Two newspaper reports last week showed the dichotomy that exists in attitudes about mandating vaccines for children.

On February 15, the Wall Street Journal reported that more pediatricians are turning away families who refuse to have their children receive immunizations.

Day 4 measles rash/ CDC, via Wikimedia Commons

The next day, USA Today reported that several states are considering changing laws that currently allow parents to opt out of mandatory vaccines only for religious reasons, and extending the opt-out to include “philosophical reasons.” These reasons invariably come back to parental fears that vaccines put their children at high risk for autism. (See the our November 2011 report on what fueled this controversy.)

Highly publicized resurgences of measles and pertussis seem to have done little to change some parents’ mindsets about the need for immunizations. Has the success of the vaccines campaigns lulled some into a false sense of security—that the “risks” of vaccines, though unproven, are more dangerous than the diseases or their complications?

I shared in an editorial a story of a childhood friend who was left paralyzed in his lower extremities from contracting polio in childhood. And a cousin has a child, now almost 40 years old, who was left blind and speechless from encephalitis following measles contracted when she was five years old.

Cases like these are rarely seen anymore, but will they become more commonplace with more parents refusing to let their children receive vaccines? These are very real risks that many don’t think about. We need to continue to educate parents on the science that supports vaccine administration.

Amanda Trujillo

Our prior post on the Amanda Trujillo case elicited many comments, on a variety of themes. There were also referrals and crosslinks to other sites supporting, analyzing, and weighing in on the situation, including statements from the Arizona Nurses Association and the ANA, and a post on a physician blog, “White Coat’s Call Room,” which has vowed to carry all the details once the case is decided.

One complaint raised by several people in response to our post was that the Arizona Board of Nursing wasn’t supporting Amanda. State nursing or medical boards are regulatory boards that exist to ensure the protection of the public and to regulate professional practice according to the law (in nursing’s case, according to nursing practice acts). They do not aim to protect the individual nurse, but to assure that all those who claim to be nurses are eligible to claim that title and practice within their scope of practice as defined by law.

Some historical context: Regulatory boards were set up back in the early 1900s, after nursing associations successfully lobbied for registration laws to keep out unqualified women who posed as nurses. In 1903, North Carolina was the first state to enact a nurse practice act; by the mid-1920s, all 48 states had laws regulating who could practice and who could use the title “registered nurse.”

Thus, boards of nursing are intended to protect the consumer and the standards of the profession.

While I agree with several comments saying that nurses should be able to practice within the full scope of their education and training, as recommended by the Institute of Medicine Report on the Future of Nursing, what’s also important to keep in mind is that we must do so in accordance with the law—which unfortunately may not always measure up to our ideals or accurately reflect actual professional practice.

Nurses and state associations need to work to change the law where it needs to be changed—and there are many people who devote themselves to making such change happen—but until the law does change, this is how nurses’ actions will be judged, whatever other motives may appear to be in play or not.

(Editor’s note: A few readers have misconstrued the last paragraph as implying a judgment in the Amanda Trujillo case. This is by no means the intended meaning. The focus here is a more general look at the roles of boards of nursing and the importance for all nurses of not leaving themselves vulnerable to accusations of going beyond their scope of practice, as it has been defined in a particular state’s practice acts.)

I recently babysat a friend’s busy toddlers, and was happy to share the long (but lovely) day with a good friend who happens to also be a nurse. We’d just gotten the babies tucked into their cribs and were stepping out of the nursery with a sigh when I noticed the family’s cat lounging in a padded rocking chair, blinking lazily at us.

“Wait!” I said, scooping up the cat. “We can’t leave the cat here. Cats suck the breath out of babies!”

My friend looked at me like I’d lost my mind, and I instantly wished that I hadn’t said it.  The absurdity of the statement was clear to me. And yet it felt like a truth I’d known forever, even if I couldn’t remember why.

As it turns out, it was something I was told as a child—by my grandmother. Knowing this makes my statement make sense, at least to me, as I adored my grandma and would have accepted anything she told me as undisputed truth. Even so, I’m surprised (and a little embarrassed) that in spite of higher education and years of nursing experience, despite the obvious physiologic impossibility of a cat sucking the breath from a baby, and despite the fact that I’ve had my own children, and cats, such a notion was lying dormant in my consciousness and escaped unexpectedly and unbidden.

In my curiosity about the idea of cats sucking breath from babies, I came across a 1930 book, Shattering Health Superstitions, by Morris Fishbein, MD. It’s subtitled “An Explosion of False Theories and Notions in the Field of Health and Popular Medicine.” Dr. Fishbein discusses 57 medical claims, asserting their fallacy only after explaining their origin.

Here are some of the chapter titles, verbatim:

• Some people think that fish is a brain food and that a lot of mackerel in the diet will convert a moron into an Einstein.
• Some people believe that warts can be removed by tying knots in a string and burying the string at a crossroads in the moonlight.
• Some people think appendicitis is just an old-fashioned stomach ache and that the doctors developed the disease for their own satisfaction.
• An apple a day keeps the doctors away.
• When the oldest inhabitant begins to feel pain in his joints, there is going to be a change in the weather.
• It takes whiskey to kill a cold.
• A favorite Midwestern cure for rheumatism is to carry a buckeye in the trousers pocket.
• Kissing can cause trouble, but it doesn’t cause cold sores.
• Most people believe that a big head is sure evidence of a massive intellect.

While there may be a shred of truth in a couple of the beliefs alluded to in these chapter titles (many people with arthritis certainly do report worsening symptoms with changes in the weather; many claims have been made for the benefits of fish oil of late; etc.), most have as much basis as certain more recent widely held beliefs regarding the various evils of vaccinations.

As for the notion that a cat will suck the breath from a baby, it’s examined in depth, and includes an excerpt from the 1929 Nebraska State Journal, in which a physician swears to have caught a cat in the very act of “sucking a child’s breath, lying on the baby’s breast, a paw at either side of the babe’s mouth,” and further, that “it required 20 minutes’ hard work to resuscitate the baby.” Dr. Fishbein goes on to render the concept as possible, yet not actually proven, and suggests that cats are unfairly targeted as culprits due to their association with magic and witchcraft. In short, the superstition is debunked on the basis that it’s . . . superstition.

It’s an entertaining book, and although I’m not sure I’d call it educational, I feel enlightened—mostly by the introduction, wherein Dr. Fishbein speaks generally about timeless concepts, like fear, hope, and the value of personal history. He says:

“Regardless of the marvels that may come as the effort of science, regardless of the mystery of the airplane, the radio, the effects of radium and of X-ray, the average man looks for something beyond.” And this: “In the superstitions of mankind regarding health and disease one may trace his evolution from stone age man and man of the caves to modern man who sails in the air and under the sea.”

I like both of those statements, as they ring true to me, in nursing and life. I rely on science but will never discount “something beyond.” And in regard to my own superstitions, examining them does remind me of my own evolution, and tracing them leads me closer to home.

(Editor’s note: for another angle on this topic, see also Marcy’s earlier post, “The Little Superstitions of Nurses.”)

Editor’s Note: Toni Inglis, MSN, RN, CNS, FAAN, writes opinion for the Austin (TX) American-Statesman. She works at the Seton Healthcare Family in Austin as a neonatal ICU staff nurse and also writes a nursing blog for Seton and edits its monthly NursingNews. This article is a reprint of an April 22nd commentary in the Statesman. Toni was inspired to write the column after a particularly disappointing legislative session, in which Texas advanced practice nurses made fewer gains than in past sessions—despite Texas ranking last in access to health care and having the most restrictive laws in the country regarding APRN scope of practice and prescriptive authority. She believes the poor access and barriers to practice are related.

AJN finds the article particularly relevant as legislatures across the country deliberate on APRN barriers to practice. You can read her commentaries at ingliscommentary.com.

Here’s an idea that wouldn’t cost Texas a dime but would save millions of dollars every year: Remove all barriers restraining nurses from practicing to the full extent of their education and training.

by Brian Romig/via Flickr

No state needs primary care providers more than Texas, which has a severe shortage. Texas ranks last in access to health care and in the percentage of residents without health insurance. Of Texas’ 254 counties, 188 are designated by the federal government as having acute shortages of primary care physicians. Of that number, 16 counties have one and 23 have zero.

If every nurse practitioner and family doctor were deployed, we still couldn’t meet the need. Texans are desperate for health care.

Doing the math and to help meet the need, the Legislative Budget Board recommended autonomous practice of advanced practice nurses after a preceptorship.

In Texas, our legislature — session after session — keeps the most restrictive laws in the country. Nurse practitioners don’t want to perform brain surgery. They just want to provide primary care and are quick to refer cases to a doctor when necessary.

Most states with far less need do not legislate practice barriers to nurse practitioners. Given the severity of our problem, shouldn’t we at least bring ourselves in line with those other states?

Texas has a large cadre of licensed, competent and qualified nurse professionals supremely educated, trained and eager to provide primary care. Hundreds of studies have shown their safety records to be equal to those of doctors —with the exception of their communication skills, which rank higher.

Superior communication skills are exemplified by nurse practitioner Naomi Warren from Winkler County in far West Texas, now famous for the whistle-blower/retaliation case. Having practiced in Winkler for more than a decade, she knew her patients well. They trusted her and were devoted to her.

When she quit her job in Winkler County rather than work alongside the doctor she and many others viewed as incompetent and dangerous, she moved her practice to neighboring Monahans Clinic. Even though they had to drive 50 miles round-trip to see her, 600 of her patients followed her.

The main legislative hurdle, or sticking point, is physician delegation. For example, a nurse cannot diagnose and treat the medical conditions of a patient without a physician willing to leave his or her practice, travel to a nurse practitioner’s site and sign charts for care that had already been provided.

Medically underserved areas are lucky to have one provider, much less two, necessitated by the delegation rule. In addition, the number of patients a doctor can see in a day is diminished. This rule significantly exacerbates Texas’ severe access problem. But physician delegation is embodied in Texas law, not federal law, so it’s amenable to legislative reform.

Hungry to have the human resources to meet the health care needs of their constituents, a wide variety of interest groups support nursing’s bills. Stakeholders include the Texas Association of Business; AARP Texas; the Texas Organization of Rural and Community Hospitals; insurance companies such as United HealthCare Texas, AmeriGroup and WellPoint; and many affected individual physicians and others.

As in years past, the only organized opposition comes from physician groups. Their opposition is vehement, and they make large campaign contributions. But why bother? It’s not as if primary care doctors could even remotely fill the need, and they won’t in the foreseeable future.

Older physicians saw the long, on-call hours of practicing primary care as an honorable profession. In turn, they were greatly respected by the people in the community with whom they developed strong relationships over the years. They were often paid in kind. But their numbers are dwindling; many are retiring.

Seeing poor reimbursement rates, few doctors in training choose primary care, where they will make two to 10 times less than their colleagues.

Organized medicine’s powerful opposition is not in the best interest of Texans with no health care. Is it about control? Is it about money? Perhaps they see autonomous advanced nurse practice as an encroachment on their territory. I don’t know why.

But I do know that given the economy, the state budget deficit, the severity of the access problem and the longevity of medicine’s success in killing nursing bills, that turning the tide will be difficult. But it will be historic, a victory for those desperate for health care.

For that to happen, legislators will need to recognize and resist the inherent conflict of interest of deep-pocketed organized medicine. It will take compassion and courage on their part. But they can be proud of their votes because it’s the right thing to do.

This is just to say that we’ve done some minor housekeeping and deleted links to a number of blogs that have been asleep several months or longer. There’s nothing personal in this, and please let us know if one of these was yours and you’ve decided to revive your blog, give it an infusion of new design and energy, or the like. We want our blogroll to be useful, and it won’t be perceived as useful if we’re linking to sites that have gone dark. Please also let us know if there’s a really great nurse blog that we don’t know about, even if it’s yours. We can’t guarantee that we’ll link to it, but we’ll certainly check it out.—JM, blog editor

We’d already guessed there was a problem at the health post—we hadn’t received the last several monthly statistical reports. As a Peace Corps volunteer in the Central African Republic in the early 1990s, I reviewed these reports as part of my job at the regional health office. Another part of my job was to join a supervisory team as it traveled over dirt roads to check on health facilities from hospitals down to the village health posts staffed by a single nurse. A few months into my assignment, on our way to the provincial hospital, the team decided to stop by this particular health post to find out why we weren’t receiving reports.

That’s from “A Face in a Village,” the February Reflections essay in AJN by Susi Wyss, the author of a well-received recent novel, The Civilized World (Henry Holt, 2011). Set in Africa, the novel, like this essay, was inspired by the author’s international health career. In this essay, Wyss recalls a vivid first encounter with the ravages of AIDS and the hopelessness it inspired. (Click through to the PDF version for a cleaner read.)—JM, senior editor

Photo by 50 Watts, via Flickr.

By Amy M. Collins, associate editor

As I watch my grandmother navigate the murky waters of her Alzheimer’s disease, it continues to surprise me that parts of her brain work at warp speed, while other parts seem to be completely defunct. For example, although she can’t remember what she’s done from one minute to the next, she can make up a lie to compensate for the memory loss in less than 30 seconds.

“Where did you get that new necklace, Grandma?” I recently asked at a family party. “Oh I bought it at the place where I work, you know, I type at a school,” she said, with certainty. Or when asked where she got a new sweater, she told my mother she went to the store. “How did you get there?” my mother asked. “I drove,” she said. “But you don’t have a car.” “Oh, well then I must have walked.”

She no longer remembers my name unless prodded, but she does remember that she has a cat in her room at the independent living center, and worries about it constantly. “I have to get back to take care of my cat,” she says when she visits us, becoming increasingly stressed the longer she’s away. Yet it’s hard for her to remember to care for herself, and she often forgets to shower or eat.

She still has a sense of humor, making fun of the “old” people at her facility and bragging about how great her own paintings are. She once complained about a photo of her that hangs in her independent living center’s entrance, together with photos of all the other residents. “Maybe it’s just the lighting, because nobody’s photo looks good,” my aunt said. “Yes, but the other residents really look like that,” my grandmother quipped.

But sometimes even her ability to laugh at things is heartbreaking. She recently called because she was worried about my grandfather—she couldn’t find him in the home. “Dad’s been dead for eight years,” my mother told her, worried at what my grandmother’s reaction might be in revisiting this particular pain. “Oh, well, then that explains it,” she said. “I was wondering how we both fit in a single bed!”

Another unexpected acuity is her ability to outwit her nurses. When it’s time for them to dispense her pills, she sometimes convinces them she’s already taken them. She’s also managed to sidestep nurses’ intervention in her diet. After my grandmother had gained weight over the past few months, the nurse we hired to keep an eye on her told the waiter at her facility not to give her any more ice cream after dinner or bacon for breakfast. While “in her right mind,” she would never have eaten these foods, even once denying my dying grandfather eggs because of “high cholesterol.” But the day after the nurse intervened with the waiter, we found out my grandmother had switched tables, got a new waiter, and got the bacon.

Recently AJN chose its annual Book of the Year awards. When it was over and the books had been judged, staff members were able to browse books they might be interested in. I picked The Alzheimer’s Caregiver Puzzle, by Patricia R. Callone and Connie Kudlacek. The book explains that in the early-to-mild stage of the disease, the temporal lobe of the brain is affected, with the changes attacking memory and language. But the frontal lobe is still intact, and as such so are social skills, reasoning, and judgment. I guess this explains why my grandmother can ask the same question repeatedly for 20 minutes, but can trick you into believing she hitchhiked to the local mall to get her hair done, when in reality she had it done at her facility.

As I read about the mechanisms behind the illness, I realize it’s just a disease—it has no personality, no vengeance. But somehow I’m still angry at it, and the way it seems to strike its victims so unfairly, in such contradictory ways, like a cruel joke.

Market St., Indianapolis/ via Wikimedia Commons

According to Stateline.org (a news site of the nonprofit Pew Center on the States), with the Super Bowl taking place this Sunday in Indianapolis, the state of Indiana has decided to toughen up its human trafficking laws.

“Though it is an honor for Indiana to host the Super Bowl, many sincere voices have brought to light the fact that human trafficking is a shameful practice we can’t ignore,” Indiana attorney general Greg Zoeller said in a statement.

The article notes that sex trafficking during highly publicized events has become an issue for many states with hosting duties. While the Global Alliance Against Traffic in Women, an international advocacy group, claims that the estimates of trafficking cases at previous Super Bowls may have been too high, whether there are 60,000 or six in a given year, any number over zero is too many.

For more info, see our award-winning article on the nurse’s role in combating human trafficking, by Donna Sabella. She also talks about her work in a podcast.—by Demaris Bailey
 

Amanda Trujillo, MSN, RN, is a nurse who until recently worked at Banner Del Webb Hospital in Sun City, Arizona, until she was fired for, as she claims, just doing what she’s obligated to do as a nurse—specifically, providing a patient information about a surgical procedure in an attempt to support fully informed decision making. (You can read her e-mail detailing her story here. She did not, as she has pointed out in comments, ever attempt to directly obtain informed consent herself.)

Amanda Trujillo

Ms. Trujillo says that, when the patient had a change of heart about the surgery, she requested a hospice consult. After a physician complained that Trujillo had overstepped her scope of practice, the hospital filed a complaint with the Arizona Board of Nursing, which has launched an investigation.

Ms. Trujillo has gone public with her story, sending e-mails and tweets to editors, public officials, bloggers, and the news media. The nursing blogosphere is full of posts with her story—Emergiblog, vdutton’s posterous (which has her attorney’s response to the complaint), and thenerdynurse, as well as a number of others. On January 31, she was interviewed on local television. She makes a compelling case that she was advocating for the patient’s right to information, and one wonders why she was fired and is under investigation.

As we have been for 112 years, AJN is all for coming out in support of nurses. Do we believe a nurse’s first duty is to the patient? You bet. We’re also all about accuracy and facts, and in this case, it’s been tough getting information from all sides. While certain assertions have been repeated in most of the supportive blog posts we’ve read, the undertone is that there is more to this case than the obvious.

Here’s what we’ve learned so far from the other parties: According to Joey Ridenour, MN, RN, FAAN, executive director of the Arizona Board of Nursing, “While the investigation is ongoing, information is kept private to protect the nurse should the complaint be unfounded.” She noted that while Ms. Trujillo can go public with details, the Board cannot. She did verify that Banner Del Webb Hospital filed a complaint about Ms. Trujillo’s practice on April 26, 2011, for “non-compliance with Federal, State or contractural arrangements.”

Ridenour also verified that at the January 24 Board meeting, the Board reviewed the case, voted to continue the investigation, and requested a psychological evaluation of Ms. Trujillo. When I asked if this was unusual, she said that in general, if the board feels that there is a lack of understanding in complex cases, the Board will ask for “expert opinion.” The Board will reconvene in March to review the findings and rule on the complaint. In the interim, Ms. Trujillo’s license remains active and without restrictions.

I spoke with Arizona Nurses Association executive director Robin Schaeffer, MSN, RN, CNE. The Board has been criticized for not supporting Trujillo. Schaeffer says the association is “right there to advocate for nurses,” but it must wait for the Board investigation to be completed. Until then, it will monitor the situation. It’s the association’s policy not to comment on the specifics of any ongoing investigation and the association supports the Board’s obligation to regulate the profession. I asked Schaeffer about any conflicts of interest that might prevent the AzNA from supporting Ms. Trujillo’s position, and she said that, contrary to what’s been purported on some Web sites, she is NOT an employee of Banner Health.

I haven’t had any response to phone calls to Banner Health, but on its Twitter page they have noted that “Banner Health, like most companies, does not publicly discuss employee matters.” No surprise there.

It’s regretful that any nurse has to go through what Ms. Trujillo has gone through, and we hope all will work out well for her. We’re following the story and will update you when we have more facts.

In January 2009 an independent community hospital in Massachusetts switched from using older, outmoded IV pumps to using “smart” pumps—pumps that have built-in computers with libraries of information on selected drugs and fluids, including predetermined concentrations and volumes with relevant administration limits. Library subsets (called profiles) contain information specific to certain patient populations or care areas. When properly implemented, these devices can be invaluable tools in reducing the risk of medication errors and improving patient safety.

Photo courtesy of Alaris

But when the hospital conducted a review, it found that smart pump libraries had been used in only 37% of all smart pump infusions done between January and June. One reason was that no “owner” had been assigned to oversee the implementation process. So the hospital’s nursing quality team (NQT) and pharmacy quality team began collaborating to find ways to increase nurses’ use of the pump libraries.

From July through October 2009 the NQT implemented several interventions. Author Andrew D. Harding describes the project as it evolved and reports on the results in this January CE feature, “Increasing the Use of ‘Smart’ Pump Libraries by Nurses: A Continuous Quality Improvement Project.”

The interventions included, among others:

• communicating with direct care nurses to find out why pump libraries weren’t being used.
• running weekly usage and monthly limit override reports from the pump database.
• e-mailing nursing staff weekly with current usage reports and requests for feedback.
• contacting the pump manufacturer’s clinical representative regarding best practices.
• adding and amending therapies in the pump libraries.
• tweaking the pump “screens” so that the most-used therapies were more readily accessible.

Over the four-month period of the project, for all infusions given via the smart pumps, the pump library usage rate nearly doubled. Asking for nurses’ feedback and incorporating it as the project evolved appears to have been an essential factor. Harding concludes with a plug for nurses’ active participation (and this is probably the case for any new technology): “Those who provide direct patient care must be involved with the planning of the smart pump libraries, especially [those] used in specialized patient care areas.”

Does your hospital use smart pumps? How comfortable are you with this technology, in particular the pump libraries?