Shortened lifespans and risk of death from cardiovascular disease in night-shift workers have been linked to lack of sleep.
I have worked my fair share of night shifts—8 hours, 12 hours, and 9 p.m. to 6 a.m. In the late-90s, I even worked a rotating schedule that consisted of alternating one month of night shifts with one month of day shifts.
For me, the most difficult schedule to adjust to was working two 12-hour night shifts on Friday and Saturday. You would think that having the rest of the week off would have made it easy, but just as my body recalibrated to a daytime schedule, I would get knocked off course again by those night shifts.
I was tired. I got headaches. More than once, as I was driving home, I realized the last thing I remembered was pulling out of the hospital parking garage. I had driven about 30 miles without being aware of my surroundings.
I'm not the only nurse who has ever felt the ill-effects of shift work. The American Academy of Nursing understands this, too. To support safe nursing practice and patient care, the organization recently released a position statement on nurse fatigue advocating for policies and practices that promote adequate, high-quality sleep among nurses.
Shift Work Risks
In a 2014 article on the risks of shift work and long hours published in the journal Rehabilitation Nursing, its reported that in 2007, 32% of healthcare workers said they got six hours or less of sleep a day. When compared to day shifts, risks for error are 15% higher for evening shifts and 28% higher for night shifts. By the third consecutive night shift, risk increased by 17%, and 36% by the fourth consecutive night.
Night-shift workers can also experience ill-health effects. Data from the decadeslong Nurses' Health Study found that 11% who worked rotating night shifts for more than six years experienced a shortened lifespan. Those who worked rotating night shifts for six to 14 years had a 19% increase in risk of death from cardiovascular disease. Working rotating night shifts for more than 15 years increased CVD risk by 23%.
Lastly, in a 2011 American Nurses Association survey, one in 10 nurses reported a motor vehicle crash they believed was related to fatigue or shift work.
Call to Action
The nature of healthcare requires night shifts for the care of patients—so no one is advocating that night shifts be abolished—but there are ways to make shift work healthier and safer for nurses and patients.
In its position statement, the American Nurses Association recommends the following actions:
Healthcare organizations and nurses must educate themselves on the health risks linked to shift work and long work hours, including evidence-based strategies to reduce those risks.
Healthcare organizations should use evidence-based practices when designing employees' work schedules and establish policies, programs, practices, and systems to promote sleep health and an alert workforce.
The workplace culture should promote employees' sleep health to achieve optimum functioning, health, safety, and sense of well-being.
Leadership must recognize the role that shift work, long shifts, and nurse fatigue have on turnover, absenteeism, patient safety, and related costs.
To relay evidence-based personal practices and workplace interventions to maximize sleep health and alertness among nurses, experts must develop continuing education courses for nurses and nurse managers.
"The academy is pleased to publish this important statement on reducing fatigue in nurses," says Karen Cox, PhD, RN, FACHE, FAAN, the academy's president in a news release. "Many healthcare organizations may not fully understand the health risks for both nurses and their patients from a tired workforce."
Healthcare executives should consider how laboratory services can be integrated into their strategic plans in order to reach organizational goals.
The strength and stability of a building comes from its foundation so it seems fitting that a longstanding healthcare industry tradition has been to locate the laboratory services department in a facility’s basement.
“When people make reference to the fact that the laboratory is in the basement, my usual response is, that from my perspective, the laboratory is the foundation of the organization,” says Alvaro Candel, MD, chairman/medical director, department of pathology and laboratory medicine at Elmhurst Memorial Healthcare in Elmhurst, Illinois. “Although admittedly a biased opinion, my point is that the laboratory is in a somewhat unique position in that it interfaces with almost every aspect of the healthcare system and, therefore, is an integral piece of the strategic plan.”
And, in an era of payment reform, changing care models, mergers and acquisitions, and increased consumerism, the pervasiveness of laboratory services gives it the potential to help healthcare organizations remain financially viable while delivering high-quality care across the continuum.
“Lab is an ambassador for the health system, because if you have outreach, if you are operating as a network, chances are your lab is already interacting with the region, the providers, and the customers before the health system gets there,” says James Crawford, MD, senior vice president and executive director, laboratory services at Northwell Health in Lake Success, New York. “Start with your phlebotomists, but also your logistics and client service support of physician practices and, yes, the expertise of the pathologists and the clinical scientists who are supporting those diagnostics.”
To assist in this integration of laboratory services across the continuum, technology solutions are evolving.
“This is why Sunquest is transforming from an LIS to providing end-to-end diagnostic informatics, integrating siloed products into a single solution. Change won’t happen until we can apply computation to this problem. We’re at an inflection point…we have to do something different. I’m optimistic we can turn a corner – and diagnostics is front and center. The lab and diagnostics are in the middle of patient care day in and day out,” says Manish Muzumdar, senior vice president of product development at Sunquest in San Francisco, California.
Forward thinking healthcare organizations are extending laboratory services beyond traditional sites.
“Being a smaller hospital, we had to figure out how we can have different collaborative relationships. In January, Catholic Medical Center became part of a system with two critical access hospitals. We joined together allowing us to forge a collaborative relationship with the smaller hospitals and be able to provide lab services and create an economy of scale,” says Tina Legere, senior vice president, operations at Catholic Medical Center in Manchester, New Hampshire. “In rural New Hampshire, we have a hub and spoke model and because of our cardiac service line we provide a lot of satellite clinical services at the critical access hospitals. Lab is one of those outreaches that we’re doing. We’ve also done a lot of work with the nursing homes and providing the lab services. From a business development piece, we have really been ahead of the curve.”
Articulating how laboratory services can contribute to an organization’s success is an essential function of those in laboratory services leadership.
“Our organization has a plan and it’s in years—in the next year, in the next three years, in the next five years. What I have done is to take the hospital strategic plan, the hospital vision and very carefully match our [laboratory] strategic plan to the strategic plan of the organization. So, for example, we want to take our health plan to market. What does that mean? What does that mean for the lab? And then we develop our strategic plan,” says Marci Dop, system vice president of laboratory and support services at OhioHealth in Columbus, Ohio.
Connecting with staff on a personal level is key to nurse manager success.
Few would argue that nursing's traditional pathway into management is a sure model for success—promote a strong clinician into a managerial role without much training in administrative skills and, violá, you are a manager.
Fortunately, more organizations are delivering the training and support nurse managers need to become successful managers with intentionally designed programs to help them develop skills in budgeting, cost-benefit analysis, and the economics of healthcare.
But, while building nurse managers' business acumen is essential, the importance of "softer" relationship skills for a manager's success should not be overlooked.
"I think [nurses] have to have good communication skills. I'd say that's probably right up there with clinical judgment," says Tina M. Marrelli, MSN, MA, RN, FAAN,author ofThe Nurse Manager's Survival Guide, president of the consulting firm Marrelli & Associates, Inc., and chief clinical officer for Innovative Caregiving Solutions, LLC, and e-Caregiving.com.
Marrelli shared her thoughts on the value of relationship-based leadership. Here are a few of her insights.
Connection Builds Teamwork
The secret to a well-oiled nursing unit is connection, Marrelli says, so nurse managers must build a culture that fosters togetherness. They can do this by making the unit's mission clear.
"We're all in this together, we like each other and, though we might have differences, we respect each other," she says. This is something nurse managers can model by encouraging staff to connect with each other on a personal level such as sharing breaks and common meals.
"It's an opportunity to really know each other as people because once you get there, you all communicate, everybody's willing to cover for each other, and everybody thinks they're an equally competent nurse," she says.
Be Mindful of Staff Stress
In the current healthcare environment, there are many expectations—from patient satisfaction to preventing readmissions—being placed on both healthcare leaders and bedside staff. Being attuned to how these demands are affecting nurses is a positive attribute of a nurse manager, says Marrelli.
"When a manager knows enough to say to somebody, 'Are you OK?' usually, people will say what's going on," she says. "It really is all about relationships. Do we schedule time with team members when we know there's a problem going on or a concern? You know everybody's busy, but think about how 'more busy' you'd be if you have to go to HR to hire a new person.
"Their stress could be short staffing or an education gap if they are caring for [a type of] patient they don't usually care for on the unit," she says.
Marrelli also encourages managers to make staff meetings a safe place to bring up issues.
"Depending on the environment, sometimes they feel like they can't say [anything]," Marrelli points out. "So just saying, 'If anyone has anything they want to discuss,' " is a supportive gesture.
Take Action
Listening goes a long way, but if staff members share issues that are negatively affecting their work environment, nurse leaders should act to help resolve the problems.
For example, if nurses express inexperience in caring for a certain patient population, a nurse manager can find a way for them to increase their knowledge base.
"During an in-service, you can do some education and make it fun and engaging so people walk out of there with a skill set that they feel better about," Marrelli says.
She also emphasizes taking to heart the feedback that employees leaving the organization share.
"The problem we have sometimes is people are hired and they don't get that support," she says. "So, what does our onboarding look like? What does our orientation look like? Do we really want to hear why people leave?"
While the truth can be hard to hear, acting on the feedback can lead to positive results.
"We're going to keep hearing the reason people leave. It's time we think about how we can help retain [employees] and ways to make things better," Marrelli says.
Empire State becomes first in the nation to require that nurses obtain a bachelor's degree.
New York State starts the new year with a newly passed nursing law. Governor Andrew Cuomo last month signed into law a bill that requires new nurses to earn a bachelor's degree within 10 years of initial licensure.
The legislation takes effect immediately though the requirement that nurses obtain a baccalaureate degree or higher within 10 years of licensure begins in 30 months.
The new education requirement does not affect nurses already in practice.
There has been a push toward this legislation, commonly known as "BSN in 10," for years, but its passage makes New York the first state to pass this type of law.
BSN-preparation affects patient outcomes
Research, particularly that by Linda H. Aiken, PhD, FAAN, FRCN, of the University of Pennsylvania School of Nursing, has shown that having more nurses with bachelor's degrees improves patient outcomes. For example, her research has found that for each 10% increase in nurses with BSN degrees, there was a 5% decline in risk-adjusted patient mortality.
"NYU has been a strong supporter of "BS in 10" legislation, given its implications for improving patient care. Research shows that patients benefit from baccalaureate-prepared nurses—in fact, several large studies show that it saves lives. Earning bachelor's degrees also creates opportunities for career mobility and leadership among all nurses," she says.
"The Council supports the BS in 10 law. We believe it recognizes and values the contributions of associate degree graduates. We as educators have always encouraged our graduates to continue their education to the BSN degree and beyond," she says in a news release. "This law further expands the strengths of our graduates to meet the increasingly complex healthcare needs of the citizens of New York State. The Council is confident that associate degree nursing programs in New York State will continue to provide high-quality curricula that successfully prepare a diverse pool of graduates for both entry to professional RN practice and seamless academic progression."
Nurse executives supportive of law
Those in education are not the only ones supportive of the new law. Nurse executives also issued favorable statements about the move to BSN in 10.
"As nurse leaders, we support advancing registered nurse education to improve the health of our communities throughout the state. Residents will be better cared for in their homes, expensive hospitalizations can be avoided, and—as validated by research—health outcomes will improve," say Ann Harrington, MPA, BSN, BA, RN, NEA-BC, executive director of the New York Organization of Nursing Executives and Leaders, and Joanne Ritter-Teitel, PhD, RN, NEA-BC, president of the organization in a press release. "Registered Nurses will have the same academic credentials whether they practice in homes, hospitals, nursing homes or other settings where care is provided. And baccalaureate preparation will ensure that RNs are able to move into nursing faculty, nurse practitioner and administrative positions to continue to advance the profession."
In addition, the bill establishes a temporary commission to evaluate and report on barriers to entry into the nursing profession and make recommendations on increasing availability and accessibility of nursing programs.
An annual review on popular nursing topics of 2017, including readmissions, burnout, and the use of APRNs.
This year is soon to be in our rearview mirror, and what a year it's been! We've seen a new president take office, multiple (failed) attempts to repeal the ACA, a shortened health insurance marketplace open enrollment period, higher insurance premiums, and end-of-the-year health system mergers.
The past 12 months have been challenging and, at times, chaotic in the healthcare arena, so you may not have had the chance to delve into all the content, news, and information HealthLeaders Media has to offer. In case you missed them, here are five popular 2017 HLM stories of interest to nurse leaders.
Nurses are major players in trying to prevent avoidable readmissions. But a new study has found the emphasis on reducing 30-day hospital readmissions has inadvertently led to increased risk of death for Medicare patients hospitalized with heart failure.
The study's coauthor Gregg C. Fonarow, MD, a researcher and professor of cardiovascular medicine at UCLA, shares his thoughts on the findings, including how to recalibrate 30-day readmissions to be an accurate metric for value-based, care coordination.
Just because chief nursing officers are away from the bedside does not mean they are immune to experiencing moral distress—the disequilibrium resulting from the recognition of and inability to react ethically to a situation—finds a qualitative study published in the February 2017 Journal of Nursing Administration.
The study's coauthors Rose O. Sherman, EdD, RN, NEA-BC, FAAN, and Angela S. Prestia, PhD, RN, NE-BC, discuss the typically taboo subject of moral distress among CNOs and the lasting effects it can have on nurse leaders.
Despite the often-heard warnings that the U.S. is on the verge of a nursing shortage, data predicts that nationally, the country is on the verge of a national nursing surplus.
"Assuming that Title VIII keeps funding the education and the colleges have faculty, if we keep getting 150,000 new nurses a year over 10 years, that's 1.5 million. [The Bureau of Labor Statistics] says the vacancies are 1.2 million," says Peter McMenamin, PhD, senior policy advisor and health economist at the American Nurses Association.
But that number doesn't tell the whole story. Find out more about the complexities of the nursing workforce and where shortages and surpluses are expected.
The prevalence of clinicians experiencing burnout should be cause for concern among healthcare executives. Burnout is not, as many believe, a failing of an individual. Rather, it's a sign something is amiss within an organization. If left unaddressed, healthcare organizations may experience quality, safety, and retention problems.
To have success in the current healthcare environment, healthcare leaders need to do more than simply acknowledge that burnout exists. They need to uncover the root causes of burnout at their organizations and implement systemwide changes to fix it. Read about what healthcare executives did to do just that.
Healthcare executives don't need a crystal ball to predict the current interest in achieving safe, high-quality, cost-effective care that will continue to grow well into the future. To meet the goals of a value-based care environment, organizations around the country are increasing their use of APRNs, and some are already seeing quality outcomes improve as a result.
"You can't function in a silo anymore. Care must be managed and coordinated across the continuum, and who better than the APN to help coordinate that? There are so many different roles that the APN can play in so many different environments. Why not take advantage of the role and allow it to help foster the healthcare system that right now is just so confusing to people?" says Sheryl Slonim, DNP, RN-BC, NEA-BC, APN-C, executive vice president, patient care services and chief nursing officer at Holy Name Medical Center in Teaneck, New Jersey. Learn more about why APRNs are important to quality outcomes.
Despite a request to be classified as advanced practice registered nurses, the Office of Management and Budget once again categorizes clinical nurse specialists as general RNs.
When I wrote about this issue in 2016, the OMB had opened a second public comment period for input on its recommendations for revisions to the SOC. At that time, only nurse practitioners, certified nurse anesthetists, and certified nurse midwives were included in the APRN category. The NACNS, its members, and other nursing organizations submitted comments requesting CNSs be categorized as APRNs as well.
But those requests have gone unheeded.
"Sadly, yet again the Office of Management and Budget has incorrectly classified clinical nurse specialists as a title within the broad occupation of general registered nurses in the federal government's Standard Occupational Classification System's 2018 revision. NACNS had once again requested to be treated as other advanced practice registered nurses," Vince Holly, MSN, RN, CCRN, CCNS, ACNS-BC, president of the 2017-2018 NACNS Board of Directors says in a news statement.
The Dilemma of Inaccurate Data
The OMB's decision does not mesh with the policies of many other influential groups.
The National Council of State Boards of Nursing recognizes CNSs in its APRN Consensus Model. The VA extended full-practice authority to CNSs in January (though it did not do so for CRNAs).
Congress recognized CNSs as APRNs in the Balanced Budget Act of 1997 when it allowed them to directly bill their services through the Centers for Medicare & Medicaid Services.
Though these groups have more sway over APRNs' practice and reimbursement than OMB, there is still cause for concern over the categorization.
"This decision is disappointing and problematic as clinical nurse specialists' skills and work are sufficiently distinct to reliably collect workforce data as an SOC detailed occupation," Holly says.
Indeed, CNSs education and training go beyond that of a general RN. They hold either a master's or doctoral degree, take advanced anatomy and physiology, pharmacology, and assessment prior to graduation, and can function as independent healthcare providers and clinical experts with prescriptive authority and autonomous patient management.
"Lumping CNSs into the general RN category prevents federal researchers from accurately capturing healthcare workforce data. Incorrectly categorizing clinical nurse specialists skews the quality and utility of federal healthcare policy data because CNSs perform specialized advanced nursing tasks versus the generalist tasks of the RN," he says.
"By wrongly classifying clinical nurse specialists as registered nurses, OMB is devaluing CNS work and diluting the explanatory power of their data. This is happening at a time when the increasing healthcare needs of the nation require both improved quality and reduced costs that are afforded by the specialized, advanced level competencies of the CNS," Holly says.
Despite this setback, NACNS intends to continue its work to ensure that the role CNSs play "in acute, chronic and primary care is respected, valued, and accurately represented."
Recognizing there is no one-size-fits-all approach to staffing issues, healthcare leaders across the country are creating customized solutions to meet their organizations' current and future clinician workforce needs.
This article first appeared in the December 2017 issue of HealthLeaders magazine.
And it worked.
At its most vulnerable, the organization had only three physicians and two nurse practitioners.
Today there are five family practice physicians, one ENT surgeon, and six physician assistants.
"We actually don't have a hard time finding doctors," he says.
Key to this model is an emphasis on both domestic and international service work. While it is in a rural area, Kearny County Hospital's surrounding area is culturally and ethnically diverse.
The hospital serves patients from 30 countries, Anderson says, most of whom are political refugees from some of the most challenged parts of the world—Somalia, Sudan, Ethiopia, Eritrea, Burma, and parts of Central and South America.
Anderson says the refugees are a factor in recruitment. "People are coming because of them," he says. "What we're saying is there are people from 30 countries here, and you get to live among them. We'll give you time to go serve people overseas as well."
All physicians are given 10 weeks paid time off to use however they choose, but Anderson says they all use some of their time to volunteer overseas.
The providers, he explains, can be categorized into three groups—senders, goers, and bridgers. Senders are those who intend to spend their entire careers at Kearney County Hospital.
"What [the bridgers have] done for us … is they've stabilized our hospital … because they eliminate our need for locum work."
"They choose to spend some of their time going overseas, which reinvigorates them and encourages them as they serve here locally. It also equips them to serve locally," he says.
The senders are also motivated by the role they play in mentoring, training, and preparing the next group of physicians—the goers—to practice abroad.
Goers are physicians who come out of training and spend three to five years at Kearney County Hospital with the intent of moving abroad.
"[They] commit to coming here to get their loans paid off, to improve their language skills, to mature in their family relationships, and to strengthen their clinical skills so that they may move permanently overseas," Anderson says of this group. "They come here to live among Somalis, Burmese, Sudanese people so that they may move to those places and be better equipped."
The bridgers make six-month to one-year commitments to the organization, work a greater share of hours, and carry a heavier patient load in exchange for a short-term contract.
"What they've done for us, at least previously, is they've stabilized our hospital so that we can recruit goers and senders, because they eliminate our need for locum work," he says.
Anderson says the model has resulted in cost savings from elimination of costly locum tenens coverage. The organization has also seen an increase in operating revenue from $23 million to $31 million annually.
Over the past two years, Kearney County Hospital has added nearly 4,500 new patients, in part, because of the loss of providers in the geographic region. If they stay on pace, the organization may reach up to 360 deliveries this year. In the past, 189 deliveries a year was typical.
Anderson's advice for those who wish to replicate this model is to know your mission, identify your core values, and have a vision for the future.
"It's got to be simple and easy to understand and to articulate," he says. "If you don't know your mission, then the default mission becomes to stay open another day, and I don't know very many mission-hearted, bright medical providers or clinicians that get excited working for an organization whose goal is to stay open another day."
In turn, healthcare leaders should ask recruits what their personal mission and cores values are.
"It really is about understanding each recruit's motivations, and knowing the mission and purpose of the organization, and matching the two," he says. "If they don't match, the person is not going to stay. If they do, it's a very good thing."
International nurses fill a need
At the national level, the U.S. Department of Health & Human Services' Health Resources & Services Administration projects RN supply to exceed demand, resulting in a projected excess of about 293,800 RN FTEs in 2030.
And while Spetz thinks nursing schools will be able to keep pace with nurse supply, there are other factors influencing the nursing workforce supply.
"Overall, I think nursing is graduating the right numbers. There's a distribution problem, just like there is for physicians, and there's a skills problem," she says. "Employers are saying that new graduates don't really quite have the skills we need. We have all these experienced nurses who are leaving their jobs. We need to fill these gaps."
Texas, according to the HRSA data, is one state grappling with these issues, and by 2025 the state is expected to have an RN shortfall of 15,900 FTEs.
Shannon Medical Center in San Angelo, Texas, a town of more than 100,000 in the western part of the state, is already feeling the pinch.
During the past few years, a local university changed its nursing program from an associate's degree program to a baccalaureate degree program, significantly affecting RN supply at the 409-licensed bed organization.
"There was a lag of supply, and increased demand with retirements and everything else that's going on in healthcare at this point," says Pam Bradshaw, DNP, MBA, RN, NEA-BC, CCRN-K, chief operating officer and chief nursing officer. "If you look at my organization, the average age of a nurse is approximately 48. So as the workforce ages and we have less people coming into healthcare, you're going to end up with this imbalance somewhere. And we don't have the pipeline to backfill it. I will say it does differ based on where you live. In a rural area, it's much harder to recruit and retain than it is if you were in a metropolitan area."
New graduates often head off to larger cities such as Dallas, Austin, or San Antonio in search of big-city experience, she says.
"Realistically, from a complexity and acuity perspective, we provide that same level of care. It's the appeal of the nightlife and the restaurants and the shopping that we battle," Bradshaw says.
Around 2015, in an effort to increase RN supply, Shannon turned to international nurses on long-term contracts through staffing agencies.
"We started relatively small, with about 15," Bradshaw says. "But we quickly realized that in order to accommodate growth, because we are a growing organization, and to accommodate the lack of supply, we really needed more."
Today, 60 of Shannon's over 600 nurses—or 10%—are international nurses on long-term contracts. Additionally, 5% of the nursing workforce is short-term temporary staff.
This is by no means a low-cost solution. Bradshaw estimates the organization spends about $10 million a year on temporary labor.
An agency nurse costs about two-and-a-half-times more per hour than a nurse who is hired directly by the hospital. Some of this cost is accounted for in the annual budget, but at the same time, the organization recognizes the need to evaluate cost avoidance opportunities to stay fiscally on track.
But the investment has enabled Shannon to maintain its quality of care, including a four-star rating by the Centers for Medicare & Medicaid services.
"We have some of the best quality that you'll find anywhere. We're in the top decile [for CMS measures] when you compare us to hospitals across the country. From a quality perspective, there's no issues," she says.
"I think there's no question that we're going to need more physicians than we have been historically producing, but I would agree with the assessment that the solution involves developing care providers across multiple disciplines."
Bradshaw says the hope is that the international nurses will choose to stay on at Shannon once their two- to three-year contracts are complete.
"They're doing well," Bradshaw says, "and of course our goal is to retain them once we complete their contract."
To help increase the odds of retention, Shannon has created an inclusive culture that treats the international nurses just like its traditional staff nurses.
"If we have any sort of celebration or if we have an incentive that we offer, anything like that, they are eligible just like any other nurse would be. That's one of the ways to integrate them into the culture," Bradshaw says.
For example, a few months ago, an international nurse from the Caribbean won the Daisy Award for Extraordinary Nurses, a recognition that values the clinical skills and compassion of individual nurses.
Meaningful recognition programs are components of a healthy work environment, according to the American Association of Critical-Care Nurses, and research has shown that nurses nominated for the Daisy Award report lower rates of compassion fatigue.
"I'm optimistic that by the time our current contracts are done, we'll either retain those nurses or we'll have improved our local supply, which is something we're also working on," Bradshaw says.
New care models necessary
A 2017 study on behalf of the Association of American Medical Colleges predicts the U.S. will face a shortage of between 40,800 and 104,900 physicians by 2030.
However, a 2014 Institute of Medicine (now the National Academy of Medicine) report on the future of the healthcare workforce notes these projections are based on traditional healthcare delivery systems rather than newer models that include team-based care, advanced practice nurses, and physician assistants.
Spetz has a similar assessment.
"If you look at doctors only, there is a shortage coming, but if you recognize that NPs and PAs can do a lot, and I think they can do more than 25% [of the shortage differential] … there is a lot more they can do to fill the gaps," she says.
OhioHealth, the faith-based, not-for-profit health system in Columbus, has 11 hospitals, numerous ambulatory sites, and more than 200 physician offices serving a 47-county
service area in central Ohio.
"I describe a lot of the work we're doing as, ‘How do we try to get some of the work that needs to be done for our patients out of the exam room?'" says Hugh Thornhill, president of the
OhioHealth Physician Group, which employs over 700 physicians. "I'm trying to get a lot of that load off the physicians' shoulders, to have them move into a care team coaching role, plus taking care of our sickest of the sick patients."
Team-based care is essential to achieving this goal.
"More and more, our physicians are providing leadership for teams or providers that include folks from a variety of healthcare disciplines," says Bruce Vanderhoff, MD, MBA, senior vice president and chief medical officer at OhioHealth.
OhioHealth is achieving this, in part, by embracing the patient-centered medical home model. The organization has 39 primary care practices that are qualified for Comprehensive
Primary Care Plus (CPC+) under CMS.
"It is indeed a model of multidisciplinary care, but one that really enables our medical staff, our primary care physicians, to focus appropriately on their patients' care where their expertise and advanced knowledge is most needed," Vanderhoff says.
Additionally, OhioHealth is working to prepare physicians and other providers in this model of care through a partnership with Ohio University's Heritage College of Osteopathic Medicine. In 2014, the first group of 50 medical students began courses at the college's Dublin extension campus. The partnership expanded clinical, residency, and fellowship opportunities in central Ohio and through the OhioHealth system.
"They are a medical school whose history has been to support primary care, so we've worked very closely with them," Vanderhoff says. "Simultaneously, as we've worked to grow and expand the medical school class, we've worked with them to also develop training of some of
their advanced practice providers, very specifically, their physician assistant school."
The two organizations are also exploring similar work with the school's nurse practitioner program.
"The pipeline is a very important part that we have invested in. I think there's no question that we're going to need more physicians than we have been historically producing, but I would agree with the assessment that the solution involves developing care providers across multiple disciplines," he says.
OhioHealth hopes its commitment to team-based care will appeal to the providers who have trained in this collaborative care model.
"As we're going down the patient-centered medical home and the CPC+ journey, [we want to] hardwire that experience for our physicians through their residency training directly into our practices," Thornhill says. "If I'm finishing as a resident, and I know how it works in my residency program, I know if I go to another practice in OhioHealth, it will feel like that. It will have the same resources available."
Grow your own
Healthcare leaders at Fairview Health Services, a nonprofit health system with 11 hospitals and 56 primary care clinics in Minneapolis, recognize that investment in the clinician pipeline is essential to meeting the organization's needs.
"My point of view is there is both a skills shortage and a people shortage. What we're having to do to fill critical shortages—what we have to do to pipeline people in—it's a different game now," says Laura Beeth, system vice president of talent acquisition at Fairview. "We have to really balance our short-term recruitment with looking at incentives and sourcing, but we have to augment that with pipelines of really thought-out career pathways and academics."
At Fairview, this means prioritizing training for positions such as medical assistants, surgical techs, psychiatric associates, and nurses. The organization is doing this through registered apprentice programs, dual training, career pathways, local hiring strategies, and internship programs.
In 2015 and 2016, Fairview received two awards totaling $1,225,000 for apprenticeships grants from the U.S. Department of Labor to support 245 nurses and other healthcare workers to advance their careers, including moving from an ADN to a BSN.
To be recognized as a registered apprentice program by the DOL, programs must meet certain criteria such as 2,000 hours of on-the-job training, a progressive wage scale, and a specific number of hours of safety and training in addition to an academic credential.
"It can't just be they're learning something on the job. It has to be that they're getting a formalized credential, either a degree or something that has a test behind it, or a one-year program credential that's recognized nationally," explains Beeth. "We map out the competencies, and those competencies have to equate to that higher level of learning, higher level of wages, higher level of experience."
Currently, there are 126 employees in Fairview's apprenticeship programs.
"The idea of, ‘What are we doing to prepare for the future?' is really critical," says Carolyn Jacobson, chief human resources officer at Fairview. "The shortages right now are really challenging for our operational leaders. [We need to be] thinking about how we create programs and processes to continually build our talent pool so that our time to fill is as short as possible [to] lessen the impact on our operational areas."
This requires looking not just at the number of clinicians but their skills and experience as well.
One example of this is operating room nurses.
According to the 2014 Association of periOperative Registered Nurses Salary and Compensation Survey, approximately 13% of the 3,437 respondents were at least 60 years old; 38% were in their 50s; 27% in their 40s; and only 23% were under age 40. Of the perioperative nurses surveyed 64% planned to retire by 2022.
"In nursing, we're seeing some of the same trends, where you have older nurses in the operating room, older nurses in behavioral, older nurses in PACU," Beeth says.
That is why the organization has developed an internal program to train nurses in the perioperative specialty so that they can fill critical perioperative nursing vacancies within Fairview.
As part of the perioperative program, the cost of each nurse's education is paid and nurses earn a salary while they learn. The program includes classroom, lab, and clinical practicum and lasts about six months. Those who complete the program commit to working in an accepted position for a minimum of two years.
"Ninety percent of the nurses hired in our periop areas come from our internal operating room program," Beeth explains. "We run that program proactively several times a year, because as an aging workforce, people are exiting, but we're also training all year long on that. In addition, perioperative skills are not part of the prelicensure nursing curriculum while they attend college, so it is critical we have pipelines in place to teach these additional skills."
Beeth advises leaders not to overlook nursing students or new graduates as potential employment candidates.
"As the workforce ages and we have less people coming into healthcare, you're going to end up with this imbalance somewhere."
"Ideally everyone wants an experienced nurse—baccalaureate or above—but you have to be open to absolutely looking at new grads," she says. "You're not going to get out of this challenge without doing some work to invest in the new grad's journey to become a nurse," she says.
Last year, Fairview converted about 600 students, in nursing and other fields, to new hires.
"Those numbers are because you're working with them, people are familiar with them, and they want to hire them," she says.
This familiarity occurs in a few ways. Fairview has a formal summer nurse internship program for all newly hired nurses, in which nurses earn both academic credit and pay. Those students are also given conditional job offers a year in advance.
"That last year they're in school, we continue to place them in their clinical experience, and a high percent of those people are placed on the unit they're eventually going to work on," Beeth says.
All told, 46% of the students are hired in the same unit in which they interned.
The organization also tries to place students completing their capstones in an area of interest.
"Those are all deliberate attempts to place them here, and actually do it in a way that makes sense," Beeth says. "What we're seeing is a 50% decrease in cost for onboarding when those students are hired."
Once they begin working as fully licensed RNs, new nurses with under two years of experience are automatically enrolled in Fairview's nursing residency program.
Beyond nurses, Fairview collects its own data on 38 different healthcare job classes and compares it to other health systems in the state.
"We can see risks, we can see retention, we can see age bands, all those kinds of things," Beeth says.
In collaboration with her HR strategy leader, Beeth is also gathering information on how much is spent on contingent workforce, succession information, internal turnover, or days to fill a vacancy to better help other leaders understand what the workforce and its issues look like at Fairview.
"It is something that we talk about at our regular senior operations team meetings," says Jacobson.
The group discusses how many roles are open, what the organization is doing to make sure those openings are filled, how to best recruit candidates, and what is the mixture of experienced staff versus new staff.
"The balance of making sure we do have the appropriate workforce, both in the future as well as on the ground, and that we're keeping our retention high and our voluntary turnover low, is really what we're trying to work through across the whole system," she says. "This is the nuts and bolts of what our operations are dealing with, and in order to be a great HR partner, we need to make sure we're providing the right people, data, information, programs, and processes so our leaders can do their jobs."
This article first appeared in the December 2017 issue of HealthLeaders magazine.
Talk of shortages usually centers around the clinician workforce, but Benjamin Anderson, MBA, MHCDS, CEO at Kearny County Hospital in Lakin, Kansas, says rural healthcare organizations are facing another less talked about shortage: hospital administrators.
"We're investing billions of dollars as a country into the training, recruitment, and retention of really good, full-spectrum family physicians," he says. "We're investing very little comparatively into the training, recruitment, and retention of really compassionate and competent rural hospital CEOs or healthcare delivery leaders."
According to a report released in February 2017 by the American College of Healthcare Executives, hospital CEO turnover was at 18% nationwide in 2016.
In the survey, Hospital CEO Turnover in Kansas by the Kansas Hospital Education and Research Foundation, 57% of 78 current Kansas CEOs reported they had been in their positions for three years or less.
This churn of administrative talent should be of concern to those in the healthcare industry.
"They help determine the culture. The culture determines whether people stay," Anderson says.
With the retirement of baby boomers on the horizon—49% of the current CEOs in the KHERF survey are 60 years old and older—it's time to be strategic about developing a new crop of leaders who are prepared to tackle the challenges facing rural healthcare.
"Most efforts in our country to train hospital leadership or healthcare delivery leadership are designed for urban centers," Anderson says. "And we have a class of baby boomers that are retiring right now, and we do not have an adequate farm team to replace them."
Over 70% of the organizations surveyed by KHERF said they did not conduct formal succession planning. Organizations with greater than $29 million in revenues reported conducting more formal succession planning than organizations with less revenue. Less than 6% of organizations with revenues less than $6.3 million reported conducting succession planning.
"We're not often enough selecting bright students that are good in business, and wooing them to hospital administration or healthcare delivery transformation," he says.
And even in the cases where there is a focus on healthcare administration, the emphasis is geared toward the needs of urban centers. "You look at the rural states where CEOs are turning over, and very often people come there, they want to build their career, and they leave," Anderson says.
To increase the interest in and retention of rural healthcare administration, Anderson suggests establishing a model to develop rural hospital CEOs similar to the Scholars in Rural Health Program at the University ofKansas' School of Medicine.
"They're strategic in selecting bright, young students in rural areas that are great in the sciences, getting them into good premed programs, selecting them out of those programs, and recruiting them into medical school," he says. "They're so strategic about that, and we're not doing that for leadership."
Anderson says one group that has the potential to be a good source of future rural CEOs is the millennial generation.
"I think they are more mission-driven or they have a social conscience or a sensitivity with social justice that comes with the access of information that's available now. [There is more awareness] of global suffering now because of the Internet, because of information channels, so they are very socially conscious," he says.
A new study published in October 2017 in Health Affairs seems to support Anderson's assessment that work with meaning motivates millennials.
Researchers at Montana State University found that millennials (born between 1982 and 2000) are becoming RNs at almost double the rate that baby boomers once did.
Additionally, they are 60% more likely than those in generation X (born between 1965 and 1981) to become nurses.
"We're not often enough selecting bright students that are good in business, and wooing them to hospital administration or healthcare delivery transformation."
"[Millennials] are driven by mission and purpose, and they want to be part of something that's greater than themselves, so it takes a culture that can attract them there. I would say, among many millennials, that culture is more attractive than the bright lights [of the city]," Anderson says.
Anderson acknowledges that many rural communities are dealing with challenges such as struggling schools, poverty, or poor health outcomes. While it may seem counterintuitive, being open about these issues may be key to attracting this group.
"To attract many millennials who are mission-minded, really the cream of the crop among the millennial generation, the ones who are servant-hearted, you have to identify and promote the need," he says. "We have immigrants driving for 2 hours to get to a Spanish-speaking obstetrician. We have women with female genital mutilation that are coming in to deliver a baby. That's real stuff. We're doing this in the rural community. If you want to do that, we're as competitive as anywhere in the United States.
"And as it's turning out, there are millennials that want to do exactly that. They're willing to live, as we've learned, far, far away from conveniences of an urban center, if where they live includes being part of a cohesive team and developing deep meaningful, family relationships with other people," he says.
Stress manifests among nurses in various forms and can affect patient outcomes. Fortunately, leaders can implement solutions to help reduce this pervasive problem.
Being a nurse can be fulfilling and rewarding. We get the privilege of helping new lives enter the world, comforting those who are exiting this world, and everything in between. Yet nursing is also taxing and draining at times. Off-shifts (nights and weekends), hectic workloads, violence from patients and families, and incivility among staff members can all cause physical and emotional wear and tear among nurses.
Unfortunately, issues like depression, burnout, and fatigue are extremely prevalent among nurses. As my fellow editor Alexandra Wilson Pecci writes in a recent article, one 2016 study found that nurses experience depression at twice the rate of those in other professions.
This is not just bad for nurses but bad for patients as well. Another study Pecci highlights found a link between nurses reporting poor health, particularly depression, and higher rates of reported medical errors.
That’s a serious issue and one that certainly needs to be addressed.
Some recent HealthLeaders articles offer solutions to address stress among RNs.
There’s a common belief that burnout is a personal failing and that resolving dimensions of burnout—emotional exhaustion, cynicism, inefficacy—are that individual’s responsibility. Eat a salad, go for a walk, take a yoga class and you’ll be fine. Rather, burnout is a sign something is amiss within an organization, and healthcare leaders need to uncover both the prevalence of burnout at their organizations as well as its root causes.
"There needs be a framework to understand where the pain points are, and then how an organization can do something about that," says Karen Weiner, MD, MMM, CPE, chief medical officer and CEO at Oregon Medical Group, a physician-owned, primary care–based multispecialty group of about 140 healthcare providers, with offices in the Eugene and Springfield area.
Weiner advises that leaders implement system-wide changes to address the factors contributing to burnout. After administering the Maslach Burnout Inventory at OMG, the organization made multiple changes including creating a physician-organization compact, developing new compensation practices, and redistributing workloads.
A 2015 Gallup survey found that more than half of all healthcare workers report they are thriving in none or only one element (purpose, social, financial, community, physical) on the Gallup-Healthways Well-Being Index.
To better help employees cope with the emotional demands of caring for others, some organizations are implementing programs to prevent problems like burnout, suicide, or substance abuse.
“Strategies that could support employees include reducing the stigma about mental health concerns, providing resilience training and care for the caregiver support programs, and providing health and wellness benefits, including policies that allow for time off for mental health concerns as well as for physical health concerns,” says Celeste Johnson, DNP, APRN, PMH CNS, a member of the board of directors of the American Psychiatric Nurses Association and director of nursing, psychiatric services at Parkland at Green Oaks Hospital in Dallas.
Another source of stress among nurses is workplace violence and cyberbullying meets that definition. Thanks to technology, bullying behaviors can now occur in digital form via means such as instant messaging, email, text messaging, social networking sites, or blogs.
According to the National Council for the State Board of Nursing’s policy on social, any online comments posted about a co-worker may constitute lateral violence—even if the post is from home during non-work hours.
To confront cyberbullying, individual nurses should save evidence of bullying comments. Then, during a private conversation, present the evidence to the person who made the comments. Document the conversation and its outcome and if there is a second instance of cyberbullying, report it to the nurse manager. If the behavior continues, alert the chief nursing officer.
Nurse managers should verbalize to their staff that there is a zero-tolerance policy for bullying of any kind, including comments made online. They should also educate staff on standards and polices regarding cyberbullying and take derogatory remarks seriously.
Creating a work environment that addresses issues that contribute to nurse stress and burnout is more than something that’s just nice to do, it’s also a way to improve patient care. There are plenty of reasons to improve. Research by Linda H. Aiken, RN, PhD, FAAN, FRCN, at the University of Pennsylvania has found patients who had surgery at hospitals with better nursing environments and above-average staffing levels have better outcomes at the same or lower costs than other hospitals.
To improve millennial RN retention, nurse leaders may want to consider appealing to this generation's commitment to service.
I had the opportunity to moderate breakout sessions with more than 30 top nurse leaders from across the country at the HealthLeaders Media invitation-only Chief Nursing Officer Exchange Nov. 6–8 at the Omni Scottsdale Resort & Spa at Montelucia in Arizona.
The two major discussion topics this year were new models of care and the nurse of the future. Those are, indeed, some hefty subjects to tackle, and, as always, there was rich discussion and sharing of insights and solutions, which I'll be unpacking in the coming months. So, stay tuned!
In my role as moderator, and as a writer and an editor, it’s my job to pose questions and then sit back and listen to what others say. But, since I am also a nurse, I often can’t help myself from formulating my own insights. As I’ve just wrapped up a cover story on clinician supply and demand that will publish in the December HealthLeadersmagazine, I’ve been thinking a lot about the state of the nursing workforce.
During the exchange, many CNOs spoke about the difficulty they have retaining nurses in the millennial generation. Unlike the baby boomers, who tended to spend their careers at one facility, millennials change jobs and even organizations much more frequently. Data from the national RN Work Project study finds that 26.2% of newly licensed RNs left their first nursing job within 25 months.
Does this mean that nursing churn will just be a fact of life?
Possibly. But, what would happen if nurse leaders were able to harness another trait typical of many millennials: the drive to make a difference.
According to a new study published in the October 2017 Health Affairs, researchers at Montana State University found that millennials (born between 1982 and 2000) are becoming RNs at almost double the rate that baby boomers once did.
Matching Missions
Could millennial nurse retention improve if organizations were able to match their missions to those of their new hires?
After all, most nurses went into nursing to make a difference in people’s lives. This desire to help was a central theme during the CNO Exchange’s storytelling session where CNOs shared personal stories of why they chose nursing.
Perhaps an opportunity to work at an organization that helps improve the health of patient populations who are dealing with poverty, poor health incomes, unemployment, or are part of an immigrant population could be attractive to a millennial nurse.