Market-savvy healthcare organizations have implemented workforce development strategies to address the existing and projected labor shortages. This helps organizations determine where the strategic priorities lie.
The recent economic downturn will have lasting effects. The recession, which officially started in December 2007, has affected the job market.
Picture the current state of the nursing shortage as a tsunami. The first thing that happens in a tsunami is that the water on the beach rushes away from the shore. Nurses are filling current vacant positions en mass. Nurses who had planned to retire, work only part-time, or reduce their hours find they have had to change their plans. They are staying and taking on full-time, rather than part-time, positions (Buerhaus, 2009). "As RN spouses lost their jobs (70% of RNs are married) or worried that they might be laid off, many non-working RNs rejoined the workforce" (Buerhaus).
With RN vacancies being filled at an exceptional rate, organizations might have an urge to ease their recruitment and retention efforts. This is exactly the wrong strategy to take. As the economy begins to adjust, the tidal wave will hit. The impact of the tsunami wave depends on how quickly the economy recovers. If the economy recovers quickly, jobs will be rapidly added back to the market. Many nurses who had to come back to work or work more hours to supplement the family income will leave the job market (Buerhaus). Nurses who postponed retirement may stay in the market a little longer than anticipated to rebuild their retirement incomes, but they will also leave (Buerhaus).
What about the new graduates coming out of nursing school? In a down economic climate, employers are able to be more selective when posting positions. When employers were faced with a lack of experienced nurses applying for jobs in specialty areas (e.g., emergency room or neonatal ICUs), they had no choice but to take on new graduate nurses (Clavreul, 2009). If the economy recovers at a slower pace, nurses will not leave the workforce. This means that new graduates will continue to have difficulty finding jobs unless they are willing to be flexible and work in a more generalist role. Whether the economic recovery is fast or slow, it will have long-lasting effects on healthcare organizations.
Organizations cannot afford to simply react to the workforce shortage. Instead, they must take proactive steps to reduce the effects of the shortage on their organization and take an aggressive stance in terms of recruitment and retention strategies. The financial viability of an organization depends on it.
Case in point: The cost to fill an RN position due to turnover is between $82,000 and $88,000 (Jones, 2008). RN vacancy rates have an even greater financial effect on organizations. Costly approaches to filling the void include using agency/traveler temporary nurses, mandatory/voluntary overtime, closing patient units, and/or diverting patients to other facilities (Jones).
References
Buerhaus, P.I. (2009). "The shape of recovery: Economic implications for the nursing workforce." Nursing Economic$ 27(5): 338–336.
Clavreul, G.M. (2009). "Why nursing school grads have trouble finding jobs." WorkingNurse.com. Retrieved November 3, 2009, from www.workingnurse.com/articles/Why-Nursing-School-Grads-Have- Trouble-Finding-Jobs.
Jones, C.B. (2008). "Revisiting nurse turnover costs: Adjusting for inflation." Journal of Nursing Administration 38(1): 11–18.
Editor's note: This article is based on information found in the book Nursing Orientation Program Builder: Tools for a Successful New Hire Program. For more information, visit www.hcmarketplace.com.
Each year, Wendy Fletcher says, she and two partners see more than 5,000 patients at their practice in Morehead, KY. They are not doctors, but rather registered nurse practitioners who say they are able to increase access to healthcare and make it more affordable. "None of us are trying to play doctor," she said. The Kentucky Medical Association claims otherwise and is fighting proposed legislation that would lift some limits on the ability of about 3,700 nurse practitioners in Kentucky to prescribe medication and perform other, mostly routine tasks such as signing a child's immunization certificate or certifying the need for employee sick leave.
You probably address legal concepts when talking about documentation, medication administration, and delegation. But most orientation programs do not allot specific time to legal issues in general as there is constant pressure to conduct orientation more efficiently and in less time.
How can you introduce this additional information into an already crowded orientation schedule? One possibility is to develop a basic handout and include some scenarios for general discussion or self-study. Remember that you are not expected to offer a continuing education program on legal issues in nursing. This is beyond the scope of orientation. You are simply introducing some basic concepts and stimulating interest. Let's start with some basic legal concepts and a handout that will guide your discussions.
Laws and regulations
Each state has its own Nurse Practice Act, which contains information about the specific scope of practice and educational requirements. Each act also contains statements that prohibit nurses from performing tasks determined to be within the scope of medical practice.
You cannot review the entire Nurse Practice Act in orientation, but you should encourage nurses to obtain a copy of it from the State Board of Nursing and to become familiar with it. You should also include information about avoiding conflicts with employing organizations and volunteer organizations. Tell orientees that their employers cannot expand the scope of their practice to include actions that are prohibited by the state's Nurse Practice Act. All nurses have a legal obligation to practice within their Nurse Practice Act limits (Follin, 2004).
The first three items on the sample handout (p. 3) deal with your state's Nurse Practice Act and legal obligations pertaining to it. Exceeding those limits may result in disciplinary action by the State Board of Nursing or even loss of license. The next items deal with scope and standards of specialty practice and regulatory bodies. You don't need to go into great detail; simply mention those that are most applicable to your organization, such as The Joint Commission (particularly the National Patient Safety Goals) and American Nurses Association (ANA) Standards of Practice. Individualize the handout so it is applicable to your state and organization.
Delegation
It's a good idea to mention delegation responsibilities, especially to orientees who are newly licensed RNs. RNs may delegate to another RN, an LPN, and/or an unlicensed staff member, such as a nursing assistant. However, the RN may only delegate tasks to persons who are competent to perform them and who are able to perform them as part of their legal scope and standards of practice. The delegating RN is still ultimately responsible for his or her patient's care, even if some tasks are delegated to others (Follin, 2004).
The RN needs to know the competency, skills, and abilities of the persons to whom he or she is delegating tasks. He or she must evaluate these persons on an ongoing basis, continually evaluate patients, and report persons who are incompetent or who fail to perform tasks safely.
Elements of professional malpractice
Professional malpractice cases review the patient care provided to determine whether deviations from the appropriate standard of care took place. This is usually initiated with a review of the medical record. Standards of care are measured according to practice acts, professional scope and standards of care, and organizational policies and procedures.
To prove liability for malpractice, four elements must be shown (Morales, 2009):
Duty. There must be a duty that is owed to the patient as indicated by the nurse-patient relationship. This can be interpreted broadly. As a simple example, nurses have a duty to provide a safe environment for patients. Patients must be able to reach their call bell when they need to get out of bed to go to the bathroom. Part of the safe environment, and nurses' duty, is to make sure patients' call bells are within reach and they know how to access them.
Breach of duty. Breach of duty means nurses fail to fulfill their duty to the patient. Suppose nurses fail to adequately assess patients' environment. The nurses know a patient needs assistance to ambulate to the bathroom but fail to secure the call bell within the patient's reach. The patient can't reach the call bell and calls out for help. Unable to wait until someone hears him, the patient gets out of bed and falls. The duty to the patient was breached.
Injury. To prove liability, injury must occur as a result of the breach of duty. The patient who fell in an attempt to get to the bathroom breaks his hip as a result of the fall. He was injured due to a breach of duty. The injury must also result in monetary damage. In this example, the additional expense of hip surgery and extended hospitalization are part of the damages.
Causation. There must be a direct cause and effect between the patient's injury and the breach of duty. This is usually the most difficult element to prove at a malpractice trial. In the case of our example, it must be proved that had the call bell been within reach, the patient would not have been injured.
In addition to discussing the handout, develop case scenarios of your own that illustrate the four elements of negligence. You may also want to develop a mock court role-play scenario. Your legal department can be a big help when developing mock courts.
Legal tip: This article is intended as an introductory guide, not as legal advice. When developing legal tools, consult with your organization's legal and risk management department. Issues to address, in conjunction with your legal department, include advance directives, living wills, and hospital policy regarding employees witnessing patient wills.
References
Follin, S.A. (Ed.). (2004). Nurse's Legal Handbook (5th ed.). Philadelphia: Lippincott Williams & Wilkins.
Morales, K. (2009). "Elements of medical malpractice." Retrieved December 18, 2009, from www.nursetogether.com/tabid/102/itemid/1406/Elements-of-Medical-Malpractice.aspx.
An 85-year-old hospital patient faces first-degree assault and other charges after allegedly shooting and wounding a nurse inside Danbury (CT) Hospital. Stanley Lupienski, who was being treated at the hospital, shot a nursing supervisor three times in the cardiac care department, on the eighth floor, at 2:37 p.m. on March 2, police said. The nurse was rushed to the emergency room, where he was in stable condition, hospital officials said.
Washington, DC's largest private hospital has fired 11 nurses and five support staff members who failed to make it to work during the back-to-back snowstorms that paralyzed the region in February. Dozens of staff members at Washington Hospital Center face internal investigations, union representatives say, and it is unclear how many employees will lose their jobs. The nurses union, Nurses United of the National Capital Region, has filed a class-action grievance with the hospital, the Washington Post reports.
It is a bit of an industry joke: Hospital employees are statistically among the most unhealthy Americans, particularly when it comes to cardiovascular health.
To combat this fact, Spartanburg (SC) Regional Healthcare System—designated as an ANCC Magnet Recognition Program® (MRP) organization in 2005—sought to improve the health of its 5,000 employees as it aimed to reduce the comparatively high rate of deaths from heart disease in the region—556 versus 536 per 100,000 nationwide.
And with planning and effort, it did. Spartanburg successfully inspired employees to exercise, helped employees lose 1,759 lb. collectively, and identified 250 employees with elevated systolic blood pressure, while simultaneously improving the overall health of its community and laying a blueprint for other hospitals to follow. This included the education of three OB/GYN groups, one family medicine group, the Spartanburg Regional Medical Center (SRMC) employee health department, and all of the medical residents who rotated through the chest pain department, as well as two employee wellness challenges and screenings.
SRMC is also part of the HeartCaring® Program, a Spirit of Women national campaign focusing on outreach and education of heart health issues.
"What we realized was that we needed to give this information out and take care of our own employees," says Mary Mathes, executive director of women and children's services at SRMC.
Mathes says there was an opportunity to set up an employee health program that could reach a large number of employees, and to do so in a gender-specific way—remarkably, more than 80% of Spartanburg's employees are women. Not only could the hospital target a massive percentage of its workforce, but it could also tap into behaviors female healthcare providers tend to exhibit.
"This information will not only go out to our female employees; they would take this information back to their homes," says Mathes.
This was a deliberate thought—organizers knew that women generally make the healthcare decisions for their families, "and so, if we could educate them, we knew this information would go into the home and into the community," says Mathes.
Why do nurses and other healthcare providers so often exhibit signs of poor health?
"I think healthcare providers in general put themselves last," says Mathes. "They work long shifts and then they have to multitask lives outside the job. We recognize that as the healthcare field."
Thus, Spartanburg's goal was to help its employees realize that their own health is just as important as the health of their patients.
Distributing information
As a member of the Spirit of Women Network, Spartanburg was provided a wealth of evidence-based information and materials that could be distributed to staff.
"All we had to do was find a vehicle to provide this information to our staff," says Mathes.
Every employee has an annual health evaluation at the hospital. Organizers realized that one place where every employee would eventually find themselves—and where they would be in the right frame of mind to think about their own health—was the waiting area for these evaluations.
"There was an opportunity there to provide educational materials, and then to have them meet face-to-face with a nurse practitioner," says Mathes.
J.T. Smith, RN, MSN, BC, CVN-1, chest pain center coordinator at Spartanburg, is in charge of education for clinical healthcare providers. Smith educated the nurse practitioners and physicians on the program.
"We found there was a knowledge deficit," says Smith. "When asked what they thought the No. 1 killer in women was, the majority said breast cancer, when it's heart disease."
With the nurse practitioner actively providing information and printed materials as takeaways in the waiting area, these annual evaluations became a good opportunity for staff outreach.
The importance of 'when'
To maximize the program's impact, SRMC implemented its outreach program early in the year.
"We did it at a strategic time of year," says Smith. "In January, everyone is motivated, ready to change their lifestyle. That's when we said, 'Let's look at your heart health.' And this leads into heart month [February], when we offer different venues for heart education."
SRMC is particularly interested in employee health—beyond evaluation, cholesterol screenings, and the like, the hospital also has a half-mile indoor walking track where staff members can squeeze in a workout during their lunch break. Because of the success of the indoor track, the facility has been able to rally support to get a larger outdoor track built as well.
Once under way, the program caused a welcomed issue—education materials were flying out the door.
"The biggest problem was keeping up with materials," says Mathes.
Supply had trouble keeping up with demand, prompting frequent calls from employee health center and physician practices for additional materials.
"Honestly, sometimes getting into physician offices was a problem initially as we got them to realize this was a program that could benefit their patients, but once we got into the offices, [Smith] was able to describe what we were doing, and they embraced it," says Mathes.
Spartanburg took an MRP concept and turned it inward. "With [the MRP], when you think about your nurse practice model, our theory is caring for our own and reaching out," says Smith. "Caring for our own is paramount, that we not forget that we have a large population of women are right here in our institution."
Success stories
SRMC offers blood pressure screenings every February. In one year, it took more than 500 blood pressures and found that 50% of the employees who were screened had elevated systolic blood pressure. The hospital was able to provide guidance for those employees, whether through advice, treatment, additional tests, or further evaluation.
"It sounds very simple, but I'll venture a guess that if you talk to healthcare providers . . . we take blood pressures every day but very seldom take our own or each others'," says Smith. "We felt there was possibly a need there, and unfortunately we were right."
And once those basic healthcare needs were met, the facility knew its employees would pass on the information they learned. "Part of our education with our employees was knowing they would take it back to the bedside," says Mathes. "This information could be passed on to their patients when they're ready to go home. Just educating our staff would help our patients."
The next step is to demonstrate continual improvement and growth. This means keeping things interesting.
"The other thing is to keep up with the employees," says Smith. "We have to keep offering them opportunities to learn more about their risks and how to live a healthy life. We have to be creative and keep our employees interested in clever ways."