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East meets West in nurse practitioner's teaching trip

Laura Rosenthal, DNP, ACNP, shares knowledge with Taiwanese nurse practitioners

A trip from Denver to Taipei, Taiwan covers more than 7,000 miles. But as Laura Rosenthal recently discovered, geography is not the only measure of distance.

Rosenthal, DNP, ACNP, an assistant professor with the University of Colorado College of Nursing and specialty coordinator for CU’s post-graduate acute care nurse practitioner program, journeyed to Taipei at the invitation of Lian-Hua Huang, RN, PhD, director of nursing at the National Taiwan University Hospital, a 1,600-bed facility.

Huang, an CU Nursing alumni, planned a packed two-week schedule for Rosenthal to attend conferences, deliver lectures, join panel discussions, and visit units and departments at University Hospital and the 1,200-bed Chang Hua Christian Hospital in Changhua City, about 100 miles south of Taipei. Rosenthal helped to answer questions of providers interested in building Taiwan’s still-developing nurse practitioner profession.

Nurse practitioners (NPs) have been training in the United States for nearly a half-century, but they’ve been around in Taiwan only since 2006. Longevity is only one of many differences in the way NPs practice in the West and the East, Rosenthal said. For example, length of training for NPs is shorter in Taiwan than in the United States, nurse-patient ratios are far higher, and their salaries are much lower.

Massive system. Those differences paled, however, when Rosenthal saw the facilities in which NPs practice. National Taiwan University Hospital has three times the number of inpatient beds of University of Colorado Hospital – and that’s after UCH’s 2013 expansion. Rosenthal stepped into a 15-floor facility with rooms frequently occupied by three or four patients. In an observation unit in the emergency department, 89 patients were waiting to be admitted to the hospital. Nurses are typically responsible for eight patients and sometimes as many as 12 – far more than the one-to-four ratio that is standard in the United States.

An outpatient clinic she visited saw 200 patients in a single day. They came forward when a bell signaled their number had been called.

“I felt like was in a casino,” Rosenthal said. “It was overwhelming.”

She also found the scope of practice for NPs quite different. Unlike in the United States, they are not independent, cannot perform procedures, and can’t bill for their services. They work only in the inpatient setting, under the supervision of a physician, and perform tasks such as wound care and capacity management that are considered the province of registered nurses here.

Looking for knowledge. Rosenthal’s hosts were hungry for knowledge and keen on showing her the health care landscape in Taiwan. She visited six hospital departments, observing cases and teaching; she participated in three four-hour conferences; she gave six one-hour lectures and joined three panel discussions. She made the trip to Changhua City in 50 minutes via high-speed train and spent one whirlwind day at the hospital before returning to Taipei.

The information flowed both ways during the visit, Rosenthal said. “Their culture is very giving, and they were excited to share what they do with me,” she said. “They wanted me to see everything and try everything.”

By the same token, the providers she encountered had many questions for Rosenthal. Physicians, for example, were intrigued that NPs in the United States can perform medical procedures and questioned Rosenthal about their liability, the number of patients they treat, and the salaries they are paid. They also expressed concern about the country not having enough NPs to serve patients: Taiwan’s national health care system is much more geared toward hospital admissions than is true here, Rosenthal said.

The NPs she spoke to, not surprisingly, were also interested in compensation – they make the equivalent of about $24,000 a year and are trying to develop a clinical ladder to provide financial incentive for NPs to get more training and education.

Setting goals. Better pay was one of the things the NPs said they hoped for during a wrap-up panel discussion Rosenthal joined. But their goals also included gaining more clinical independence, learning to standardize practice, and boosting training. They were also interested in improving end-of-life care, a subject that has been difficult for providers and patients in Taiwan to discuss. In many cases, Rosenthal’s hosts told her, even broaching the subject of establishing goals for a critically or terminally ill patient is a challenge.

“I said that people have to learn to have those discussions, but we’re still trying to get good at it in the U.S.,” Rosenthal said.

The visit established a connection that could continue. Quality improvement is an important part of an NP’s duties in Taiwan. Many want to submit their work for publication, but worry that their language could be a barrier. Rosenthal offered to help, not to revise content, but to tighten the wording of their submissions.

“They set a good example with their quality improvement projects,” Rosenthal said. “I encouraged them to publish their outcomes.”

Both sides gained satisfaction from the visit, she concluded.

“I was impressed with their hospitals, and the trip helped to raise the profile of UCH and the College of Nursing,” she said.

Written by Tyler Smith in UCH Insider, reprinted with permission from the University of Colorado Hospital.