Nursing Heals Itself

Changing face of the profession: some 1941 graduates, above; a current class in the new Fast Track to Nursing program, below, directed by Michelle Renaud, center. photo below by Chris Hildreth.

Gone are the days of Nurse Betty dressed in her starched white uniform, complete with crisp cap perched on top of her head, fluffing pillows and emptying bedpans and changing sheets in Duke Hospital. Not only are the uniforms passÈ ("White was just plain stupid, really," confides one veteran nurse. "People bleed on you, for heaven's sake!"), but nurses are more likely to be seen by a patient's bedside operating a bank of monitors worthy of NASA flight control, sharing expertise with the community in nursing homes or schools, or buried in a library.

"Fifty years ago, we had traditions. Now we have research," says Mary Champagne, dean of the School of Nursing. "Here at Duke we teach evidence-based practice--what has been proven in research to be effective for most patients. And we teach thinking skills, not just facts, because facts change. So it's important to have thinking nurses with excellent research skills. The old hierarchy simply doesn't hold anymore."
This is not to say that past and present aren't connected. "Because nurses have made so many beds, they may be the ones doing the research now on the best beds, or the ones discovering ways for patients to tolerate their situation if they're bed-ridden," says Sue Schneider, director of the Graduate Oncology Nursing program. "Because we as nurses spend time with patients, we know what makes them comfortable. We deal in quality-of-life issues."

" While physicians are finding new chemotherapies, nurses are helping patients relax in the chaotic chemo environment," says Schneider, who is researching the use of technology as a useful distraction for cancer patients. She's working not only on stress reduction, but also toward better treatment outcomes. "Women with breast cancer increase their chances of survival if they receive all the prescribed chemotherapy treatment," she says. "Our goal is to break the cycle of anxiety with virtual-reality technology, hoping patients will be more likely to complete their treatments."

As Duke turns out advanced-degree nurses with research experience, the nation is struggling to fill basic nursing-care needs. Some126,000 nurses are needed to fill current vacancies at U.S. hospitals, according to the American Hospital Association's June 2001 TrendWatch. And fully 75 percent of all hospital personnel vacancies are for nurses. According to a study published in a summer 2000 issue of the Journal of the American Medical Association, the U.S. will experience a 20 percent shortage in the number of nurses needed in the health-care system by the year 2020. That translates into a shortage of more than 400,000 RNs nationwide.The chemotherapy room at Duke Medical Center is the last place people would want to find themselves, with chemo stations and dripping IVs closely lined up like soldiers in formation. But this relaxation research has helped. While donning a virtual headset provides privacy at a difficult time, it also offers patients the options of scuba diving in the deep blue sea or touring an art museum or solving a mystery aboard the Titanic. Patients report less nausea, stress, and fatigue. "It picks up my spirits," says one woman.
Learning good research techniques is a core value of the nursing program. Deirdre Fleming, a graduate nursing student in the Family Nurse Practitioner program, says she was attracted to Duke because it encourages strong research skills. But even she was surprised at how much actual research experience a student can get. "I didn't think this level of research was even a possibility. But we learn techniques in a classroom and then we get associated with a project like the virtual-reality study," says Fleming, who is assisting Schneider in her research.
The Nursing Research Center (NRC), established in 1993, is meant to foster the scholarly research efforts of nurses. The NRC is staffed with a full-time director, an administrative assistant, a full-time statistician, and data technicians who do everything, from helping to support researchers in processing research proposals and grant applications to assisting and consulting on scholarly preparation of manuscripts, oral presentations, and posters, as well as assisting with data entry and analysis and finding funding.
Barbara Turner, director of the center, is also leading the efforts at the nursing school to improve the survival rates of premature infants. "A severely premature or high-risk infant may as well have been born on the surface of an alien and hostile planet," she says. "Their survival depends on the immediate intervention and care of trained professionals who know how to use the latest neonatal technology." Joining in the fight to increase the survival odds for preemies is Debra Brandon, neonatal clinical nurse specialist. She researches the neonatal intensive-care nursery environment to determine the factors that can promote health, and she is studying at what gestational age cycled light would be most beneficial for extremely low-birth-weight infants.
While some faculty members and students are studying patients at the beginning of life, others are interested in issues found closer to the end of life. In 2000, 13 percent of the nation's population--some 35 million--was age sixty-five or older. These numbers are expected to double in the next thirty years. To meet the health-care needs of this aging population, the nursing school established the Trajectories of Aging and Care Center (TRAC). Faculty pool their expertise with that of colleagues at the nursing school and with partners from the divinity school's Institute for Care at the End of Life (the first of its kind in the nation), the medical school's geriatrics department, and the Center for the Study of Aging and Human Development at Duke. "More and more, we're bringing investigators from other disciplines into our research initiatives and leading the studies ourselves," says TRAC director Elizabeth Clipp.
As Ruth Anderson, a colleague of Clipp, puts it, "Most people who observe nurses may not realize that what nurses do is based on science. Historically, nurses have based their practice largely on science from other disciplines such as medicine and psychology. Within the past twenty years, however, the nursing discipline has been actively developing its own scientists."

Ironically, nursing at Duke had a near-death experience two decades ago. In 1984, the traditional bachelor's degree in nursing, B.S.N., was ended, and the status of the graduate program was far from secure. Four years earlier, then-chancellor Kenneth Pye presented a document to the board of trustees called "Directions for Progress"--or, internally, the "Retrenchment Report." Pye notified the trustees that costs-per-student in the nursing school significantly exceeded all other baccalaureate programs, and that nine programs within the University of North Carolina system had been started that provided nursing education at significantly lower costs. Further, the 1970s was a period when more and more careers in science opened up to women, and nursing found itself with fewer applicants. The report concluded that Duke's overall interests would "best be served by terminating the present degree programs not later than 1983-84."

Upset alumni produced a flurry of impassioned letters to local newspapers and calls to the university, prompting a letter from then-president Terry Sanford to alumni attempting to explain the decision.

But now there's a dearth of nurses. Says Champagne, "The shortage has caused us to rethink. When we looked at the situation, we couldn't say, 'Everybody else must do something.' We know that the ratio of nurses to patients directly affects outcomes, so the stakes are high. Our medical center is splendid. You couldn't have a better facility for teaching. So we decided to do something."

That "something" is the Accelerated Bachelor of Science degree in nursing, more familiarly known as the "Fast Track to Nursing" program. A "second-degree bachelor's program" being offered to college graduates, the fast-track sixteen-month program "will blend the best of the old practices in nursing care with the best of the new evidence-based care," Champagne says.

" Burnout is a tremendous problem in nursing, so we will teach skills for prioritizing duties and maximizing energy. We will teach students how to manage aides and, most importantly, we will teach them how to think."

In keeping with its emphasis on research, the school has included an evaluation component that makes the fast-track program itself a research project. It will generate the strong data and program evaluation needed--but as yet unavailable--to assess what works in recruiting and retaining new nurses, to adapt nursing curricula to reflect the rapidly evolving demographics of society, and to incorporate recent technological and medical advances into nursing education.

Champagne is optimistic that the program will work. "We hope that through its implementation at Duke, and its dissemination as a model to other schools of nursing, the Fast Track to Nursing program will exert a strong counter-force in the struggle to overcome our country's critical shortage of nurses," she says.

The Helene Fuld Health Trust has pledged $6 million to make the new program possible. The trust is the nation's largest private foundation devoted exclusively to nursing education, and its gift to Duke is the largest in the nursing school's history.

The program crossed its last hurdle last May, when the North Carolina Board of Nursing gave its unanimous approval. The school had more than ninety applicants for the program's forty slots. Two applicants already had Ph.D.s, several had master's degrees, and the mean G.P.A. was 3.4. Applicants hailed from many different backgrounds, including biology, poultry science, English, women's studies, medicine, psychology, education, marketing, and nutrition. Twelve percent of the applicants were men, and 18 percent were from an ethnic minority.

Fast Track director Michelle Renaud says, "The number of clinical hours we require is head and shoulders above other programs. Also, we offer students the opportunity to take fifteen graduate hours, which gives them a step up in becoming a master's prepared nurse, opening up more career opportunities."

Responding to career opportunities, the School of Nursing has tried to cultivate an entrepreneurial culture. When several school graduates requested a program to train them as site investigators for clinical trials, school leaders did some investigating. They realized that nurses with specific training for pharmaceutical trials would help speed the approval of new medical products, and that nurse practitioners with such training would also be able to qualify as site investigators. Site investigators implement and execute large multi-center clinical trials. They also have access to emerging drugs and therapies for their patients.

So, last fall, the nursing school became the first in the nation to offer nurses the opportunity to fill a new role by offering master's-degree-level training in clinical-research management. "During a clinical trial, a delay of just one day can cost the pharmaceutical sponsor more than a million dollars, as well as postpone the arrival of a life-saving drug on the market," says Anthony Dren, consulting professor in the creation of the program. The delay "could be caused by a simple thing such as not filing the right federal regulatory form by the right date, or something complex, such as an error in medical protocol. In view of the high stakes involved here, a workforce educated in clinical-research management is absolutely imperative."

" In developing this curriculum, we had access to experts in many fields at Duke," says George H. Turner III, assistant clinical professor and co-creator of the program. In addition to colleagues in the medical school, the Duke Health System, and the Duke Clinical Research Institute, the school drew on expertise from Duke's Fuqua School of Business and the departments of economics and biometry. Students can complete the program either on campus or online from anywhere in the country.

And the online theme continues: Students enrolled in the Partnerships for Training program pursue their master's education through flexible distance education. Nurses in rural North Carolina with a bachelor's degree in nursing, for example, can earn a nurse practitioner degree, giving them a broader scope of services they can provide, such as diagnosing and treatment. (Nurse practitioners in North Carolina can do 80 percent of what doctors do.)

Duke's experience in offering distance-based nursing programs began in 1997. Besides its Partnerships program, it includes a post-master's certificate program in Nursing Informatics that has trained nurses in fifteen states (including Alaska) and Canada.

Taking a distant look back, the then-chancellor of the medical center, William Anlyan, says he understood the rationale for discontinuing the undergraduate program, but also understood the critical need to continue to train nurses at Duke. The master's program in nursing at that time had a separate faculty and, as Anlyan describes it, "students who hardly knew where the front door to the hospital was."

" That program was more about the sociology of nursing," he says, "and I saw a chance to build a real bona-fide clinical nursing program, with nurses who knew how to deal with patients. So I used all my powers of persuasion and any brownie points I could find to advocate for a new program." The idea wouldn't succeed without the right administrators, he says. "I knew we needed to get a dean who could build a new faculty, and it had to be a faculty who knew where the front door was."

Enter Mary Champagne. "Dean Champagne came to a school back in 1991 that didn't have much of a vision of the future," says Tony Adinolfi M.S.N. '93, assistant clinical professor and a nurse practitioner. "Within a couple of years, she took us forward with a vision that could only make us better and better. She nurtured the existing staff and faculty and brought in exciting new faculty."

For her part, Champagne says the "corporate culture" now stresses innovation in delivering health care. "Because we keep that at the forefront, we can do all kinds of things."

--Sauls is a regular contributor to the magazine.