Sharon Tissell, RN, dreamed of one day helping those around the world without the fortune of growing up in a loving, middle-class family like hers. Tim Harrison, RN, MPH, flew for 10 years with a medical helicopter service and knew he had the right skill set to make a difference. Martina Ford found that she thrived in multicultural settings.
All three of these nurses have found their professional sweet spot, which, at most, pays them a modest stipend and requires them to endure Spartan—and often dangerous—living conditions for months at a time. They are humanitarian medical relief nurses who make multiple trips each year to the very places we see in the news that we are told to avoid.
Places like the Syrian-Lebanese border, which is experiencing the largest exodus of refugees in recent history as Syrians flee their country after a brutal government crackdown and civil war began in 2011. Or South Sudan, Africa’s newest nation where ethnic rivalries have destabilized a fragile government and led to violence, bloodshed, and the internal displacement of tens of thousands. Or the Philippines, where Typhoon Haiyan flattened towns and villages, crippling a country’s capacity to deliver basic services and medical care to its people.
What motivates Tissell, Harrison, and Ford to return to these situations time and again is the opportunity to offer unconditional care, comfort, and compassion to the world’s most vulnerable populations. Across vast geographic, cultural, and ethnic boundaries, their work goes to the heart of what nursing is.
They don’t let politics and war keep them away, although these are often the factors fueling the crises at hand. While fearless, humanitarian relief nurses are hardly reckless, receiving intensive security training from their sponsoring organizations and working on highly coordinated teams where personal safety is valued above all else. Moreover, these nurses hardly see what they do as a personal sacrifice.
“It’s not about you,” says Harrison, a nurse with Médicins Sans Frontières (MSF), or Doctors Without Borders, who lives in Maine when he is not traveling for MSF. “It’s really about the direct connection between donors [of humanitarian aid] and beneficiaries. You’re simply the conduit.”
Wearing Multiple Hats
While nursing can be a satisfying career, it also runs the risk of being repetitious; working internationally can be a “way to break out of the doldrums going into your shift every day,” says Sue Averill, RN, cofounder and president of One Nurse At a Time, an organization that provides information and scholarships to nurses who want to work in humanitarian relief. Averill herself has gone on eight missions with MSF and several others with Medical Teams International (MTI), based in Tigard, Oregon, and with Smile Train, based in New York City.
Averill says experiences in the ER, ICU, surgical, and critical care floors are great preparation, as are courses in public health and tropical diseases such as Dengue fever, malaria, and others rarely seen in the West.
Also invaluable are critical thinking skills that empower you to be resourceful and in situations where supplies, medicines, and equipment are limited. Reorienting yourself to medicines that may be similar to those in American hospitals but with different branding, dosage levels, and packaging is also key.
Being able to communicate crossculturally and understanding cultural biases are as important as having strong medical training, Averill says. For example, a small white pill may be perceived to be inferior to a large white pill or a colored capsule in certain cultures. Local people and medical staff may “imbue [Western nurses] with qualities [they] may or may not have,” she adds. “People believe that simply because you came across the world to help them that you come with something better than they have,” even when that may not be the case.
That’s why it’s critical to have frequent conversations with patients to understand cultural biases and figure out how to work around them. One major strategy is to make sure you and your translator are “on the same page,” suggests Averill.
Relief work also requires nurses to wear multiple hats, she adds: “You’re a human resources person. You’re diagnosing and treating. You’re hiring and firing.” But perhaps most importantly, you’re teaching local people to think critically.
Averill was once tasked with setting up a hospital for Darfurian refugees in an isolated village on the border between Western Sudan and Chad. The endeavor required training local workers, including a woman who said she was a traditional birth attendant. After asking the attendant how many weeks pregnant a local woman was, the attendant said “36,” when the woman was nowhere near full-term. It was then that Averill realized that the attendant was unable to count.
In a similar vein, other workers claimed to know how to take pulses and blood pressures, but in fact didn’t understand how to do either. Another worker wore the same pair of gloves as she screened patients for malaria.
“They were doing these tasks rotely and not understanding what they mean,” Averill says. “That critical thinking piece wasn’t there.”
So, Averill went over the basics, teaching the staff how to take vital signs, the importance of glove disposal and frequent hand washing, and how to do A/B/O typing for blood transfusions. “It was really fun to see the light bulb go on,” Averill says, similar to the one going off in her own head as she stretched her own skill set.
Similarly, Ford had little experience in obstetrics before traveling with MTI to the Nakivale Refugee Settlement in Uganda last year. The local midwives were eager to see a “muzungu,” or white person, to deliver a refugee woman’s baby. So with “no IV, no monitors, no electricity,” Ford says she stepped up to the plate and did it. “It was mind-blowing.”
“When you’re talking to people about going on these trips, many people like the idea of it,” she adds. “But nothing is what you think it’s going to be.”
Having a successful experience as a humanitarian relief nurse also requires emotional fortitude, flexibility, and the ability to think on your feet, says Harrison. Being a medical transport nurse for Boston MedFlight not only gave him a broad skill set in obstetrics, pediatrics, and trauma care, but also taught him the importance of teamwork and maintaining equilibrium in situations that are fluid and unpredictable.
Harrison first encountered MSF in 2004 working on a volunteer assignment in Chad with another medical assistance organization. What impressed him about MSF was its long-term investment in communities lacking the medical infrastructure to contend with disease outbreaks and public health emergencies. He also observed that MSF didn’t do “drop-in medicine” like other relief organizations did, allowing it to have a larger impact; he also admired MSF’s independence from government funding and its neutral stance towards political debates and conflicts. With several international assistance trips under his belt, he decided to apply for a full-time nursing position with MSF.
After a lengthy interview process with MSF, Harrison was accepted in 2008 and left Boston MedFlight with the blessings of his boss. That year, Zimbabwe was being devastated by a cholera epidemic caused by the breakdown of water sanitation and sewage systems in urban areas; the disease spread quickly to the countryside after city-dwellers visited relatives in rural areas.
Harrison’s first assignment was to manage a database that tracked the epidemic as it moved from cities to towns and villages. Later on, he joined a team responding to malnutrition and cholera in prisons around Harare, the country’s capital. Rather than focusing on the prison’s water delivery system, the MSF team focused on chlorinating the water supply, boosting the immune systems of prisoners through antibiotics and nutritional therapy, and getting infected prisoners into treatment.
After six years with MSF and multiple trips to conflict zones throughout Africa, Harrison says the work brings out his street smarts. “I seem to have the mentality that [MSF] can put me some place in the world and I can work out what’s going on,” he says.
At no other time was Harrison’s even-keeled temperament tested more than a harrowing trip to South Sudan late last year. His experience also underscores how rapidly the situation on the ground can change and the importance of staying alert and in contact with team members.
Since 2009, Harrison has made trips to South Sudan, which achieved independence from Sudan in 2011 after a protracted civil war between rival ethnic groups. MSF has had a strong presence in the region since 1983, delivering primary and secondary health care in clinics and hospitals in several major cities including Juba, the capital, as well as Lankien, Bor, Bentiu, and Malakal.
On his first trip in 2009, Harrison went to Lankien to oversee a feeding center for malnourished residents. He spent time training local hospital staff who had little or no medical training. After a brief trip to the region in 2010, he returned to Malakal in October 2013 to see the fruits of MSF’s investment in the local workforce. “You could really see the change,” he remembers. “I had skilled people working for me.”
As with his previous trips, Harrison was assigned to one of MSF’s kala azar treatment centers within the Malakal Teaching Hospital. Kala azar, a tropical disease that attacks the immune system and is fatal if untreated, is transmitted to humans through sand flies, carriers of the leishmania parasite. The disease persists in Sudan despite MSF’s long-established kala azar clinics.
On December 15, 2013, a coup was attempted on President Salva Kiir’s postindependence administration after long-simmering tensions between rival ethnic groups, the Dinka and Nuer, exploded. A Dinka, President Kirr accused Vice President and Nuer politician Riek Machar of instigating the coup. The military began splintering along ethnic lines, and armed conflict began spreading from Juba to other regions.
By the week of Christmas, the fighting had reached Malakal. Harrison and an Amsterdam-based MSF team were hunkered down in their rented house in the middle of Malakal’s downtown marketplace, gunfire and mortars exploding around them. Harrison and others had been staying in touch with MSF outposts in Juba and other cities to get the latest news. “By the time it became obvious something was going to happen, we couldn’t get out,” he recalls.
The group managed to move down the street to a house rented by an MSF team from Spain. Altogether, there were nine MSF team members who had remained in Malakal, holed up in a 12 x 12 room for 36 hours until Christmas Day, when the shooting began to dissipate. By Thursday, the day after Christmas, the teams decided to make their way back to the Malakal Teaching Hospital to assist an International Committee of the Red Cross (ICRC) surgical team with a brand new set of patients: soldiers and civilians wounded in the crossfire.
When he returned to the hospital, Harrison noticed that many of the healthier kala azar patients had simply fled. He quickly switched gears and helped set up a 60-bed triage unit to deal with the sheer numbers of wounded streaming into the hospital. With his experience as a trauma nurse, Harrison jumped in to assist the ICRC surgeons with anesthesia, wound debridement, IVs, and “whatever was needed.”
Harrison’s work continued on like this until mid-January, but what was becoming painfully obvious was the deterioration of the security situation inside the hospital. Initially, the soldiers agreed not to bring their guns inside, but soon, guns and “cases of whisky” could be found on the hospital grounds. Family members of the wounded and refugees from Malakal soon began overrunning the hospital to escape the violence.
“At one point, there were 1,000 people in the hospital,” Harrison says. “It had become an IDP [Internally Displaced Persons] camp.”
What finally convinced Harrison and his fellow MSF team members who had remained in Malakal that staying was no longer an option was when teams in both MSF residences took a hit. The Spanish team was robbed of their mobile phones and laptops at gun-point by an armed group; a drunken soldier burst into the compound where Harrison and the rest of the Amsterdam team were staying and started shooting in the air. The house’s security staff talked the soldier down and got him to leave. The next day, Harrison and the entire MSF team headed to a United Nations compound outside of Malakal and were on a flight out of the county soon after.
Harrison says the decision to leave was wrenching, but one that ultimately made sense given the escalating conflict. The hardest part was wondering whether the work could be continued by the hospital’s local staff, many of whom said that it probably wouldn’t. (By February, MSF had to suspend its activities at Malakal Teaching Hospital, according to a recent MSF report.) Still, the team’s departure weighs on his mind: “How does this look that you’re having to flee? You can always leave. You can always go home. What about the people left behind?”
A Higher Purpose
Tissell remembers clearly what inspired her to work internationally: the National
Geographic magazines her parents subscribed to at the family’s home in Kerkhoven, Minnesota. As she perused stories about hardship and traditional cultures from all over the world, she began to realize that “not everyone had the same upbringing as me.”
Her parents, now in their 80s and extremely supportive of her work with MTI, gave Tissell both a great childhood and self-awareness. “I had a strong sense as a young person that I had a whole lot and [some] people had nothing,” she says.
Ford, too, was deeply affected by the unequal distribution of medical care throughout the world. As a childhood survivor of uterine cancer, Ford pursued nursing because of wonderful care she received at a children’s hospital in Portland. “I have a lot of guilt related to inequalities in medicine and education,” she says. She channels her guilt into providing medical assistance and communicating across cultures through trips with MTI.
With her propensity to help those in need, nursing was a natural fit for Tissell. When her eldest of four children turned 17 in 1999, she decided to join an MTI month-long trip to Honduras to set up mobile medical clinics in remote villages destroyed by Hurricane Mitch. The last two weeks, Tissell’s team packed their medicine and supplies and rode mules into the dense jungles of the Mosquito Coast. “We saw a lot of Dengue fever, malaria, a lot of infections from injuries, upper respiratory infections…and childhood disease that hadn’t be treated with vaccines,” she recalls.
Over the next 15 years, Tissell went on more than a dozen medical trips with MTI. She now works shifts at two different hospitals to accommodate and subsidize her travel.
Through her work, Tissell has provided medical care to refugee communities around the world uprooted by high-profile natural disasters and wars. She has treated famine-stricken Somali families seeking refuge in Ethiopia. She served in an IDP camp in northern Uganda to receive malnourished women and children who had fled the terror of Joseph Kony and his Lord’s Resistance Army. On a trip with Los Angeles-based International Medical Corps, she was treating civilians at hospitals in Libya just days before Colonel Quaddafi was captured and killed. And she was in a tented settlement in Lebanon’s Bekaa Valley in May 2013 providing medical care to the thousands of middle-class families from Damascus and other Syrian cities streaming across the border after President Bashar al-Assad began shelling his own people.
The families, who had left homes and careers behind, weren’t suffering from exotic diseases, but rather chronic illnesses such as lymphoma, diabetes, and heart disease that they were unable to treat without access to medicines and regular medical care. “One woman said, ‘We lived in a nice house, we had three bedrooms,’” Tissell says. “This was a total disruption of what their life had been like.”
Each time she returns to her home in Happy Valley, Oregon, Tissell arrives with photos and memories of the families she has helped. Motivated by a strong sense of divine purpose, Tissell says she is perennially awe-struck by the gratitude expressed by people who have just lost everything—and in many cases, everyone. She says she’ll never forget a Congolese woman she met in Uganda whose husband had just been shot during an outbreak of violence in their native country. When she asked the woman if she thought God had abandoned her, the woman turned to her and said, “Of course He hasn’t. Otherwise you wouldn’t have made it here.”
Archana Pyati lives in Silver Spring, Maryland, and writes frequently on health and science topics.
Every hospital has stories of nurses who thrive by floating. More than likely, they have chosen to be part of the hospital’s float pool. Yet, for floor nurses who must take float assignments when their unit’s census is low or to fill staffing shortages across the hospital due to absences, vacancies, or high-acuity levels, floating can be a major source of job dissatisfaction. In the past decade, hospitals across the country have revamped their float policies to give nurses greater autonomy and agency in deciding whether or not to float.
Risi Bello, RN, has been a float nurse at MedStar Washington Hospital Center in Washington, DC, for 12 years, and for the most part, loves it. The flexible schedule, the variety of clinical experiences, and the constant exposure to new patients and coworkers are what attracted Bello, 49, to floating in the first place. She’s only required to work a total of 48 hours over a six-week period, which she can work in either 8- or 12-hour shifts. Although two of her shifts have to fall on major holidays each year, the schedule has given Bello, a married mom of six, a work-life balance she might not have achieved had she been a floor nurse.
And watching Bello work on two different floors during separate shifts in late December, it was clear that she was comfortable wherever she went in the 926-bed hospital. She confidently cared for four patients she had met only hours before, knew where to access the floor’s medication and supplies, and updated patient records on a hand-held mobile device.
“You get to meet the best people in the hospital,” says Bello, a native of Nigeria. “It’s socially engaging and you learn a lot because you’re not stuck with a particular set of diagnoses.”
Tools for Success
In an essay published last year in MedSurg Nursing, Katie J. Bates, MSN, RN, reflects on recent research gauging nurses’ attitudes towards floating as well as her own experiences with it early in her career. Recent graduates and experienced nurses alike can feel “alone, anxious, and even incompetent when floated to other units,” if they haven’t received proper orientation, she wrote in her piece, “Floating as a Reality: Helping Nursing Staff Keep Their Heads Above Water.”
Nurses who float to unfamiliar units can get stuck either with less challenging patients or with the most difficult cases to give staff nurses a break. They may feel less productive as their time is spent searching for supplies or seeking help from nurses on the unit. These scenarios make the floating nurse feel “undervalued and expendable,” and patient care may suffer as a result, explains Bates, a critical care staff nurse at Good Samaritan Hospital in Puyallup, Washington.
Bates recommends creating tip sheets, informational packets, or pocket guides for float nurses that contain specific information about subspecialties. For example, “an orthopedic tip sheet may describe hip precautions for postoperative patients,” she wrote. Bates also suggests having a dedicated resource nurse in each unit who doesn’t take her own patients, but is there to assist nurses who float to the unit. Finally, Bates says the unit’s charge nurse should check in with the float nurse periodically to ensure she is comfortable with her patient load and responsibilities.
Bates acknowledges that budgetary constraints may preclude efforts to implement these changes. Yet additional resources and staff support are critical to turning floating into a positive experience, she argues.
Float Pools or Resource Nurse Teams
In response to dissatisfaction floor nurses have expressed about mandatory floating, several hospitals have developed dedicated teams of full-time float nurses. At MedStar Washington Hospital Center, the float pool is composed of 91 nurses who are mostly full-time floaters, says Rosemarie Paradis, RN, MS, NEA-BC, CENP, FACHE, the hospital’s vice president of nursing excellence. Additionally, the pool is also staffed by nurses from other hospitals who want to pick up shifts on their off days.
Over time, the float pool has attracted new employees, with 20 nurses being added to the float pool in the past two years, according to Dennis Hoban, the hospital’s senior director of recruitment services. Float pool nurses, Paradis says, are expected to improve their skills and maintain their competencies just as floor nurses are.
While the hospital relies on the float pool first to cover deficiencies in staffing, occasionally staff nurses are called upon to float outside their home units. “As has been our normal practice, nurses float to areas that are similar to their own…and where they have the competency to work,” says Paradis.
In 2006, University of Utah Health Care’s University Hospital in Salt Lake City transformed its resource nursing unit—what the hospital calls its float pool—from an underutilized tool into a highly valued asset. Until that point, the nurses in the unit had been perceived as fill-ins and denied opportunities to take on challenging assignments and complex patients. Now, the 45 nurses in the unit are sought after by other units because the 654-bed hospital decided to invest in training them, explains Karen Nye, BSN, RN, the resource nurse manager.
“We have a timeline of expectations,” says Nye. “We make sure they have training opportunities within a certain date of their hire, and we make sure they adhere to that timeline.”
Now, resource nurses can earn advanced certificates in the ER, ICU, burn, and neurology units. The hospital’s AirMed medical transport team relies heavily on resource nurses since its work requires flexibility and versatility, says Nye. Most recently, a new cardiovascular ICU opened with the assistance of Nye’s resource nurses.
Since there is greater trust and utilization of resource nurses across the hospital, Nye preschedules them in units at risk of paying out too much overtime to staff nurses. The result has been a significant cost savings for the hospital. In five ICUs that accepted pre-scheduled resource nurses in 2010, there was a 62% reduction in overtime hours over a ten-month period, according to a 2011 nursing report published by the health system.
More Options for Staff Nurses who Float
Other hospitals have done away with mandatory floating by floor nurses altogether to boost employee morale and reduce turnover. In 2005, Aultman Hospital in Canton, Ohio, eliminated mandatory floating in response to frustration nurses expressed at being floated from their home units on days when patient volume or acuity was low.
The 808-bed hospital replaced its old float policy with a “Willing to Walk” program, which gives floor nurses the right to decline an offer to float without negative consequences, according to Eileen Good, MSN, MBA, RN, Aultman’s senior vice president for clinical advocacy and business development. Good oversaw the development of the program when she was the hospital’s chief nursing officer.
A floor nurse who declines to float to other units can either take time off without pay or use benefit time. Giving nurses choices and greater autonomy helped Aultman earn Magnet recognition from the American Nurses Credentialing Center in 2006.
Before Good proposed the “Willing to Walk” program, Aultman had developed specialty float pools of nurses trained to work in similar units across the hospital. Good noticed that only a few floor nurses were being floated each day because units were taking advantage of the specialty float pools, composed of 40 to 50 nurses. The rates of floor nurses required to float had decreased significantly. “If we could improve this process with float teams, then why couldn’t we just eliminate [mandatory floating]?” she asks.
As a result of these changes, Aultman reduced its turnover rate from 8.3% in 2007 to 4.3% in 2010. The hospital is in the process of reapplying for Magnet designation, says Good.
While Mercy Hospital, a 175-bed facility in Portland, Maine, hasn’t eliminated floating, it created a tiered system of compensation directly tied to the floating nurse’s competency level in 2007. The new policy was aimed at easing ill will on both sides of the float divide: nurses who floated felt unwelcomed and out of their depth when working in unfamiliar territory, while floor nurses resented the fact that float nurses were getting paid a higher daily rate regardless of their skill level.
Aside from compensation issues, there were also no clear expectations of float nurses or the units that received them, explains Scott Edgecomb, RN, RRT, CCRN, clinical nurse lead in the hospital’s critical care unit. “The expectation was that they would function at a pretty high level when they arrived,” says Edgecomb, a member of a retention and recruitment council that developed the policy. Yet, no structure had been put in place to ensure float nurses received adequate training.
The new policy created four distinct levels of competency for nurses who float, with Level One functioning as little more than “helping hands” on the receiving unit all the way to Level Four, demonstrating the highest level of competency and an ability to take complex cases on specialty floors. Now each level is compensated differently, replacing the across-the-board pay differential float nurses received before.
Edgecomb says the new float policy creates greater incentives for nurses to develop their skills, and that nurses who float now are most likely functioning at a Level Three or Four. Floating is no longer looked upon with dread, but as an opportunity to earn more and develop competencies in specialized units. And the recruitment and retention council has sought to mentor nurses who are proactively seeking floating assignments that expand their skill set.
“People were stepping forward and saying they were interested in assuming those higher level roles,” he says.
Floating as New Nurse Orientation
Advocate Christ Medical Center in Oak Lawn, Illinois, has developed a new program that aims to introduce new nursing graduates to their professions through floating. The program aims to solve two problems: the high number of seasoned float pool nurses who were leaving the pool to take positions as floor nurses and the inability of new nursing graduates in the area—south of Chicago— to find jobs, explains Kristen Brown, MSN, BA, RN, CPN, the hospital’s professional nurse educator and nurse residency coordinator.
Growing out of Brown’s practicum requirements for her master’s degree, the program is starting small but could change the way the 695-bed hospital recruits its nursing staff. In 2013, the program’s pilot year, six nursing graduates were hired from over 100 applicants, and Brown plans to hire at least two more rounds this year.
Nurses in the new graduate float program receive a 12-week orientation and participate in a 12-month nursing residency program, where they receive training with content specialists and have a chance to interact with their peers. Once they start to float, they are sent to specific zones within the hospital—medical-surgical units, orthopedics, surgical trauma, and women’s surgery—where clinical coaches work with them one-on-one over a three-month period.
Brown says the program will enable the hospital to rebuild its float pool with clinically competent nurses. By moving away from hiring to a specific vacancy and capturing strong candidates early in their careers, the hospital can fill vacancies as they occur. It also gave new graduates a chance to learn about the health system and specialties they may want to explore in the future.
“This could be the way new nurses are hired here, potentially,” Brown says. “If you have high quality candidates, you don’t have to worry about finding a spot for them. You’ve got a continuous pipeline of individuals coming in.”
Archana Pyati lives in Silver Spring, Maryland, and writes frequently on health and science topics.
It’s just after lunchtime at Community Clinic Inc. (CCI), a federally qualified health center in Takoma Park, Maryland, a Washington, DC, suburb with a large immigrant and refugee population. Team Nurse Jose Aguiluz, RN, leads the afternoon huddle, a daily ritual where primary care providers—physicians and nurse practitioners—discuss their most complex cases with other members of the clinical team, including community health workers, medical assistants, and Aguiluz himself.
The huddle’s purpose is to spotlight patients with multiple conditions that need to be carefully monitored. The team identifies those who may benefit from “care management,” an approach that combines intensive patient education, follow-up calls and visits, and coordination with specialists. Most of CCI’s patients are low-income and face significant barriers to care, including a lack of transportation, lack of health insurance for those not covered by Medicaid or Medicare, lack of family support like child or elder care, poor nutrition, and mental health complications.
Today’s discussion, for example, includes a woman with bipolar disorder, schizophrenia, and breast cancer who is leery about undergoing a mastectomy and an encephalopathic patient who is convinced he has been followed for the past 20 years.
Care management at CCI has been in the works for two years, ever since the organization decided to become a “patient-centered medical home,” where patients follow a treatment plan and are cared for by a multidisciplinary team of professionals, led by a doctor or nurse practitioner.
Care management, or care coordination as it is also called, is intended to keep patients healthy and is one of the guiding principles of the Affordable Care Act (ACA), President Obama’s signature health care law passed in 2010. In addition to requiring everyone to carry health insurance starting this year, the ACA attempts to lower costs by discouraging episodic care and incentivizing care that anticipates acute illness before it occurs.
“The focus now is on preventative care,” says Aguiluz, who fields daily inquiries about the ACA from patients. “The questions we’re asking ourselves is: How are we treating chronic conditions? How do we prevent people from seeking care in the hospital?”
Nurses will play an instrumental role in an evolving health care system brought forth by the ACA. The law presents both opportunities and challenges to both registered nurses and advanced practice nurses since both groups will be called upon to meet the needs of newly insured patients seeking care on a more regular basis.
Nurses will be integral not only on care coordination teams as both managers and clinicians, but also in a more robust primary care sector the ACA mandates. Health policy experts question whether there will be an adequate supply of primary care providers with fewer medical students pursuing careers in primary care. Nurse practitioners are eager to fill the need—particularly in underserved communities—but face unique battles when it comes to being uniformly embraced in primary care roles.
The Role of RNs in Care Coordination
According to the Department of Health and Human Services, health centers like CCI are expected to be a testing ground for how well the ACA works since they serve as a magnet for uninsured patients. Some of CCI’s uninsured will now be eligible for Medicaid while others will qualify for subsidies to purchase individual policies. The ACA set aside $11 billion for health centers nationwide, although no funds are specifically designated for care management. Navigators have been hired or contracted by many health centers to assist patients shopping for insurance on the online health care exchanges.
“If you look at the law, it talks about shifting care into the community away from hospitals,” says Susan Hassmiller, PhD, RN, FAAN, senior advisor on nursing at the Robert Wood Johnson Foundation. “In my mind, nurses are the ideal people to deliver care in this changing model. We need people who can take care of patients holistically, over their lifetime. ”
Health centers have hired more nurses in recent years not in direct anticipation of the ACA, but as a result of structural changes to the way they serve clients. Since CCI began its transformation into a medical home nearly two years ago, its nursing staff has grown from two to 10, says Shobhna Shukla, RN, MSN, FNP, clinical programs director at CCI. The “linchpin” of each clinical team at each of CCI’s seven locations, nurses could be a determining factor when newly insured consumers select a primary care provider, explains Shukla.
“Health centers are often measured by the quality of their nursing staff,” she adds. “What we do with nurses here…is going to be very important in terms of when people make choices about where to go.”
For years, Andrew Swiderski, MD, MPH, a pediatrician at CCI, felt frustrated by his inability to keep up with the “big pile of chronic issues” presented by certain patients—asthma, obesity, allergies, and diabetes among them. Now that care management is part of CCI’s culture, a dedicated RN and community health worker help Swiderski’s patients navigate the maze of specialist referrals, prescriptions, and other preventative services they need. It frees Swiderski to focus on the patient’s immediate medical issue in the short window of time he has with them.
“I feel so much better about what I do,” says Swiderski. “I don’t have to feel guilty about patients who need constant follow-up.” After Swiderski’s visit with a patient, the team nurse spends time educating the patient and his or her family about the next steps in their treatment plan.
“It’s amazing the depth [the team nurse] covers,” he says.
Empowering the Uninsured
The medical home model being implemented at health centers around the country and guidelines set forth by the ACA are, in many ways, complementary, says Margarita Sol, RN, the nursing care coordinator who oversees care management efforts at each of CCI’s seven clinics. Both initiatives prioritize access to health care, care coordination, prevention, health outcomes, and choice. “Choice means it’s patient-centered,” she adds.
In Maryland, like other states who opted to expand Medicaid, patients who previously didn’t qualify for the program will be eligible now. Meanwhile patients who earn too much for Medicaid could receive subsidies to purchase insurance on the exchange.
While they can’t predict how many new patients they’ll see as a result of the law, CCI clinicians say current patients who are self-paying are likely to benefit from expanded insurance options. They won’t have to shoulder the cost of necessities like labs, visits to specialists, and medical supplies or equipment entirely on their own.
“There is a pool of patients who have been waiting for more care outside of our clinic [that] has been on hold or at a sluggish pace,” says Sol. Now, adds Shukla, “they won’t have to delay if they don’t have the cash.”
Ruth Jackson of Brandywine, Maryland, knows firsthand the anxiety that comes with delaying care. Jackson, 41, is an uninsured single adult and a full-time student who pays for her own medical expenses. Before she became uninsured, her primary care doctor noticed her thyroid was enlarged. By the time Jackson got around to scheduling an MRI, she had quit her job so she no longer had health insurance. She paid $200 for the MRI, which revealed nodules on her thyroid. Jackson has since postponed a biopsy of the nodules because she can’t afford one.
“It’s worrisome,” she says. “I don’t know if my condition has gotten worse.”
Before starting a master’s degree in public administration, Jackson’s goal was to keep working while pursuing her studies. Then her parents became bedridden and wheelchair-bound, and Jackson became their full-time caregiver. Faced with a choice of having employer-sponsored health insurance or caring for her parents, she chose the latter.
For her master’s thesis, Jackson is writing about the experience of uninsured consumers—herself included—using the online health exchange. Her research focuses on clients of Greater Baden Medical Services, a Brandywine-based community health center where 44% of patients are uninsured, according to Colenthia Malloy, chief executive officer. Jackson also serves as a client representative on Greater Baden’s Board of Directors.
To Jackson, the ACA’s long-term promise is that “every person including myself will have access to care,” which means she’ll have better control over her asthma and will be able to visit a dentist, whom she hasn’t seen in two years. In the short term, she says, having insurance means “being able to determine whether I have cancer.”
Nurses, Jackson says, can play an influential role in educating consumers about how the ACA benefits them. One nurse-managed health center in Baltimore is doing just that. The East Baltimore Community Nursing Centers are in the process of becoming training sites for navigators who will assist clients sign up for health insurance, says Patty Wilson, RN, MSN, director of the centers.
Some of the centers’ clients are having difficulty enrolling, particularly with technical glitches in the Maryland health exchange website. Also, clients don’t prioritize purchasing insurance as work and family obligations take up most of their time. While they “have other things on their plate,” says Wilson, each center’s goal is to assist clients “become advocates for their own health care.”
Nurse Practitioners and the Primary Care Workforce
At Unity Health Care, a federally qualified health center in Washington, DC, the number of nurse practitioners occupying slots as primary care providers has grown from a “handful” to about 50 across Unity’s clinics in DC, says Sarah Price, RN, MSN, director of nursing development. While MDs make up the majority of providers at Unity, nurse practitioners have their own patient panels and are “very independent and focused on primary care,” she says.
“We weren’t able to be where we are in terms of thinking outside the box without hiring nurse practitioners,” says Malloy of Greater Baden Health Services, which will extend hours at all their clinics this year to keep up with demand. Nurse practitioners make up 30% of Greater Baden’s providers.
According to the American Association of Nurse Practitioners (AANP), 89% of nurse practitioners receive training in a primary care specialty, including family medicine, pediatrics, and women’s health. And while the AANP reports growth in enrollment and graduation rates for nurse practitioners, other experts say the shortage of faculty and the lack of clinical training opportunities and dedicated mentorship cripple the ability of nursing schools to contribute meaningfully to the primary care workforce.
Unlike family physicians, nurse practitioners in primary care don’t undergo a residency program before taking on their own patients. Nurse practitioners from earlier generations usually earned their advanced degrees after years working in a clinic or hospital as a registered nurse. Newer graduates, however, are heading straight to graduate programs with fewer clinical experiences under their belt. Swiderski, the CCI pediatrician, says he has seen inexperienced nurse practitioners “get thrown into the fire” only to deliver “suboptimal care.”
“There has not been equivalent support for undergraduate or graduate nursing education until now,” writes Jackie Tillett, ND, CNM, FACNM, in a 2011 paper published in the Journal of Perinatal and Neonatal Nursing.
The ACA somewhat rectifies this situation by setting aside money to bolster the clinical experiences of registered nurses and nurse practitioners. The law lifts the cap on grants given to nurses to repay loans if they pursue doctoral degrees, and it also gives financial support to nurses who want to teach at the university level. The National Health Service Corps has also expanded under the ACA, with nurses receiving $50,000 for every two years of service with an at-risk population.
Additionally, the ACA funds demonstration projects at five hospitals throughout the country to train advanced practice nurses. The Centers for Medicare & Medicaid Services (CMS) will reimburse the hospitals to place advanced practice nurses with clinical preceptors in their communities, says Matthew McHugh, PhD, JD, MPH, RN, FAAN, associate director for health outcomes and policy research at the University of Pennsylvania, one of the five sites chosen by CMS.
“It’s important to focus on the substance and quality of the training so that nurses can work in a new and more complex health care system,” says McHugh.
Legislative and political barriers preventing nurse practitioners from fully occupying primary care roles need to be removed, say McHugh and other experts. Only 17 states and the District of Columbia allow nurse practitioners to practice independently without a doctor’s supervision. Reimbursement rates of private insurance and government programs to nurse practitioners and physicians performing the same services also vary greatly, with nurse practitioners usually receiving less money. In 2010, the Institute of Medicine with the Robert Wood Johnson Foundation issued a policy statement urging states to allow nurse practitioners to practice to the full extent of their training, regardless of where they work.
Yet until laws are liberalized across all 50 states, nurse practitioners will have to continue to advocate for their rightful place as primary care providers, even with the ACA as the law of the land.
“There is lot of care that needs to be provided,” says McHugh. “And we need everyone practicing to the top of their abilities to make the most of the workforce that we can.”
Archana Pyati lives in Silver Spring, Maryland, and writes frequently on health and science topics.
The women trickle in, one by one, into a brightly lit ground floor conference room at Providence Hospital, a large urban hospital in Washington, DC. A vibrant social worker greets each one as “honey” as they take their seats in a circle of chairs. Each is pregnant and in her third trimester; some are alone, a few with male partners by their side. A teenager has brought her mother. Refreshments and gifts sit waiting for them on a table at one corner of the room.
The warm atmosphere couldn’t resemble a waiting or examination room any less, yet this space functions as both. All of the women are here for their prenatal checkups, one of many they will experience together leading up to their deliveries a month from now. They are participating in a “centering” pregnancy group, an innovative form of prenatal care that Providence—and other hospitals around the country—are offering to pregnant women. By moving them out of the clinic and into a group space, centering seeks to revolutionize prenatal care by reducing racial disparities in birth outcomes, boosting caregiver morale, and controlling costs.
Centering is the brainchild of Sharon Schindler Rising, CNM, MSN, FACNM, president/CEO of the Centering Healthcare Institute based in Silver Spring, Maryland, and Boston, Massachusetts. She dreamed up the word “centering” to describe the model of care she wanted to provide while driving her daughter to school one morning and formally introduced it to her colleagues at a national conference for nurse-midwives in 1995. In her own words, Rising says centering brings together three components of prenatal care: the medical assessment or checkup, patient education, and community building. The last feature is at the heart of what centering is about as it erases the hierarchy between clinicians and patients and encourages women to seek out expertise in one another.
Centering empowers women, says Rising, allowing them “to make friends and to sort out problems with each other and get solutions that are more appropriate than what a provider would be able to give in this very short touchpoint of a traditional visit.”
A Circle of Support
Over a two-hour period, the freewheeling conversation in the conference room ranges from the serious to the lighthearted, covering everything from cervical mucus to coping with sibling jealously after the baby comes home to having a game plan for when contractions start. How will first-time mom Lawanne Johnson remain calm in the final stretch towards delivery? “Keeping people who annoy me away from me,” she says, eliciting smiles and nods of agreement from her peers.
Indeed, this last phase of pregnancy is making everyone—moms and dads alike—a bit high-strung. Group facilitator Alexandra Ebken, MSW, encourages the group to let loose. “I have this terrible attitude,” admits DeWayne Felder, 25, adding, “I don’t know where it’s coming from. I just be spazzing. I’m just snapping at everyone.” His partner, Takia Hungerford, 24, admits to running hot-and-cold, making it difficult for Felder to guess her mood. “Sometimes I’m like, ‘leave me alone, I don’t want to be bothered,’” says Hungerford. “And then some days, I just want to be cuddled with or paid attention to.”
The centering group has offered some desperately needed continuity for 19-year-old Johnson, who has recently experienced more than her fair share of upheaval. Her pregnancy was unplanned and she is no longer in a relationship with her baby’s father. In the spring, she and her family were evicted from a home they were renting in DC’s Brightwood neighborhood that was foreclosed upon. Johnson came home to find their belongings strewn on the sidewalk stretching across an entire city block. The family’s church paid for the family to stay in a hotel while they found new housing.
Not only does the centering group feel like a refuge from the stresses of her personal life, but it has given her more courage to ask questions she might have been too intimidated to ask during a one-on-one doctor’s visit. Plus, women in the group who are already parents share their tips on childbirth and parenting.
“Coming in that first time, it felt warm,” she recalls. “Everyone was interacting. They welcomed me in. Everyone was so helpful to each other. I felt like I was better off with the group.”
Every centering group gets a workbook covering pregnancy basics, yet they are not opened even once during the group. In fact, Rising insists that centering group should never be called “class,” as it was created to stand in sharp contrast to the didactic model of clinician-knows-best. Centering’s emphasis is on sharing lessons gained from day-to-day experiences, and receiving wisdom from family members, friends, and folk traditions that may not be sanctioned by the medical establishment. Even when a practice is mentioned that gives a clinician pause, the corrective message is never preachy, but always delivered using the Socratic method where facilitators ask more questions instead of providing ready-made answers.
Rising recalls a centering group she attended in Atlanta where women discussed the virtues of eating clay for nutritional purposes during pregnancy – a practice known as geophagy. She insisted they take her to a market where varieties of clays were sold because she was more interested in understanding their worldview than correcting them. Centering’s way of challenging certain deeply held beliefs or practices during pregnancy—particularly if they are harmful—is to discuss their origins and to provide another perspective. “It’s not going to win us any friends if we just say, ‘this is bad and you need to stop doing this,’” she says.
Ebken maintains a light touch by broaching necessary topics with open-ended questions, drawing in quieter participants by directly asking their opinion. She tries to get the group to anticipate the long road of parenting ahead of them by asking, “have you thought about how you are going to raise your babies?” What follows is a spirited discussion on how not to spoil your child, how to keep kids away from sexual predators, and what to do when kids become sexually active.
“At the end of the day, their agenda is more important than mine,” says Ebken. “As a facilitator, my job is to make sure everyone feels like they have a voice. Giving the group power is way more important. So often their voices go unheard a lot of the time.”
Greater Personalization of Care through the Group
It’s clear that everyone is enjoying the camaraderie and commiseration. Yet mixed in is the serious business of making sure each woman’s pregnancy is on track. As the morning progresses, nurse-midwife Suz Brown, CNM, MSN, calls each woman to an examination bed set up at one end of the room where she checks fetal heart beats and chats with mothers about how they are feeling.
The paradox of centering is that caregivers seem to feel a deeper connection to patients who participate in groups over those whom they see individually. Nurses and nurse-midwives have more time to get to know patients’ individual histories since centering is spread out over ten two-hour sessions and usually facilitated by the same two individuals. It’s easier for Brown to notice changes or milestones when she gets consistent exposure to the same cohort of patients. Trust and rapport develop not only among women but between them and the group’s facilitators.
“There’s a bond that gets established,” says Brown. “You worry about them when you wake up in the morning. It’s more intimate in a way; you have that time with the group.” She also feels more invested in making sure a centering member has a positive experience with delivery.
By contrast, Brown says that it can be difficult to remember patients’ names in a clinic due to the sheer volume of appointments each day brings. Centering groups tend to consist of 10 to 12 participants, but can sometimes be as large as 20. In her position at Providence, Brown sees patients one-on-one in the clinic and co-facilitates a number of groups. “It becomes really focused on what do I have to get done [in the clinic],” she says, such as administering tests or reading charts rather than building a relationship with the patient. “When I first started at Providence, I was notorious for running behind. I just didn’t feel right doing the ten-minute visit.”
Centering, Brown says, makes explicit the mind-body connection that traditional care often does not. “We medicalize [obstetric care] so much, but there’s such an emotional and spiritual component that you can bring out in the whole group.” There is also an emotional payoff. “The interaction for people never gets old,” she says. “It gives me new energy because it’s always different.”
One of the main reasons Rising began centering is that she’d grown weary of repeating the same answers to the same questions day in, day out with her patients. “One woman’s question is another woman’s question, and so you don’t just continue with the repetitive question-answering that is so much a driver in traditional care,” she says.
The other critical piece of centering is that patients take a more active role in their own care. At the beginning of each session, each woman weighs herself and takes her own blood pressure. They keep track of their own data and often read their own lab results. They understand what’s happening to their bodies better and can use the proper terminology to behave and speak with confidence when they deliver.
“We hear anecdotally time again and again that…when a woman who has been in centering arrives, [the hospital staff] know it without looking at the chart because she just behaves differently,” says Rising. And because centering groups always meet at the same time for a two-hour period, it makes it less likely that a patient will miss her checkups, improving her chances of having a full-term delivery. This consistent scheduling makes centering an attractive choice for women who rely on public transportation, have inflexible work schedules, or depend on child care. “Traditional care runs around the needs of the agency and the clinicians,” says Rising. “It really doesn’t revolve around the needs of patients. With centering, groups start and end on time. It’s honoring a woman’s time.”
Centering: Does it Actually Work?
While centering doesn’t target a specific demographic, practitioners and researchers have found it works particularly well with high-risk groups: women who are low-income, Latinas and African American women, and teen mothers.
“It works particularly well with vulnerable populations,” says Debra Keith, CNM, MSN, and the director of Providence Hospital’s Center for Life. “Groups that we have have…a lot of issues at home, they may be struggling in school and not have a lot of support. Group just does wonders for them. It gives them an opportunity to feel like they’ve been heard.” Providence, like other hospitals in major cities, offers centering groups conducted entirely in Spanish. Other hospitals around the country offer groups conducted in Vietnamese and Arabic.
A 2007 study in Obstetrics & Gynecology co-authored by Rising found that among 1,047 women participating in centering groups at hospitals at Yale and Emory Universities, the risk of preterm birth lowered to 9.8% from the 13.8% risk women receiving conventional prenatal care face.1 The average age of the study’s participants was 20.4 years, and 80% of the women were African American. The risk reduction among African American women was more dramatic with the centering participants having a 10% chance of a preterm birth compared to 15.8% for those in conventional care.
More recently, a 2012 study published in the American Journal of Obstetrics & Gynecology that followed 316 low-income women in a CenteringPregnancy group at the Greenville Hospital System Obstetrics Center in Greenville, South Carolina, found a 47% reduction in preterm delivery among centering participants compared with women receiving traditional care. 2
Other studies show higher rates of breastfeeding among centering participants, lower rates of sexually transmitted diseases, and greater spacing between pregnancies, particularly among teens. At the end of the day, all the preterm births and complications from STDs that are averted translate into cost-savings for hospitals, says Rising, who estimates that centering saves hospitals $2,000 per pregnant woman.
Most telling, moms and dads who participate in centering report consistently higher levels of satisfaction with their prenatal care. As Felder, the young father who participated in Providence Hospital’s centering group, put it: “It’s almost like a therapy session. You rarely come out of here upset. You were mad out there, but not in here.”
1. Ickovics JR, Kershaw TS, Westdahl C, et al. Group Prenatal Care and Perinatal Outcomes. Obstet Gynecol. 2007 August; 110(2 Pt 1): 330–339.
2. Picklesimer AH, Billings D, Hale N, et al. The effect of CenteringPregnancy group prenatal care on preterm birth in a low-income population. Am J Obstet Gynecol. 2012;206:415.e1-7.
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