often hire predominantly faculty prepared at the Masters level. Nursing accreditation bodies evaluate programs on standards. These are subtle differences that have a major impact on the availability of nursing faculty, particularly given that the average age of the new doctoral graduate is greater than 45 years. Another significant factor impacting nursing school capacity is that nursing education programs are required by state regulation and accreditation requirements to have nursing faculty prepared in a specialty area; this requirement contributes to a specialty shortage, particularly in the areas of pediatric, obstetric, operating room and psychiatric nursing. Nursing faculty must also be present when students are in the clinical setting, again contributing to the faculty shortage. The state regulations require a minimum of a 1:10 faculty student ratio to ensure safe clinical supervision of entry-level student nurses as they practice in clinical environments. While the faculty to student ratio is a maximum, many clinical agencies require that schools of nursing reduce this ratio from 1:10 to 1:6-8 depending on the acuity level of patients (University of Massachusetts Worcester, 2005). Lastly, unlike medical education, the costs for these faculty members who supervise nursing students in the clinical area is borne by the nursing school rather than by the hospital or clinical agency (Thies & Harper, 2004).

Clearly faculty vacancies and the lack of qualified faculty are creating a bottleneck in the nursing workforce pipeline and are the most limiting factors in building the capacity of nursing education programs. Today’s health care demands call for more and better educated nurses to ensure high quality, safe, patient-centered care that is cost-effective. So what is nursing education and service doing to address these challenges?

Accelerated programs for students with a non-nursing Baccalaureate have experienced significant growth over the past five years, creating a new, highly-talented cohort of new nursing students in the country. Accelerated programs are full-time and generally prepare new entry-level nurses in approximately 15 months at the Baccalaureate or Masters level. The accelerated program is tailored to the specific types of students in the program. Accelerated PhDs in nursing programs have also been developed to recruit younger nurses into faculty positions and to reduce the average length on time for doctoral program completion from 7 years to 4 years.

The steady growth in nursing program enrollments and graduations over the past five years has stretched faculty, clinical, and classroom resources to the fullest extent. Funding for nursing education comes from public entities such as federal, state and state governments and from private entities such as foundations, health industry, and consumers. Partnerships to support nursing education have begun to emerge with various stakeholders including higher education, hospitals, businesses, federal and state agencies, policy makers, consumer groups, health care and nursing organizations. These stakeholders have begun to work collaboratively to strengthen and invest in nursing education. The result has been the creation of innovative workforce strategies aimed at increasing the number of nurses and nursing faculty.

Nationally, the Department of Health and Human Services, Bureau of Health Professions, Division of Nursing has funded nursing education programs through Title VIII of the Public Health Service Act and amended the Nursing Workforce Reinvestment Act of 2002 to support nursing education and practice, scholarship and loan programs. The fiscal year appropriation for 2006 was 150.5 million dollars (DHHS, 2006). This extramural federal funding has stimulated innovative programming in nursing practice and education in the areas of faculty development, graduate nursing residencies to retain newly registered nurses, geriatric care and career ladders for nursing at all levels from nursing assistants to Registered Nurses to Masters and doctoral nursing preparation. Several states (e.g. Texas, Georgia, California) have also invested significant state funds to expand nursing education programs (Source: Greene, D. L., Allan, J. D. & Henderson, T. (October, 2003). The Role of States in Financing Nursing Education. Report of the National Conference of State Legislatures: The Nursing Workforce).

In Massachusetts, the Board of Higher Education in Massachusetts, led by Commissioner Judith Gill, developed the Nursing Initiative in 2004 (MA BHE, 2005). The Board, with $500,000 from the state and additional matching funds from the Massachusetts Hospital Association, has funded numerous small grants to support nursing education in the following areas:

Senator Moore’s Senate Bill 1260 to promote safe patient care and support the nursing profession has some limited support for nursing workforce capacity building; the bill is currently pending in the Joint Committees on Public Health and Higher Education.

At a national level, several initiatives have begun to set an agenda for change in nursing education. In 2004, the redesign of graduate nursing education was begun by the American Association of Colleges of Nursing. This redesign is aimed at improving patient outcomes, retaining nurses in the profession and at the point of care, recruiting talented candidates into the profession, and strengthening nursing leadership and faculty development. The AACN initiated three new programs: The clinical nurse leader (CNL), the Doctorate of Nursing practice (DNP), and the graduate nurse residency (GNR). Lastly, AACN also began to highlight models of accelerated entry-level Masters and Baccalaureate programs for preparation of Registered Nurses. The clinical nurse leader (CNL) offers a new role in Masters level nursing education as a generalist at the point of care with a combination of knowledge and skills to practice in all settings. Clinical nurse leaders maintain oversight of patient care and serve as clinical experts while teaching and mentoring nursing teams and collaborating with physicians (AACN, 2006). The Doctorate of Nursing Practice (DNP) is designed as a terminal degree for advanced specialty preparation at the highest level of practice in nursing. It is not an entry-level degree, but instead builds on RN entry-level preparation. Nurses prepared at the practice Doctorate level provide leadership for nursing practice and increase the availability of clinical faculty. The curriculum is designed to enhance knowledge and leadership skills to strengthen practice and improve health care outcomes (AACN, 2006). These two new programs have begun to transform graduate nursing education and the focus on quality improvement.

Finally, AACN ~ in collaboration with University Health Consortia ~ initiated Graduate Nurse Residency Programs for newly graduated registered nurses to improve nursing satisfaction and improve retention in tertiary care hospitals. Partnerships with hospitals and other health entities have also begun to spawn new models for clinical leadership and additional entry-level Registered Nurses. These initiatives are centered on improving the quality of patient care, improving the work environment and satisfaction among nurses, and improving retention and reducing turnover rates in acute care hospital settings (AACN, 2006).

The goal of all these initiatives is to prepare more nurses who are educated with not only required clinical and specialty knowledge, skills, and competencies, but also with quality improvement, team, and evidence-based practice and informatics competencies. Academic nursing is transforming nursing education through partnerships with clinical practice and service. Together, they have rejuvenated linkages among institutions of higher education and hospitals, accelerated programs for non-nursing Baccalaureates for entry level RN pre-licensure and faculty preparation, post-graduate residency programs for newly licensed nurses, and the Doctorate of Nursing practice degree for advanced practice nurses. These initiatives are focused on one objective: Preparing a competent nursing workforce that is patient-centered, quality-oriented, and ready to serve tomorrow’s health care demands.

Donley, Rosemary Sister. (2005). Challenges for nursing in the 21st century. Nursing Economics. 23(6): 312-318.

Institute of Medicine. (2004). Keeping patients safe: transforming the work environment of nurses. Washington, DC: National Academies Press.

Aiken, LH, Clark, SP, Sloane, DM, Sochalski, J, Silber JH. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. Journal of the American Medical Association. 288(16): 1987-93.

Needleman, J, Buerhaus, P, Mattke, S, Stewart, M, Zelevinsky, K. (2002). Nurse staffing levels and quality of care in hospitals. New England Journal of Medicine. 346(22): 1715-22.

Unruh, L. (2003). Licensed nurse staffing and adverse events in hospitals. Medical Care. 41(1): 142-152.

Needleman, J, Buerhaus, P, Stewart, M, Zelevinsky, K. Mattke, S. (2006). Nurse staffing in hospitals: is there a business case for quality? Health Affairs. 25(1): 204-211.

Thies, K. & Harper, D. (2004). A policy agenda for Medicare funding for nursing education. Nursing Outlook, 52(6), 297-303.

Massachusetts Association of Colleges of Nursing. Ensuring Educated Nursing Workforce for the Commonwealth, July 2005. Available at:
http://www.massnursing.org/MACN_July05.pdf

Kathleen is the Nurse Clinician for the acute care pediatric inpatient unit (5 East), UMass Memorial Children’s Medical Center, Worcester, Ma.

I have been a pediatric nurse for 22 years, providing family-centered care in the acute care setting to children age 0-18 years. Each child and family is unique in their response to illness, trauma, or a congenital anomaly; yet they all benefit from a healing relationship with a nurse. The pediatric RN is foremost the patient’s advocate. Whether it is navigating the health care system, providing evidence-based nursing care, or collaborating with other disciplines, nursing is a challenging and meaningful profession. To share a role in meeting the basic human needs of an individual is a privilege and gives one a valuable perspective on life.

Jennifer is a staff nurse at UMMHC Memorial Campus and is a NP student at UMASS Worcester Graduate School of Nursing.

One of the greatest challenges of being a new registered nurse is providing excellent patient care in an efficient and competent manner while still trying to learn the complex roles and responsibilities of a “real-life-nurse.” Specific challenges include dealing with unexpected events and still accomplishing all of the work required during an 8 hour shift and mastering the art of concise conversation. Thankfully, experienced nurses share their expertise and assist the novice in gaining time management and other necessary skills. The satisfaction of positively affecting the lives of patients by caring for them competently and compassionately is one of the reasons I chose the nursing profession. I am grateful for the special moments I have shared with my patients and I anticipate many more encounters in the years to come.

Graduating from nursing school in the late 1960s, I never considered working in Long Term Care. I worked in hospital nursing and then taught at a local hospital nursing program. Later, I earned my Baccalaureate Degree in Nursing and planned to return to the hospital environment. A professor suggested that Long Term Care was the way to “get my feet wet” again. So 20 years ago I entered the world of Long Term Care. Because Long Term Care acknowledged my life experience skills, I was able to integrate quickly, rising from Charge Nurse to Nursing Supervisor to Director of Nursing. It is a privilege to work in a job that has challenged me in ways I never could have predicted.

Long Term Care is one of the most regulated industries. When I began, restraints, both physical and psychological, were the norm. It was a challenge to lead a team of health professionals to change both the mindset and the practice. Today, most nursing homes are restraint free. Certified Nursing Assistants (CNAs) are now professionally trained and licensed. This carries with it responsibility and accountability. There is a nurse aide registry to make sure there have been no allegations of abuse as there is zero tolerance for abuse within the industry.

An Ethics Committee has been developed, allowing the review of resident care by giving attention to any dilemmas from a resident, family or staff member. This type of support had long been part of hospital care but absent in Long Term Care.

Activities in Long Term Care used to consist of Bingo and an outside entertainer each month. Today, we have the benefit of a full time music therapist at our facility. Residents who are unable to communicate respond to the beautiful music played. There are also resident bell and singing choirs. Intellectual, adult-oriented programs are offered as is a morning exercise program.

The nursing home setting has become more welcoming and care is now based on the individual resident, the family and the goals for care. The care of each resident is based on assessments and documented facts. This process leads to the development of individualized care plans. The use of the computer has created a national database which provides valuable information for research, tracking and quality assurance.

These changes have been challenging but have paved the way for great rewards for residents, families and staff. Long Term Care Nursing remains an enriching career choice.

I am new member of Worcester’s nursing workforce. While transitioning into this new role, I have found the initial stress of increased responsibility overwhelming at times. I am just beginning to realize the specific challenges that nurses face on a daily basis. The most important challenge I have encountered is the limited time available to spend with each patient. Nurses are well known for their holistic approach to care, specifically the psychosocial aspects. I currently work on a medical/oncology floor. Psychosocial and emotional support are essential elements of care for these patients. I often find myself struggling to meet the demands of both the physical and emotional needs of my patients. However, the satisfaction and gratification at the end of each day far outweigh any of the stress or challenges faced. Knowing that I have facilitated the healing process and increased the comfort level of my patients, combined with the appreciation I receive from the patients and their families, is very rewarding. I am proud to be a member of a profession whose contribution to society is so life changing.

The History of Nursing
By Pam Guillotte, RN, BSN, Clinical Instructor, LPN Program, Quinsigamond Community College

Nursing has been in existence since ancient civilization. While writing this article, I learned more than I knew about the History of Nursing. I really never gave any thought to pre-Florence Nightingale. I hope you’ll be as enlightened as I was.

In ancient civilization, the physician was skilled in treating FXs, filing teeth, and classifying what few drugs were available. Midwives delivered babies and friends or family served as nurses. As advances in medicine, surgery, and obstetrics were made, public hospitals came into being. Most were staffed by males who were by today’s standards Practical Nurses. The few female nurses were no more than household servants or slaves; physicians provided most of the nursing care in early Greek medicine.

During the early Christian era (1 - 476), nursing by women was now beginning to unfold. The rise of Christianity taught caring of others. Men and women of equal rank provided mercy care to the sick and fed and clothed the needy, prisoners, and the homeless. Also included in their role was burying the dead. Groups of women were forming and dedicating themselves to providing a merciful, selfless service for those in need. They may have been considered the first organized public health nurses.

The Early Middle Ages (476 - 1000) showed a very small growth in nursing due to the barbaric nature of society during the Dark Ages. This led to the non-existence of learning for the next 500 years. After this time, the monks who had lived and learned in the safety of the monasteries emerged to perpetuate the idea of caring for people. They ~ along with the nuns ~ performed nursing tasks in the monasteries under the direction of the Catholic Church.

The High Middle Ages (1000 – 1475) were still dominated by the monasteries’ development of strict principles of discipline, obedience and devotion, all of which became an important aspect of traditional nursing in the years to come. Secular orders began providing nursing care to hospitals and to newly developed hospices. Nursing was an important way of life and a valuable service to those in need. It was a strict organization with the expectation that its members be obedient, unselfish, and totally devoted to the performance of their duties. The number of women entering the profession grew. Nursing had become an acceptable occupation for women although the care that the nurses provided was more custodial than centered on treatment.

Nursing went into a decline during the Renaissance Period (1300-1600). Monasteries were closed and the nursing work performed by women virtually vanished. Women were again considered subordinate to men and were expected to stay home and raise children. Respectable women did not work at nursing. Instead, wayward women such as prostitutes and alcoholic women served as nurses as an alternative to being sent to jail. Nursing fell on hard times and its practitioners were reduced to poorly paid servants. Nursing remained dormant until the early 1920s.

Deteriorated social conditions existed from the 18th to the 20th centuries (1700-1940). The sick, insane, poor and homeless were warehoused in hospitals, jails, and asylums. The health and sanitary conditions were deplorable. Hospitals started to emerge with the nursing programs that would lead to modern nursing. Florence Nightingale attended one of these schools in Germany. She had a vision of nursing and more than 200 years later that vision is still being taught in nursing schools. The status of women was improving. Florence Nightingale’s example led to advances in nursing education and practice. She changed the negative image to a positive one by being selective of nurses and providing classroom education and clinical teaching. Schools of nursing were emerging and were created after the Nightingale model. These teachings replaced the informal programs that were common in the United States. The scarcely trained nurses were now being much better trained.

The Civil War dramatized the need for skilled nurses. People realized that society was responsible for its own health. Male nurses dominated the nursing duties. Most were convalescing soldiers who had neither the inclination nor the skill for this type of work. Clara Barton began her nursing career during this time and worked tirelessly for the American Red Cross. She made a timely arrival with a wagon load of sanitary supplies (surgeons had been using corn husks for bandages) and medicines and began nursing the wounded. She became known as “The Angel of the Battlefield.”

The nursing profession was flourishing and a number of distinguished women emerged as leaders. These leaders brought definitions and goals of the Practice of Nursing ~ and thus emerged Nursing Theorists. Nursing schools adopted a theorist which defined the basis for their nursing education.

The effects of nursing during and after World War I are still felt today. There were not enough nurses to deliver care in the United States. Most were providing nursing care to military personnel overseas. Despite the efforts of nursing leaders to provide high quality education, hospitals were hiring untrained women to provide basic care. Nurses’ Aide programs were a “quick fix” and the practice seemed to imply that anyone could be a nurse with minimal training. These aides were taking the place of trained nurses in the hospital settings. The negative effects of the war brought many of the trained nurses back from overseas only to see them leave the profession because of its poor image. This image was in part due to the widespread use of nurses’ aides. It created a nursing shortage which in turn led to the creation of more nurses’ aide programs. Several important trends developed: The federal government became the largest employer of trained nurses and a commission was organized to deal with nursing and health care problems. The shortage was slowly abating.

World War II produced yet another nursing shortage. Measures were taken, but none like those necessary during WWI. Women were recruited and sent to nursing schools ~ some with all expenses paid ~ and in return made a commitment for 2-4 years. Minimal educational standards were established and met. Better pay, no discrimination, and a realization that nurses were not interchangeable in the workplace helped the profession’s image. Nurses were encouraged to enter specialty areas. The need for nurses continued to increase and another “quick fix” was necessary. Licensed Practical Nursing programs can be traced to this period. Hospitals and technical/vocational schools offered this one-year program in how to provide bedside care. The nursing model of care that emerged was team nursing.

Modern nursing is only 100 years old. In the 1970s, nursing took an enormous leap forward. During these years, nurses moved into spheres of professional, social and political responsibilities. In the 1980s, the ANA (American Nursing Association) published a social policy statement on the nature and scope of nursing practice. The statement was intended to promote unity to allow a common approach to practice.

As technology advances, nurse will have to continue to define their role to the public. We have learned from the past and strengthened our professional practice. It is difficult if not impossible to envision a health care system without nurses.

Legal Consult: Physicians' Duty To Protect Potential Victims
By Peter Martin, Esquire

Late last year, a Superior Court judge ruled that where a neurologist failed to warn a patient not to drive, where the patient’s medical condition increased the risk of suffering a seizure while driving, the physician may be sued by a pedestrian injured when the patient ran into him. In so ruling, the judge found that the physician owed a duty of care not only to his patient, but to those whom the patient might foreseeably injure if he were to drive and suffer a seizure. In this case, the physician violated the duty of care by failing to issue a warning not to drive, and not by any affirmative act by the physician.

If the Supreme Judicial Court were to establish a common law rule that a physician owes a duty in these circumstances, Massachusetts would join at least three other states in finding that a doctor owes a duty to the traveling public to act with reasonable care when a patient’s medical condition or medication makes it dangerous for the patient to drive. In order to reach that result, the court found no parallel duties in existing Massachusetts law and engaged in a somewhat strained legal analysis to establish such a duty.

Generally, the law finds that in certain situations, a special relationship imposes a duty to take affirmative actions to protect against dangerous or unlawful acts of third persons. In this case, the court found four such “special relationships” and sought to assimilate the situation at hand into the existing legal framework ~ with imperfect results.

The first such “special relationship” is created when an individual takes an affirmative act that creates or increases the risk that the third person will harm a potential class of victims. As a result, the individual owes a duty to that potential victim class to act reasonably. Examples of this relationship are of the “social host” who furnishes alcohol to his guest; the social host owes a duty to the potential class of victims to stop serving the guest when he becomes intoxicated. By analogy, the trial court reasoned that the Supreme Judicial Court would hold that if a physician prescribed a medication with side effects posing a significant risk that the patient would fall asleep while driving, that physician would owe a duty to the potential class of victims to warn the patient not to drive when taking the medication.

Here, however, the physician, in failing to warn the patient not to drive, took no affirmative act that increased the likelihood the patient would suffer a seizure while driving. The court reasoned, however, that the physician’s act of treating the patient in and of itself was such an “affirmative act” that increased the likelihood of harm because the patient did not seek out the advice of another physician who might have given that warning. Thus, the court sought to make the physician’s alleged error of omission stand in the place of the “affirmative act” generally required to create this kind of special relationship and its consequent duty to the public.

The second type of “special relationship” exists between the defendant and a limited class of persons that includes the plaintiff. Examples of this relationship are those between a college and its students, a landlord and its tenants, or a hotel and its guests. In each case, the college, landlord or hotel must take reasonable steps to protect persons on its premises from reasonably foreseeable risks of harm. This relationship is founded on the reasonable expectation of the student, tenant or guest that the defendant will anticipate and take reasonable steps to protect him/her from harm.

Here, it is difficult to see that the pedestrian injured by the patient/driver has a reasonable expectation that the patient’s physician will protect him from harm. The trial court merely noted in this connection that the risk to the pedestrian and to the patient was the same ~ both could be injured if the patient suffered a seizure while driving. Apparently the reasoning here is that because the risk was the same, and the reasonable step the physician could have taken to help the pedestrian avoid that risk ~ advising the patient not to drive ~ is consistent with the duty owed to the patient himself, the patient and the pedestrian fall within the same “special relationship” class with the physician.

The third type of “special relationship” giving rise to a duty to third persons is where a defendant takes control of a person who may cause harm to others if not controlled. Examples are of a psychiatric hospital transporting a patient dangerous to others outside a ward, or of a psychiatrist’s statutory duty to warn identified third persons of a specific threat to kill or harm those persons.

In this case, there was neither a custodial relationship with the patient nor an explicit threat or history of harming any identifiable third person. The court merely noted that, like the psychiatric hospital or psychiatrist, the physician in this case was in the best position to have known of the patient’s dangerous condition and to have taken reasonable steps to avert that risk. The outlines of a physician’s duty to the public based on this logic are indistinct at best.

The fourth type of “special relationship” exists between public employees and the general public where inaction could lead to calamitous harm and the law reflects a public policy to protect the general public from the threat. For example, a police officer owes a duty to the public to remove an intoxicated motorist from the road.

Here, the physician clearly is not a public employee, but the court noted that the duty the plaintiff seeks to impose on the physician is consistent with state regulations that establish a presumption that a person who suffers a seizure is unfit to drive an automobile, unless a physician has certified otherwise. The court further noted that fulfilling this duty to the potential class of victims creates no conflict with the duty the physician owed to his patient ~ that of rendering appropriate advice. Does this mean that a physician has an obligation when caring for a patient whose condition might result in harm to others to take actions consistent with public policy to protect the general public, so long as such action does not conflict with the physician’s duty to his patient?

The trial court concluded that the physician owed a duty in this case to the potential victim class because of his physician-patient relationship, the regulatory requirement that a patient suffering a seizure surrender his driving license, and “…the absence of any meaningful distinction between an affirmative act and an omission in the context of advice offered within a doctor-patient relationship.”

This troubling case does not change the applicable standard of care (an expert opined that the standard required the physician to advise the patient against driving), but it does suggest that where negligence occurs and the patient harmed a third person, the physician could be sued by the injured third party. Particularly because the imposition of a physician’s duty to this larger class of potential victims does not seem to require the physician to take an affirmative action that increases the risk of harm to that class, it is not at all clear how physicians are to fulfill their expanded duty. Does this case stand for the proposition that physicians must advise patients against a much broader range of behaviors that could harm others, if that advice is consistent with public policy? It is difficult to see the outer limits of such a duty, if indeed such limits exist.

Science Corner: How Do Teens Take Care of Their Type 1 Diabetes?
By Lynne Schilling, RN, PhD, Professor and Associate Dean for Research and the Doctoral Program in the Graduate School of Nursing at the University of Massachusetts Medical School.

Diabetes is a 24/7 lifetime responsibility until we find a cure. Children with the disease share responsibility of managing the disease with their parents. Although the direct participation of parents in disease management decreases as children get older, teens still require the help of both of their parents and their health care providers to optimally care for their diabetes. Studying how children and teens take care of their diabetes is important because self-management of the disease is central to the control of the disease. Although teens assume more responsibility for managing their disease than younger children, they sometimes have more trouble doing all the necessary things to keep their blood sugars in the optimal range. We now know that if teens can keep blood sugars in the optimal range, they can delay onset and slow the progression of complications from the disease. We also have data that suggests that good metabolic control of the disease by teens leads to good metabolic control in early adulthood.

Our research team has been working to describe how the self-management of diabetes changes as children get older and what is involved in the self-management of the disease in youth. One of the problems we encountered is that there is no good self-report instrument for clinicians and researchers to use to measure self-management of type 1 diabetes in teens. To address this problem, we wrote a grant to develop such an instrument and in 2004 we received funding by NIH to do so.

This project, now ongoing at the University of Massachusetts, Worcester will result in a reliable and valid self-report instrument and will yield data on the self-management of diabetes from a sample of 600 teens drawn from two diabetes centers (Yale Program for Youth with Diabetes and the Children’s Hospital of Philadelphia). We call the instrument the SMOD-A, an acronym for Self-Management of Type 1 Diabetes in Adolescents.

It is our hope that having such an instrument will not only help researchers more accurately evaluate the effects of interventions, but will also help clinicians evaluate the self-management needs of the teens in their practices.

Delemater, A.M. (2000). Critical issues in the assessment of regimen adherence in children with diabetes. In D. Drotar (Ed.), Promoting adherence to medical treatment in chronic childhood illness: Concepts, methods, and interventions (pp. 173-195). Mahwah, New Jersey and London: Lawrence Erlbaum Associates.

Diabetes Control and Complications Trial Group (DCCT) (1994). Effect of intensive Diabetes treatment on the development and progression of long-term complications in adolescents with insulin-dependent diabetes mellitus: Diabetes Control and Complications Trial. The Journal of Pediatrics, 125(2), 177-188.

Grey, M., Insabella, G., & Knafl, G. (2002, June). Intensive therapy in adolescence and quality of life in young adulthood. Paper presented at the American Diabetes Association’s 62nd Scientific Sessions, San Francisco, California.

Schilling, L. S., Knafl, K. A., Grey, M. (in press). Changing patterns of self-management in youth with type 1 diabetes. Journal of Pediatric Nursing.

Dr. Millstine is a primary care physician in her 2nd year of practice in Concord, MA.

Mara found her new patient sitting under layers of newspaper. “Joe Franklin?”

“I’m Dr. Holden.” Mara shifted her papers under one elbow and extended her other hand. “I’ll be your new physician.”

“That’s fine.” He grasped her hand gently. “So, then, when can I go home?”

“Home, I want to go home.” He raised the paper halfway, then peered over the top. “Don’t call me ‘Sir.’ Makes me feel old.”

Mara rechecked his date of birth and her math. Sure enough, 94. “I’ll look into it.” She jotted a note to herself. “No promises, your labs don’t look so great.”

Mara nodded slowly. “We’ll see,” she managed. She headed into the busy nursing station, buzzing with early morning staff.

Charts and messages tipped precariously in Mara’s inbox and her outbox stood pathetically empty. “Honey, eat without me,” she sighed to Aaron on the phone. “I have too much to do.”

“I’m sorry. You’re probably really hungry.” She squinted at an X-ray report describing an enlarged heart. She didn’t recognize the patient’s name. “I don’t know these patients.” She sighed, “Or maybe I just don’t know what I’m doing.”

“You’re doing fine,” he sighed. “You can’t expect to be perfect when you’re brand new.”

“She’s nuts.” Mara dropped her briefcase on the counter, pulling leftover pasta from the fridge. “Doesn’t she know her father has heart failure, not to mention the multitude of other medical problems? She wants him alive for his birthday party.”

Aaron chomped down on a baby carrot and picked at the peeling countertop. “Is she really that bad?”

“Refuse him,” Aaron shrugged. “I know you’re flattered, but you don’t have to accept him as a patient just because they asked you.”

The stove burner wouldn’t light and the trash smell escaped from under the sink. “He’s got a bad heart, kidney failure, and a daughter who is in my face. It’s not his fault.” She stopped and turned toward Aaron. “He’s a delightful man. I’m going to take him.”

“Load the boat, then. He sounds like hard work. You should get the specialists involved right away.” He looked at her over his wine glass. “Right?”

“I will, I will,” she said, balancing the pasta dishes, forks, and napkins and headed for the table.

Joe sat in the exam room, his cane leaning against the wall. His yellow sweater sported a button: Precious Antique.

“You’re late,” he said, tapping his watch face as Mara rushed into the room.

“Busy day,” she pulled her hair into a ponytail and fanned a paper in front of her face. “Sorry to keep you waiting.”

“It’s no way to run a business,” he said, passing his cane from one hand to another.

A shrill ring made Mara jump, dumping Joe’s chart on the floor. She took the phone call, then turned toward him. “Sorry.” She straightened the disarray of papers. “Now tell me about your cardiologist.”

“No cardiologist and no other doctors.” He folded his arms on his chest. “Just you.”

She glanced down. His last echocardiogram report sat on top of the stack in her hands: Severe heart failure, incompatible with life. “Great.” She forced a smile.

“After all these labs and changes in my medications? What would you expect, good Doctor?”

The following week, Joe brought a snapshot to his appointment. He stood in a dark gray suit, leaning on Rebecca’s arm. A tiered birthday cake stood, sagging slightly under ninety-five candles. His lips were pursed, ready to blow them out.

The next week, Rebecca called. “My father couldn’t eat his oatmeal today. Do you think he should go back in the hospital?”

“Because he couldn’t eat his breakfast?” Mara shook her head and sorted through prescription refill requests. “Just wait, see how things go.”

Later that day, Joe landed in the emergency department, then the ICU. He struggled for breath, but waved Mara out of the room. “Get out of here, I’m fine.”

Mara looked at Rebecca, eyebrows raised. “You tried to tell me,” she started.

“You’re very sick. I’m sorry,” Mara started. “I should have listened.”

“Do you know how many changes I have made with his medications? I diuresed and his breathing got better. Then, his kidneys started to get worse.” She slammed down the menu. “I rehydrated with 250 ccs. What’s that? A can of soda?” She shook her head. “I put him back in heart failure.”

“You didn’t ‘put’ him.” Aaron touched her elbow. “He has a bad heart.”

“I can’t do it.” She pressed her fingertips into her temples. “I don’t know enough. I’m messing this up.”

“You’re doing great.” He wrapped his arms around her waist. “You know, he would be dead now if you weren’t watching him this closely. He’s just tough to balance.”

“I’m doing everything I can.” She tilted her head down, then met his eyes. “Not to change a thing.”

“Graduating with honors.” Joe zipped up the hall with his walker, physical therapist in tow.

“You look great,” Mara perched on the edge of his bed. “It’s really amazing.”

Settling in his chair, he pulled a box of chocolates closer. “It’s time I go home.”

“Joe.” Mara looked down. A nurse pushed an IV pole down the hall. “Your heart,” she started.

“Home is where I want to be.” He pushed his wife’s picture toward her. “We were there together. My things are there, and her memory is there. I should be there.”

Mara left the room and pulled his chart. She reread her notes, his labs, and his x-rays. She sat up straight, and flipped to the orders section.

Discharge home, Mara wrote. She slammed the chart closed, placed it squarely in the rack, and left the hospital.

Mara pulled salmon, broccoli, and corn from her shopping bags. Aaron looked up. “No frozen chicken nuggets?”

Mara’s pager rang and she patiently picked up the phone. Joe’s nurse asked, “Did you see his labs and urine output? You really think it’s wise to send him home?”

“Send him,” Mara hung up, and she met Aaron’s eyes. “It’s what he wants,” she told him.

“Doesn’t matter.” She splashed olive oil into a sizzling hot pan. “Actually, it does. That he gets home matters, not for how long.”

Mara gazed outside at the rolling green, grassy hill beyond her office window the next day. “My father’s back in the hospital,” Rebecca said.

Mara put the phone down and rushed into the ER. Joe breathed through an oxygen mask. His eyes were slits, crinkling at the edges. He weakly squeezed Mara’s hand back. His skin was dusky, gray, and cool.

“He was so proud.” Rebecca dabbed her eyes with a crumpled tissue. “He made his own bed and kissed my mother’s picture goodnight.”

“He needed to do it,” Mara said. His head nodded only slightly, but they both saw. She looked at the monitors; the pulse oximeter line hovered in the 80s. His blood pressure was too low.

“He’s so sick,” Rebecca started. “If he had just stayed in the hospital…”

“He still would have been sick,” Mara finished. “Getting home was more important.”

She squeezed his hand firmly and grazed his cheek with her hand. She straightened taller and looked squarely at Rebecca. “We’ll let him go,” she said quietly, but with conviction.

Rebecca nodded. The women hugged. Joe’s face relaxed, and his muscles eased. He was ready for the final journey home.

Off Call: "Cooking is like love. It should be done with abandon or not at all."
By Helen Van Horne

I love cooking and I love reading, so it is not surprising that I have hundreds of cookbooks in my library (literally six bookcase shelves). But I regularly use only a few of them. However, that does not stop me from being constantly on the lookout for new recipes, especially ones that are easy to prepare yet taste like you have been working for hours.

Entertaining, preparing food for those we love, and eating together is always a pleasure. My secret to enjoying myself on the day of the dinner is organization. I do everything that I can do ahead of time. Unless you use your dining room table during the week, your table can easily be set the weekend before your dinner party. Many appetizers and desserts can be made the night before the social gathering. I also wash my salad greens and store them in a towel ~ this keeps them fresh and dry.

Today I’d like to share one of my favorite recipes ~ it’s is easy to make, yet high quality enough for company. If you like fresh lemon, tender chicken and a quick recipe, then you will love this classic Italian dish.

4 chicken cutlets
Flour
2 Tbsp. vegetable oil
¼ cup dry white wine
1 tsp. minced garlic
½ cup low sodium chicken broth
2 Tbsp. fresh lemon juice
1 Tbsp. capers, drained and rinsed
2 Tbsp. unsalted butter
Fresh lemon slices
Chopped fresh parsley

Season the chicken cutlets with salt and pepper, then dust with flour. Spray a sauté pan with nonstick spray; add vegetable oil and heat over medium-high. (I slice a chicken breast lengthwise and put in a Ziploc bag with a little water and pound to ¼ inch thick.)

Sauté cutlets 2-3 minutes on one side. Flip the cutlets over and sauté the other side 1-2 minutes with the pan covered. (I cover with a heatproof plate and use the hot dish to keep the chicken warm.) Transfer cutlets to a warm plate and cover with aluminum foil to keep warm; pour off fat from pan.

Deglaze pan with wine and add minced garlic. Cook until garlic is slightly brown and liquid is almost gone, about 2 minutes. (Be sure to use a good wine ~ I use a chardonnay.)

Add broth, lemon juice and capers. Return cutlets to pan and cook on each side 1 minute. Transfer cutlets to warm plate and cover.

Finish sauce by adding butter and lemon slices. Once butter melts, pour sauce over cutlets.

Garnish with chopped fresh parsley and serve with your choice of pasta and Italian cheese.

Call for Nominations
Take this opportunity to honor a colleague you feel deserves recognition.

A message from the Worcester District Medical Society Alliance.

WDMSA gratefully acknowledges Whole Foods, Inc. for the generous support of The Pedometer Project.

Julianne Hirsh, President

The New "Massachusetts Physicians Executive Retirement Program"
Giving Physicians Better Options
By Jack King, President, Physicians Insurance Agency of Massachusetts

By all accounts, physicians need more and better help when it comes to retirement planning. Despite years of hard work, physicians are finding it more and more difficult to enter retirement with adequate income. And the problem is only going to get worse. It’s not that doctors aren’t targeted by investment houses and advisors of all types. Overwhelmed and always busy, it’s often difficult for them to take the time and really focus on this critical issue. Some are a little embarrassed to admit they need help. Too many physician retirement plans end up being a “1-800” number and a drawer full of mutual fund statements.

Having “enough” to retire couldn’t come at a more important time. According to the U.S. Census Bureau, the fastest growing segment of the population is people age 65 or older. The Bureau estimates that from 2000 to 2020, the number of Americans age 85 or older will increase by 71%, far out-pacing the growth rate of any other age group. This means that many physicians could end up being in retirement longer than they were in practice. Their ability to cover day-to-day living expenses, as well as skyrocketing future healthcare costs, could strain their retirement income to the breaking point.

Enter the “Massachusetts Physicians Executive Retirement Program”: A New Strategy for Doctors

Better planning and better retirement plans can help physicians a lot. PIAM, the insurance and financial subsidiary of the Massachusetts Medical Society, has developed a special retirement program for physicians. The goal is to give to doctors the same high level of retirement plan design, administrative support and investment choices that Fortune 500 companies give to their executives. According to George Ghareeb, MD, Chairman of the Board of PIAM, “We want to give physicians the best quality retirement planning anywhere. We have combined excellent plan advisors with the best administrators and a vast selection of investment options.”

The new Massachusetts Physicians Executive Retirement Program is really many different retirement plan options under one umbrella. Doctors will get a selection of plans and capabilities unlike anything they are used to seeing. Because our program combines flexible plan designs, state-of-the-art administration, and great investment selections from our advisors, there is just no comparison to the usual retirement plans. We want to see physicians use more effective plan designs and the one-on-one higher level of service from our advisors. Our goal is to get physicians to upgrade and improve their retirement options.

For more information about the new “Massachusetts Physicians Executive Retirement Program,” call Chip Moynihan, Director of Financial Services Operations at PIAM at (781) 434-7398.

Born in Istanbul, Turkey of Armenian parents in 1919, Dr. Anthony (Antranig) Varjabedian came to the United States at age two. At Clark University, he was elected to the Scholarship Society and was Call Orator at graduation in 1941. He received his MD from the Yale School of Medicine and interned at Worcester City Hospital. His psychiatric training was at Worcester State Hospital and his neurological training was at Cushing VA Hospital in Framingham and at Boston VA Hospital.

He was in the US Naval Reserves and served in World War II and the Korean Conflict. He was a Diplomat of the American Board of Psychiatry. He practiced Psychiatry and Neurology in Worcester until his retirement in 1990.

He was a Visiting Lecturer at the Clark University Graduate Department of Psychology and Visiting Professor in Psychiatry at the University of Massachusetts in Amherst. He was also a consultant for the Rutland VA Hospital, the Division of Child Study of the Worcester Public Schools, and the Worcester District Court.

Dr. Varjabedian was on the Neurological Staff at Worcester City Hospital and the Psychiatric Staff of St. Vincent Hospital (as Chief for five years), the Memorial Hospital, and the University of Massachusetts. He was also an Associate Professor of Psychiatry at the University of Massachusetts Medical School.

Deeply interested in his racial background, he was a member of the Armenian Revolutionary Federation for over fifty years.

“How is it,” he once reflected, “that man has been able to invent, discover, and produce those materials which contribute to a more comfortable life, and yet has been unable to produce the essential stabilizers for a peaceful and happy life?”

Tony Varjabedian devoted his professional life to providing “stabilizers” for his patients in their attempts to seek “…a peaceful and happy life.” He accomplished this with the highest degree of professionalism.

He died on February 25, 2006 at the age of 86 after a lengthy illness, leaving Lois (Freeman) Varjabedian, his wife of 51 years, and three sons: Michael of Chicago, Arthur of Sutton, and Aram of Middleboro.