Hill looks at nursing on the bench, at the bedside


Rachael Le Goubin | Staff Photographer
Martha N. Hill, dean emerita at the John Hopkins University School of Nursing, speaks about the importance of recognizing the integral role of nurses in medical care during her morning lecture Thursday in the Amphitheater.

“Have you looked at nursing lately?” Martha N. Hill asked the audience by way of opening her Thursday morning lecture in the Amphitheater, the fourth in Week Nine, “Health Care: From Bench to Bedside.”

Hill looks at nursing every day: a professor and dean emerita at the Johns Hopkins University School of Nursing, she is a registered nurse and a fellow of the American Academy of Nursing.

“Nurses do more than you think,” she said. “They are the most numerous of health care providers, and they are everywhere. They are at the bench … and they are at the bedside. They are at all of the bedsides, everywhere. They’re at the bedsides of the intensive care units, the bedsides in the emergency rooms, the bedsides in long-term care, the bedsides at the hospice, the bedsides in people’s homes. And so, it’s really impossible to think about the medical care and the health care of people without realizing the centrality of nursing.”

The demand for nurses has continued to increase, she said, citing more serious illnesses and shorter stays as well as more technology that requires its own “nursing” as factors that increase demand. And the supply of nurses has not kept up. Nursing programs do not have the capacity for larger student bodies, she said.

Smaller hospital budgets when the economy is weak mean that hospitals can offer nurses fewer incentives, compounding the imbalance between supply and demand. And the recession led many nurses who had been expected to retire to keep their jobs in order to support spouses who had been laid off.

Nursing programs have taken note, Hill said.

The last 10 years have seen a 50 percent increase in enrollment in the 850 baccalaureate programs for nursing in the United States, she said, reflecting efforts by nursing schools to expand student bodies, faculties and clinical sites.

Graduate programs in nursing have also seen steady enrollment increases. But despite the 50 percent increase in nursing doctorate program enrollment, the graduation rate from such programs has plateaued.

Hill attributed this to a decrease in the number of scholarships and training grants, noting that most nurses in graduate school must continue to work full-time, which slows their academic progress.

Clinical work for nursing students is hard on hospitals, Hill said, because of the supervision that they require.

“Freeing up the staff nurses to teach the students is a dilemma because the hospitals are under pressure,” she said.

External accreditation and certification requirements impose mandatory student-to-patient ratios, another stressor on the system.

Turning her attention to nursing school demographics, Hill said that men only make up about 11 percent of nursing programs in the U.S., as opposed to 40 percent in Jordan, a disparity that she attributed to cultural differences. In Jordan, women nurses cannot treat male patients, leading to a greater demand for male nurses.

Racial demographics are not uniform across the profession, Hill said. The number of minority students coming into the profession has increased only 5 to 10 percent, but in doctoral programs, it has increased 50 percent.

“We know that one factor that influences whether minority students come to a college or to a school has to do with ‘Are there people there already who look like me?’” she said. “And if you don’t have minority faculty, your ability to attract minority students is diminished. So there’s a lot of emphasis being put on recruiting and preparing minority future faculty.”

Some first-time nursing students have been out of college for several years and have pursued other careers, Hill said. Many of the second-degree nursing students at Johns Hopkins, she said, tell her that they had always wanted to be nurses, but had been questioned by someone in their lives why they would not go to medical school instead.

“The answer should be: ‘Because I choose not to. I choose to go to nursing school,’ ” Hill said. “And the answer should be: ‘Patients and families need all kinds of health care providers, and I want to do what nurses do.’ ”

Hill spoke to the benefits of advanced degrees for nurses, even though a nurse can enter the profession with only an associate’s degree and licensure.

“It has been shown through research that the better educated the nurse, the better outcomes for the patient,” she said. “Where nurses are baccalaureate-prepared, patients live longer and more of them live.”

Noting that all other health professions require a clinical doctorate, Hill argued that advanced degrees should be more accessible, and, in some cases, required for nurses.

“Why would anybody want nurses to be the least-educated of all the health professionals?” she said. “How can you possibly justify that when they’re the ones who are 24/7 at the bedside, making the observations, doing the triage, when they are the glue, and when they are the nucleus?”

As the glue and the nucleus, nurses are expected to be a “jack-of-all-trades,” Hill said.

“If it needs to be done, we’ll do it. And this has led to a pattern and expectations that somehow, the nurses will always do it,” she said. “Well, they can’t keep doing everything if they’re going to get back to the bedside, which means some other people have got to do some of this work.”

Q&A

Q: Can you comment, certainly in the physician realm, where there have been issues around the training of physicians here domestically? There’s been more international input into the system, is that happening in nursing also?

A: Oh yes, and has been. There are places like the Philippines that are major exporters of nurses. And if you go around the world — go to Africa, go to Asia, India — the nurses come from Bangladesh, they come from the Philippines, even from India. There are advantages and disadvantages to this, but I think it doesn’t relieve us from the responsibility of educating our own workforce.

Q: What are the restrictions the nursing schools face in obtaining funding to expand?

A: The first is that there’s not a lot of money that is designated for expansion of nursing schools. Budgets have been cut on capital growth and they have been cut on training grants and curriculum development proposals. This is true not only for nursing. It’s a phenomenon across the professions. We are increasingly reliant on philanthropy, as are other academic institutions, and we are looking — you can’t keep increasing tuition. There is a finite level at which people are going to say, ‘I can’t afford this,’ and not come. And these are the very same constraints that you see in other high education, but education of nurses or education of medical students is expensive — particularly because of all of this clinical training and the need for intensive precepting.

Q: With the shortage of RNs in the United States, why not expand the scope of practice of LPNs? Could academic nursing support this?

A: It’s not only expanding the role of licensed practical nurses. Increasingly, what we’re seeing is the hiring and training of unlicensed personnel. And, again, back to my point about looking at the tasks that need to be done, looking at the skill set and competencies, and then mapping it out. So I think that we are definitely seeing more people being brought in to complement and supplement what nurses do, and for nurses, if you will, moving up to become the supervisors and the trainers. And you make a team where you might have one masters-prepared nurse working with several staff nurses, working with several LPNs, working with unassisted personnel.

Q: Everyone now encourages exercise, but what do we say to a family member with listed disabled walking issues, with a loss of driver’s license. How do we help these people get more exercise and get out?

A: That’s an excellent question, and one that I think calls for community-based solutions. And in neighborhoods, identifying for example, the person who if they had a ride they could then go to an exercise class for seniors. And getting people aware of the need some people have. I mention my water aerobics is something I recently started because I’ve developed a lot of severe arthritis. It’s a wonderful, wonderful thing to do. And it’s a social group and people care about each other and you have to report out if you’re not coming — like I had to tell them I’m not going to be there this week, because they would be worrying about where I was and why I wasn’t there. I think framing it not just as exercise, but as doing something for yourself that is good for you. But if you don’t know about water aerobics you should think about it, because you can do an awful lot of things in the water with resistance that are good for you that you can’t do yourself on dry land.

Q: A couple of questions here about the role of unions and whether the regulations of unions are being used to limit patient care. Do you want to just talk on that subject generally?

A: Yes, well unions are a historic phenomenon of real importance in the U.S., and in many situations have much less influence than they had in the past. My son’s college roommate is a union organizer for doctors and nurses, and I asked him how is it going. And he said, ‘Piece of cake. These people are miserable; they’ve got a lot of problems. They need help.’ California is a real leader in the union movement in nursing, and they have, for example, put in policies in the nurse-patient staffing ratio, how many hours the nurses can work, how many shifts the nurses can work. And their argument is that this is safer for patients and improves patient care. Well the data on that are equivocal. It does help many things in many situations. It also causes problems. And for example, if you are the director of nursing for a hospital and you’ve got a shortage of nurses in one area and yet the union policy says you can’t move nurses from one area to another. And you may have an overstaffing of nurses from one area if the patient needs have shifted from when the staffing ratio was designed, and you may have another area with a huge shortage. So it has a little bit of the ying and the yang, and I think probably what we need are guidelines or policies that allow flexibility to adapt to the current situation. So that the patients’ needs are met, not just the nurses’ or doctors’ needs.

Q: How can communication be improved between and among nurses when the shift changes?

A: This is what is now called a handover. The shift change when you handover the care of patients from one shift to the next, and this is an enormous problem not just for the nurses but for the physicians as well. This is where there’s the technology people and then there’s the verbal communication people. You need both, I think. There needs to be distinct, clear communication and increasingly it’s being tied to the old days when they did rounding, and they went from bed to bed to bed and you could see the patient and talk with the patient while these handoffs were being done. There’s a turn to setting goals for each patient for each day, and those need to be looked at and adapted by each of the shifts. It’s a major issue, a major challenge. See I learned with the Heart Association there are no problems, there are only opportunities. So I would say, there needs to be some sort of research done by behavior scientists or communication specialists or even some engineers on how do we improve these handoffs and communication from one shift to the next? It calls for some new looks and some new solutions.

Q: Could you comment on the training that nurses’ aids receive?

A: OK, the training the nurses aid receives is very dependent on the institution and what they have in their human resource department, and what they call orientation and staff development.  It varies widely. And much of it depends on the unit where the aid would be working, and what are the skills and competencies that are needed for them to be a part of the team. It should be done, it should be done well, and it needs to periodically be revitalized — to check and see, are the skills still competent? And some new ones get added. And it’s not just for the aids. It’s for everybody at every level. So that’s another question you could ask if you are in a setting. Ask what are the policies of staff development and training and checking of skills.

Q: Could you talk about infection rate and the overall quality of the health of nurses, compared to non-health care providers?

A: Well I mentioned the age of nurses and the increasing age of the workforce. And depending on the setting where nurses work, they take a real beating physically. And there are a lot of problems with nurses with back problems, for example, with having to lift and move heavy equipment and lift and move patients. There are issues, just as there is in the aging population, so I think there is a lot of concern in occupational health. One thing we are seeing with people — more on the academic than on the clinical side, but the clinical side is coming — is the problems associated with intensive computer use, and people leaning forward and putting a lot of pressure on their cervical spine, and what are the ergonomics of the environment. And I’m not sure that enough attention is being paid to that in hospital settings. But occupational health has a responsibility for being proactive about looking at the environment and what are the threats and issues, And then they have to look in their workforce: what are the reasons for absenteeism, what are the reasons for medical disability cases, and then be thinking about to what extent were any of those preventable?

Q: Your opinion of clinics springing up in various drug stores.

A: I think these are actually quite good. I think, like anything else, it depends on the people and how well qualified they are. And do they have the right skill set, and are they documenting what they’re doing so that we can evaluate the quality of the care that they are giving? But if you can go get your flu shot at the drug store, why not? You don’t have to pay for parking. You don’t need to make an appointment. They’ll send an email to your doctor saying you had it done. It may cost you an absolute fraction of the cost. Why not?

Q: Are salaries for nursing faculty competitive with clinical salaries, and if not what can be done about this?

A: The answer is no… And that has changed. It didn’t used to be that way. One more cycle in the supply and demand equation. It’s about the supply and the demand. It’s also about the research base and how much is in the pot that’s available to pay the salaries. And we are having a lot of joined appointments now. Nurses who are both still active in the clinical setting, and who do teaching — and that’s a wonderful combination because we know that there are still current competent practitioners and they are really good role models for the students. Salaries vary. I mean the nurse executives make a whole lot more than the deans, and they get bonuses. Staff nurses, depending where you work — if you work in a high demand area where it’s hard to get people to stay, such as emergency rooms, some ICUs, operating rooms — those salaries are harder. If you work evenings or nights and you work holidays, you get a differential and get paid more. So there are ways for staff nurses. And we have nurses at the bedside who are making in the six figures. Some of that is based on seniority, but some of it is also based on these differentials that are available.

— Transcribed by Kelsey Husnick