MR. KOJO NNAMDIFrom WAMU 88.5 at American University in Washington welcome to "The Kojo Nnamdi Show," connecting your neighborhood with the world. They give shots, insert IVs, scrub down for surgery and deliver babies. They're the largest segment of the health care workforce, 3 million nurses who work in doctors' offices, hospitals and community health centers. Most are women and the majority became nurses after earning a two-year degree, but their numbers are expected to shrink in coming years while the American population gets bigger and older and needs more care.

MR. KOJO NNAMDITo meet the challenges of heath care reform and high-tech medicine, a new report says nurses need more leeway to practice and need to further their education. But not everyone agrees that's the answer. Joining us now in studio is Flo Richman, dean of nursing with Northern Virginia Community College. Flo Richman, thank you so much for joining us.

MS. FLO RICHMANThank you for having me.

NNAMDIJoining us from studios in Portland, Oregon, is Dr. Michael Bleich, dean of the School of Nursing of Oregon Health & Science University. Michael Bleich, thank you for joining us.

DR. MICHAEL BLEICHI'm very happy to be with you this morning.

NNAMDIAnd joining us by phone from California is Rebecca Patchin, anesthesiologist and member of the American Medical Association's board of trustees. Rebecca Patchin, thank you for joining us. Oh, Rebecca Patchin will be joining us shortly. Allow me to start with you, Michael Bleich. When you were 18 years old, you made an unusual career choice for a young man. Tell us about your decision to become a licensed practical nurse and your path to becoming dean of nursing at Oregon Health & Science University.

BLEICHNursing was never on my radar screen when I was growing up in terms of it being a career. I actually was interested in music and took piano lessons following with a student whose father was the administrator of a psych mental health facility in Columbia County in the Wyocena, Wisconsin area and offered me a job. And at 18, the thought of getting employment in a rural area of Wisconsin was very attractive. And so I took that position and that was the onset of what has been a fabulous career for me.

BLEICHI started working as an orderly in a psychiatric mental health facility. Went on and actually obtained a diploma to become a licensed practical nurse and then eventually went through a diploma nursing program and then finished my bachelors, masters and Ph.D. So I've had a fabulous career in clinical nursing. I've been a chief nursing officer in a hospital -- two hospital systems. And then worked in academics and now have -- am very pleased to be the dean of this wonderful school of nursing here in Oregon.

NNAMDIFlo Richman, you're a locally-trained nurse starting with an associates degree at Montgomery College. What drew you to nursing and where did you go from Montgomery College?

RICHMANWell, I have a similar story. I actually started my college interest in music, but my instrument was voice and came to a point that I had to choose a discipline. And at that time in the '70s, it was mainly a teacher, a secretary or a nurse. So I selected nursing, went to Montgomery College and obtained a wonderful associates degree. I worked in construction and owned a company for five years. It was the first woman-owned construction company in sheet metal in the area, the Washington D.C. area.

RICHMANWent on to American University and completed my bachelors in nursing and took two weeks off and went over to Catholic University and completed my masters degree in nursing, home health administration. And worked in hospitals as a staff nurse, as a head nurse, as an assistant director of nursing and then owned two corporations, one community health professional in Silver Spring, Md. and a school for entry-level providers in Washington, D.C. So then, I went back and got my MBA and then completed my Ph.D. at Walden University, which I enjoyed thoroughly, and worked at -- was hired at the University of Phoenix as the chair for graduate business in management and then applied to Northern Virginia Community College as the dean of nursing where I've been for seven years.

NNAMDISo you basically started your professional career at, like, what two years old?

RICHMANThat's right. Thank you.

NNAMDIRebecca Patchin. Rebecca Patchin, you're an anesthesiologist now, but you started your career as a nurse. You're a medical doctor now. Tell us about your nursing experience and your decision to go to medical school.

DR. REBECCA PATCHINWell, I went into a two-year nursing program right out of college and then went on and obtained my bachelors degree. During that time, I worked as a registered nurse and then I worked for about a dozen years as a registered nurse before I decided that, in addition to the bachelors degree, I wanted some more education. And instead of going for an advanced nursing degree, made the decision to go to medical school so at 35, I started medical school. And the difference between nursing and medical school -- there is a difference, certainly.

DR. REBECCA PATCHINI did a year of pre-med requirements and then I went to medical school. Started at 35, went through the four years of medical school and then for residency training, went through another five years. And so I have a training in anesthesia and a sub-specialty in pain medicine.

NNAMDISo much for the past, now on to the future of nursing. And we're inviting your calls at 800-433-8850. Are you interested in nursing as a profession? Have you tried applying to nursing school? What was your experience? Or if you're a nurse, tell us where you think the future of the profession is headed. Call us at 800-433-8850. Send us e-mail to kojo@wamu.org Send us a tweet at kojoshow or go to our website to join the conversation.

NNAMDIOur website is kojoshow.org, but the phone 800-433-8850. Michael Bleich, of all the health care professions, nursing has the greatest variety of entry points. You can be a nurse with a two-year associates degree or a ten-year doctorate. Explain the alphabet soup of nursing titles and the amount of education that each entails.

BLEICHYes. It's always been fascinating to me that nursing does have these very many entry points. I think one of the reasons for that historically, and it does help frame why there are many entry points, is that nursing is so pervasive. We are not only present in the hospital setting where many people have access and that's their mental orientation of thinking about the nurse. Even in your introduction, you talked about giving shots and doing some of those kinds of things that's typically assigned to thinking about the hospital base.

BLEICHBut nursing is also very key in long-term care. We practice in public health, in community health settings. We're virtually everywhere. And when the world wars happened in our country, there was a huge influx and a shift from what used to be getting medical care literally, and I do mean physician-based care, in the homes of physicians or in small clinics. And as technology advanced and the numbers of Americans came into institutionalized settings, nurses were and still are the backbone of many of those practice settings. And so consequently, every time we've needed to add nurses, we've tried to make access points for people from various career points to be able to get into school.

BLEICHThe original schools, many of them were diploma-based, meaning that they were apprenticeships aligned with a hospital to meet the demands for who was staffing and spending the majority of time with patients were, in fact, the nurses. So the diploma-based schools, some of which still exist today, are predominately aligned with hospital settings. At some point, it was recognized that nurses should and could benefit from advanced education so they moved into the baccalaureate programs. And then in the '80s in particular, there was a large movement to really increase the entry points again because of need. And so the associate degree programs came about and those programs are based in the community college settings.

BLEICHAll three, the diploma, the baccalaureate and the associate degree nurse all take an exam at the end of their respective programs. And this was an examination that tests basic and safe competencies to practice entry-level nursing. We don't have any examinations for RNs that are prepared differently in terms of beyond that basic examination until you become a nurse practitioner or some of the other advanced practiced areas of nursing, in which case you take certification examinations that test your competency and proficiency in those areas.

BLEICHSo today, it's possible that one could enter nursing through the associate degree route, through the diploma, which are really not very prevalent anymore -- or through the baccalaureate route. But one of the things that is very important is that we're encouraging all nurses to advance their education because of the public need. And that's what this institute of medicine report really has addressed is what is the public need and how can nurses best fill that need as we look at some very changing demographics in our country.

NNAMDIFor those of our listeners who may be unfamiliar with it, let me run through a quick laundry list. There can be CAN certification, a registered nurse, licensed vocational nurse, licensed practical nurse, clinical nurse specialist, certified registered nurse, anesthetist, certified nurse midwife, nurse practitioner and advanced practiced nurse. Michael Bleich, you served on a committee convened by the Institute of Medicine that studied the future of nursing and recommended expanding the scope of practice for nurse practitioners. Why?

BLEICHWell, that's a fascinating area. First of all, in regard to the scope of practice, many of our institutional settings where nurses practice long-term care, hospital care and so on and so forth, there are opportunities there as well. There are institutional constraints sometimes put on what nurses can do and can't do. But in particular, this particular -- the report that you're referencing, which is called "The Future of Nursing Leading Change and Advancing Health," that particular report spends quite a bit of time talking about the advanced practice nurse. Now, the advanced practice nurse includes the nurse practitioner, the registered nurse, anesthetist, the clinical nurse specialist and the nurse midwife. So there are four categories of nurses that have specialized training in the area that we call advanced practice.

BLEICHSo the points of the scope of practice issues are quite simple, basically. There have been a number of studies that have been done to look at the primary care needs of our society and those are the kinds of things that, as we look at the American health system, one has to realize that we probably have never devised a system for all of our citizens, for all of our people in this country. Rather, we've developed a system that's primarily oriented around specialty care and that takes place primarily in the hospital system.

BLEICHSo many argue this, but it's pretty clear to the public today that we've created more of a sick care system than we have a healthcare system. So the advanced practice nurses focus on areas like health promotion and disease management so people don't get to those more sophisticated levels of illness and don't require the same degree of high cost care. So the scope of practice issue has become one that is -- it's quite fascinating because there are states that have allowed advanced practice nurses to practice caring for those people that are -- that have been disenfranchised through the traditional sick care system.

BLEICHOr in frontier areas of the country where there aren't physicians to practice. And there have been a number of randomized clinical trials and these trials, which the Institute of Medicine studied, these are fascinating studies where they compared basic primary care to the -- in the capacity of nurses, to deliver that care safely and effectively and to reach out to people that are unable to get care.

NNAMDIAnd it's my understanding -- it's my understanding that in a city like Kansas City, which one half is in Missouri and the other half is in Kansas, that the same qualified nurses can do completely different things in the same city within...

BLEICHThat's...

NNAMDI...in a distance of about 500 feet.

BLEICHThat's...I came from the University of Kansas. And what you're saying is exactly true. The state line road there divides -- we have legal aspects and politicized aspects of advanced practice nurses. And in that particular community where -- that I worked for 12 years of my career, an advanced practice nurse on one side of the state could work in collaboration with physicians. We could cross the state line and we were restricted from the very skills, knowledge and abilities that we have safely and effectively delivered on the other side of the state line.

NNAMDII do have...

BLEICHSo many of these issues have become political issues and it's sad.

NNAMDI...I do have to move on. Rebecca Patchin, a lot of us have had the experience that when we're sick, we call the doctor's office to make an appointment, we're told the doctor can't see you, but the nurse practitioner can. You've said on behalf of the American Medical Association that, quoting here, "nurses are critical to the healthcare team, but there is no substitute for education and training." Why do you apparently think nurse practitioners and their piers need supervision by a doctor?

PATCHINWell, we think the patient is best served by working in a -- by being seen in a care system that has a team approach and where a physician is involved in that care. There is -- as you've heard the nurses talk about, there is no substitute for education and training. Each of the other folks on the line have sought additional education and experience. And there is no substitute for that. And there is a difference between the education and training of an advanced practice nurse or nurse practitioner and a physician. The physician goes through a minimum of seven years after college where the nurse practitioner is two to three.

PATCHINWe're looking at the difference of 10,000 hours of supervised clinical experience versus 700 to 900. I think there's one other thing that we need to clarify, too. And that's that nurses tend to practice in advanced roles in the same communities as physicians. And so if that means that physicians tend to be in cities, so do the advanced practice nurses. With -- there are a few exceptions, but generally when you look at state by state demographics, they're very similar for physicians and for advanced practice nurses. It is true that there is a difference in licensure for physicians as well as nurses, state to state.

PATCHINAnd I, too, lived in Kansas City and practiced nursing there. And when I lived in -- I lived in Kansas and worked in Kansas. But when I wanted to take a job on the Missouri side, I had to apply for a Missouri license to practice nursing. And it would be the same way even if I was a physician. If I practiced on the Kansas side, I would need a Kansas state license. If I wanted to practice in Missouri, I would need a Missouri license. So the licensure for almost all health professionals is state by state.

NNAMDIBut physician supervision doesn't have to...

BLEICH(unintelligible)

NNAMDI…physician p -- oh, you wanted to say something Michael Bleich?

BLEICHI do because these were nurses licensed in both states and so it really isn't about licensure. In these situations and, you know, it is -- what Rebecca states is very true. But we're not trying to compare to ourselves to physicians. We're not trying to treat all of the medical conditions that physicians are licensed and trained to treat. And this, I think, is where it gets confusing and politicized, is that nurses understand that we work collaboratively with physicians and we very much desire that collaborative relationship. So it isn't about licensure, it's about permission from that (word?) to restrict people who are competent and capable to meet care...

NNAMDIFlo Richman...

BLEICH...care needs of all people.

NNAMDI...care to weigh in on this?

RICHMANYes. I think that the nurse practitioner can care for many in the community and in the hospitals without physician supervision at different levels of care needed. Of course, physicians are physicians and nurses are nurses. We're trained differently, but in the same arena. And we're distinct, but we are team members and I've always looked at being on the team, working with a physician. Different levels of education, nurses, physical therapists, pharmacist as a team that really the center focus is the patient.

NNAMDIAnd Rebecca Patchin, being on the team, apparently these days, doesn't necessarily mean being in the same room at the same time. Because in your practice, you're using technology to let physicians do preoperative exams by remote.

PATCHINAbsolutely. We are working in -- and it's a pilot project we're doing in an ENT office, where we have a remote telemedicine link-up instead of requiring the patients in that practice to go through our usual preadmission testing process. We're finding, one, it improves patient satisfaction, two, we have eliminated and reduced the number of pre-op tests that were ordered by having the patient and the physician hooked up telephonically there. And certainly the patients are very grateful at not having to take a half day out of their life to go through the preadmission testing process through our usual clinic.

PATCHINBecause we cover 40 operating locations every day and so our pre-op assessment clinic is a most proficient way for us to do all of the outpatient pre-ops. I also think it's important that if -- that people understand that a physician involvement, as you say, doesn’t always mean that the physician is seeing every patient. It would be that the physician is there for a resource and working in their role as part of the team, while many times it would be the nurse practitioner or the physician assistant who's doing the face to face exam. But in the -- in my chronic pain practice, I work with non physicians and we have a continual dialogue going on all the time about many of our patients.

PATCHINI don't see every patient every time, but there is that dialogue going back and forth which I think the patient benefits from. And if given a choice, most patients will choose to have a physician involved in their care.

NNAMDIAnd I'm afraid we're going to have to take a short break. And Rebecca Patchin, I know you have to leave us. Thank you so much for joining us.

PATCHINAnd thank you. I'm sorry, but I am in the middle of my clinic this morning and have a great day.

NNAMDIYou, too. Rebecca Patchin is an anesthesiologist and a member of the American Medical Association's board of trustees. She joined us by phone from California. We have a lot of people joining us by phone who'd like to join the conversation. If you've already called, stay on the line. If the lines are busy, then you can go to our website, kojoshow.org, join the conversation there. How do you feel about seeing a nurse practitioner rather than a doctor when you've got the flu? 800-433-8850, I'm Kojo Nnamdi.

NNAMDIWe're discussing the future of nursing with Flo Richman, dean of nursing at Northern Virginia Community College. She's joins us in our Washington studio. And Michael Bleich joins us from studios in Portland, Oregon. He is dean of the School of Nursing of Oregon Health and Science University. We're taking your calls at 800-433-8850. You can send e-mail to kojo@wamu.org.

NNAMDIWe got an e-mail that says, "There is no shortage of nurses. I repeat, there is no shortage of nurses. There are so many nurses available, both experienced nurses and new grads, that unemployment for nurses that exceeds a year is common place. There is a shortage of jobs for nurses at hospitals and other employers of nurses cut hours and jobs to keep payrolls and benefit costs down."

NNAMDIFlo Richman, it's my understanding that the economic downturn has for stalled a nursing shortage because nurses on the verge of retirement have decided to keep working and some retired nurses have returned to work. If indeed there is no shortage now, when do you think the projected shortage might hit?

RICHMANAbsolutely. It is definitely coming. It's -- I compared an analogy as being in the center of a hurricane. It can be very quiet. It can be the lull before the rest of the storm comes through. And that's what we're going to see. Yes, there are nurses that are looking for positions currently. They will be getting them. I would say in the next two to four years, we're going to have a large need for registered nurses at every level. So I think it's a good time to stay in school. Those that have the associate degree should continue their education to a bachelors, masters, PhD. And nursing, it's a wonderful time to prepare because the need is going to be great with the baby boomers retiring.

RICHMANThey're in the leadership positions. They're by the bedside. They're into specialty areas and there's going to be a big void.

NNAMDIMichael Bleich, we have a call, Silvia in Tyson's Corner, who thinks has a question, maybe, for you. Silvia, you're on the air. Go ahead, please.

SILVIAYes, good afternoon. Well, I'm one of those nurses. I'm an advanced practitioner. I practice in the District of Columbia. I have a clinical practice of psycho therapy. And by virtue of the fact of my license in the district, I also have prescriptive privileges. Now, I live in Virginia and I also must carry a Virginia license. But because of the discrepancy in the scope of practice laws between the two, I cannot practice as independently in Virginia as I can in the District of Columbia.

NNAMDIMichael Bleich, what do you think needs to be done about that?

BLEICHWell, clearly, we have to come to some better understanding about advanced practice nurses like your caller who has a knowledge set of skills and abilities and a willingness to meet the needs of people. Psychiatric mental health patients are her practice. Many of these are not in the acute care settings. They're in communities or they need private practice. And so this is a very good example of where we need to shift our energy. We have, through the nursing community, created a scope of practice statement that is commensurate with the skills knowledge of how we educate nurses in these advanced practice rolls.

BLEICHAnd one simple solution is to get the states to -- each state to recognize this standardized scope of practice that has been developed so that nurses could have parity crossing state lines to be able to do what they're so able to do and in some cases, you know, there may have to be incentives to help the states move and help the public better understand what's at stake here. Because contrarily to the conversation earlier with Rebecca, there are a lot of people that need healthcare that don't get into the sickness care system and so this is where advanced practice nurses can reach out. They can provide care in community clinics, they can provide care even in industries where they don't have to leave their job to take off.

BLEICHSo this is where we get excited about the future and the scope of practice, the freedom to practice would allow nurses to play a much bigger role in shifting the healthcare system to meet people's needs.

NNAMDISilvia, thank you very much for your call. We move on now to Claire in Northern Virginia. Claire, you're on the air. Go ahead, please.

CLAIREHi, Kojo, thanks for taking my call and hi, guests. I'm calling with a question regarding my daughter. She's recently -- well, within the past three months, relocated back to McLean. She'd been living in Richmond and working for about eight years as a data analyst and has finally decided that nursing is what she wants to pursue. She's got a bachelors degree and really has her heart in the nursing field. She's got the personality and the sensibilities for nursing.

CLAIREHowever, she has no money. And that's a big problem. Do you have any suggestions perhaps as to where she might start?

NNAMDITalk with Flo Richman.

RICHMANCome to Nova. We have financial aid for our students. We have scholarships, many resources that can help your daughter and many others that want to gain an associates degree in nursing. We -- it's a very affordable program and you can take it online, hybrid. You can -- we have a three -- we have a program called Momentum, two plus one, which is actually a three year BSN where you do -- where she would do two years of education, come out with two associate degrees, one in general studies and one in nursing. Sit for her boards and transfer to affiliated universities and complete her BSN in another two semesters...

NNAMDIWhich is a bachelors...

RICHMAN...or year, yeah.

NNAMDIThis is a bachelors in nursing. The majority...

RICHMANCorrect.

NNAMDI...of nurses enter the profession through an associates degree program like the one you run at Northern Virginia College. Just so that Claire and her daughter can know, in addition to classroom learning, students also have to do clinical work and then take a licensing exam. Please explain that process.

RICHMANThat's right. When students come in to study nursing, there's the lectures or the didactic and there's the nursing skills lab where they come in and they practice the skills in which they're going to perform in the hospital. And we also have a simulation center at Nova where they come and they can experience and be trained in a wonderful learning environment, such as things that they might not be able to experience in the hospital, like responding to a code or when, you know, a patient stops breathing, they are usually in a hospital setting as a student asked to leave the room.

RICHMANAlso, I wanted to add, that many of our students that come to Nova for the associates degree, have a bachelors degree or a masters degree and we even get PhD's coming to our wonderful program at Nova.

NNAMDIClaire, thank you very much for...

CLAIREOh, okay.

NNAMDI...and good luck to your daughter.

CLAIRECould you just tell me, really quick, how would she look into this?

RICHMANWww.nvcc.edu.

CLAIREGreat. Thank you so much.

RICHMANGood luck.

NNAMDIYou're more than welcome...

CLAIREThank you, bye-bye.

NNAMDI...Claire. Michael Bleich, half of today's nurses do have a bachelors degree, but the Institute of Medicine Committee wants to boost that number to 80 percent by the year 2020. Why?

BLEICHWell, they're -- we live in a fascinating time. Knowledge around healthcare and healthcare issues is expanding at an enormous rate. And so the need for nurses to pursue additional education, regardless of the point of where they've entered, I think -- in all three of your guests this morning, each of us, one went to medical school with her nursing degree and others of us have pursued other areas. And so there is this -- there's this time and place of where we're at in our country where the healthcare needs are expanding.

BLEICHSo we absolutely know that if we're going to have enough faculty to teach nurses, scientists to conduct scientific research, many people fail to understand that there are nurse scientists who contribute to knowledge that helps manage symptoms that promotes health. You need advanced degrees in order to do that. And if we don't reach this 80 percent number, we're not going to have enough people in the pipeline to get to these advanced opportunities where nurses can practice in all of these areas where nursing makes a difference.

NNAMDIWe're talking about the future of nursing and inviting your calls at 800-433-8850. Have you been involved in a medical situation where you noticed or felt there weren't enough nurses? How did that affect the care that you or your loved one received? Call us 800-433-8850, or go to our website, kojoshow.org, make your comment or ask your question there. Here is Mark in Rockville, Md. Hi, Mark.

MARKOh, hi, Kojo. Thanks very much for taking my call. I appreciate it. I guess I just wanted to inject kind of a comment as a cautionary note. I was -- a couple of years ago after a serious accident, I was in a couple of nursing homes and a couple of hospitals and I was on the receiving end of lots of medical care from a wide variety of nurses and other folks.

MARKAnd I -- the cautionary note is that when I was hearing your discussion earlier about, you know, master's degrees and RN and certification and et cetera, et cetera, from a patient's perspective, I learned the hard way that a lot of the times the letters following somebody's name were meaningless. I had an RN take three times to get an IV into my arm which kind of hurt.

MARKAnd there were other folks who didn't have maybe that same level of education or whatever, who for whatever reason had more common sense or more of a human touch and they were able to do things sometimes more effectively than folks who appeared to have a lot of education. So I just wanted to sort of toss that out there from a patient's perspective. I don't know...

NNAMDIYou know, I'm glad you brought that up because in the final analysis, Flo Richman, what we're really talking about is regardless of the specific level of qualification, is the relationship with the patient.

RICHMANPeople skills almost in any industry. It's people skills. It's having the empathy to be able to connect with the other human being that you're caring for. I certainly understand what you're talking about with the IV starts. You know, we all are trained in that and actually it's too bad I wasn't your nurse. I'm very good at that. But, you know, we're patient advocates. Nurses are patient advocates and patients should expect knowledgeable people, licensed people with expert skills and being a part of the team that takes care of you.

RICHMANSo it is quite necessary for each nurse to have compassion for who they're caring for and look out for their best interests.

NNAMDIThank you very much for your call, Mark. We've got to take a short break. When we come back we will continue this conversation on the future of nursing. If you have called, stay on the line, we'll get to your call. If the lines are busy, go to our website, kojoshow.org, join the conversation there. I'm Kojo Nnamdi.

NNAMDIIt's a conversation that we are having on the future of nursing. A conversation we invite you to join by calling 800-433-8850, or by going to our website, kojoshow.org, joining the conversation there. Here is Leah in College Park, Md. Leah, you're on the air. Go ahead, please.

LEAHHi, good afternoon. Thank you for taking my call. My question regards the widening scope of advanced practice nurses in administering primary care and preventive medicine, and I personally would feel a bit worried if an advanced practice nurse instead of a physician in my annual physical. Is my anxiety justified? Would a nurse pick up on the same -- like on a pattern of symptoms that a physician would? Are there any risks associate with this, including malpractice insurance and stuff like that? Thank you.

NNAMDIMichael Bleich is dean of the school of nursing of the Oregon Health and Science University. Michael Bleich, care to answer Leah's question?

BLEICHYes. I think it's very safe to presume that if you were going in for a routine history and physical, that would be conducted by an advanced practice nurse that you would be able to have that nurse successfully perform that procedure, that set of interview questions, and do all of the things that a physician would do and come up with the kinds of diagnoses that physicians would.

BLEICHI think where nurses are also trained that would alleviate your concern, is the fact that we recognize that we're not the only providers here. We would refer you to a physician. It could be a physician specialist or we would refer you to a primary care physician, were we to detect something that was beyond our competency area to manage.

BLEICHBut I think what you could expect as well is a real emphasis on health promotion, health teaching, and for many patients, they really like that experience that nurse practitioners are able to infuse in their care. And in some ways patients prefer that because nurse practitioners tend to incorporate that thinking more into the care that they would give. So I think you'd probably surprise yourself and have a very positive experience.

BLEICHNurse practitioners do carry malpractice insurance just like physicians do. I mean, going back to the previous caller, you know, caring for the human condition is challenging. Having certain skills perfected. The ongoing competency of advanced practice nurses and general care nurses is part of what the Institute of Medicine report also calls for, is that we continue to grow not only in our technical knowledge but that we continue to keep abreast of the latest advances in science.

NNAMDIOkay. Thank you for your call, Leah. Flo Richman, we got this e-mail from Pamela who says, "In addition to a nursing shortage, there is a nursing school shortage. I'm currently applying to nursing schools in the Virginia/DC/Maryland area, and all of the programs are extremely competitive. You hear about the need for nurses, yet people wanting to be trained in nursing are having trouble getting into programs.

NNAMDIThere needs to be an increased focus at the public university level to provide more nursing programs." Before you respond, here is Tim in Fairfax, Va. Tim, you're on the air. Go ahead, please.

TIMThank you very much. I want to thank Kojo for this wonderful topic. He always brings the best topics to us. And I want to thank your panel for being there today and answering the questions. Very quickly, I just want to reiterate what that e-mail said. I've applied to local nursing schools and NOVA specifically, and found that while I could begin taking non-nursing related classes immediately, the nursing programs I'd have to wait at least a year to a year and a half to get into.

TIMAnd beyond that is the employment perspective. That being that most places do not want to hire new grads. They want nurses with experience. So, you know, it's the old problem of where do you get the experience if you haven't been working. But I'd just like to hear what your panel has to say about that.

NNAMDII'll even add something to that for Flo Richman. One challenge in the realm of education seems to be a shortage of nursing faculty. Not enough nurses have earned advanced degrees to fill the openings for nursing professors. So you can talk about the challenges in recruiting nursing faculty even as you address the questions about the competition and difficulty of getting into nursing school.

RICHMANThat's correct. As the whole IOM report states that bachelors prepared nurses, masters, we need them to go on up to the doctoral level to become consultants, researchers, (unintelligible) scientist, and also for faculty. That's one of the barriers for accepting larger numbers of students into their programs. I will say to the one caller, the gentleman, we do have momentum where there is no prerequisites to get that except for your GPA has to be a certain level. I believe it's a 2.75.

RICHMANAnd there's a pre-entrance exam that you need to take. If you choose the online or other programs at NOVA, or any other community college or college or university, they do have prerequisites for getting in and being accepted. It is competitive. A lot of people want to get in, and the bottlenecks are brick and mortar. That's one of the bottlenecks. And also, another bottleneck is clinical placements.

RICHMANWe have to have enough clinical placements. That means places where we can take students to hospitals, nursing homes, outpatient clinics, etc., surgical units, so that they can have hands-on experience. So that's a limiting factor of enrollment everywhere in the United States.

NNAMDIThank you very much for your call, Tim. Michael Bleich, thanks to advances in both technology and drugs, nursing is becoming more complex. How much of the job now requires new skills like using data management systems and mastering technical information?

BLEICHWell, it absolutely does. If you think about the field of genomics, where it is possible now to predict -- to do actual mapping of your DNA and understand that you may have certain conditions that are going to appear in your lifetime, that's unprecedented. We've never had that level of scientific knowledge. The use of computers and technology.

BLEICHRebecca referred earlier to Telehealth using electronics to reach out to new populations of patients. It's a fascinating time, but this is, again, one of the reasons why advanced education and ongoing competency growth in those competencies is so critical. So absolutely, the scientific knowledge, the fact that people are living so much longer creates situations where people have multiple health conditions that overlap and intersect in ways that we've never really studied before because people didn't live that long 50 years ago.

BLEICHAnd so if you look at just in this century the kinds of circumstances that we're creating where people live longer, geriatric syndromes, knowledge is coming at us from all different perspectives, yes. Technology and technological skills, working with IV pumps, working with different kinds of radiographic devices. It's fabulous and fascinating to look at the things that are happening, and nurses are in the middle of all that.

NNAMDIHere now is Connor in Washington D.C. Connor, you're on the air. Go ahead, please.

CONNORHi. I'm actually a nurse, and I practice in northern Virginia, but I live in the District. And I -- this is such a multifaceted discussion, and I wish we had time to cover more topics. But honestly, I'm really disturbed by the fact that we're pumping out these nurses and they're leaving school, they barely know what they're doing, and they're expected to take somebody's life in their hands and create something or change something or help that person when they barely know how to take a blood pressure or start an IV.

NNAMDIWhere have you been seeing evidence of this, Connor? Do you care to give a specific example?

CONNORI, you know, I've worked in a couple of different hospitals, and I mainly work with children, and I've seen it across the board. In ICU, I've seen it in general care, and I just want to know how these people feel about putting these nurses out there and filling these positions and this is just not okay.

NNAMDIWell, what do you...

CONNORAnd I don't see how people turn to nursing as a, you know, this is going to take care of me and I have a job and it's going to be a paycheck and -- it's more than that. You have to care. You have to be responsible. You have to be passionate and interested in people -- in helping people. It's not just a job and a lot of these nurses coming into the field -- just a job.

NNAMDIMichael Bleich, is this a complaint that you have heard before?

BLEICHWell, you know, this is a fascinating area and Connor, I totally appreciate your observations. One of the things that the Institute of Medicine report called for was the use of residency programs. And a residency program would help nurses who are in those transitional states to actually perfect some of the skills, knowledge, and abilities that they have working with more senior nurses and other healthcare providers -- other team members.

BLEICHSo I think Connor makes a wonderful point in that, you know, nurses do -- are able to pass their examination that prepares them for safe practice, but added competencies are important. And so we're advocating the use of residency programs to help transitioning nurses move from one setting to another, but also for newer graduates so that they can perfect and really advance their competencies so that those kinds of circumstances don't happen.

NNAMDIAnd I'm afraid we're just about out of time, but I'd like to share two e-mails with you. One from Samantha. "I'm in the midst of finishing my RN. Two days ago I saw a nurse practitioner for the first time, and have never been happier with the level of attention paid to my visit. I was told I have an ear infection, and although I have visited a doctor's office twice for my ears, this was the only practitioner to diagnose my double ear infection.

NNAMDII had not mentioned my ears on this visit as it was just a physical for my school, yet she saw what the docs did not. I was so happy with the service that the nurse practitioner provided, I plan to continue my education to become one myself." And this from Keith in Silver Spring. "I've worked in healthcare for over 30 years in various capacities. I began as a Navy corpsman and I know how hard nurses work.

NNAMDII'll take a good nurse over a doctor any time. Nurses are underappreciated, overworked, catch doctor's mistakes, have to act as peacekeepers with families, et cetera, et cetera. They deserve higher pay and higher respect." Flo Richman is dean of nursing at Northern Virginia Community College. Thank you so much for joining us.

RICHMANOh, thank you for having me.

NNAMDIMichael Bleich is dean of the school of nursing at Oregon Health and Science University. Michael Bleich, thank you for joining us.

BLEICHThis was a fascinating conversation. Thank you for having me.

NNAMDIAnd thank you all for listening. I'm Kojo Nnamdi.