Millions of people work hours other than the standard 9 to 5, Monday through Friday and, unbeknownst to them, their health may be severely affected because of it. Shift work (defined as working anything other than the traditional 9 to 5) was designed to cover industries that operate twenty-four hours per day. Hospitals fall into that category and need staff coverage at all times, leading to employees that are more prone to a condition known as shift work disorder (SWD).
Although mainly an issue for those who work overnight shifts, SWD can cause problems for those who regularly work longer than eight hours per day, too. Working twelve hours at a time, day or night, can cause problems for some people. Nurses are particularly affected by SWD due to the nature of hospital working conditions.
The American Academy of Sleep Medicine (AASM) identifies those who work early morning, evening, overnight, and rotating shifts as the ones most affected by SWD. Aside from excessive sleepiness, shift work can lead to difficulty falling asleep or staying asleep, decreased energy, difficulty concentrating, headaches, and poor mood and irritability.
Dianne Jones, RN, has experienced the effects of working odd hours firsthand. “When I worked 3 pm – 3 am in my first ER position, I had difficulty sleeping,” she says. “It was made worse by the next job when I worked 7 pm – 7 am.”
Jones’ problem is all too common among those who work overnight shifts. The human body has a natural circadian rhythm that sets sleep and wake patterns over a 24-hour period—and working the overnight shift disrupts that cycle since the normal circadian clock is set by a light-dark cycle. Jones describes the feeling of this disruption after working a night shift as follows: “Once my eyes were exposed to daylight as I left work, I felt as if I became almost manic…my body was telling me it was time to be awake and active.”
Those who work dayshift can also be affected by SWD, not necessarily because of working a non-traditional shift, but mainly because of quick returns. Quick returns, or working back-to-back shifts, are a practice all too common among nurses. A study on nurses who worked various shifts found that quick returns of day shift nurses were just as strongly correlated with SWD as those who worked strictly night shift. Quick returns—just like shift work in general—cause disruptions in the circadian rhythm. The mismatch in the natural circadian rhythm eventually leads to sleep/wake disturbances and internal desynchronization.
Jones noticed that the amount of time she slept varied with the length of her shift and the stress associated with her job at the time. “When working twelve-hour shift in the ER, I slept about 5 hours max. With an eight-hour shift at a less stressful job, I slept about 7 or 8 hours.”
Jones, who has worked nearly every shift imaginable as a nurse, has finally settled into a day shift position after spending a considerable amount of time working evening and overnight shifts in her 10-year nursing career. She believes that nurses who work 12-hour shifts in high acuity areas can burnout over time: “I think most nurses can maintain a high level of stress on the body and mind for a while, but it does begin to take a toll and may lead to errors, substance abuse issues, or burnout.”
Shift work can cause many health issues, some with longstanding effects. The AASM attributes SWD to work disturbances such as work-related injuries, vehicle accidents related to drowsy driving, and substance abuse (to improve sleep). Many serious medical conditions, including hypertension, diabetes, obesity, and an increased risk of breast and bowel cancer have also been attributed to SWD. Certain risk factors can predispose some people to developing SWD when working alternative shifts. Those who are older, have comorbidities, drink alcohol, smoke, or have had previous sleep issues in the past are at highest risk.
There are ways to combat the symptoms caused by SWD, but for some, a change in schedule may be necessary to reverse them altogether. Here are four recommendations for those who may be affected by SWD to help alleviate any sleep issues:
1. Have a consistent room temperature
Sleep experts recommend a room temperature of 68 degrees Fahrenheit to help promote sleep, as it’s easier to sleep with cooler temperatures.
2. Keep the room dark
If working nights, using a blackout curtain during the day can dramatically improve sleep. Use eye shades if the room cannot be darkened enough for sleep. Along the same lines, wearing dark sunglasses on the drive home in the morning can blunt the impact the sun has on making you feel alert once sunlight hits your eyes.
3. Reduce noise
Reducing noise before bed and limiting screen time with the TV, computer, and cellphone will help your brain “wind down” for sleep. Silence your cellphone and unplug any landlines before you lie down. Heavy carpeting and drapes in the bedroom can also help dampen noise. Lastly, ask family members to respect your sleep time if others are awake when you plan to be asleep by limiting noise in the home.
4. Avoid large meals and caffeine shortly before bed
Large meals can cause indigestion and make it hard to sleep when your stomach is full. Avoid large meals at least 2 hours before bedtime. Ingesting caffeine can keep you amped up when it’s time to sleep.
Other ways to decrease SWD include working less shifts in a row, shortening your work commute by finding another job closer to home or moving closer to your job, and taking naps when possible. Another possible solution that may help some nurses is to switch from working twelve-hour shifts to eight-hour shifts. Symptoms related to working an alternative work schedule need to be present for at least 3 months for an official diagnosis of SWD, so it’s imperative to be evaluated by a provider if sleep issues are still a problem after implementing recommendations.
Fifty years ago, it was common for doctors to make home visits to care for their patients. Fast-forward to today when home visits aren’t common anymore, but an ill patient can still receive medical treatment from the comfort of his or her own home virtually thanks to telemedicine. Health care has come a long way since the days of personalized home visits from physicians. The advancement of telemedicine has drastically changed the delivery of health care.
What is Telemedicine?
Telemedicine allows delivery of near instantaneous communication between patient and provider—or in many cases, provider-to-provider consultations. The technology has evolved so much that a provider can communicate with a patient in real-time with the use of audio and video, which is how many people believe telemedicine is delivered, but in reality telemedicine takes many forms.
One form of telemedicine one may not consider is the transmission of information from provider-to-provider such as electrocardiograms (ECGs) and radiologic images for consults. Telemedicine has made consultations between providers millions of miles away possible. Providers can also use telemedicine to get real-time information from their patients like blood glucose, blood pressure, and other vital data to coordinate effective care.
Early telemedicine applications were developed due to concerns of limited access to remote populations of health services rather than the convenience it’s used for today. Forms of telemedicine have been around since the invention of the telegraph in the mid 1800’s. Telegraphs and telephones pioneered telemedicine, since health care consults were delivered through these means among providers. The concept of the virtual consult we are accustomed to today was astonishingly predicted by a magazine entitled “Radio News” in 1924. The magazine published a prophetic cover depicting a “radio doctor” who could see and be seen by patients through the television screen decades before the technology existed.
The most common form of telemedicine that comes to mind when discussing telemedicine today is the virtual provider-to-patient consultation. Providers are able to diagnose and prescribe to patients who can’t make it to the doctor’s office when they are ill. Systems are so advanced now that patients can download an app and set up a consult with a provider over their cell phone in minutes. Applications and uses of telemedicine vary depending on the setting.
How it Benefits Nursing
Natasha Prevost, FNP-BC, provides telemedicine services for a Dallas-based wellness company providing corporate biometric screenings and heart disease prevention education. “I am responsible for providing each health plan member with a consultation in regards to their biometric screening results. I also provide education in regards to modifiable risk factors and disease prevention, specifically metabolic syndrome and heart disease.”
The ability to provide care in a virtual manner to isolated communities is a way for nurses to reach people who may not otherwise be able to get medical help. Telemedicine also offers convenience for the nurse and patient alike when one is unable to leave their home due to illness or transportation issues. Prevost’s company switched to virtual consults early this year and, though there was backlash at first, the patients and providers have embraced the change for the better. “This mode of care delivery has been well received with our population,” say Prevost. “Providing services via telemedicine has been a highly effective avenue for use to reach increased volumes of patients living in remote areas. In this way, we are able to spend an adequate amount of time promoting prevention and wellness comfortable and privately to a diverse population.”
Implementing virtual consults can offer many benefits; it can save money, allow for greater time with patients, allow more flexibility for scheduling, and allow more patients to be seen since multiple providers can consult at the same time. Telemedicine is a convenient alternative to the typical doctor’s vision offering convenience to both the patient and the provider. Some telemedicine applications can be accessed from home by the provider allowing less missed work time if the provider cannot be on-site. Remote sites can also be covered when the conditions are not favorable or when there is a shortage of nurses in the immediate area.
Although it can provide many benefits, telemedicine is not without problems. One issue is that providers cannot do a consult across state lines unless the provider is licensed in the same state the patient is located. The ability to reach certain populations is limited based upon how many state licenses a provider holds.
Another issue is in regards to billing—some insurance companies will only pay for face-to-face consults; over the phone consults don’t count. Telemedicine carried out through a virtual manner with audio and video would be considered a face-to-face consult and can be billed, but a grey area could arise when the audio portion of the virtual consult is working, but the video is not. How would a company be able to bill then? In addition, IT issues that may arise with a virtual consult could ultimately affect the patient experience, lowering patient satisfaction scores.
The types of conditions addressed vary among the companies who have forged ahead in virtual medicine. Some companies actually diagnose and prescribe virtually, while others only offer consultations through telemedicine. Prevost’s company employs nurse practitioners to communicate with patients regarding their risk factors for metabolic syndrome—all while the patient is at work. The company is known for completing worksite evaluations, but just recently transitioned to the remote format earlier this year. “Because my company simplifies processes for our consultations, both the patients and providers have been highly satisfied,” she says. Patients connect with a nurse practitioner—who must be licensed in the state in which the patient is located—to review risk factors after they have undergone a series of biometric screenings at their place of employment. The whole process, including the consult with the nurse practitioner, takes about 45 minutes from start to finish.
Today’s advances in technology have taken health care to a new level because of the ability to send and receive information instantaneously. Health care is continually evolving and virtual consult services are one of the latest trends gaining popularity. Only the future holds what’s to come next with advances in telemedicine.
Nurses make up the largest sector of the health care system with over 3.1 million RNs nationwide. Even with this astounding number, the nursing field is still in jeopardy of not being adequate enough to care for the aging population. The number of nurse educators has dwindled, and in turn, less people who desire to become nurses are able to enter nursing programs.
The key to alleviating the shortage lies not only in the number of qualified nursing applicants, but in the number of nursing faculty available—without quality educators, nursing will not survive the shortage. “Nursing education is the leader of the nursing profession as a whole because it all has to start with education,” says Nicole Thomas, MSN, CCM, LNC, an adjunct instructor at Virginia College in Baton Rouge, Louisiana. “If nurses and other health care professionals are not properly educated then our industry will not thrive,” she adds.
In August 2010, the National Advisory Council on Nurse Education and Practice (NACNEP) issued a report to the Secretary of the U.S. Department of Health and Human Services and the U.S. Congress titled The Impact of the Nursing Faculty Shortage on Nurse Education and Practice, which outlines the nursing faculty shortage. The NACNEP report addressed 4 key challenges to the educator profession:
1. Recruitment challenges, including:
Difficulties in attracting and retaining qualified nurse faculty
Challenges in achieving demographic diversity within nursing facult
A general lack of awareness on the part of the public and among nurses that the faculty role is a viable career option
2. Problems in providing adequate nurse educational preparation specific to teaching
3. Obstacles to sustaining and funding nurse faculty programs
4. The aging and imminent retirement of current nurse faculty
As a direct result of the nursing faculty shortage, as recent as 2014, 31% of all BSN qualified applicants, 37% of ADN qualified applicants, and 27% of PN qualified applicants were turned away, according to the National League for Nursing’s Annual Survey of Schools of Nursing Academic Year 2013-2014. Nurses who want to continue their education and pursue a higher degree have also been affected by the shortage. In 2014, 22% of qualified MSN applicants and 16% of qualified doctorate applicants were rejected.
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The large number of nurses pursuing higher education being turned away not only affects the general nursing population, but also those who wish to pursue a nurse educator role in the future. Decreasing acceptance rates at the master’s level is in part exacerbated by increased competition and the fact that one in four MSN programs has highly selective requirements for admission. Trends like these help perpetuate a continual cycle of not having enough nursing graduates to take on nurse educator roles in schools of nursing.
Another issue facing nurse educators is that the current nurse educator population is aging, and therefore, not enough newer educators are able to fill the gap. This is in part because of a general lack of awareness of the profession as an option to nurses. More awareness to this specialty in nursing needs to be made. Surprisingly, a nurse does not need to major in education specifically to become an educator; a nurse can become an educator with either a master’s or doctorate degree.
Rebecca Harris-Smith, EdD, MSN, BA, an assistant dean and interim director of an entry level master’s program, has her own take on nurses who want to move into academia: “Many nurses and nurse practitioners move into education with little to no training in education; I would require that nurse educators spend time learning the art of education. Let us not forget the need to ensure that we are expert facilitators of the teaching/learning process.”
For the Love of Teaching
Stark salary discrepancies between clinical nurses and nurse educators may discourage many from pursuing academia. Some nurses may not be drawn to academia simply because of the pay. Salaries of nurse educators are notably lower than those in similarly ranked faculty across education according to The NLN Faculty Census. Salaries at the professor rank averaged nearly 45% less than those teaching in non-nursing fields. Harris-Smith, who teaches at Charles R. Drew University of Medicine and Science in the Mervyn M. Dymally School of Nursing, acknowledges the pay discrepancy: “Nurse educators prepare future nurses and often watch graduates’ salaries increase beyond the educators’ salary within a few years, so if money is your motivation then you are not prepared for academia.”
Neither Thomas nor Harris-Smith are motivated by money and both enjoy teaching. Thomas always knew she wanted to be a teacher: “I am a teacher at heart. I would spend countless hours as a floor nurse educating my patients and their families because I think it’s important to empower them with the knowledge that they need to take care of themselves beyond an inpatient setting—the hospital is just a interim fix, but if they are equipped with the knowledge that they need then they can properly manage their health.”
Harris-Smith’s path to academia was slightly different, with her mother urging her to pursue nursing at her reluctance. “My mother wanted me to be a nurse, and at first, I was not open to the idea,” she says. Even after pursuing a degree in education, Harris-Smith didn’t put it to use until years later. “I put that degree (education) on the shelf for many years, but as I matured, I could not shake the desire to work with students. One day I finally realized that it was my destiny to become a nursing educator.”
Nurse education is changing with technology taking the forefront. Technology is expanding with online classes, patient simulators, and other tools that make education more accessible when it otherwise wouldn’t be. “Nurse educators and students must be open to the use of technology because it is here to stay,” notes Harris-Smith. “The use of human patient simulators when clinical sites are unavailable is a major help for schools of nursing, and the use of technology in the classrooms invaluable when it comes to engaging students.” Electronic Medical Records (EMRs) have also played a large role in nursing education over the years, with students learning new charting systems during clinical rotations.
The face of nursing is becoming more dynamic in nature as well, which poses other necessary alterations to nursing education. Nursing as a whole has become more diverse and nurse educators must adapt to this change. “The influx of intergenerational, multicultural students that are currently in the class requires the nurse educator to facilitate the learning needs of a very diverse population of students,” says Harris-Smith.
Nurse educators must continuously stay abreast of nursing issues and trends to keep up with the ever-changing nature of the field. Nursing as a whole can and will improve with active recruitment of this underrepresented specialty. Those who choose to pursue academia hold a special role in the profession, because without them, nurses wouldn’t exist. When asked of the most notable change she has seen in education, Thomas adds: “The biggest change I have seen is an increased rigorous curriculum for nurses and other health professionals, which I think is good.” Thomas’ statement reflects what nurses already knew—nurse educators are doing their job well; we just need more of them.
The Nurse Practitioner (NP) profession was ranked #6 in the U.S. News and World Report’s 100 Best Jobs of 2016, and it’s easy to see why: good working conditions, the ability to be a dedicated provider, and increased job satisfaction, just to name a few.
According to the American Association of Nurse Practitioners (AANP), there are more than 205,000 NPs in the United States as of 2014, with an estimated growth to 244,000 by 2025. Nurse practitioners care for patients across the lifespan in a variety of settings and are one of four recognized advanced practice registered nurse (APRN) roles, which also includes Clinical Nurse Specialists, Nurse Anesthetists, and Certified Nurse Midwifes. All NPs must complete a master’s (or doctorate) degree program, and they hold certificates in one of 8 recognized specialties, with Family Nurse Practitioner (FNP) being the most popular at 54.5%.
What Exactly is a Nurse Practitioner?
“I think the public is sometimes confused on what the NP role is and what we have to offer to health care,” says Kaulette Clark, a FNP who works in the ER at Delano Regional Hospital in Delano, California. Many people, the general population and patients alike, agree with Clark and are confused by the function of an NP. With the title including nurse, and the connotations associated with that role, coupled with working in the capacity of a physician, anyone could see the potential dilemma. Simply put, NPs diagnose and treat as physicians do, but they also integrate the compassion of a nurse.
Christene Ingram, MSN, APRN, FNP-C, who works at Clinic 45, a family practice clinic in Houston, Texas, sees the importance of a nurse’s touch as a NP in her practice: “NPs are qualified health care providers that provide care that is safe, effective, and patient-centered. Most [patients] appreciate the warmth that is associated with being a nurse.”
The AANP defines an NP as a registered nurse with advanced education and clinical training. Furthermore, NPs provide patients with high quality, comprehensive, patient-centered primary, acute, and specialty health care services. In addition to diagnosing and managing acute episodic and chronic illnesses, NPs also focus on health promotion, disease prevention, health education and counseling, and guiding patients to make smarter health and lifestyle choices. Services NPs provide include, but are not limited to, ordering, performing, and interpreting diagnostic tests such as lab work and x-rays; diagnosing and treating acute and chronic conditions such as diabetes, high blood pressure, infections, and injuries; prescribing medications and other treatments; and managing a patient’s overall care.
Roles and Specialties
NPs practice within the specific population focus in which they are trained. There are eight recognized NP specialties by certification examination: Family [FNP]; Adult and Gerontology Primary Care [AGPCNP]; Adult and Gerontology Acute Care [AGACNP]; Pediatric Primary Care [PPCNP]; Pediatric Acute Care [PNP-AC]; Women’s Health [WHNP]; Neonatal [NNP]; and Psychiatric and Mental Health [PMHNP]. Further, NPs can branch out in a wide variety of sub-specialties after completion of their NP program through additional education and work experience.
A 2015 AANP survey revealed that more than 80% of NPs are educated in one of the primary care specialties (Family, Adult and Geriatrics, Women’s Health, and Pediatrics). Ingram, for example, felt like taking the FNP route would increase her job prospects the most after school. “I personally didn’t want to limit myself to one particular specialty,” she says. NPs can be found working in hospitals, community health centers, or managing their own clinics. The role and capacity in which a NP can work is ubiquitous.
History of Nurse Practitioners
The NP profession is a fairly new profession with history dating back to the late 1950s. Due to a shortage of primary care physicians in the United States, the need for NPs developed. Physicians began training nurses to identify and treat the primary care needs of children and families. With collaboration from pediatrician Dr. Henry Silver, Loretta Ford, a public health nurse, developed the first training program for NPs at the University of Colorado in 1965.
When Ford conceptualized the NP role she envisioned the NP to assess, diagnose, treat, and evaluate—the same as it is today. The early NP programs granted no degree upon graduation, only a certificate. The first master’s degree NP program was established in 1967 by Boston College and the American Academy of Nurse Practitioners, the first organization for NPs of all specialties, was formed in 1985.
Today’s NP student graduates with either a master’s or doctorate degree and the ability to provide care in a wide range of settings, including inpatient, outpatient, and rural settings. Prospective NP students are RNs who typically have one year or more nursing experience in the area in which they desire to specialize. Current requirements for all NPs to practice include: a bachelor’s degree in nursing, registered nurse licensure, graduate nursing education, national board certification, and state-specific NP licensure and registration.
NP education is divided between didactic and clinical training. The amount of clinical hours required to graduate vary depending on the school. All clinical training is completed in a specific population focus and upon completion of school, graduates must pass a board examination in order to practice. Graduates must also fulfill state nursing board requirements to be recognized within their respective state—including prescriptive authority, in order to practice in that state. Scheduled medication authority for all states is granted through the U.S. Drug Enforcement Agency. NPs hold prescriptive authority in all 50 states and the District of Columbia, including controlled substances in 49. Currently, 21 states and the District of Columbia allow NPs to practice independently, with more states on the horizon.
The timeline for NP education after completion of a BSN and required RN experience varies depending on the educational path chosen. NP education can be completed either part-time or full-time, allowing the most flexibility for nurses wanting to continue their education while working. The doctor of nursing practice (DNP) is considered the terminal clinical degree for the profession, but there is no current requirement for it to be the entry-level education for NPs. Consequently, NP students can choose to complete either a master’s or doctorate degree to practice.
Full-time course studies for a master’s degree can typically be completed in 2 years, with part-time studies in 3-4 years versus a doctorate degree completed in 3-5 years. Additionally, nurses who already have master’s degrees can build upon their education and become an NP through post-master’s programs.
Although the average time it takes to complete NP education from start to finish is 7 years, many nurses spend a considerable amount of time as a nurse before continuing their education. Both Clark and Ingram’s path to the NP profession was a long one; Clark spent 15 years as a nurse before pursuing advanced education and Ingram was a nurse for 21 years before enrolling in NP school.
Why It’s a Good Time to Consider the NP Profession
Once again, the United States is faced with a primary care provider shortage. The implementation of the Affordable Care Act (ACA) in 2010 made way for NPs to be active participants in solving the primary care provider shortage by way of implementing provisions for increased clinical training funding and student loan forgiveness. In addition, grants were provisioned to place NPs in more Federally Qualified Health Centers (FQHCs) and Nurse Managed Health Centers (NMHCs). Many more provisions were made that pertain to increasing funding for APRNs to help alleviate the primary care provider shortage.
Less physicians are going into primary care, whereas over 80% of NPs specialize in a primary care role—which is good news considering NPs can help fill that gap. Almost half of the United States has legislation to allow NPs to practice without physician supervision, allowing NPs more access to those who need it the most. Clark sees how changing legislation in the remaining states would benefit others: “I hope all states will grant full practice authority; there are so many underserved areas that would greatly benefit.” Those who chose to become an NP will have many job prospects in the primary care specialties for years to come because of the shortage. Primary care provided by NPs also results in cost-effective care for those that need it the most since NPs are not reimbursed by insurance companies as much as their physician counterparts.
Both Clark and Ingram would recommend the profession to others, citing both autonomy and the rewards of being an NP in terms of patient relations. “I love the autonomy that an NP has,” states Ingram. “It’s very rewarding to contribute and provide cost-effective primary care. Patients will often request to schedule with me because they feel I spend more time with them.”
Clark knows she is making a difference in her role as an NP when patients comment on her patient-centered approach: “When someone says, ‘No one has taken the time to teach me or explain things to me the way you have,’ I know I am making a difference in my role as an NP.”
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