Major Job Growth for NPs, PAs … in Prisons

Major Job Growth for NPs, PAs … in Prisons

Expect more non-physician professional hires in correctional institutions

When correctional nurse author and educator Lorry Schoenly, PhD, RN, was writing a book about nursing in prison, her publisher asked her who would buy the book. “We were trying to figure out how many correctional nurses there are,” said Schoenly who scoured state boards of nursing for the numbers of those specializing in corrections. But, unlike cardiology or obstetrics, correctional nursing was rarely listed as a specialty and Schoenly was unable to get a reliable count. “It’s an invisible field,” she said.

But even though centralized data on staffing trends in corrections healthcare is elusive, the demand for NPs and PAs is expected to grow. According to UConn Health, which currently staffs Connecticut’s correctional institutions with “half MDs and half midlevels,” increasingly more “midlevels” are being utilized. “Future job growth will most likely continue to rise as incarcerated populations rise and the age of the population rises,” a UConn Health representative told MedPage Today in an email.

Although rising rates of overall incarceration leveled off in 2006 and reversed a bit after 2015, life sentences have increased almost five-fold since 1984.

This increase in life sentences, along with longer sentences and more incarceration late in life, has contributed to a trend, often referred to as the greying of the inmates. “People are growing old in prison,” said Owen Murray, DO, MBA, vice president of offender health services at the University of Texas Medical Branch in Galveston.

UConn Health noted that inmates 50 and older are the fastest growing demographic in federal prisons. With advancing age comes an increase in chronic disease, physical disability and cognitive decline. In Texas, there is pressure to either maintain current staffing or add more providers due to this shifting demographic. Spending per state is associated with, among other factors, the percentage of individuals 55 and older who are incarcerated, according to the Pew Charitable Trusts.

Greater use of NPs and PAs is one way prisons can provide legally required standards of care at lower cost. “The real impetus to use the lowest cost practitioner is not because there is less attention to quality, but to drive down healthcare costs,” said Kamala Mallik-Kane, MPH, a researcher at the Justice Policy Center at the Urban Institute.

Murray has noticed a rising presence of NPs and PAs over the past three decades. “Certainly as it relates to both jail and prison medicine, there has been a significant increase not just within the state of Texas but pretty much every other state that I’m familiar with in terms of the growth opportunities for midlevel providers.”

According to the American Academy of Physician Assistants, the absolute number of PAs working in prisons increased from 1995 to 2015. For NPs, a survey conducted by the American Association of Nurse Practitioners demonstrated that since 1999 the estimated NP population working in corrections has grown from 550, or 0.8%, of total NPs in 1999, to 2,400, or 1.1%, in 2016.

According to UConn Health, staffing depends on the medical acuity of the inmates, the inmate population and the level of onsite infirmary services.

Predicting future workforce demand for NPs and PAs depends on many conditions beyond sentencing, policy, and crime rates, according to National Institute of Corrections, and incarceration rates could change again depending on policy of the Trump administration. Whether that means releasing low-level offenders, potentially increasing the number of immigrant detainees, diverting offenders from the criminal justice system, or rollbacks in sentencing reform is unclear.

As people enter prison with high health needs – from a lack of preventive healthcare, substance abuse, or homelessness — for some, incarceration provides stability. “There’s an expression,” said Mallik-Kane, “three hots and a cot,” meaning regular meals and shelter. “A person with medical needs might now have access to healthcare. On the other hand, there’s criticism of the quality of prisoner health services.”

In an Urban Institute study of a group of people returning to a major city from prison, 80% of men and 90% of women had chronic health conditions requiring treatment or management; 15% of men and more than one-third of women reported a diagnosis of depression or mental illness.

In Texas, as the complexity of care has grown, the demand for PAs and NPs has grown. “The midlevel provider group has really become the backbone of our delivery system augmented with our physician group,” said Murray.

Yet as prisoners’ medical acuity has increased, healthcare spending in corrections has decreased from a peak in 2009. In some states, the downturn stems in part from a reduced prison population. But states with relatively larger shares of older inmates have higher per-inmate spending for these more complex patients continues to pose a fiscal challenge.

According to Maria Schiff of The Pew Charitable Trusts, outsourcing the employment of clinicians has become increasingly appealing for states to overcome the challenges of recruiting healthcare workers to remote prisons. Private entities can offer hiring incentives, student loan repayments, and bonuses where state agencies are prohibited from doing so.

Schiff said there are 50 different programs in the U.S. since each state raises its own tax money and allocates to corrections. “There’s no nurse to patient ratio that is standard among hospitals, and [corrections departments] are no different, but states do track the age, the gender and certainly the average daily census of who they’re incarcerating,” she said. Anecdotally, several states noted that their staffing ratio of NPs or PAs to physicians is about two to 2.5 to one.

Two issues that remain for any provider considering a job in corrections is their personal safety and litigation exposure.

Unlike outpatient settings, providing continuity, rapport and safety in correctional healthcare can sometimes prove impractical. Inmates are moved often and even in secured settings, the risk of violence and danger is ever present. “A big theme is always personal safety,” said Schoenly. “And the expectation is that you’re doing evidence based standard of care because it’s very litigious. We have a saying that if you haven’t been named in a lawsuit, you haven’t been in correctional healthcare very long.”

The Joint Commission’s presence is limited in correctional healthcare. Unless a health care organization is in a state that requires its accreditation or is in part of an agency such as Veteran’s Affairs or the Department of Defense, which also require accreditation, its process is voluntary. The Joint Commission doesn’t require specific staffing levels, but it does require a sufficient number and mix individuals to support safe care. The American Correctional Association (which declined to comment for this article) and National Commission on Correctional Healthcare operate in corrections and can be consulted to review their policies and procedures. Accreditation can sometimes offer a layer of protection against malpractice, but does not ensure immunity.

These risks do come with rewards, said Schoenly, who views correctional healthcare as a mission to serve the most underserved population in healthcare, and one with broad public health implications, since most inmates do return to society. “You realize that this is really a part of our society who is marginalized and who desperately needs healthcare,” said Schoenly. “And the idea that it’s a vulnerable population with great need can draw in individuals who want to possibly help and improve society.”

This story was originally posted on MedPage Today.

VA North Texas Nurse Uses 44 Years of Service to Mentor Next Generation

VA North Texas Nurse Uses 44 Years of Service to Mentor Next Generation

In 1975, with the Vietnam War still fresh in the minds of the American public, most high school senior graduation plans did not include joining the U.S. Army. But for eighteen-year-old Virginia “Ginny” Warren, the North Texas daughter of a cotton farmer, the Army looked like an ideal path. Much to the chagrin of her father, Ginny Warren had just set forth on a 44-year journey from soldier to VA Nurse.

“The Army offered me a way to broaden my horizons and to learn,” said Warren, Nurse Manager at VA North Texas Health Care System.

Warren began her military career with two-years in medical administrative field before spending the next twenty-two years as a medic with the U.S. Army Reserve’s 94thCombat Support Hospital, based in Seagoville, Texas. With a primary mission to take a 150-person deployable hospital anywhere in the world and be ready to receive casualties within 72 hours of arrival, Warren continuously trained for the opportunity to apply her talents while developing a new passion to become a Registered Nurse (RN).

Through her career in the Reserves, the Army sent Warren to licensed vocational nurse (LVN) training and Warren quickly realized she had an aptitude and attitude for nursing. Warren went on to attend the University of Texas at Tyler School of Nursing to become a RN and was subsequently commissioned in the U.S. Army Nurse Corps.

“I had to find my place as a new nurse and new military officer,” said Warren. “I had a lot to learn, but I felt I had a lot to offer as well.”

After becoming an RN, Warren brought her health care experience to VA and joined another family of nursing professionals at VA North Texas in 1997.

In 2003, Warren’s Reserve unit was called upon to deploy to Landstuhl Regional Medical Center to treat wounded servicemembers straight from the battlefields of Iraq and Afghanistan. The ability to muster tremendous internal strength and compassion, coupled with her many years of training to deploy on a moment’s notice, was exactly what the soldiers, Marines and airman she treated would need to make their next journey back stateside to recover with family and friends.

“I vividly remember leaning over this big sergeant, hugging him, and whispering in his ear that it would be okay, and the pain won’t last,” said Warren.

Warren would go on to give more than 40 years in uniform, retiring as a field grade officer in 2015.

With over 22 years of service as a VA nurse, Warren now walks the inpatient wards of the Dallas VA Medical Center where she once served as junior nurse, as a manager and mentor to a new generation of nursing professionals who rely on her expertise and experience to care for many of the 134,000 active patients who use VA North Texas for their health care each year.

“Nursing is not just a career, it’s a passion and a devotion,” said Sheila Wise, VA North Texas Nurse Manager, and herself a retired U.S. Army Nurse. “To bring that passion and devotion to the service of our Veterans the way the Ginny has, and continues to do every day, for as long as she has, makes her an inspiration and a guiding figure for our nursing team. She makes all of us better.”

While eighteen-year-old Ginny Warren could have never foreseen the impact she would have on our nation through her service to military servicemembers and Veterans over 44 years, the nearly 3,000 nurses who apply their skills at VA North Texas are glad that the cotton farmer’s daughter left home to make the journey of a lifetime.

“Nursing has always been where I could pour my heart and soul,” said Warren. “I can’t imagine doing anything else.”

This story was originally posted on VAntage Point.

Nurse Safety Highlighted in Twin Cities Hospital Negotiations

Nurse Safety Highlighted in Twin Cities Hospital Negotiations

The Star Tribune reports that nurses across Twin Cities hospitals are pressing for more workplace safety in their contract negotiations. As hospitals are in negotiations with the Minnesota Nurses Association (MNA), they’re hearing that protections for nurses are becoming a top priority, as nurses are wearied from being hit, shoved, or yanked by their patients.

This is the first time nursing contract negotiations are being held since 2016, when Allina hospital nurses went on strike for health insurance benefits. These current negotiations have been in talks, with contracts set to expire May 31. But it appears that no deal will be happening by then, and the MNA is planning to strike again.

One nurse, Mary McGibbon, shared with the Star Tribune that she wore a sling for her elbow injury (brought about accidentally by a patient) to a contract negotiation meeting. Accidents with patients are common enough, but there is more concern as hospitals have seen an increase of patients with mental health issues. Sometimes the patients will deliberately attack their nurses, which can be so traumatic it affects their ability to work.

“These can be life-changing attacks,” McGibbon said. “Some [nurses] can’t go back to the bedside.”

Steady Increase of Patient-Caused Injuries

Workers compensation claims increased by nearly 40 percent between 2013 and 2014, up to 70 percent, and have remained at 65 percent or higher since then. These numbers reported by the Minnesota Department of Labor and Industry only count the most severe cases reported, including those where nurses missed three or more days of work due to injury.

Talks for nurse protection have been gaining speed since a 2014 incident, where a patient attacked and injured four nurses with a metal bar. Minnesota passed a law in 2015, making hospital staff training on de-escalating and preventing violence mandatory.

Another nurse, Michelle Smith, is back to work in surgical recovery but still going through recovery from a concussion she got roughly two years ago. She similarly is pushing for more support in negotiations to prevent these incidents from happening.

“There’s that fear,” Smith shared with the Star Tribune. “You still treat your patients the way you’re going to treat your patients, but there’s that thing in the back of your head — ‘could this happen again?’”

New Report Shows Nurses Need More Support for Necessary Challenges

New Report Shows Nurses Need More Support for Necessary Challenges

A new report from the Robert Wood Johnson Foundation (RWJF) looks into how nurses in the United States can help boost health and well-being for all Americans, but data shows that those in the field are concerned about being able to do all that they can.

Despite wanting to put their skills to use to help communities as care providers, community educators, and policy advocates, nurses across the US are held back from all they can do by challenges like outdated nursing education, looming staffing shortages, and a steep lack of resources for the healthcare system. These difficulties cast a shadow on the future of nursing in the United States.

“There are many issues affecting the health of our nation—opioids, measles outbreaks, low literacy rates, untreated mental illness, lack of affordable housing, and many others. Conversations with hundreds of nurses made it clear that they are willing to help people face these challenges, but they can’t do it alone,” said Paul Kuehnert, DNP, RN, FAAN, associate vice president at RWJF. “Nurses need support from their employers, other health care professionals, community organizations, and government entities to better address unmet needs.”

The nurses interviewed shared that nursing as a profession must evolve to meet the ever-growing needs of patients, as well as the shifts within the industry that hinder nurses from learning and helping to the best of their abilities. They also provided their points of view regarding how prepared nurses are after their training and education, and what resources are provided to them by their employers. Interviewees also discussed that while patient needs are expanding, there is not enough focus on them in health care settings.

“Nurses are uniquely qualified to address many of the unmet needs of people and communities, and this research shows they have a strong desire to do that,” Kuehnert shared. “Nursing is consistently ranked among the most trusted professions, and nurses have firsthand knowledge of what patients and communities need to be healthier.”

To download the report, visit the RWJF website and click the link that says “Nurse Insights on Unmet Needs of Individuals” under the Additional Resources sidebar.

In-Hospital Delirium: A Problem and a Predictor

In-Hospital Delirium: A Problem and a Predictor

In-hospital patients with delirium are vulnerable during the early posthospitalization period

In-hospital delirium is a predictor of readmission, emergency department visits, and discharge to a location other than home, recent research shows.

The development of delirium in the hospital setting impacts about 12.5% of general medical admissions and as many as 81% of intensive care unit patients. Earlier research has shown delirium among hospitalized patients is predictive of prolonged hospital length stay, lengthened mechanical ventilation, and mortality.

The recent research in the Journal of Hospital Medicine featured data collected from more than 700 delirious patients and nearly 8,000 non-delirious patients. The researchers found delirious patients had increased odds for 30-day readmissions, ED visits, and discharge to postacute care facilities.

These results suggest that patients with delirium are particularly vulnerable in the posthospitalization period and are a key group to focusing on reducing readmission rates and post-discharge healthcare utilization,” the researchers wrote.

Linking in-hospital delirium and readmissions

The Journal of Hospital Medicine research builds on earlier studies about in-hospital delirium, the lead author of the research said. “Prior studies have shown that delirium is associated with functional decline at discharge, so these patients may be particularly vulnerable in the days and weeks following hospital discharge. Our work helps to confirm this as we show that patients who become delirious in the hospital are far more likely to be readmitted within 30 days of discharge, compared with patients who do not develop delirium,” said Sara LaHue, MD, a resident physician in the Department of Neurology, School of Medicine, University of California San Francisco.

The new research indicates that hospital-based interventions should be targeted at delirious patients to reduce readmissions, she said. “Hospital-based interventions that reduce the development of delirium may then reduce the complications of delirium, such as readmission.”

Reducing delirium-associated postacute care service utilization

To avoid hospital readmissions linked to delirium, clinicians should focus on preventing patients from becoming delirious in the hospital.

This may include systems for identifying patients at high risk of becoming delirious, screening for active delirium, and enacting interventions that target the underlying cause in order to reduce the severity or duration of delirium. While such a program can take a bit of work to get off the ground, the benefits for patients, their families, and the hospital system can be significant,” LaHue said.

One team member who is often overlooked is the caregiver at home, she said. “Educating caregivers about delirium risk factors can be very helpful — he or she can bring glasses or hearing aids from home, engage the patient in meaningful conversation to help with orientation, and encourage regulation of sleep-wake cycles. If a patient does become delirious, the caregiver can continue to help with these interventions.”

Caregivers at home are an essential component of postacute care, LaHue said. “We know that delirium is associated with functional decline at discharge, so coordinating safe discharge plans with the caregiver, especially to identify [the] need for resources — physical therapy, occupational therapy, home health, and nursing — can potentially help reduce post-discharge complications.”

Follow-up care is another crucial factor, she said. “Ensuring expedited follow-up with a primary care provider, who can assess for any additional needs, is also important.”

This story was originally posted on MedPage Today.

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