International nurses bring skills and experience to areas in dire need of nurses. Healthcare leaders need to articulate the value of these RNs to ensure they continue to flow into the nursing workforce pool.
For decades, healthcare organizations have been turning to international nurses as a way to address nurse staffing challenges.
"I've been a CNO since 2004, in various locations, and in every location I've had international nurses. For 13 years there has been a steady supply for healthcare organizations across the country, not just my hospital," says Pam Bradshaw, DNP, MBA, RN, NEA-BC, CCRN-K.
Bradshaw is chief operating officer and chief nursing officer at Shannon Medical Center, a 409-bed medical center in San Angelo, TX. The community of 100,000 people is located in the western part of the state.
"We've seen a dramatic uptick in demand [in international nurses]. We're getting a lot of inbound leads and people calling us. We're adding new clients all the time," says Shari Dingle Costantini, RN, MBA.
"Hospitals and health systems are really looking at international nurses and asking, 'How do we plug them in and how do we make them part of our solution?'" Costantini is CEO of Avant Healthcare Professionals, an Orlando-based staffing firm specializing in international recruitment of healthcare professionals.
But, just as the desire to employ international nurses has been on the rise, so too has political rhetoric regarding immigration.
"That's been something that we feel we've had to combat around the world," says Costantini, who is also vice president and chair of regulatory affairs for the American Association of International Healthcare recruitment.
A Brief History of Visa Policy Confusion
Even before he was elected president, Donald J. Trump was talking tough on immigration by calling for a wall along the U.S.-Mexico border and pledging to find and deport those without legal immigration status.
Once he moved into the Oval Office, his talk became action. In January, Trump issued a chaotically implemented travel ban that caught some international physicians, including a Cleveland Clinic physician with a valid H-1B visa, in its web.
That ban was blocked in court and a revised version is currently being scrutinized in a U.S Circuit Court of Appeals with speculation that it will ultimately end up before the U.S. Supreme Court.
In March, confusion over U.S. visa policy led to some Canadian advanced practice registered nurses working in Michigan healthcare systems to be turned away at the U.S.-Canada border. These nurses typically hold non-immigrant NAFTA professional visas called TN-1 visas.
Fortunately for them and for their US employers, the travel ban and policy confusion has not had a huge effect.
"The seven countries that were listed on the travel ban… represent a very small number of nurses, primarily because many of those countries just, from a cultural perspective, don't educate their own nurses," she says.
Because RNs in the U.S. are not required to have a baccalaureate degree to work at the bedside, they have managed to steer clear of issues that may arise from changes to the H-1B visa program, which allows highly skilled international workers such as physicians and technology industry workers into the U.S. in order to fill employment gaps.
"The H1-B visa that we hear a lot about in the news is for specialty professions that require a bachelor's degree or higher. So most nurses don't qualify, unless, say I'm bringing a clinical nurse specialist over and that position requires a masters' [degree]. That's why nursing has to go with this EB-3 visa (employment-based immigrant)," Costantini says.
Under current visa regulations, between 5,000 to 7,000 international nurses travel to the U.S. for work annually. Costantini estimates the total number of international nurses in the U.S. is around 400,000 to 460,000.
"That's not a huge number. It's not going to cure the shortage, but it's certainly going to help a lot in rural areas or areas or specialties where there's critical shortages," she says.
"Our nurses are filling an experience gap. Our average nurse has 6 to 11 years of experience. They're coming in and within a year of acclimating to a new environment, they become a preceptor. The other big benefit is that we put people on two- to two-and-half-year assignments, and at least in my company's experience, 75% of those nurses convert onto the staff of the hospital."
Rural Healthcare Needs International RNs
Like many healthcare organizations in rural areas, Shannon Medical Center has had challenges recruiting RNs.
"We do have two nursing schools here, which is great, but… when younger nurses graduate, they want to go to Dallas, Ft. Worth, Austin, San Antonio—those places where they can get that big city experience," Bradshaw says.
"From a complexity and acuity perspective, we provide that same level of care, but it's the appeal of the nightlife and the restaurants and the shopping that we battle as well."
About two years ago, just after Bradshaw came to Shannon, the organization had begun to look at international nurses as a workforce solution.
"We were forced into the position because our local university went from an associates' degree program to a BSN program so there was a lag of supply and increased demand with retirements and everything else that's going on in healthcare," she says.
About a year and a half ago, 15 international nurses came onboard at the organization.
"We quickly realized that in order to accommodate growth, we really needed more [international nurses] than that," Bradshaw says. Presently, the medical center has between 600 and 700 RNs. Ten percent of those (60) are international nurses. They come from variety of places including the Philippines, Nigeria, and the Caribbean.
"We have had great success with [the international] nurses. Last month, our Daisy award nurse was one of our international nurses and she is from the Caribbean. We're only about year in, but so far they're doing well," she says.
Bradshaw hopes once their contracts are up, the international nurses will choose to stay. "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.
A Multi-pronged Workforce Development Approach
"As you know, there's no magic bullet. You have to have multiple options or multiple solutions to really make sure you're addressing staffing in a comprehensive way," Costantini says.
To ensure international RN remain a viable component of the workforce pool, Costantini advises healthcare leaders to advocate for the value of international nurses.
"Our biggest challenge is getting the message out to lawmakers. If international healthcare professionals are important in their [healthcare leaders'] organizations, they [need to be] sharing that," she says.
"Although the U.S. wants to hire Americans, we also want to care for Americans. We won't be able to deliver patient care to Americans if we don't have enough healthcare professionals."
Advanced practice RNs improve quality outcomes across the care continuum in multiple ways, including decreasing readmissions.
This article first appeared in the June 2017 issue of HealthLeaders magazine.
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.
Some organizations, like Englewood, Colorado–based Catholic Health Initiatives, a nonprofit health system with operating revenues of $15.2 billion in fiscal year 2015, have already recognized that a bright future will require them to alter care delivery models to meet the demands of the nation’s changing healthcare system.
"We were beginning to look at what was going to be happening in the future and where we were going and all the different things that we needed to do to increase quality and decrease costs at the same time," says Kathleen D. Sanford, DBA, RN, FACHE, FAAN, senior vice president and chief nursing officer at CHI. "We were also looking at the types of shortages we were going to have in the future, and we figured out that there is no way that we are going to be able to continue doing things the way that we are doing things right now."
To help plot a new path, leaders at CHI compared evidence on quality outcomes of advanced practice practitioners (advanced practice RNs [APRN]—also referred to as APNs—and physician assistants) to quality outcomes of physicians.
A large body of evidence has found that APPs produce quality outcomes similar to or better than physicians. For example, a systemic review of 71 studies published from 1990 to 2009 found that clinical nurse specialists, certified nurse midwives, and nurse practitioners produced quality, financial, and clinical outcomes that were equal to or better than physicians.
At the time it was done, there were not enough studies on certified registered nurse anesthetists that met the criteria to be included in the review. However, newer studies have found that CRNAs and physicians have similar complication and mortality rates, and care by a CRNA did not increase risk of harm to patients.
Based on evidence, CHI made a commitment to strengthen advanced practice across the organization, including hiring Michelle L. Edwards, DNP, APRN, FNP, ACNP, FAANP, as system vice president, advanced practice.
"We want to use more advanced practice practitioners. We want to move into a team care model because everything we looked at said that was where we needed to go if we were truly going to keep people well, as well as take care of them in the hospital, across the care continuum, and as populations," Sanford says.
CHI isn’t alone in recognizing how valuable APRNs can be in affecting clinical, quality, and financial outcomes. Organizations around the country are also increasing their use of APRNs, and some are already seeing quality outcomes improve as a result.
Improved readmission rates
A few years ago, Judith Kutzleb, RN, DNP, CCRN, CCA, APN-C, vice president of advanced practice professionals at Holy Name Medical Center was given carte blanche to design a new nursing care model at the organization, a private nonprofit 361-bed acute care hospital in Teaneck, New Jersey. After working with a subcommittee of APNs, she launched the NP Care Model in 2012, a patient-centered collaborative care model.
"The nurse practitioner is the conduit throughout the disciplines in order to make the patient experience and outcomes the very best, and that’s basically how we designed the model. Then we looked at the framework of complementary responsibilities that an APN possesses and what would bring relevance to the program such as, 'What are the opportunities for the physician? What would be the organizational benefit? And is there a return on investment?' " Kutzleb says.
The model’s goals were threefold: Reduce 30-day readmissions by 11% over 12 months, decrease cost per case, and enhance quality patient outcomes through NP-directed patient education on disease self-management.
The program, which originally focused on heart failure patients, far surpassed these initial goals. Over a 12-month period, 30-day readmission rates dropped to 8% from 26%. Healthcare costs for the group of 312 patients receiving care via the NP Care Model was $311,818 during the 30 days after discharge. Prior to its implementation, cost of care for this patient population during the 30 days postdischarge was $1,019,405.
The drop in recidivism went beyond the initial 30-day discharge period. The 60-day and 90-day readmission rates for the group receiving care through the model were 4% and 3% compared to 27% and 29% in a group receiving typical care.
Because of these significant results, the model has expanded beyond heart failure patients, and advanced practice providers are being added to more of the medical center’s service lines, including cardiology, chronic care management, oncology, and genetics. Presently, there are approximately 40 advanced practice providers (including PAs) at Holy Name, up from five in 2009.
Sheryl Slonim, DNP, RN-BC, NEA-BC, APN-C, executive vice president, patient care services and chief nursing officer at Holy Name says her vision is to continue to expand the number and use of APNs at the organization.
"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?" she says. "What I don’t think people realize are the many different roles and areas where APNs can function. Whether it’s in the home, whether it’s in the community, whether it’s in the hospital, whether it’s in long-term care, whether it’s in subacute, whether it’s in a surgery center, 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?"
APRNs at CHI have also delivered strong results in terms of patient outcomes, Edwards says.
In the organization’s Nebraska division, an NP-run program in skilled nursing facilities has grown from three NPs to nine over the past 11 years. Working in collaboration with a physician, the NPs see more than 2,000 unique patients a year, up from 300 when it began. The readmission rates for patients in the program are around 12%, double digits lower than the national hospital readmission rates of 25%.
By working collaboratively with the SNF nursing and therapy staff, the team has been able to identify and resolve barriers that prevent patients from being discharged home. During the first six months of fiscal year 2017, length of stay at the SNFs decreased by 3.68 days—or 8.6%—compared to the same time period the prior year.
Based on a projected volume of over 2,200 unique patient admissions, this reduction in SNF length of stay would result in nearly $2.7 million in savings for fiscal year 2017.
Additionally, no negative effect on clinical outcomes, including hospital readmissions, was seen as a result of the shorter lengths of stay. In fact, the cost-avoidance savings for thwarting preventable rehospitalizations in fiscal year 2016 was $1.8 million.
In a different CHI division, a comparison of NP utilization within the orthopedic group found that patients cared for by orthopedic teams with NPs integrated into the team had lengths of stay that were one day less than orthopedic teams without NPs.
Edwards says performance indicators and metrics—like how often a provider is meeting CMS core measures—should be applicable to APRNs, PAs, and physicians.
"Excellent care is excellent care," she explains.
Challenges to APRN use
Despite the benefits APRNs bring to organizations, there are still challenges about whether they are used to their full potential.
As Edwards points out, granular data collection regarding APRNs is a work in progress.
"Because of CHI’s sheer size, and the various EHR platforms that we have today, we’re still working on trying to establish a process where we’ll have an enterprise view of the APC performance on the various metrics," she says.
CHI employs 1,600 advanced practice providers, operates in 18 states, and has 103 hospitals plus an array of other facilities and services across the inpatient and outpatient continuum, including community health-services organizations, home-health agencies, and living communities.
UK HealthCare, a Level 1 trauma center and academic research institution made up of hospitals and clinics of the University of Kentucky in Lexington, has also seen challenges collecting specific data on APRNs.
"We’re in the process of having a switchover from our data warehouse, so we’ve had a hard time pulling the individual (APRN and PA) data because of the way our system is set up. Our information technology system is evolving to help us pull a lot of those data," says Lacey Troutman Buckler, DNP, RN, ACNP-BC, APRN, NE-BC, assistant chief nurse executive, advanced practice and strategic outreach, and director of cardiovascular nursing services and the office for advanced practice at UK HealthCare.
Another challenge is ensuring standardization of practice, duty, and roles among all APPs across an organization.
In 2008, when UK HealthCare made a move to grow its advanced practice offerings, there were about 80–90 APPs throughout the organization. Buckler embarked on an assessment to better know how and where these practitioners were functioning in the system.
"We were trying to get ourselves prepared because we knew advanced practice would expand in both inpatient and outpatient,” Buckler says. "We wanted to make sure that we had our arms around what advanced practice looked like here, and if we were going to increase that model in the future, how we would do that."
One thing that became apparent was the need for consistency and standardization of practice.
"We had a lot of opportunities to standardize our approach to advanced practice here," Buckler says. "We realized at that point we had lots of great work going on, but we wanted to make sure that there was some way to connect these providers to a professional home that understood what their role was and understood how we could support them in practice."
Hence, the creation of UK HealthCare’s office for advanced practice. The office standardized job descriptions, restructured compensation, and continues to act as a resource for scope-of-practice standards for the organization’s more than 400 APPs.
Vicky Turner, RN, DNP, ACNP-BC, APRN, CCRN, is the former codirector of the office for advanced practice, where she was able help others, including physicians, understand APRNs’ scope of practice.
"It took, and continues to take, a lot of education and reeducation. Nearly every time we meet, I have to say, 'Oh yes, this is within the scope of practice of APRNs,' or 'Oh no, we cannot be doing those kinds of things.' But I have to say this group is very established," Turner says.
Holy Name’s Slonim agrees that education is needed on APN scope of practice.
"I think the biggest barrier is people understanding the role," she says. "Once the public accepts what the APN does and embraces it, then there really isn’t a barrier. Once they grasp the concept of partnership between the APN, the physician, and the patient, that’s when the silos break off, and it just becomes a solid continuum."
And, as Kutzleb points out, solidification of the care team produces the goal everyone is after—better patient care.
"I look at it as a partnership, and in a partnership, if I bring my best to the table, and the physician brings his best to the table ultimately, the patient’s going to win," she says.
Three nurse executives share the challenges they've faced and the solutions they've developed to effectively staff their clinical management teams.
Healthcare is complex (who knew?) and so is staffing the nursing workforce.
It's not enough to follow the basic "a nurse is a nurse" equation. In addition to filling open positions, it's essential that the positions be filled with RNs who have the right experience and the right skills to provide quality nursing care.
Earlier this month, I moderated a panel discussion during the 2nd Annual Nurse Leadership Summit at the 14th Annual World Health Care Congress Washington, DC.
During the session, titled Challenges and Solutions to Staffing Your Clinical Workforce, three nurse executives covered a variety of topics related to the nursing workforce. Our conversation covered the challenges and solutions related to staffing the clinical management team. The transcript below has been lightly edited.
Teresa Fisher, RN,
COO and CNO, Lakewood Health System
Staples, MN
Like many organizations, we've found that some of your greatest nurses are promoted to managers and, while they're great clinicians and great nurses, they don't always have the tools to be successful nurse managers. We did implement a couple of different things [to address that].
One is our VIP program. All nurse leaders and nurse managers new to management are assigned a VIP, so for one year they are mentored with either a director or one of our executives. We have a requirement that all our executives mentor two to three new managers every year. We've done a lot of investing in how to have the right conversation, the right timing of that conversation, as well as just investing in them as leaders.
The second thing we did was bring in a company called GiANT to work with our leaders. [Their program is] all about learning about who you are, how you handle stress, and developing as a leader. We did that about two years ago, and it's been very successful.
We are seeing a huge transformation in our culture and our nursing leaders are stepping up. They're not just seeing themselves as nurses, they're seeing themselves as leaders who have an obligation to our patients to manage every situation even if it's tough.
We also noticed many of our nursing leaders had never had formal training when it came to budget and budget process. We have a whole online option for our nurses focusing on the budget—how to manage your budget, how to put in capital requests, etc. There are classes they can take and some are required when they come into the role.
The Healthy Nurse Healthy Nation Grand Challenge offers nurses an opportunity to give themselves the gift of good health.
Keeping with my annual Nurses' Week column tradition, I'd like to talk about gifts—and not mugs and lunch bags. In the past, I've written about intangible gifts such as mentorship, compassion, and happiness.
Since the American Nurses Association has declared 2017 The Year of the Healthy Nurse, this Nurses Week I'd like to encourage RNs to give themselves the gift of good health by joining the ANA's Heathy Nurse Healthy Nation Grand Challenge.
We know it's challenging for nurses to engage in healthy behaviors. The ANA's 2016 Health Risk Appraisal found that RNs and nursing students:
On average, had a BMI of 27.6 (overweight)
12% have nodded off while driving in the past month
Only 16% eat the recommended daily amount of fruits and vegetables
Less than half perform the recommended quantity and time of muscle-strengthening exercises
"We know that nurses on average are less healthy than the average American," says Jaime Murphy Dawson, MPH, director of program operations and nursing practice and innovation at the ANA.
"There's a lot of reasons for this, one being that the work environment can be very stressful. Of course healthcare services are needed 24 hours a day, seven days a week, and nursing and healthcare pose some unique hazards to workers."
The Heathy Nurse Healthy Nation Grand Challenge is designed to give nurses the tools, motivation, resources, and social connections to improve their health.
"When nurses are healthy themselves, they are more credible role models, educators, and advocates for their patients," Dawson says. "They're more likely to counsel their patients about health behaviors when they themselves are healthy."
5 Areas of Good Health
Launched on May 1, The Healthy Nurse, Healthy Nation Grand Challenge is a national movement to improve the health of the nation by improving the health of nurse by broadly connecting and engaging individual nurses and partner organizations to take action within five areas:
Physical activity
Rest
Nutrition
Quality of life
Safety
The ANA has launched a web platform where individual nurses and employers of nurses, schools of nursing, nurses associations, can join the grand challenge. Once they register on the website, individual nurses take a brief health survey and get a "heat map" of their health risks.
Nurses can then make a health commitment in one (or more) of the five areas above. They can also participate in health challenges and connect with other nurses through social media and discussion boards. The ANA is providing content and resources to help nurses make improvements in the five domains.
Participants can retake the health assessment annually to gauge how far they've come with their health commitments.
The ANA is also encouraging organizations to get involved in the grand challenge. Organizational partners include employers of nurses, schools of nursing, specialty nursing associations, state nurses associations, and any company or group that could influence the health of nurses.
"What we're asking them to do is make a specific commitment at the organizational level to improving the health of nurses," Dawson says.
"We're asking them to make a measurable commitment that they can report back to us so we can then share [the results] with other organizations. The idea is we want to highlight successful initiatives."
For example, one organization is making a commitment to improving the quality of food in its vending machines and another is focusing on improving its safe patient handling and mobility programs to reduce injuries. Several state nurses' associations are hosting 5K walks and runs.
Individual nurses and organizations can register for the grand challenge at any time throughout the year and movement will continue far beyond 2017, Dawson says.
"We want people to be onboard, but we want to make sure they're having meaningful conversations about improving health and that policies are changing in the workplace to support the health of nurses," Dawson says.
"We know that until that happens, we can ask nurses to make healthier choices, but they need to be supported by their employers and supported by healthy workplace policies. So that's really success in our eyes is that engagement and that action."
Patients treated with methadone during spinal fusion surgery required less hydromorphone and reported improved satisfaction with pain management.
Patients who received intraoperative methadone during spinal fusion surgery required less postoperative opioid pain medication and reported decreased pain scores and improved satisfaction with pain management, finds a study published in the May issue Anesthesiology.
For the study, 115 patients were randomly assigned to one of two groups. One group received methadone at the start of surgery while the control group received hydromorphone during surgical closure. Hydromorphone was also given to both groups to treat postoperative pain.
To gauge methadone’s effectiveness in reducing postsurgical pain, researchers measured how much hydromorphone patients took during the first three days after surgery. Patients’ pain scores and satisfaction with pain management were also measured during that time.
Patients who received methadone required less hydromorphone than the control group (a median of 5 mg vs 10 mg) on the first day after surgery. On postop day two, patients in the methadone group required less than 1 mg of hydromorphone while the control group required 3 mg. By day three, patients in the methadone group no longer required hydromorphone while the control group required less than 1 mg.
In addition to less postoperative opioid medication, patients receiving methadone reported lower pain scores at rest, with movement, and with coughing than the control group. The intervention group also reported higher satisfaction with pain management than those receiving hydromorphone alone.
“This is a new application for an old pain medication that offers hope for reducing the development of acute pain in the first few days after surgery, as well as chronic postoperative pain and the need for opioid medications following discharge from the hospital,” Glenn S. Murphy, MD, lead study author and physician anesthesiologist at NorthShore University Health System in Evanston, Illinois, said in a media statement.
“There is currently an opioid crisis in the United States, and intraoperative methadone offers promise as a drug that can reduce the need for these pain medications during recovery.”
Indeed, data on the prevalence and cost of prescription opioid abuse is alarming. According to the CDC, the rate of overdose deaths involving opioids (prescription opioid pain relievers and heroin) has quadrupled since 1999, and over 165,000 people have died from prescription opioid overdoses. The agency estimates that prescription opioid abuse results in over $72 billion in medical costs each year.
To help combat prescription opioid abuse, the CDC issued guidelines for prescribing opioids for chronic pain in March.
The Relationship-based Nursing Workforce Pipeline Model takes a comprehensive approach to workforce planning with the help of stakeholder ethics, systems science, and branding.
There's a tendency to view nursing shortages as cyclical events that come and go. But, nurse leaders may do well to move away from a strict recruitment and retention mindset by applying a more comprehensive approach toward RN supply and demand.
"We really have to change our thinking from the nursing shortage [being a] cyclic idea to really understanding nursing supply and demand in terms of economic and non-economic factors," said Richard Ridge, PhD, MBA, RN, CENP during his presentation at AONE 2017 in Baltimore.
Ridge acknowledged that the nursing workforce is a major concern for nurse leaders.
"Many of us spend inordinate amounts of time on this issue—developing our workforce, understanding our workforce, preparing our workforce, presenting business plans for FTEs as we move forward trying to meet the needs of our patients," he said.
Drawing on both his own experiences and those of his colleagues, Ridge developed the Relationship-based Nursing Workforce Pipeline Model as a way of assessing and planning nursing workforce needs.
"It's a model that, hopefully, you can look at and try to better conceptualize your own plans," he said. "Nothing here is presented as a recipe; it's really presented more to open up possibilities."
Three Pillars
The three theoretical underpinnings of Ridge's model are:
"That's really the major theoretical underpinnings of a good, effective workforce model," he said.
Stakeholder Theory
This emphasizes the need to identify all stakeholders, including primary, secondary, and tertiary parties, and understanding what makes them successful. These stakeholders can include nursing schools or even competing organizations.
"It doesn't necessarily mean you have to help them be successful, but it does mean that you have to understand how they define success," he explained.
Systems Theory
By applying systems theory, nurse leaders consider nursing workforce issues at the macro, meso (intermediate), and micro levels.
"Macro could be considered what's happening in the country, what's happening at the state level," Ridge said.
Nurse leaders need to understand the macro level data—like HRSA workforce projections and state workforce center supply and demand reports—and then consider how it affects the nursing workforce at the local level.
"What does that have to do with your hospital, your organization, your county, your city? It's the context," Ridge said. "Our plans are at the local level, but within the context of the overall."
Individual facilities are considered the meso level and the interacting departments are the micro level, Ridge explained.
"One of the big pitfalls when we don't think of systems is we end up with department level programs. Everybody's working on their own thing… and what it's called in systems theory is suboptimization," he said.
"All these little micro units, departments, might be doing a terrific job, but in the whole scheme of things, then at the meso level, your organization's level, you're really not seeing synergies, you're not seeing the outcomes that you need."
Nursing is a Brand
The third underpinning is development of a nursing brand. Many hospital and healthcare system brands market the organization's services to the community, Ridge said. But leaders also need to be mindful about marketing their organizations to prospective employees.
"When we look at brands, at many hospitals, it's really two approaches. We're marketing our services to the community and then we market our brand as an employer," he said. "Look at your own organizations and see how you're tying the two brands together."
A few years ago, when Ridge was assessing how Magnet designation and nursing was portrayed on hospital websites in New Jersey, he found that 30% of Magnet hospitals mentioned they had Magnet recognition but only 20% identified their CNOs.
Data Matters
Of course, even when taking a comprehensive approach to nursing workforce planning, nurse leaders need to assess and adjust their workforce plans based on data.
"You must have metrics that strategically support change at all levels," he said.
Informal caregivers, postacute care connections, and direct care worker compensation can all influence patient outcomes positively.
Healthcare leaders are constantly on the lookout for ways to improve patient outcomes, especially preventing unnecessary readmissions and staff turnover.
A few recent HealthLeaders articles show how organizations can achieve the goals of value-based care by educating informal caregivers, strengthening connections across the care continuum, and improving direct care worker compensation.
According to the research report Caregiving in the U.S., published in June 2015 by AARP's Public Policy Institute and the National Alliance for Caregiving, about 43.5 million U.S. adults had provided unpaid care to an adult or a child in the 12 months prior to the data collection.
Another study found that when unpaid caregivers such as spouses, partners, family members, or friends are included in discharge planning patient outcomes improve.
In fact, when unpaid caregivers of elderly patients were systematically integrated into discharge planning there were 25% fewer readmissions at 90 days and 24% fewer readmissions at 180 days.
The interventions used to integrate the caregivers varied. Some connected patients and caregivers to community resources, others focused on medication reconciliation, and others incorporated learning validation like teach-backs to a nurse.
2. Improving Postacute Care Reduces Readmissions
Hospital and healthcare systems are recognizing that consistent care across the continuum is a must in order to meet the goals inherent in value-based care.
Forming strong partnerships with postacute care providers such as skilled nursing facilities is one way to improve patient outcomes and to reduce readmissions.
Reducing Readmissions From the Postacute Setting, looks at a variety of ways acute care and postacute care facilities are working together to improve patient outcomes including standardizing care with "readmission bundles," using telemedicine to connect SNF nurses with acute care nurse practitioners, and having health system NPs onsite at specific SNFs.
3. Raising Direct Care Workers Wages Improves Care Quality
Good certified nursing assistants are worth their weight in gold, but unfortunately their pay doesn't always reflect that.
While the Bureau of Labor Statistics projects employment growth for personal care aides will grow by 26% through 2024 (and by 38% for home health aides), some are currently paid as little as $8.00 an hour.
Low pay can contribute to recruiting and retention woes. High-turnover rates in turn, can affect the quality and consistency of patient care.
In addition to raising wages, other ways organizations can improve direct care employee compensation is by providing healthcare or childcare benefits as well as career growth opportunities.
Educational debt is a leading factor in nurses' decisions about academic progression, study data shows. Mentoring students about financial matters such as responsible borrowing may help.
Students are graduating from college with significant amounts of educational debt—in 2015 the average student borrowerhad $30,100 in loans upon graduation—and a recently published study finds that nurses are no different.
When Jan Jones-Schenk, DHSc, RN, NE-BC, national director for the college of health professions at Western Governors University, surveyed 1,299 working nurses for the study, 62% of the respondents reported they had prior college debt.
More than 39% of those with debt said their debt ranged from $1 to $24,999 while 23.5% reported debt greater than $25,000. Approximately one-third of the respondents said they had no prior college debt.
"Some had debt as high as $100,000, and 7% reported debt greater than $50,000. That's a lifetime of debt," Jones-Schenk says.
The study also found that educational debt influences nurses' decisions about academic progression.
"The data showed that most of the people who have an education plan are going to go on, and they have debt," she says.
"But if they have more than $10,000 in college debt they're going to delay their educational advancement so they're not going to go on as quickly."
Debt's Influence on Education Decisions
When the National Academy of Medicine (formerly the Institute of Medicine) report, "The Future of Nursing: Leading Change, Advancing Health," was released in 2010, it had very specific recommendations on the educational preparation of RNs.
The report called for 80% of nurses to hold a baccalaureate degree by 2020, and for the number of nurses with doctorate degrees to double during that time as well. It also called upon healthcare organizations to encourage nurses with associate's and diploma degrees to enter baccalaureate nursing programs within 5 years of graduation, and for accredited nursing schools to ensure that at least 10% of all baccalaureate graduates enrolled in master's or doctoral program within 5 years of graduation.
"We all understand the basis of that," Jones-Schenk says. "But I do think that nurse leaders may not understand that while they may offer tuition reimbursement or other incentives for their staff, they may not be aware of the current level of debt those people have already."
While nurses with ADNs may want to obtain BSNs, they may already carry a large amount of educational debt from their associate's degree program.
"Because I do have students in all 50 states, I was seeing programs where students were coming to me with an associate degree and it seemed like their college debt was already pretty high," she says of her inspiration for the study. "Some of the associate degree programs were at $60,000."
The Need for Financial Knowledge
Jones-Schenk says good financial mentoring is one way to help nurses keep their educational debt in check.
"If [students] are eligible for federal financial aid or state financial aid, without good counseling they may take the maximum amount of eligibility. But they may not need all that," she says.
"In our university, we have a specific initiative called 'the responsible borrowing initiative.' We counsel students about how much borrowing they really need and not to over-borrow… so they're going to be able to go on without that debt as a barrier."
Nurses should also look at the overall cost of a program, even if a college or university is offering a discount to their employer.
"'If you're saying, 'Well, I'm going to go to the school that offers the 20% tuition discount vs. one that offers a 5% discount,' that percentage of discount is meaningless. What matters is the ultimate cost to the student," Jones-Schenk says.
"That's where I think a lot of people get hung up. They think they're going to go to a school because they offer a 20% discount, but the ultimate cost to the student is still $30,000 grand to the student vs. $10,000 [with a smaller discount]."
Responsibility for minimizing debt shouldn't be placed entirely on the student. Jones-Schenk says low-interest rate loans and loan forgiveness programs are tools that could help defray educational debt.
"Nurse leaders, people in higher education, the government and other individuals who have an interest in healthcare are all worried about healthcare costs," she says.
"This is part of it as well. I would hope that we would take a serious look at the cost of higher education and its value and contribution to the health of the nation."
"How many of you right now, if I asked, would say the two most important values in my life are one and two? How many of you could name them right off the bat? For me, it's courage and faith," Brown told the audience during the March event in Baltimore.
Though the answers undoubtedly vary from person to person, having clarity of values is essential to thriving as a nurse leader. "You have to know those [values] because when things get hard, you have to know why you're putting yourself though that," she said.
And as Brown has learned through 15 years of social science research on vulnerability, courage, worthiness, and shame—courageous leaders will experience difficulties.
One Thing is Certain
"The only guarantee I can give you is this: If you show up and be a brave leader, you will go down. You will get your ass kicked. You will be criticized. You will be made fun of. You will be put down. People will not understand you," she said.
The only way to for nurse leaders to recover from getting chewed up and spat out, is having clarity of their values.
"When you fall, you have to know why you are in there and why you are taking the risk. If your face is marred with dust and sweat and blood, and you're in the arena, and you're not clear about what took you in there, you will not survive it. You will not get back up," Brown cautioned.
Dare to be Brave
Brown spoke about how courage intersects with leadership. Contrary to common opinion, she said, courage is not about power. "It's about showing up. It's about persistence. It's about tenacity."
She named four elements that foster courage:
1.Vulnerability (uncertainty, risk, and emotional exposure)
2.Clarity of Values
3.Trust
4.Rising skills (the ability to reset after a failure or setback)
Joan Shinkus Clark, DNP, RN, NEA-BC, CENP, FACHE, FAAN, president of AONE and senior vice president/chief nurse executive of Texas Health Resources, has relied on these skills throughout her career.
"I am persistent in trying again when I believe in the purpose of something meaningful," she said during her keynote address.
Challenge: Take a Chance
Leaders need to take chances that may result in failure, be able to get up, and use what they learned to move forward, she told attendees.
"Successful leaders know the importance of reflection on actions and experiences to inform the future. They are willing to challenge themselves and others to take the next leadership step," she added.
And with that, Shinkus Clark issued a challenged to the nurse leaders in the audience to start getting into the habit of getting outside their comfort zones.
"If you know me well, you know I like to dare people. Actually, I like to double dog dare ya. I'm double dog daring you to push yourself here in Baltimore," she said. "[Connect with] people willing to give you a nudge, push you just beyond your comfort zone, and help you realize your full leadership potential."
Courageous leadership springs from the clarity of one's values and willingness to step beyond one's comfort zone, say two AONE 2017 keynote speakers.
Clinician burnout is pervasive in the healthcare industry, yet many healthcare leaders are unsure of how to solve the issue. If it is left unaddressed, healthcare organizations may experience quality, safety, and retention problems.
Signs of clinician burnout—a response to chronic workplace stressors—have become a reality in the healthcare industry.
"It's somewhere between 30% and 50% nationally in physicians and it is rising," says Mark Linzer, MD, FACP, director of the division of general internal medicine at Hennepin County Medical Center in Minneapolis, which includes a 484-staffed-bed safety-net hospital, downtown clinics, and a system of neighborhood clinics. "The data are pretty compelling depending on which instrument you use for measuring it."
A study published in the December 2015 issue of the Mayo Clinic Proceedings found just that. When researchers surveyed 6,880 physicians in 2014, 54.4% of them reported having at least one of the three components of burnout on the Maslach Burnout Inventory—emotional exhaustion, cynicism, and inefficacy—compared to 45.5% in 2011.
"With 50% of people experiencing at least one component of burnout nationally, you're looking at problems with morale and turnover. There are risks to patient safety, quality, and patient satisfaction, not necessarily from the burned-out physician, but from the adverse work conditions that led to the burnout," Linzer says.
The prevalence of burnout in healthcare should be cause for concern, not only for the clinicians experiencing it but for healthcare executives as well. Burnout is not, as many believe, a failing of an individual. Rather, it's a sign that something is amiss within an organization, and that systemic dysfunction can prevent an organization from achieving the desired outcomes of today's value-based care efforts.
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.
Measurement is key
Healthcare executives may be aware that burnout is common in the industry, but they seem to be less certain about the specifics of how it's playing out at their organizations.
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 throughout the Eugene and Springfield area, received 151 replies for her survey of three of AMGA's leadership councils (Chief Executive Officer/Board Chair/President council; Chief Medical Officer/Medical Director council; and Chief Administrative/Chief Operating Officer council) in the fall of 2015. The survey results show that 86% of CEOs, 86% of CMOs, and 81% of COOs reported that they thought burnout was a problem within their organizations. But when asked if they were doing formal assessments of physician burnout at their organizations, only 21% of CEOS, 18% of CMOs, and 21% of COOs said yes.
Linzer, who has been researching physician work-life since the 1990s, says measurement is key to tackling burnout.
"You can't reduce burnout without measuring stress and the things that cause it," he says.
He advises that leaders distribute an annual wellness survey like the 10-item Zero Burnout Program survey, also called the Mini Z, which he and his colleagues at HCMC helped develop.
"They should measure some metric of wellness that they can report—satisfaction, engagement, stress, burnout, turnover—but they should have something to point to about the health of their workforce," he says.
Once leaders understand the extent of burnout at their organization, they need to dig deep and discover what is causing the burnout, and work to address the root causes.
"You have to intervene and have some sort of infrastructure in place," he says.
According to Weiner's survey, this is where many healthcare executives are struggling to find answers.
In response to the survey question "As a healthcare leader, do you think you have a sufficient understanding of the causes of physician burnout?" 57% of CEOs, 65% of CMOs, and 42% of COOs answered yes. As to whether they felt that they were sufficiently addressing the organizational factors that contribute to physician burnout, only 23% of CEOs, 16% of CMOs, and 6% of COOs said yes.
Weiner is one healthcare executive who has sought to tackle burnout at an organizational level. In 2013, after stepping into a newly created full-time medical director role at the medical group, she got to work evaluating burnout at the facility and uncovering its root causes.
"I have no information at all that it had anything to do with burnout, but the fact is one of our colleagues committed suicide the year before. We were all quite shaken. I thought it important to measure what was going on in our organization," she says.
Weiner used the Maslach Burnout Inventory to gauge physicians' burnout experience.
The research tool was developed by Christina Maslach, PhD, professor of psychology at the University of California, Berkeley, who has studied burnout since the 1970s. It breaks burnout into the following three key dimensions:
Emotional exhaustion—feeling tired and fatigued at work
Cynicism—developing a callous or uncaring feeling, even hostility, toward others, including patients and colleagues
Inefficacy—feeling like you are not accomplishing anything worthwhile or making a difference at work.
Because burnout is complex, the MBI does not give a single score that determines the overall intensity of burnout. Rather, each component is measured on a subscale that looks at the frequency of a person's experience ranging from every day to never. For example, "Working all day with people is really a strain for me," or "I feel I'm positively influencing other people's lives through my work."
"The burnout measure is designed only to really assess people's experience. It doesn't measure causes," says Maslach.
Though the MBI is widely used to assess burnout, she cautions against thinking of it as a diagnostic tool.
"We weren't saying burnout was a disease. We were saying clearly people in various kinds of places and occupations that we've been studying are going through an experience that is really difficult," she says. "They get depressed, they quit their job, they don't show up, but making it a disease puts it kind of within the individual. It says the individual really is responsible for taking care of this, and it basically ignores [the question of] what is the environment and situation in which this is happening."
Weiner, who has worked at the medical group since 1997, describes the MBI as an instrument to take an organization's vital signs.
"It takes the vitals, it gets the current state, and then you need to do the diagnostics," she explains. "You need to find out what is going on in your organization."
After using the MBI, Weiner uncovered that 58% of the medical group's physicians reported experiencing at least one component of burnout, and 10% of the physicians were experiencing all three components.
Morale at the organization was low. On a 2012 AMGA employee satisfaction survey, overall satisfaction among staff was at the 18th percentile.
Physician engagement was poor as well.
"Nobody was showing up to meetings," Weiner says. "There were no department meetings in adult primary care. There was just a disengagement across the organization, and any attempt to change or do anything different was met with resistance and resentment and frustration."
She then began to delve deeper into the situation.
"You need to find out what is going on in your organization, because it can vary from department to department. You really have to use your diagnostic skills to figure it out, and then you have to do an intervention based on what you found."
Part of the issue may have been what attracted Weiner to Oregon Medical Group in the first place: a large degree of physician independence. They had the autonomy to train their medical assistants as they saw fit, to set up their patient templates the way they wanted, and to see patients at their own pace.
Yet, as healthcare changed, the group struggled to come together.
"In the late 2000s, we started to feel some of the pressures of the changes in healthcare, of some of the health plans expecting us to improve quality," Weiner says. "They were giving us feedback and measuring, and we didn't quite know what to do with it."
The organization reached its tipping point in 2011 with the implementation of its electronic medical record.
"It really highlighted the lack of standards that we had. Everybody practiced differently, and everybody collected data differently. That created a lot of frustration," she says. "We have 140 intelligent clinicians who went about figuring out how to collect data and put it in the EMR in 140 different ways."
The results of Weiner's 2012 assessment of the organization was proof things needed to change.
"It was a way to make the case that we can't stay here anymore. That this was unsustainable, that we needed to change, and we needed to do something different," she says.
Jack Silversin, DMD, DrPH, a consultant whom Weiner calls the "grandfather" of physician-organization compacts, was brought in to speak to the medical group. The organization's leadership met with the clinics' physician practice leaders and began having meetings to describe the organization's current state and to describe the future state they wanted to achieve. From those conversations, a one-sentence vision was crafted: "We collaborate to provide the highest-quality patient-centered care."
The vision may have been succinct, but it was a far cry from the organization's starting point.
"We weren't collaborating. We were siloed," Weiner says. "We all thought we provided excellent care, but we weren't really measuring it. We weren't doing process improvement, and we were physician-centered."
A physician-organization compact was created to guide both the physicians and the leadership toward their new vision.
"The next step was to look around and see: 'Is our system set up to help people achieve what it is we said we want to achieve?' Namely physician engagement and the change process," Weiner says.
This led back to the whole issue of those meetings and committees that no one was attending.
"We took all of the leaders of the committees and brought them into one think tank called the TIC—the tactics and implementation committee," she explains. "It takes a strategic plan, takes the feedback from what's going on on the frontlines, and synthesizes and prioritizes projects based on what we are trying to achieve strategically and what the pain points are out on the frontline."
When an issue "rises to the top," the committee calls a work group, which is headed by a physician who is knowledgeable about the issue. A charter is created so there is a beginning, middle, and end to the project, and there are deliverables and measurables to be met.
"There's an executive sponsor that's overseeing it and supporting it, and who's making sure it has all the resources it needs," she says.
The group's solution is piloted, and, if approved, it's implemented throughout the organization.
"The point is, it's results-oriented and it's prioritized based on pain points for physicians," Weiner says.
Other changes at the medical group include establishment of fair compensation practices and redistribution of workloads.
The changes seem to be having some impact.
On the MBI, 27 and above is considered high on the emotional exhaustion subscale. In 2013, the average emotional exhaustion number on the MBI was 27.7, and in 2015 it had dropped to 23.1, a moderate level (17–26 scores are considered moderate burnout levels on the MBI scale).
Reports of depersonalization dropped from 8.6 to 8.1 (between 7 and 12 is considered a moderate level on the depersonalization subscale) and a sense of personal accomplishment went up from 40 to 41 (39 and above is considered a high level of personal accomplishment).
Results on the AMGA employee satisfaction survey have showed improvement as well. Those reporting rewarding work went from the 8th percentile in 2012 to the 50th percentile in 2016.
In that same four-year period, AMGA employee engagement went from the 15th percentile to the 35th percentile, happiness with workload went from the 48th percentile to the 69th percentile, and growth opportunities went from the 30th percentile to the 65th percentile. Overall satisfaction among staff went from the 18th percentile to the 58th percentile, and staff satisfaction with physician interaction rose from the 8th percentile to the 50th percentile.
"It helped me to feel good that there's this ripple effect in what we're doing," Weiner says. "Our vision is of collaboration and pursuit of quality in patient experience so we have achieved a culture of collaboration. It's an expectation now, and it's what we expect of each other. It's how we do things around here. We have significantly improved our quality both on our internal measures and the feedback we're getting from our health plans."
But Weiner says the work isn't done, and realistically it may never end.
"Are we a culture of quality and safety yet? I think we're working on it. Are we a culture of being patient-centered? We're working on it," she says. "I don't think that there's an endpoint."
Demands vs. resources
When burnout occurs there's often an imbalance or mismatch between a person and his or her job. Decades of research by Maslach and her colleague Michael P. Leiter, PhD, have found these mismatches often occur in six key areas of the work environment:
Workload—the amount of work to be done in a specific period of time
Control—the opportunity to make choices and decisions
Reward—the recognition (financial and social) received for job contributions
Community—the social context of the work environment
Fairness—the presence of consistent and equitable rules
Values—the consistency between an employee's and organization's values
"Those are things that really put people in very difficult imbalances … and can predict burnout down the road," Maslach says.
Weiner says burnout is related to the ratio between demands and resources, and in today's healthcare environment, demands have grown faster than the resources needed to handle them.
"There's the workload of being a physician, the time demands, the intensity of the work—that's always been the case. But the inefficiencies and barriers to providing care have increased as well. In that ratio, when you're increasing those demands without increasing the resources, it contributes to burnout," she says.
And healthcare professionals need organizational support to bring that ratio back into balance. "It's not just a matter of if I, the provider, learn how to do this workflow, it's going to be OK," she says. "So what can an organization do to help? There needs be a framework to understand where the pain points are, and then how an organization can do something about that."
"One thing burned-out doctors reliably do is leave the practice. When people leave, it costs a quarter of a million dollars to replace them."
Linzer's own research has uncovered similar themes. In 1996, The Physician Worklife Study, a national survey of physician satisfaction funded by the Robert Wood Johnson Foundation, found that time pressure diminished physician satisfaction and that physicians were experiencing stress related to lack of work control.
The Minimizing Error, Maximizing Outcome (MEMO) Study published in Annals of Internal Medicine in 2009, looked at how organizational climate and work conditions affected clinicians and quality of care.
Among 422 physician respondents, 48% said their office environment was tending toward or, frankly was, chaotic, while 49% said their work was stressful; 27% noted burnout symptoms; and 30% said they were at least moderately or more likely to leave their jobs within two years.
"One thing burned-out doctors reliably do is leave the practice. When people leave, it costs a quarter of a million dollars to replace them," he says.
Even a modest investment in burnout prevention can yield positive results, says Linzer.
"It doesn't take too many folks to leave to easily pay for a wellness program. Certainly, that's more than our budget for just one person leaving," he says.
Linzer is speaking of HCMC's Office of Professional Worklife, a program that focuses on offering wellness services to improve the work lives of HCMC providers.
"Our task is to oversee the work lives of almost 800 providers here," says Sara Poplau, assistant director of the Office of Professional Worklife. "They engage with us in different ways. Every new provider that comes in gets a presentation from either myself or Dr. Linzer."
Poplau's office is in a busy area of the hospital, which allows for high visibility and easy access for providers.
"I will get some foot traffic from people who come by and say, 'I need help with this.' But then you talk to them and find out it's maybe this other thing that's causing stress," she says. "We can help connect them with someone who can advocate with them for changes or connect them with another department that had a similar challenge."
There is also a "reset room," a small, inviting space (there are flameless candles and a sound machine) where providers can go if they need some quiet time.
In addition to these types of programs, an organization must have policies, procedures, and protocols that create a healthy work environment where providers thrive.
In The Healthy Workplace Study published in 2015, Linzer and his fellow researchers identified three categories of effective interventions in regard to burnout: workflow redesign, communication improvement, and quality improvement projects.
For example, giving physicians control over how they balance their workload is one way to help control chaos and decrease burnout. And according to the "demand-control model" of job stress, a greater amount of demands calls for greater amount of control on the part of an employee.
"They need to get more control to figure out how to get that work balance and still get out at the end of the day," he says.
"How you organize and how you manage your personnel and how much you let it just be random motion will determine the difference between a hectic, chaotic place and a well-organized one."
Some interventions Linzer recommends are:
The use of scribes for alleviating stress from electronic medical records
Allowing for flexible scheduling that gives physicians the ability to work outside the 9-to-5 time frame
Scheduling uninterrupted "desktop time" for physicians to complete charting
Scheduling visits with more complicated patients earlier in the day
"How you organize and how you manage your personnel and how much you let it just be random motion will determine the difference between a hectic, chaotic place and a well-organized one," Linzer says.
Engagement is contagious
Around 2012, Thomas Jenike, MD, senior vice president and chief human experience officer at Novant Health, a not-for-profit, integrated system with 14 medical centers, 1,380 physicians in 530 locations, and numerous outpatient centers headquartered in Winston-Salem, North Carolina, experienced what he recognizes in hindsight as burnout.
"I was just stretched too thin, and I got to the point where I didn't feel, personally, like I was doing anything right or even up to my level of good," he says. "I'm not certain that anyone else would have said that. I still had great patient experience scores and no issues and everyone else said I was doing great, but I just didn't feel like I was."
When Jenike started his practice in 1998 he had no patients. But that soon changed.
"Part of that was I was always accessible and I was very attentive to all my patients and my partners. I was willing to work in extra people and extend my hours, and that really worked well to help build my practice pretty quickly," he says.
"I was just stretched too thin, and I got to the point where I didn't feel, personally, like I was doing anything right or even up to my level of good."
Even after he had built a successful practice, Jenike continued to work in the same way and at the same pace.
"I just kept running the same play over and over again even when I had a full practice and then started having administrative obligations and duties," he says. "That same model of saying yes to everything and trying to be responsible for everyone and everything, that just became overwhelming."
He says he felt a constant level of stress because he "wanted to make sure everyone was OK, but didn't feel like I was doing that."
Even though he was supposed to be practicing half-time as a clinician and half-time as a Novant Health physician executive market leader where he oversaw the health system's practices in a specific region of Charlotte, he still carried over 4,000 patients in his panel.
When he was at his administrative job, he was worrying about his patients. When he with his patients, he was worrying about the administrative job.
"The amount of joy and fulfillment from the patient experiences, which I loved so much, started to diminish," he says. "My patients would tell me how great I was and how much they loved me, but basically I got to the point where it was going in one ear and out the other. I just didn't believe it, so I didn't even take it in."
A recommendation for a youth hitting coach for his son was instrumental in turning things around. It turned out that Nicholas Beamon, the hitting coach, worked at a leadership development firm that specialized in personal and professional development. For six months, Jenike worked with Beamon, meeting with him twice a month for a few hours.
"We started around me getting more clear about how I got to the position I was in, what was working, what wasn't working, what adjustments I wanted to make moving forward to bring the fulfillment and joy back to my professional life, personal life," he says. "It was hard reflective personal work but well worth it."
Jenike discovered that he had committed himself to doing a number of things that didn't align with what was most important to him and what he was most passionate about.
"I knew that I wasn't alone, so I got very committed to creating something to help my partners and my colleagues," Jenike says. "I had read all about burnout. I have experienced it to a certain extent. This is very important to me that we create something with more of a proactive approach to physician resiliency and wellness."
Jenike started talking with Novant's system leaders, its CEO, and medical group president about their interest in him trying to develop a program for the 1,400 providers at Novant.
"Our CEO is very physician-friendly. He gets a lot of phone calls from doctors around things like burnout and he didn't know what to do for them," Jenike says. "He understands the business case that we could not grow our company to where we wanted to go if nearly half of our physicians are burned out. It was easy to convince him to give me a shot to try to resolve this. And our medical group president was the exact same way."
Together with Beamon, Jenike created a pilot program specific to physicians. He targeted influential physician leaders in the system and enrolled 32 physicians in the pilot program.
"Our theory was that they were experiencing some of the same things I was in terms of juggling practice and juggling leadership positions," he says. "If we could show value to these folks starting at the very top, they would be the best champions to drive the work down."
Unlike, Weiner and Linzer's approaches, there was no statistical assessment of participants prior to enrolling in the program.
"We certainly did some survey questions on how they were experiencing their job, how they were experiencing their personal life, their level of fatigue, things like that, but it was not intended to be a data statistical–driven questionnaire. It was really more of a self-reflection questionnaire," he explains.
Jenike describes the two goals of what is now the Novant Health Leadership Development Program.
First, Jenike wants those who participate in the voluntary, three-day intensive program to have an enhanced experience of his or her life. The second goal was for those around the participants—colleagues, family members, friends—to have an enhanced experience of that person.
A good litmus test for whether the second goal has been achieved is when others start saying, "I don't know what it is about you, but it's just better to be around you."
Since the pilot project in 2013, about 500 physicians have been through the program, with more waiting in the wings.
Jenike says that while the program benefits its participants, it also benefits the organization as well.
"People start to care more and more about the organization, because they feel cared for by the organization. We see the people that go through our program step up into new leadership positions," he says.
Engagement rates at the organization have been on the rise since the program began. In 2015, through a team-member engagement survey, Novant Health was able to compare the engagement scores of providers who went through the leadership program and those who did not. Those who participated in the program scored 50% higher than nonparticipants on measures such as personal fulfillment and alignment with Novant Health's mission and vision, as well as engagement and positive attitudes toward the organization. In 2016, the program's participants were in the 97th percentile for both engagement and alignment. For all employees in the medical group, engagement is in the 86th percentile and the 90th percentile for alignment.
"So remember, the second outcome is: We want people to have an enhanced leadership experience of you. We find that when you go back to your hospital and you go back to your unit and you go back to your office and you are more engaged, you're more positive, you're more aligned, you're feeling more joy, and that is contagious," Jenike says. "People around you start to act the same way. We didn't get to 86th and 90th percentile for the whole medical group because we put that many more people through the program. It's just that the culture has changed."
Burnout as fuel for improvement
Burnout affects not just physicians but registered nurses as well.
A 2011 study by nurse researchers at the University of Pennsylvania School of Nursing found that 34% of nurses scored higher than the average for healthcare workers on the MBI emotional exhaustion subscale.
Though she didn't have a label for it at the time, Elizabeth Scala, RN, MSN, MBA, the founder and owner of Nursing from Within, a consulting business focusing on burnout prevention and career enjoyment, experienced burnout as a new graduate psychiatric nurse at a large urban teaching hospital.
"I felt like I wasn't making a difference in my patients' lives, and in hindsight, I had a diminished sense of personal accomplishment," she says.
Over the span of about four years, these feelings worsened until, after a sleepless night of uncontrollable sobbing, she resolved to take action.
"I realized I wasn't doing anything for my own well-being," she says.
She changed her work environment, began seeing a counselor, and read books to shift her perspective to one that was more solution-oriented.
And it worked.
Today, Scala works with healthcare organizations to teach nurses how to identify signs of burnout as well as strategies to prevent or cope with the issue.
"I think it's really helpful to get some support and to get some help, because when you're experiencing burnout, you're so wrapped up in what's going on that it's really hard to get out," she says.
Vanderbilt University Medical Center in Nashville is one organization that has developed its own resources to help nurses cope with the stressors they face on a daily basis.
"I think that nurses are experiencing great waves of change. Changes in models of care. Changes in economic rules and regulation. Changes in the way people come in out of hospitals or are seen in clinics, pay for performance," says Marilyn Dubree, RN, MSN, NE-BC, executive chief nursing officer at Vanderbilt University Medical Center. "I think the external environment changes actually impact our clinical staff and leadership, but I also think that nurses, in a special way, are impacted by compassion fatigue and by the real expenditure of the emotional and physical energy in caring."
In 2002, to better provide its nurses with psychological support, Vanderbilt launched the Nurse Wellness Program, headed by Margie Gale, RN, MSN, CEAP, a nurse wellness specialist, at the Work/Life Connections-EAP Department part of VUMC's Health and Wellness Division. The program offers services such as counseling, workplace outreach, and the promotion of wellness activities.
The program's advisory council is the Nurse Wellness Committee, a group of leaders and staff nurses who meet monthly to advise Gale and her colleagues on what the nurses' greatest needs are and what problems need to be addressed.
"We then work on projects on how we can improve conditions to create a positive work environment," says Gale.
For example, Gale partnered with another committee to establish a workplace violence prevention nursing task force. In 2016, she launched a workshop on burnout and compassion fatigue that will be offered every three months.
"We are teaching them about what burnout is and how to recognize it. We're teaching them about compassion fatigue, and then we're talking about self-care techniques," Gale says. "How to develop hobbies, how to set boundaries, how to take breaks."
Gale has even done things like bringing a yoga instructor to the pediatric ICU to teach nurses how to take a 7-minute yoga break during their shift.
Health and wellness information is also disseminated by a group called the Nurse Wellness Commodores.
"We push information out to them to take to their units," Gale says. "They help deliver that information by ways of their staff meetings, newsletters, and unit boards."
VUMC also offers a monthly program called Bedside Matters, where staff, including nurses, talk about the social and emotional issues of caring for patients and families. The group may discuss a case where a patient wanted to die with dignity but the family wanted to continue with invasive medical treatments.
"They talk about a difficult case," says Gale. "How did we deal with it? What impact did it have on the staff? How did we handle it? How did we support our staff?"
Ethical challenges like the ones discussed during Bedside Matters rounds can be contributing factors to burnout among nurses, says Cynda H. Rushton, PhD, RN, FAAN, the Anne and George L. Bunting Professor of Clinical Ethics in the Berman Institute of Bioethics and the School of Nursing at Johns Hopkins University in Baltimore.
"One of the things that I've spent a fair amount of time looking at is how ethical conflicts and all the stress surrounding them contribute to burnout," she says. "I think that creates a condition for people to then become emotionally and physically exhausted, trying to reconcile that difference between what they ought to be doing and what they're actually doing. You add onto that organizational factors like workload, which also lead to physical exhaustion, and it tends to intensify the feelings of stress that people are feeling at the bedside."
When this stress occurs, Rushton says individuals and leadership should see it as an opportunity rather than a failure.
"It's a signal that something is off-balance. We don't get burned out because we failed. It's because we've been trying so hard to address issues, some of which are not solvable in our skills and resources and abilities," she says. "I think leaders have to really take stock of the organizational processes, policies, and structures that are contributing to burnout and to allocate resources to support diverse strategies for clinician well-being, recognizing that one size doesn't fit all."