As the single largest group of oncology care providers, RNs face a disproportionate risk of exposure to hazardous drugs. It's up to nurse leaders to create and promote a culture of safety.
Nurses are often described as being on the "front lines" of healthcare, a phrase that evokes potentially dangerous fields like the military or law enforcement.
Christopher Friese PhD, RN, FAAN
That description might seem overly dramatic until you stop to consider what registered nurses might encounter in the course of their workday (or night): Angry, emotional, and sometimes violent patients; risks of injury from needle-sticks or lifting too-heavy patients; the ever-present risk of illness; and the intimacy of caring for and comforting the sick and the dying in ways that few others do.
So it's no exaggeration to say that America's more than 3.1 million RNs are certainly on the front lines of healthcare. And it should come as no surprise that one particular group of nurses, oncology care providers, face a disproportionate risk of exposure to hazardous cancer drugs.
"We've known for about four decades that drugs that are used to treat cancer… are potentially harmful to those who handle them," says Christopher Friese, PhD, RN, FAAN, a University of Michigan School of Nursing assistant professor and member of U-M's Comprehensive Cancer Center and Institute for Healthcare Policy and Innovation.
Although the dangers are known to exist, experts aren't sure how much exposure is too much, and "there can be both short-term and long-term side effects," Friese told me.
In the short term, side effects might include headaches, nausea, rashes, and asthma. Exposure could also lead to long-term side effects such as miscarriage, difficulty conceiving, and unusual cancers, such as leukemia.
Dangers Known and Unknown Whereas patients are only treated for a relatively short period of time, nurses are exposed continuously, sometime for years. Ambulatory clinics, where the bulk of these drugs are administered see an average of 10–12 patients per day, many of whom are on multiple medications, Friese says.
"It's the long-term, small amounts that we worry about the most, and that's where there's the greatest risk to nurses," he says. "It's a lot of cumulative, low-dose exposure, potentially."
Friese is at the helm of a new study that will examine oncology nurses' use of personal protective equipment (PPE) and biological exposure to hazardous drugs at 11 of the nation's top cancer centers. The four-year DEFENS: Drug Exposure Feedback and Education for Nurses' Safety study has funding from the National Institute for Occupational Safety and Health (NIOSH) and will involve about 380 nurses.
In a preliminary study, Friese found that among 242 surveyed oncology nurses, 16.9% reported skin or eye exposure to hazardous drugs in the past year, and that organizational factors, such as nursing workloads, practice environments, and performance of safety behavior are associated with an increased risk of spills.
The DEFENS study will take that research further. In its first component, nurses will provide information about chemotherapy spills in the clinic and provide blood samples to determine whether the agents are detectable.
The second part of the study will involve nurses receiving an educational module on safe drug handling, with and without specific feedback about how to improve their practice. Friese says some of the nurses will also have access to data about how whether the agents were detected in the participants' blood.
Personal Protection The study's goal is to increase the number of nurses who use PPE such as gowns and gloves on a consistent basis.
"We hope that we can learn as a community, together, about what practices and procedures clinics across the country can use," Friese says. "We hope that this will allow us to recognize the cause of and the reasons for the spills and the exposures."
In addition, assessing nurse workloads, environments, and performance of safety behaviors "will provide managers with the data that they need… so they can improve the safety within their units," Friese says.
But nurse leaders don't need to wait for the results of the DEFENS study to start improving nurses' handling of these potentially hazardous drugs, he says.
For one thing, Friese says that not every clinic that handles these drugs actually provides PPE to nurses, so nurse leaders need to ensure that such equipment is readily available to all nurses.
A Culture of Safety When PPE is available, leaders need to create a culture of safety by encouraging nurses to wear it, praising them when they do, and questioning them when they don't. Despite other messages about saving money, nurses need to know that this one-time-use equipment is there for them, to keep them safe.
"Management needs to set the tone," Friese says.
Also, "there's a lot of blame and shame that happens when drugs spill," Friese says. "Nurses really want to do everything perfectly and if there's a drug spill there's often a lot of paperwork and hassle to get it cleaned up. And potentially a lot of expense."
Because of these factors, spills are likely underreported. Instead of using the "blame and shame" tactic, managers should encourage nurses to report and talk about spills with their supervisors. Training activities, such as "spill drills" can help instill proper clean-up and reporting procedures, Friese says.
"It's really up to the leaders and the front line staff to make the environment as safe as possible," he says. "There are certain steps that managers can take today."
Understanding nurse turnover is critical for nurse leaders and hospitals, but they don't always have a great grasp of it.
Christine Tassone Kovner, PhD, RN
Here's a startling statistic: An estimated 17.3% of newly licensed RNs leave their first nursing job within the first year and 33.5% leave within two years, according to a new study conducted by the RN Work Project and published in the journal Policy, Politics & Nursing Practice.
Moreover, "When we asked new nurses what the primary reason for them leaving was, they consistently said the managers," one of the study authors, Christine Tassone Kovner, PhD, RN Professor, College of Nursing New York University and Faculty, New York University Langone Medical Center, said via email.
Clearly, understanding nurse turnover is critical for nurse leaders. It can negatively affect everything operational performance, to patient outcomes, to a hospital's bottom line; the latter to the tune of up to $6.4 million per year for a large acute care hospital, research says.
Yet hospitals don't always have a great grasp of nurse turnover.
"There is a lack of consistency in definitions of nurse turnover. These inconsistencies result in various turnover rates," Kovner said. "In addition, turnover rates vary depending on the method used to get data, response rates to surveys, and the geographical area included."
Kovner says she and the other study authors believe that their newly published turnover rates for new nurses are the most reliable and valid rates currently in the literature. I asked Kovner via email to run down some of the most important results of the study for nurse leaders.
HLM:Why are new nurses leaving?
Christine Tassone Kovner: There are several groups of turnover determinants. They include other job opportunities, the work environment, characteristics of the individual (e.g. their partner has taken a job in a distant city and the nurses decide to move with their partners), and broad concepts such as satisfaction and organizational commitment.
HLM:When they don't leave their jobs, why do they stay?
CTK: We know less about why they stay. One reason may be embeddedness—they have a lot invested in the people with whom they work and they like the geographical location of their jobs (e.g. in a rural area there may be only one hospital and the nurse can work there or travel 40 miles to a hospital in another town).
HLM:What's are the most important and/or surprising of the study findings?
CTK: We were surprised that so many rates in the literature do not carefully define the definition, methods, and response rates. We were surprised how often rates from a few hospitals in a relatively small geographic are used to discuss turnover rates of nurses in all settings as well as measures of nurses leaving the profession.
Nurses change jobs, but few new nurses leave nursing. Turnover is not inherently bad. It is usually best if poor performers leave the organization.
HLM: What are the "good" versus "bad" kinds of turnover?
CTK: Good turnover occurs when someone is fired. Thus, if the unit manager cares enough to want the nurse gone one can suppose that is good turnover. Another example is someone who has bad work habits (comes in late, calls in sick), but not bad enough to fire. If that person leaves, that is probably good turnover.
Bad turnover is when a wonderful nurse who exemplifies all the characteristics that managers want in a nurse leaves. The manager didn't want that person to leave.
HLM:What are the most important take-aways from the study for nurse leaders?
CTK: Before you start quoting turnover rates from other places to your board and/or CEO be sure that the group of nurses and organizations are comparable to your organization. Look at the response rate. I would not have a lot a confidence in findings when the response rate is below 30%. Some of my colleagues might say when it is below 50%.
HLM:How can nurse leaders improve turnover among new nurses?
CTK: Nurse leaders should look at the work environments in their organizations and find out from nurses in their organizations what the nurses find satisfying and what they don't like.
It is important to get to the nurse before he or she makes the decision to leave. When we asked new nurses what the primary reason for them leaving was, they consistently said the managers.
Nurse[s] who are good or even great clinicians are not necessarily good managers. Nurses need to know what management research findings are and then use the research. There is a reason why so many CEOs have management education, often at the master's level. People can learn to be managers at universities.
Most nurse leaders aren't born with the same medical conditions as their patients, but it is possible for them to provide care from a place of empathy and understanding.
Asked "Why do you want to work in the PICU?" during an interview for her first inpatient nursing job, Christy Sillman, RN, MSN, gave a strange answer: "I don't."
Christy Sillman, RN, MSN
"I don't want to be here, but I feel like I have to be here," she remembers saying. "I felt this drive to work in the pediatric ICU with post-op cardiac babies, even though it was the thing that held the deepest anxiety for me."
That anxiety was borne from decades of experience. Sillman, now 34, was born with tetralogy of Fallot with pulmonary atresia. She had five defects of the heart, including the absence of the pulmonary artery, and has spent her share of time in hospitals.
Today, Sillman is using that experience to relate to patients in a deep and profound way as the nurse coordinator for the Adult Congenital Heart Programat Stanford Health Care in Palo, Alto, CA.
Although most nurses and nurse leaders aren't born with the same kinds of medical conditions as their patients, Sillman says it is possible for them to care for patients from a similar place of empathy and understanding.
In 1980, the outlook wasn't good for babies like Christy Sillman. "They basically told my parents…take her home; keep her comfortable. She'll die within three days," Sillman recounts.
But the baby girl didn't die within three days. Instead, she was enrolled in a drug trial, had a shunt placed, and underwent multiple surgeries, including open heart surgery at the age of 4.
Although Sillman's health issues inspired her father to give up his successful plumbing business and become a physician, Sillman herself fought against entering medicine as a profession. In fact, she planned to study acting until a series of heart surgeries at the age of 17 left her with vocal cord paralysis for more than a year.
"I'd have made a great mime, but that was about it," she quips.
The Pull of a Medical Career "I started to think about what I wanted to do with my life, and I started to get more interested in medicine," she says. "But I said again and again, I would [would say I would] never be a nurse. I hated hospitals."
After all, Sillman had spent years as a patient—and a "terrible" one, at that. At the age of 17, she was a volatile patient, flipping nurses the bird, hitting them, and "yelling" at them (albeit silently, because of her paralyzed vocal chords).
"That's not who I am," Sillman says. But she was angry and scared, and acting deeply out of character. And one nurse in particular just made things worse, dealing with Sillman's thrashing and flailing by putting her in restraints, giving her meds to knock her out, and intubating her without explaining why or for how long.
Nurses like that were "just doing what they needed to do to get through their shift," Sillman says.
No, she did not want to be a nurse.
Instead, she entered health education, and after graduation, was teaching menopause classes at the age of 22. Although Sillman says she found empowerment in patient education, she wasn't satisfied, and was searching for the right path. She'd avoided hospitals at all costs, but finally entered one again to visit a friend who'd been in a car accident.
"It was the first time I had been in the hospital since my open heart surgery," she says. "I just watched all the nurses and what they were doing."
Sillman sat with her friend for hours, and watched as a nurse made the difference between her friend feeling depressed and defeated and being uplifted and ready to fight.
Falling in Love with Inpatient Care
Finally, Sillman realized she wanted to enter nursing, and on her first day of her first clinical rotation in the hospital, she knew she'd found her place.
"I fell in love with inpatient care," she says. "I could relate as a patient. I know firsthand the difference between a good nurse and a bad nurse. I know firsthand what it's like to be intubated and be confused from medication."
Over the subsequent years working as a nurse in both inpatient and outpatient settings, with both children and adults, Sillman has been able to apply her own experiences to the nursing care she provides. She's especially adept at caring for difficult patients and is an advocate for patients with congenital heart defects.
Nurse leaders can use the lessons of being a patient, too.
"Not every nurse leader is going to have that personal connection," Sillman says. "But what they can do is get involved with the community of whatever specialty they're dealing with."
She says doing so will help nurse leaders become a trusted voice within the community, as well as help them get a deeper perspective on the issues and struggles of those patients. They can learn and understand that patients who sound like they're "complaining" or being overly anxious, might actually be advocating for themselves.
"You'd be able to develop relationships with active members of the patient community. You're going to have that pulse, that inside information," Sillman says, adding that nurse leaders can apply information, such as what patients complain about and worry about, to advancing care.
"We should take account of that," she says.
Nurses should also remember that patients are people with lives that don't involve their illness—and they can help patients remember that about themselves, too.
"What a bad nurse was for me was one that just saw me as a disgruntled teenager," Sillman says. "The good nurse explains everything, is calm, and helps the patient remember the life outside the hospital. It's very easy as a patient to fall into depression. I always say the walls are very white."
"A good nurse asks them about their life outside the hospital," she continues. "What do they enjoy? What do they love?"
Because at the end of the day, that's what we're all really fighting for.
The CNO of a Florida health system calls the organization's switch to new uniforms for 6,000 employees 'change management at its finest.'
Change can be tough for anyone, whether it's starting a new job or moving to a new city. But a $1 million, industry-first change that involves more than 6,000 employees requires exceptional leadership. That's where Diane Raines, DNP, RN, NEA-BC, senior vice president and CNO for Jacksonville, Florida-based Baptist Health comes in.
Raines, along with Baptist Health COO John Wilbanks, FACHE, was the executive champion for an initiative to adopt new work garments made from antimicrobial, fluid-repelling, moisture-wicking fabric. Baptist Health was the first health system to widely adopt the Vestex uniforms from Vestagen Technical Textiles.
But the adoption of the new uniforms didn't happen overnight; and it also didn't happen without a lot of staff help and input.
"This has been three years in the making," Raines says. The process started with physicians and nurse epidemiologists watching and waiting for a couple of years as data started to show that the fabric was able to do things like reduce MRSA on apparel.
"From a medical standpoint, you want to make sure if you're going to make a change like this there is evidence behind it," Raines says. "We really looked at this not as uniforms but as technology that could help protect our staff and patients."
Once the health system decided to adopt the new apparel, it didn't simply order 30,000 new sets of scrubs, lab coats, and uniforms. Instead, hospital leaders assembled an interdisciplinary implementation team of 100 employees to participate in a day-long session about fabrics, styles, and colors. Among those 100 volunteers were people who weren't initially sold on the idea of new uniforms.
"We also asked our leaders to put some of the skeptics in there. You could tell people thought, 'This is ridiculous, I'm not doing this,'" Raines says. But, "the more information you can give people the more likely they are to adapt. Those 100 people became champions themselves, and that was one of their duties: to go among their peers and talk this up."
Once the 100-person team chose some initial designs, "we took their decisions on the road," Raines says. "We called it a trunk show."
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The "trunk show" took the uniform options to all of Baptist Health's locations—including five hospitals, a home health agency, and a free-standing emergency department—and let everyone who passed through the shows to vote on the colors and designs that they liked best. Raines says about 1,000 people came through the trunk shows, giving the employees a chance to see, touch, and have a say in the new uniforms.
Altogether, about 6,000 of the system's 9,000-person staff will be wearing the new technology, including nurses, physicians, aids, housekeepers, imaging staff, and others who go in and out of patient rooms and have repeated contact with patients.
The organization purchased initial sets for existing employees, giving three sets to full-time employees, and two sets to part-timers. Staff members started wearing the new uniforms about a month ago, and the health system's official "go live" date for everyone to be in the new apparel is September 1.
"As units get their uniforms, people send me text messages with pictures," Raines says. They'll write things like, "Here's out pediatric intensive care unit in our new uniforms… here's how great we look."
Next up is new patient apparel, too, which was designed by a team of caregivers (mostly nurses) to provide more dignity to patients, as well as add functionality with elements like pockets and slits for drainage tubes.
The patient apparel includes a wrap gown with double-back panel, as well as shorts and shirts for patients who don't need to be in gowns. Raines says the production on the new patient apparel is wrapping up and implementation will begin at the end of September.
Raines says the process of designing and implementing the new apparel has been interesting, calling it "change management at its finest." Although she says the vast majority of the staff were thrilled that they were getting an extra level of infection protection, there are still have a handful of people who complain that they don't like the colors or don't want to wear the technology.
"As more and more people adopt and adapt that kind of goes away," Raines says. And although leadership requires strong decision making—9,000 people can't be involved in every decision—when appropriate, staff involvement is crucial.
"We felt like we had a lot of buy-in going into it," she says. "The more we can involve staff in decision making the better we can be. We search and hire independent critical thinkers to take care of our patients, and you can't ignore that when it comes to decisions."
The chief nursing officer at a new Texas hospital made sure that the concerns of nurses and nurse managers were carefully considered in the new plans.
Not every nursing team gets to have a role in designing a brand-new hospital. That's why Irene Strejc, RN, BSN, MPH, CENP, CNO/vice president of nursing at Methodist Richardson Medical Center in Texas made sure that her nurses and managers were front and center when the chance to do so came their way.
Strejc says designing the newly opened, 125-bed, four-story facility was a "once-in-a-lifetime" opportunity for its nurses to really "put their imprint" on a hospital. But despite her role as vice president of nursing, realizing her own vision of the hospital wasn't Strejc's focus.
Instead, her focus was bringing to life the vision of the front-line caregivers and nurse managers who actually use the facilities every day and provide the patient care. "I stepped them forward and stood beside them, because this is not my hospital, it's our hospital," she says. "I was the coach, they were the stars."
The hospital's president, whom Strejc says was the most involved leader she's ever seen in a hospital rebuild, frequently hosted meetings with department managers, who would take the information back to staff during the two-year long project. In addition, nothing was finalized until nurse managers signed off on the design, Strejc says.
The new facility, which opened in April, was designed to stand the test of time, and not to be trendy, says Strejc.
"A lot of thought goes into what is in the patients' and the nurses' best interest," Strejc says. Without consensus-building and clear-set goals, "you may find yourself building for the moment and not for the millennium."
The design also includes elements that nurses helped bring to life.
For instance, "one of the things that we did was move the hand-washing sink into the patient's room," Strejc says. In the old facility it was either outside the room or in the bathroom, so "the patient didn't see you wash your hands."
"That was one of the things that the nurses felt strongly about," Strejc says, adding that patients have a right to see their healthcare providers wash their hands.
Other design elements contribute to both the flow and ambiance of the space. Gone are the traditional box-shaped units with desks at either end. Such design can lead to a "wild mix of acuity" and nurses having to race from end-to-end, creating the need for "more thoughtful assignment systems to counteract the design of the building," Strejc says.
Instead, the new facility's hallways have a serpentine shape with no corners, decentralized infection control carts, and a nursing workstation between every two rooms.
"Things are happening closer to the bedside," Strejc says.
In addition, the hallways' S-curves give a feeling of peace and quiet, serving to decrease noise and clutter. Also adding to the ambiance is indirect lighting in the hallways, rather than the customary row of fluorescent lights on the ceiling. Teaming rooms provide space for tasks like meetings and huddles, and break rooms open onto balconies for fresh air.
"It just feels and looks like a place of healing and a place of peace," Strejc says.
In order to make the patient rooms flow more efficiently and comfortably for everyone in them, the hospital worked with Steelcase Health to design distinct "zones" families, nurses, and patients. On one side of the bed is the family zone, which includes a couch under the windows that turns into bed; a recliner that vibrates and heats; lighting for reading; and a view of the TV. On the other side of the bed is everything that the nurses need to provide patient care.
Of course, not every CNO and nurse leader has the chance to design a hospital from the ground-up, but there are learnings here for everyone. For example, Strejc says anytime a hospital buys new equipment there's a chance to assess whether it's as patient- and staff-friendly as possible. There are also lessons about valuing and listening to your staff. Strejc says her hospital has a shared governance system, so staff is used to speaking up.
"If they don't speak up, I keep bugging them until they do," she says. "Silence is not an option. They know they have a voice, and I expect them to use it. I respect them very much. I want them to feel that they make a difference in everything that they touch."
And although it's easy to get lost in the busy, day-to-day management of a project, Strejc also points out that it's important to circle back with people who spoke up and championed something that didn't pan out.
"You've got to close the loop and communicate that," she says. "You need to get back to a person that championed an idea. You can't over-communicate."
Nurses can help drive strategies that affect cost and quality "because they deal with it every day," says an RN and veteran member of multiple boards. Yet nurses—especially women—are grossly underrepresented on hospital boards.
Here's a question for you, hospital executives: Why don't you have a nurse on your board?
To the handful of you who actually do have a nurse on the board of directors, kudos. But the chances are good that you don't have one: data from 2011 shows that only 6% of board members are nurses.
Gender is certainly a contributing factor here. Most nurses are women, and in general, women are grossly underrepresented on corporate boards across industries. According to data from Catalyst, women hold just 16.9% of board positions in the United States.
"If it were proportional, it would be 52%," says Connie R. Curran, RN, EdD, FAAN, CEO of Best on Board. She serves on boards of directors for Hospira, Inc., DePaul University, and the University of Wisconsin Foundation. Curran was also the former chairperson of the board of Silver Cross Hospital in Lenox IL, and has served on many others.
She has lots of experience, not only with being the only nurse and the only woman on a board, but also with encountering blatant sexism along the way.
Curran was once appointed to the finance committee of a board, she learned later, because the hospital's CFO assured the CEO: "She's a dumb blonde. Give her to me, she won't cause any trouble."
Sexism is certainly a way of life. But equity for the sake of it is not the reason hospitals should work to get more nurses on their boards. They should do it because it makes good business sense.
Strategy, Not Management
"The purpose of a board is to oversee, to provide guidance," Curran says. "It's not to manage. It's to provide strategy, and in the case of hospitals, it is to make sure you're meeting the needs of the community and stakeholders."
Curran remembers how one hospital board she sat on was in the midst of approving several quick budget cuts. One of the planned cuts was to close the hospital's pharmacy on the weekends; it was something the other board members thought was a good idea.
"They were all about to say yes when I raised my hand and said, 'How will the meds get up to the units?'" Curran says.
The pharmacist will get them ready Friday night, she was told. But what about medication changes? Emergencies throughout the weekend? Well the nurses can handle that, said proponents of the change.
Curran explained that nurses don't practice pharmacy, and moreover, they shouldn't leave the unit during their shifts, especially on weekends when the hospital operated with a skeleton crew.
In the end, the pharmacy didn't close on the weekends, and the anecdote illustrates how important it is for board members to understand the real workings of a hospital. Too often, board members, even if they are physicians, don't understand the practicalities of how a hospital operates. The board needed a nurse to get that crucial perspective.
"I think nurses understand a lot of the practical things that affect cost and quality because they deal with it every day," Curran says.
She says she often hears excuses about why nurses aren't on boards, ranging from "I never thought of it" to "Where do I find a nurse?" Here are three of those excuses, busted:
1. "I never thought of it."
In her book Lean In: Women, Work, and the Will to Lead, Sheryl Sandberg, COO of Facebook, writes that there was no designated parking for pregnant women in Google's huge parking lots. Her male bosses weren't being intentionally insensitive, they just had never been pregnant before, and didn't know such a thing was needed.
So Sandberg asked for it, and got it. If you're a hospital executive who's never thought to have a nurse on the board, consider this your "Lean In moment." And "if you're a CNO, you should be bugging your board about getting a nurse," Curran says.
2. "Where do I find a nurse?"
"The average hospital board is about 12 people, and typically 20%–30% of those people are physicians," Curran says. There are 3.1 million nurses in the United States, so if you can find a physician for your board, you can find a nurse.
Look to places like nursing schools or hospitals in neighboring areas that don't compete with yours. "Boards meet about six times a year and there are 5,000 hospitals in this country," Curran says. Hospitals who put in even a little bit of effort can find a nurse for their board.
3. "Are nurses qualified?" "Nurses maybe are not viewed as being affluent enough," to sit on a board, says Curran, especially since some boards are upfront about expecting their members to donate. But nurses who don't have deep pockets can help the board in other ways that are just as valuable, and arguably more so, since their knowledge of how hospitals operate can contribute meaningfully to the board's decisions.
Many boards have a banker and a lawyer at the table, Curran points out, and if they're qualified to help guide a hospital, a nurse certainly is, too.
The healthcare industry is getting more complicated by the day, so it's more important than ever for hospitals and executives to show their business savvy and choose board members who truly represent the interests of the organization and its stakeholder. The days of near-lifetime, "who-you-know" appointments to hospital boards will no longer cut it in such an environment, Curran says.
"It's not the old boys club anymore," she says. "We really need board members who are passionate about patient care and are willing to roll up their sleeves and work hard on behalf of patients."
Forward-thinking nurse leaders who are at the forefront of unit-level changes can help lead change throughout the organization.
The idea of making huge, institution-wide changes can seem daunting, even to the most seasoned nurse leader. That's why when Linda Talley, MS, BSN, RN, NE-BC, Vice President and CNO at Children's National Health System in Washington, DC, wanted to pilot LEAN initiatives, she started with units that she already knew were helped by people whom she calls "change agents."
"You want to look for your early adopters so they can pilot," Talley told me. "We knew we needed to have a unit that was already successful."
Doing so not only ensures that the most forward-thinking nurse leaders are at the forefront of such changes, but also means that once the pilot is successfully completed, those forward-thinkers can help make institutional changes and "lead on behalf of the organization."
In the case of Children's National, some of those change agents are the nurses on its 7 East Medical Care Unit, which just received the Beacon Award for Excellence from the American Association of Critical-Care Nurses.
The more than 100 RNs on 7 East, a 50-bed acute care unit with a staff of 160, have been working on LEAN initiatives for the past nine months, says Debbie Freiburg, MS, RN, director for Medical Nursing and Patient and Family Education Program at Children's National.
Among the ways that Freiburg and her team got staff engaged and involved in making changes and keeping up with them is through the use of what they call a "huddle board," a white board where unit metrics are posted for everyone to see in the conference room.
The metrics include real-time outcomes directly related to care, and features personal notes, such as who's gotten married, had a baby, or achieved a new professional certification.
"You want to get the staff more involved," Freiburg said, and the huddle board provides that in black-and-white, actually showing staff how their actions have made a difference, "letting them know how they have increased the patient satisfaction."
For instance, their LEAN work has helped them improve their patient discharge scores, as well as see a reduction in pressure ulcers and falls, and increased accuracy and compliance with Pediatric Early Warning Scores (PEWS). In fact, Freiburg says they've achieved 100% compliance with everyone using the PEWS.
Another interesting element of the huddle boards is what Freiburg calls "Just Do Its." These address little problems or annoyances that could have easy fixes. Instead of simply complaining about such problems, and wishing that someone else would fix them, the staff puts the problems on a grid in the middle of the huddle board. That way, they can "just do it" and solve them. The grid includes four sections:
High impact of change, low complexity; do it now
High impact high complexity; needs help, is a challenge, and will do soon
Low impact, high complexity, might be a "not do it" for now
Low impact, low complexity; we will work on it when we can
The action items are voted on by the staff, who decide where they belong in the grid. Among recent "just do it" items were fixing a broken chair and getting a printer hooked in a more convenient location, so staff could get discharge summaries to patients more quickly.
The printer, for example, had a high impact: Using its Press Ganey patient satisfaction scores as a guide, the unit knew it had room for improvement when it came to elements such as providing clear discharge instructions and getting patients discharged in a timely manner.
In the case of fixing chairs, the impact was felt by both patients and staff. Freiburg said one of the nurses on the unit had pointed out the broken chair, and finally feels like he's being listened to now that it's been fixed.
"He's able to have more time with the patients… we have fixed those little things," she said. "He felt empowered because we listened to him, but more importantly we had it fixed within two weeks."
Now that the 7 East Unit has had such success with its LEAN initiatives, its leaders can help spread that change to the rest of the organization. They know what they're doing because they've already done it.
"We have experts now," Talley said. "You really need to people who are at the sharp edge of the knife, driving the change."
Nurse leaders and other hospital and health system executives can take several lessons from a regional grocery chain's unusual and unresolved management nightmare.
There's something unprecedented going on in Massachusetts, New Hampshire, and Maine: Thousands of non-unionized employees of the Market Basket grocery store chain have walked off the job after the company's CEO, Arthur T. Demoulas, known as Artie T., was voted out by the company's board of directors.
The CEO's ouster is the latest incident in a year's-long feud between two rival factions of the family that owns the company, but employees are refusing to work for anyone but Artie T.
Under his oversight, Market Basket employees enjoyed unusually good benefits, pay, and bonuses; decades-long careers; and the opportunity to rise up the ranks of the company into management positions.
On the customer end, the store is well-known not only for its low prices, but also for its helpful, knowledgeable, and incredibly loyal staff. The store is profitable, too, raking in an estimated $4.6 billion annually.
As Market Basket's employees protest the board's action, they've also encouraged a boycott of the stores, and customers are listening. As a result, operations at the chain's 71 stores have nearly ground to a halt. Shelves are bare.
Supportive customers are shopping elsewhere, taping receipts from rival grocery stores to Market Basket's windows and emailing its board of directors demanding that they listen to their employees. Politicians are also voicing their support of the employees.
What does all this have to do with nursing? Nurse leaders and other hospital executives can take several lessons from the Market Basket dustup, from appreciating the importance of an organization's culture, to understanding the need for nurses to be on boards of directors. Here are three lessons nurse executives can learn from the grocery aisle.
1. A healthy culture creates a healthy business: Promoting a culture where everyone feels valued and respected goes a long way toward productivity and outcomes. Flexible scheduling; encouraging teamwork; and making sure nurses take breaks and have plenty time between shifts may not sound like tactical moves, but they all pay off in terms of patient care. Being part of a healthy culture where everyone is valued helps with productivity, too.
"A culture of inclusiveness breeds success," Kathie Krause, MSN, RNC, NNP-BC, NEA-BC, Vice President of Patient Care/CNO at Le Bonheur Children's Hospital, told me via email.
"Nurses are part of multi-disciplinary teams and have a strong voice as advocates. It is important that all employees feel empowered to make a difference or contribute ideas. This makes staff feel like they have purpose and meaning in their work."
On the other hand, factors like requiring nurses to work overtime; units being chronically short-staffed; and an all-too-common culture of bullying create toxic environments with high nurse turnover and unhappy employees.
"Nurses who rise to executive leadership positions develop a keen ability to work collaboratively with colleagues to maintain a workplace culture where every individual is respected and feels that their contribution is valued," Bobbie Berkowitz, PhD, RN, FAAN, Dean of Columbia University School of Nursing, told me via email.
2. What workers think, experience, and say matters: Within days, Market Basket's productivity came to a standstill because everyone up and down its supply chain—from the high school students who bag groceries, to the people who stock shelves, to the 40-year managers—stopped doing their jobs. It's a reminder that every cog in the wheel is an essential one.
I'll never forget something that Maureen White, RN, MBA, NEA-BC, FAAN, senior vice president and chief nurse executive of North Shore-LIJ Health System, told me last year: "The best ideas are not coming from the C-suite when it comes to care delivery." Instead, the best ideas are "coming from front-line staff."
Nurse managers and other leaders should always take the time to listen to everyone on staff, from the bedside nurses to the CNAs and everyone in between. They keep the place running, day in and day out, and see things that people in the c-suite don't.
"Bedside nurses know patients and know their needs," Krause said. "We have to create an environment where we listen to bedside nurses to ensure they have the tools needed to do their jobs. They will deliver excellent care and fulfill their mission of providing excellent, thoughtful care for their patients if we empower them."
On the flip side, punitive environments often prevent nurses from speaking up to make needed patient safety changes. For instance, a survey last year showed that although 90% of nurses say it's important to have a culture where nurses are not penalized for reporting errors or near misses, 59% agree that nurses often hold back reporting patient errors in fear of punishment. Most nurses (62%) say the same about reporting near-misses.
"The best nurse executives recognize that patients benefit from being treated in an environment that encourages nurses at the bedside to speak up when they see a problem or an opportunity for improvement," Berkowitz said.
3. Get nurses on boards of directors: Market Basket's board of directors has appeared tone-deaf to the public, and has seemed to underestimate the importance of the store's culture and employee loyalty. Hospital boards of directors, too, can suffer from the same kind of tone-deaf behavior when nurses aren't included in decision making.
"Nurses are trained on the care of the whole patient," Krause said. "This makes us advocates for people—our patients. Our expertise and background can give boards perspective and puts this empathetic thinking at the core of business decisions."
Still, a 2011 survey of 1,000 hospital boards found that only 6% of board members were nurses, even though nursing is the largest healthcare profession, with 3.1 million RNs in the United States.
"Nurses are experts in communicating with patients, families, and communities in a way that is culturally sensitive and inclusive—expertise that would benefit any board of directors," Berkowitz said.
Only time will tell what will happen with the Market Basket feud. But nurse executives and other members of hospital leadership can take lessons from the store's struggles today.
The co-director of a nursing scholars program says doctoral degrees can help nurses become visionary thinkers, researchers, policy makers, and leaders.
Julie Fairman, RN, PhD, FAAN
Of the nation's 3 million nurses, only about 1% of them hold doctoral degrees in nursing or a related field, but a new program from the Robert Wood Johnson Foundation aims to boost that number.
"We certainly hope to cause a bump in the trend," says Julie Fairman, RN, PhD, FAAN, Nightingale Professor in Nursing and Director of the Barbara Bates Center for the Study of the History of Nursing at the University of Pennsylvania School of Nursing.
Fairman is also co-director of the Future of Nursing Scholars program, which earlier this month selected the 14 schools of nursing that will receive grants to support 17 nurses as they pursue their PhDs. These inaugural grantees will select students to receive financial support, mentoring, and leadership development over the three years of their PhD programs.
The IOM's Future of Nursing report is often cited for its call for 80% of nurses to hold a Bachelor of Science degree in nursing by 2020. But the report also calls on the field to double its number of nurses with doctorates by 2020.
Faculty Needed One barrier to doctoral-prepared nurses is the dearth of faculty at nursing schools. Fairman tells me that already, nursing schools are turning away applicants because of a shallow faculty pool. Plus, she says that the average age of nurse faculty is 60 years old.
"We really need to replenish that," she says. "We really don't have the capacity to replace those who will retire in five years."
Earning a PhD doesn't simply prepare nurses to work in academic fields.
"The idea of nurses with PhDs is a really important one, especially for C-suite nurses and nurses in health systems," Fairman says. She adds that because PhD education is research-focused, earning one prepares "visionary nurses" who are skilled leaders, and who know how dive deeply into data.
Prepared to Lead Because of this preparation, nurse executives and other nurse leaders with PhDs are well-equipped to develop and lead research- and evidence-based quality and safety initiatives, as well as get a larger team involved in such efforts, too. Fairman says CNOs with doctoral degrees "are some of the most creative nurse leaders in the country."
"These are things that nurses are really, really good at understanding and leading initiatives around them," Fairman says. "A lot of the CNOs who have PhDs have done incredible research on developing new models of care, how to improve safety, and how to institute measures to improve patient outcomes."
Fairman also told me that holding a PhD could potentially help with parity for nurse leaders, saying that it's helpful to have a PhD when dealing with physicians and other PhD-prepared administrators.
"The degree and the study they do for that really situates them as different thinkers," she says.
In addition to boosting the number of PhD-prepared nurses, the program also aims to encourage nurses to earn their PhDs while they're younger so they can have a longer career trajectory.
According to the RWJF announcement of the grantees, the average age at which nurses get their PhDs in the United States is 46. That's 13 years older than PhD earners in other fields. Often, that's because nurses tend to earn their nursing degrees and practice for several years before earning a more advanced degree.
A 'Different Career Trajectory' "There's a tradition in nursing that you practice to get experience in the real world, and there's something to be said for that… but [this] career trajectory is different," Fairman says. "We'd really love a lot of young people to enter the profession as leaders."
The Future of Nursing Scholars program plans to support up to 100 PhD nursing candidates over its first two years. In addition to RWJF, this year's funders include United Health Foundation, Independence Blue Cross Foundation, Cedars-Sinai Medical Center, and the Rhode Island Foundation.
Fairman says that although rigorous, the program will include "exquisite support," leadership development, and opportunities for networking throughout. She hopes that three years down the road, she'll be able to say that these students have become "crackerjack researchers, policy makers, scientists… and the leaders of tomorrow."
A nurse CEO describes the "good investment" her hospital has made in a 20-year-old program that sends specially trained nurses into the homes of low-income women during pregnancy and early childhood.
The nurse CEO at Le Bonheur Children's Hospital in Memphis knows firsthand the power of nurses working in the community.
"There's a great deal of need with young mothers and their children suffering from lack of prenatal care," says Meri Armour, MSN/MBA, Le Bonheur Children's Hospital's president and CEO. "Every family should have a nurse in it, just to be the interpreter."
In the late 1980s, Memphis was one of the first cities to pilot the Nurse-Family Partnership, a program that sends specially trained nurses to visit low-income women in their homes during their first pregnancy and throughout the first two years of their children's lives.
When Armour stepped in as CEO in 2007, she wanted to bring the program to Le Bonheur Children's Hospital. It's been in place there since 2010.
"We think that is a good investment," Armour says. "If there are good moms, there will be good kids eventually. There will be a trickle-down effect."
The Nurse-Family Partnership at Le Bonheur is free to participants, who must be first-time, low-income, pre-natal mothers who reside in Memphis/Shelby County. It's funded by Le Bonheur and by a grant from the Tennessee Department of Health.
Here's how the program works: BSN-prepared nurses are sent to expecting and new moms' homes to fill in gaps in care and provide advice.
Whereas other moms might get this kind of information and support from their own families, friends, or extended support systems, the moms in the Nurse-Family Partnership program usually don't have this kind of network and support system. Many of them are teenagers.
The nurses, who each have a caseload of 25 families, are available 24/7 by phone to answer any questions and to provide council. The nurses also visit once a week, often going into rough neighborhoods, in order to connect with the mothers and families and provide regular guidance and education.
They teach the moms about everything from how to deal with a colicky baby to the importance of regular well-child visits. They're not homecare nurses, however. If a child is ill, the nurses will advise mothers to call the pediatrician or visit the ED.
Instead, they provide intimate advice, support, and mentoring until the child is two years old.
"These are children who would not get the best of care or the best parenting without this intense support," Armour says. "We are… the grandmother, mother, and support system" that these new and expecting moms don't have.
There have been numerous studies showing the success of the Nurse-Family Partnership, which, according to its website, is now in 43 states, the U.S. Virgin Islands and six tribal communities.
The latest study, which was published online July 7 in JAMA Pediatrics, looked at 20 years of the program in Memphis. It found that the Nurse-Family Partnership produced a reduction in preventable child death from birth until age 20.
Children in the control group who didn't receive nurse-home visits had a mortality rate of 1.6% for preventable causes, such as sudden infant death syndrome, unintentional injuries, and homicide, whereas there were zero preventable deaths among nurse-visited children.
The program reduced maternal deaths, too: Mothers who didn't receive nurse-home visits were eight times more likely to die of external causes, such as unintentional injuries, suicide, drug overdose, and homicide, than nurse-visited mothers.
Armour says that since she, herself, is a nurse, she understands the importance of having nurses in the community. They're trusted and knowledgeable and often easier and less intimidating to talk with than even a pediatrician. It's a perspective that she's brought with her in her role as CEO.
"I think when you have a nurse at the helm… I think I see things differently sometimes," she says. "I'm a huge believer that we need to help every child every time."
Although the job is tough—and, Armour admits, doesn't pay all that well—Le Bonheur's Nurse-Family Partnership nurses are extremely dedicated to their families. They receive training and support; know that their own safety comes first (security or police are available to help them in unsafe situations); and love what they do. They get satisfaction when they see the difference they're making in lives every day.
"That's why they like their jobs so much, and why they do it for less money, and are willing to drive into bad neighborhoods," Armour says. "Every month that a child passes their well child visit is good."