Nurse practitioners are staffing retail health clinics, diagnosing and treating ills from strep throat to conjunctivitis. They’re giving flu shots and prescribing drugs. And the influential Institute of Medicine says they should not only work side by side with physicians, but replace them in some cases.

But a survey published on Wednesday shows a huge gap between what nurse practitioners think they can and should do, and what doctors think. And that’s bad news for patients, Karen Donelan of the Mongan Institute for Health Policy at Massachusetts General Hospital says.

“We were surprised by the level of disagreement reported between these two groups of professionals," says Donelan, who led the survey published in the New England Journal of Medicine.

Her team’s survey of 467 nurse practitioners and 505 physicians found both groups agree that nurse practitioners should practice “to the full extent of their education and training.” Where the disconnect comes is just what this training should allow them to do, and how much they should get paid for it.

Only 17 percent pf physicians agreed that nurse practitioners should coordinate a patient’s care as a leader of a “medical home”, versus more than 82 percent of the nurse practioners, the survey found. And only 3.8 percent of doctors felt that a nurse practitioner should be paid the same for providing the same service as a physician, compared to 64 percent of the nurse-practitioners.

“At the core of the controversy is whether nurse practitioners have the education and experience to provide high-quality services and lead clinical practices without supervision by a physician,” Donelan’s team wrote.

The Institute of Medicine tried to settle that question in a 2010 report, saying that nurses can handle much of the strain on the health care system and should be given both the education and the authority to take on more medical duties.

But the American Medical Association, which represents about 120,000 practicing physicians and students, rejected the idea immediately.

"Nurses are critical to the health care team, but there is no substitute for education and training," the AMA said at the time.

The Association of American Medical Colleges estimates that by 2015, the United States will be short about 62,100 physicians. Many experts are looking to the 180,000 nurse practitioners now in the field to help cover the gaps.

When the Robert Wood Johnson Foundation set up a series of meetings among doctors’ and nurses’ guilds to try to smooth out the disagreements in 2011, things looked up until the organizers issued a report urging less hierarchy, says John Iglehart of the journal Health Affairs in a separate commentary in the New England Journal. “The `captain of the ship' notion  … needs to be eliminated, focusing on the patient as the driver of care,” the report read. “A physician, nurse, social worker or other provider may take the lead in a given situation.’

The American Academy of Family Physicians,  American Osteopathic Association and the American Academy of Pediatrics pulled out and the whole attempt collapsed, Iglehart says.

Dr. David Blumenthal and Melinda Abrams of the Commonwealth Fund said the survey confirmed that doctors and nurse practitioners often “inhabit different universes”.  And clearly they have different training and skills. Nurse practitioners, often referred to as advanced practice registered nurses, usually have a four-year bachelor's degree with at least a master's degree and sometimes a doctorate beyond that, depending on the requirements of their state.

But nurse practitioners can fill the growing gap in the supply of health care prviders for the U.S., they argued. “The existing literature shows that nurse practitioners provide care similar to that of physicians with respect to health outcomes, resource utilization, and cost, and the same studies show that nurse practitioners get higher grades than physicians with respect to communication with patients seeking urgent care,” they wrote.

Jan Towers, policy director for the American Association of Nurse Practitioners, saw it coming. “There is nothing surprising there,” she said in a telephone interview. “The disconnect has been there a long time.”

She thinks relationships will improve as doctors and nurse practitioners work together more. A bigger issue, Towers says, is the way the U.S. healthcare system pays for care. “How do we institute value-based purchasing so that we look at outcomes rather than who is performing the task?” she asked.

Once the medical system evolves toward taking care of a patient’s health, instead of the current system of paying for each individual test, treatment or consultation, the differences should even out, she predicts.

Donelan isn’t so hopeful. “Our findings suggest that a substantial number of primary care physicians are unlikely to embrace policy recommendations aimed at further expansion of the roles and supply of nurse practitioners,” her team wrote.

“In particular, physicians' concerns about the likely effect of an expanded workforce of nurse practitioners on several aspects of health care quality need to be addressed in discussions of strategy for the development of the U.S. health care workforce.”

Peter Buerhaus, director of the Center for Interdisciplinary Health Workforce Studies at Vanderbilt University and a registered nurse with a Ph.D who worked on the survey team, agreed.

"It is unsettling that primary care physicians and nurse practitioners, who have been practicing together for several decades, seem so far apart in their perceptions of each other's contributions. I am concerned that these large gaps in perceptions will inhibit efforts to redesign care delivery and to improve the productivity and configuration of the primary care workforce,” Buerhaus said in a statement.

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Patients can refuse a flu shot. Should doctors and nurses have that right, too? That is the thorny question surfacing as U.S. hospitals increasingly crack down on employees who won't get flu shots, with some workers losing their jobs over their refusal.

"Where does it say that I am no longer a patient if I'm a nurse," wondered Carrie Calhoun, a longtime critical care nurse in suburban Chicago who was fired last month after she refused a flu shot.

Hospitals' get-tougher measures coincide with an earlier-than-usual flu season hitting harder than in recent mild seasons. Flu is widespread in most states, and at least 20 children have died.

Most doctors and nurses do get flu shots. But in the past two months, at least 15 nurses and other hospital staffers in four states have been fired for refusing, and several others have resigned, according to affected workers, hospital authorities and published reports.

In Rhode Island, one of three states with tough penalties behind a mandatory vaccine policy for health care workers, more than 1,000 workers recently signed a petition opposing the policy, according to a labor union that has filed suit to end the regulation.

Why would people whose job is to protect sick patients refuse a flu shot? The reasons vary: allergies to flu vaccine, which are rare; religious objections; and skepticism about whether vaccinating health workers will prevent flu in patients.

Dr. Carolyn Bridges, associate director for adult immunization at the federal Centers for Disease Control and Prevention, says the strongest evidence is from studies in nursing homes, linking flu vaccination among health care workers with fewer patient deaths from all causes.

"We would all like to see stronger data," she said. But other evidence shows flu vaccination "significantly decreases" flu cases, she said. "It should work the same in a health care worker versus somebody out in the community."

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Cancer nurse Joyce Gingerich is among the skeptics and says her decision to avoid the shot is mostly "a personal thing." She's among seven employees at IU Health Goshen Hospital in northern Indiana who were recently fired for refusing flu shots. Gingerich said she gets other vaccinations but thinks it should be a choice. She opposes "the injustice of being forced to put something in my body."

Medical ethicist Art Caplan says health care workers' ethical obligation to protect patients trumps their individual rights.

"If you don't want to do it, you shouldn't work in that environment," said Caplan, medical ethics chief at New York University's Langone Medical Center. "Patients should demand that their health care provider gets flu shots — and they should ask them."

For some people, flu causes only mild symptoms. But it can also lead to pneumonia, and there are thousands of hospitalizations and deaths each year. The number of deaths has varied in recent decades from about 3,000 to 49,000.

A survey by CDC researchers found that in 2011, more than 400 U.S. hospitals required flu vaccinations for their employees and 29 hospitals fired unvaccinated employees.

At Calhoun's hospital, Alexian Brothers Medical Center in Elk Grove Village, Ill., unvaccinated workers granted exemptions must wear masks and tell patients, "I'm wearing the mask for your safety," Calhoun says. She says that's discriminatory and may make patients want to avoid "the dirty nurse" with the mask.

The hospital justified its vaccination policy in an email, citing the CDC's warning that this year's flu outbreak was "expected to be among the worst in a decade" and noted that Illinois has already been hit especially hard. The mandatory vaccine policy "is consistent with our health system's mission to provide the safest environment possible."

The government recommends flu shots for nearly everyone, starting at age 6 months. Vaccination rates among the general public are generally lower than among health care workers.

According to the most recent federal data, about 63 percent of U.S. health care workers had flu shots as of November. That's up from previous years, but the government wants 90 percent coverage of health care workers by 2020.

The highest rate, about 88 percent, was among pharmacists, followed by doctors at 84 percent, and nurses, 82 percent. Fewer than half of nursing assistants and aides are vaccinated, Bridges said.

Some hospitals have achieved 90 percent but many fall short. A government health advisory panel has urged those below 90 percent to consider a mandatory program.

Also, the accreditation body over hospitals requires them to offer flu vaccines to workers, and those failing to do that and improve vaccination rates could lose accreditation.

Starting this year, the government's Centers for Medicare & Medicaid Services is requiring hospitals to report employees' flu vaccination rates as a means to boost the rates, the CDC's Bridges said. Eventually the data will be posted on the agency's "Hospital Compare" website.

Several leading doctor groups support mandatory flu shots for workers. And the American Medical Association in November endorsed mandatory shots for those with direct patient contact in nursing homes; elderly patients are particularly vulnerable to flu-related complications. The American Nurses Association supports mandates if they're adopted at the state level and affect all hospitals, but also says exceptions should be allowed for medical or religious reasons.

Mandates for vaccinating health care workers against other diseases, including measles, mumps and hepatitis, are widely accepted. But some workers have less faith that flu shots work — partly because there are several types of flu virus that often differ each season and manufacturers must reformulate vaccines to try and match the circulating strains.

While not 100 percent effective, this year's vaccine is a good match, the CDC's Bridges said.

Several states have laws or regulations requiring flu vaccination for health care workers but only three — Arkansas, Maine and Rhode Island — spell out penalties for those who refuse, according to Alexandra Stewart, a George Washington University expert in immunization policy and co-author of a study appearing this month in the journal Vaccine.

Rhode Island's regulation, enacted in December, may be the toughest and is being challenged in court by a health workers union. The rule allows exemptions for religious or medical reasons, but requires unvaccinated workers in contact with patients to wear face masks during flu season. Employees who refuse the masks can be fined $100 and may face a complaint or reprimand for unprofessional conduct that could result in losing their professional license.

Some Rhode Island hospitals post signs announcing that workers wearing masks have not received flu shots. Opponents say the masks violate their health privacy.

"We really strongly support the goal of increasing vaccination rates among health care workers and among the population as a whole," but it should be voluntary, said SEIU Healthcare Employees Union spokesman Chas Walker.

Supporters of health care worker mandates note that to protect public health, courts have endorsed forced vaccination laws affecting the general population during disease outbreaks, and have upheld vaccination requirements for schoolchildren.

Cases involving flu vaccine mandates for health workers have had less success. A 2009 New York state regulation mandating health care worker vaccinations for swine flu and seasonal flu was challenged in court but was later rescinded because of a vaccine shortage. And labor unions have challenged individual hospital mandates enacted without collective bargaining; an appeals court upheld that argument in 2007 in a widely cited case involving Virginia Mason Hospital in Seattle.

Calhoun, the Illinois nurse, says she is unsure of her options.

"Most of the hospitals in my area are all implementing these policies," she said. "This conflict could end the career I have dedicated myself to."

__

Online:

R.I. union lawsuit against mandatory vaccines: http://www.seiu1199ne.org/files/2013/01/FluLawsuitRI.pdf

CDC: http://www.cdc.gov

Reza Estakhrian / Getty Images stock

Even nurses can get squeamish, but it's not always what you'd expect.

The triggers span green, brown and all the vibrant colors of the digestive rainbow. Sudden squeamishness is prompted, for some, by fountains of phlegm and, for others, by certain fragrant excretions.

In the nursing profession, it’s often just called “the one thing” -- that single human function or unappealing appendage that can instantly disgust and distress seasoned medical professionals who otherwise handle all sorts of discharges, emissions and oozing with barely a wince.

“Even though very little in the way of bodily fluids bother me, I do have one thing that sparks the heebie-jeebies,” said Barb Dehn, a women’s health nurse practitioner who has often lectured at Stanford University.

“Despite years of attending births with gushing amniotic fluid, blood and other slimy secretions, doing gynecologic exams on sex workers, and changing dressings for people with gangrene, the one thing that makes me gag is … wait for it … the sight of dentures in a glass. No kidding, I can't stand it and begin to retch every time,” said Dehn, who works at El Camino Hospital in Mountain View, Calif. “When I was caring for some elderly relatives, I could do everything else: change diapers, change oozing dressings, give enemas. But brushing their dentures was just too much for me. Go figure.”

Ask 10 nurses the same question – what is your “one thing?” – and you may hear 10 different answers.

Warning for the easily grossed out: This is stomach-turning stuff.

For Terry Ann Black, who spent 46 years nursing in Vermont and Maryland, it’s “anything having to do with the eyes,” including punctures and foreign bodies.

“Why do eyes bother me? Not really sure, but I think I am afraid that something will gush out of them,” said Black, author of a “Caring is Not Enough,” an end-of-life planning workbook. “I also had a recurring patient who had a fake eye and he would pop it out just to get a reaction. I accommodated him.”

For Sandy Navalta, a certified nursing assistant in San Francisco, the problem is way at the other end.

"The one thing that absolutely grosses me out are situations where a patient has been constipated for days. When the patient is given a stool softener, what comes out is three days of hard stool followed by projectile diarrhea,” Navalta said. “And that diarrhea flows down the leg and into the cast, if the patient is wearing one – and, yes, that has happened to me. I've had to clean it up.”

And for Deonne Brown Benedict, a family nurse practitioner and owner of Charis Family Clinic in Edmonds, Wash., the human juice that makes her woozy her is something with which many of us also struggle.

Her impetus is vomitus.

“I almost didn't become a nurse because I figured I might come in contact with vomit more than once in my career. Thankfully, it hasn't been as frequent as I had envisioned,” said Benedict, who has invested 17 years in the medical profession.

She vividly recalls an early, nursing-student moment when one of her first patients began to hurl. As the woman upchucked, Benedict tossed her an emesis basin, “and went running out of the room so that I wouldn't be the next person to lose it,” she said.

“I happened to see a group of eager medical students looking for a good ‘case study,’ so I pointed them right to my patient. They went right in, probably wondering what had happened to the nurse on duty.”

Benedict “recovered,” she said, from her guilt and her own wave of nausea and forced herself to “toughen up in this area.”

At least in terms of cookie tossings, some people gag when they see others vomit because it’s believed that mirror neurons in their brains make them more empathetic and cause their bodies to emulate what they see. Like forming tears when you see someone crying, experts say.

Following similar logic, Stanford lecturer Dehn theorizes that many nurses have varied causes for their on-the-job cases of the cold sweats because they all are wired differently, and have had distinct life experiences that they can't check at the examination-room door. 

She points to the brain’s limbic system, which help control the body’s reactions to and actions during perceived moments of self-preservation.

“In my own opinion, it must derive from an imprinting that occurs early on in life, and that there are neural pathways that get laid down early and maybe get reinforced throughout life,” Dehn said.

This may explain why Becki Hawkins, a nurse who worked for 30 years in oncology and hospice in the Tulsa area, sites just one aversion when it comes to hands-on human care.

“Not the blood, not the open wounds, not the poo, not the body odor, nor the feet,” Hawkins said.

“The only thing that would really make me scoot out of a room real quick was,” she added, “when a tracheotomy patient would cough up a huge, green ball of phlegm into my face – accidentally and without warning.”

Let's be honest, though, that's going to make pretty much anyone scoot. 

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Adding extra patients to nurses' already heavy loads, or logging more nurses with high levels of burnout was tied to an increase in two kinds of hospital-acquired infections.

Heavy patient loads and chronic burnout have long been among the top complaints of nurses at the nation’s hospital bedsides. But a new study shows that those problems affect not only the nurses themselves, but also the number of infections in the people they care for.

For every extra patient added to a nurse’s workload, there was roughly one additional hospital-acquired infection logged per 1,000 patients, according to researchers from the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing.

For each 10 percent jump in the proportion of nurses who logged high levels of burnout, there was roughly one additional catheter-associated urinary tract infection per 1,000 patients and almost extra two surgical site infections per 1,000 patients, according to a study published today in the American Journal of Infection Control.

“One infection is too many,” said Jeannie P. Cimiotti, the study’s lead author, who directs the Collaborating Center for Nursing at Rutgers University. “If you’re really serious about infection control and providing the best care for patients, you have to address these issues.”

Cimiotti and her colleagues surveyed more than 7,000 registered nurses working in 161 hospitals in Pennsylvania, and then merged that with data on hospital infections from the Pennsylvania Health Care Cost Containment Council, or PHC4, and with national data on the characteristics of the nation’s hospitals.

What they found was alarming, Cimiotti said. More than a third of the nurses reported high levels of job-related burnout. That was measured by the Maslach Burnout Inventory, a recognized scale that tracks factors like emotional exhaustion, depersonalization and whether the nurses feel a sense of personal accomplishment. 

“Nurses deal with life and death every day,” Cimiotti said, explaining why burnout occurs. “How many people go to their job and say, ‘This one died and this one died and this one died?’ Often they see as much failure as they see good.”

The nurses cared for an average of 5.7 patients apiece, and when even one extra patient was added to that load, the result was an additional 1,351 infections within the hospital population studied.

That could mean additional risk of serious illness or death for patients who catch those infections while in the hospital, Cimiotti said. For people with cancer or other conditions that compromise immune system function, even a low-level bladder infection or a common infection in a surgical wound can tip them into far more serious illness.

“They’re associated with morbidity and mortality, no doubt about it,” Cimiotti said. “A bloodstream infection can kill someone.”

This study is important because it is among scant research to factor in the impact of burnout, she added. When nurses are chronically stressed and feel unsupported by the work environment, it can lead to lapses in infection control practices.

“If a patient is moaning for help over here and you’re changing the dressing over there, maybe you touch something in the sterile field,” Cimiotti said.

At the same time, the study found that reducing burnout cuts infections – and saves money.

Reducing reports of burnout by 30 percent cut urinary tract infections by more than 4,000 and surgical site infections by more than 2,200, saving between $28 million and $69 million per year in estimated costs to treat those infections.

This certainly isn’t the first time that UPenn nursing researchers have found that staffing levels have had direct effects on patient health. A 2002 study found that adding a single patient to a nurse’s caseload increased the risk of dying within a week by 7 percent. Boosting the load from six patients to eight increased the risk by 31 percent over a nurse caring for four patients.

And a 2010 study found that patient deaths would drop by 14 percent in New Jersey and 14 percent in Pennsylvania if those states adopted California’s hard-won mandated nurse-to-patient ratios of 1 to 5 in surgical units. That study was led by Linda Aiken, director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing, who also collaborated on the current study.

Though it may appear very sympathetic to the nursing profession, the controlled study was conducted by experts known for the reliability of their work, said Cheryl Peterson, director of nursing practice and policy for the American Nurses Association.

“This study does confirm what most of us have been saying within nursing,” Peterson said. “There is a direct link between staffing, the number of nurses providing patient care, and patient outcomes. What we would add is the work environment … that can have an impact on burnout.”

The issue of nurse-to-patient ratios is hotly debated in the U.S., where no one appears to track nationwide staffing averages. Neither the ANA nor the American Hospital Association keep such statistics, staff members say. Nursing patient loads can vary from as low as one nurse for every one or two patients in intensive care units to far higher than the 1:5 ratio mandated in surgical units in California.

“I don’t have the evidence, but I would believe, yes, some workloads are definitely higher than that,” Cimiotti said.

Some hospitals in the U.S. have worked hard to address those issues.  Nearly 400 of the nation’s 5,754 registered hospitals have achieved so-called “Magnet” status, which recognizes health care organizations that achieve structural and clinical practices that empower nurses and lead to good patient results.

But it will take more, the experts agree.

“Now that we see that burnout is playing a role in this relationship, we have to look at more than just the staffing,” said Cimiotti. “We have to look at the system, the organizational structure where the nurses provide care.”

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Jeaux Rinehart, president of the Washington State Emergency Nurses Association, said he's not surprised by a new survey that shows violence in the ER remains high, with more than half of nurses reporting verbal assaults and more than 1 in 10 experiencing physical attacks.
Rinehart was beaten in the head by a patient in 2007.

Tammy Mathews was working a late-night Sunday shift in an Alabama emergency department when a patient, drunk and high on drugs, grabbed her around the neck, choked her until she couldn’t breathe -- and then spat in her face.

Jeaux Rinehart was staffing a Seattle emergency room when a patient in a triage room, upset that he couldn’t get methadone, pulled a billy club out of a backpack and beat Rinehart in the back of the head and across the face, breaking his cheekbone.

So neither Mathews nor Rinehart was surprised to learn that an ongoing poll of nearly 7,200 emergency nurses finds that violence in the ER remains high, despite increased attention to a problem that leaves some health workers worried about danger every day.

“It’s so global,” said Rinehart, 51, president of the Washington State Emergency Nurses Association. “It’s actually getting worse.”

According to latest figures from the national Emergency Nurses Association, between January 2010 and January 2011, more than half of nurses in the ER -- 53.4 percent -- reported experiencing verbal abuse and about 13 percent said they had encountered physical violence at work in the previous week.

Being grabbed or pulled was the most common physical assault, while yelling and swearing were the most common kinds of verbal attack.

That’s about the same rate previously detected by the ongoing survey conducted by the ENA starting in May 2009. The Des Plaines, Ill., association surveys nurses at three-month intervals, partly to determine if the problem is getting any better, said AnnMarie Papa, the group’s president.

Frustrated, she admitted that it isn't.

“It’s upsetting to me that we can’t change the culture,” Papa said. “What is this with society that says it’s OK to do this to people who are trying to help them?”

Nurses on the front lines, like Mathews, 49, of Auburn, Ala., say that long waits, crowded conditions and growing numbers of mentally disturbed patients all exacerbate the stress of emergency department visits.

“Tempers kind of flare up and it just happens,” said Mathews, who was assaulted in 2005.

Both Mathews and Rinehart have worked in emergency departments for decades and they say they’ve come to expect vile treatment by patients and their families.

“I’ve been called things that, honestly, I have never even thought about putting those words together,” said Rinehart, who was attacked with the club in 2007.

The problem has received serious attention in recent years. At least 25 states have strengthened penalties for attacking health care workers and a growing number of hospitals have bolstered both physical security measures and staff training, according to the American Hospital Association.

At Virginia Mason Medical Center in Seattle, the hospital where Rinehart works, a new emergency department opened just last week with greatly enhanced security features, among other amenities, according to spokesman John Gillespie.

But that progress hasn’t curbed the crisis, said Papa, who advocates a zero-tolerance policy to stop ER violence. Only about a third of nurses actually submit formal reports about physical violence and less than 15 percent report verbal assaults, the survey found. That might be because in almost half of cases of physical violence -- 46.7 percent -- no action was taken against the perpetrators. In nearly three-quarters of cases -- 71.8 percent -- nurses received no response from hospital officials about the assaults.

In Mathews’ case, she said the hospital wanted her to drop assault charges against her attacker, and that officials fired her when she refused. She works in the emergency department of a different hospital now and she says she's still wary of erratic patients. Rinehart said he has transferred out of the emergency department to focus instead on patient safety.

“I miss it, but I don’t miss being called every name in the book," said Rinehart, who worked in ERs for 32 years. "I miss it, but I’m not going back.”