Nurse leaders could provide President Trump with insights to improve the nation's health and healthcare system, but they have not yet been included in the president's talks regarding healthcare reform.
Nurses are integral to the working of the healthcare system, yet not one has yet been called to advise the Trump administration on healthcare reform.
At more than 3.1 million strong, registered nurses are the largest group of healthcare professionals in the United States. They are also (for the 15th year in a row) the most trusted of any profession.
Yet, despite their number and esteem, President Donald Trump's administration has not actively sought input from nurse leaders regarding the future of the Patient Protection and Affordable Care Act, it's promised replacement, or healthcare reform in general.
Nursing groups such as the Tri-Council for Nursing and the Nursing Community coalition, reached out to Vice President Mike Pence, head of the Trump presidential transition team, after the election with offers to engage with the new administration regarding its healthcare agenda.
No nursing leaders were on the roster at Trump's Dec. 28 meeting with healthcare executives, however.
"I like to see that he's surrounding himself with people like Toby Cosgrove and the CEO of the Mayo Clinic [John Noseworthy] and those types of folks," says Claire Zangerle, MSN, MBA, RN, Chief Nurse Executive for Allegheny Health Network in Pittsburgh.
"But I'd really feel good if I saw him surround himself with some very knowledgeable and insightful nurse leaders."
Beth Houlahan, RN, DNP, CNEP, Chief Nurse Executive and Senior Vice President, UW Health in Madison, WI, agrees that nurses would be invaluable in shaping the new president's healthcare agenda.
"Why isn't [Trump] meeting with the head of the ANA or the president of AONE to get the nursing perspective as well? To me that would be one of the things that could be very advantageous to his leadership," she says.
"If he's well-versed in nursing's impact on healthcare in the country and he asks the right questions, he may be able to make some positive changes."
Both Zangerle and Houlahan hope nurse leaders will be brought into the picture to share their insights, but until such a meeting occurs, here's what the two nurse executives say the Trump administration should consider as it moves forward in setting healthcare policy.
The Ups and Downs of the ACA
The ACA has been under scrutiny since it was signed into law in 2010, and vows of repeal were made long before Donald Trump began his promises to overturn the legislation during his 2016 election campaign.
It's too simplistic to label the ACA all good or all bad, however.
In a recent HealthLeaders Media survey, "Healthcare in the Trump Era," two-thirds of respondents say the best option for the ACA is to make some changes, but otherwise retain it.
Zangerle and Houlahan agree that there are pros and cons to the current legislation.
"I don't want to say that the ACA is terrific or the ACA is terrible," Zangerle says.
The law "has done a good job of increasing the awareness of the importance of access to care, and access to care for everybody is really what the foundation is for the ACA. It also focused on managing one's own health," she says. "It started a larger conversation about of the cost of healthcare and the sustainability of an inclusive system."
But it has also created some stresses and strains on the healthcare system. "Our patient volumes were really going up even before the ACA," Zangerle says. "But once the ACA was enacted, that volume increased dramatically. "
"I can tell you it stressed the system and nursing specifically because there was an immediate rise in the number of new patients that were seeking healthcare."
"From a hospital perspective," says Houlahan, "the exchange is covering their ED visits and their primary care visits, so from a bottom line perspective it's really good."
"From a nursing perspective, these people have a multitude of chronic illnesses, some that they've never seen a doctor for so on an inpatient side people are much, much sicker."
Nurses Needed
The ACA's push towards ambulatory care has also affected staffing by creating new roles for nurses.
These roles include navigators, care managers, and transition care nurses. Yet, as important as these are, they also pull nurses away from the bedside.
"The ACA gambled, I think, on this assumption that we had the staff to take care of this influx of new patients, which wasn't really the case," Zangerle says.
"We didn't really get time to ramp up [the labor force] so you may see nurses leaving acute care to go into ambulatory care, which is fine, but there's little attention to the dilemma of backfilling those acute care positions especially, since many of those new patients present as acute care cases."
There is a silver lining to this obvious need for nurses, says Zangerle.
"The increased volume of patients really provides a stable growth trajectory of the nursing profession over the next 20 to 30 years," she says. "We just have to do a better job of recruiting and retaining the nursing talent so we can meet the demands."
How the Trump Administration Could Help
In order to have an adequate supply of RNs to care for patients in every setting, something needs to be done to fix the bottleneck at the beginning of the nursing pipeline.
"We've got the nursing programs, but we can't get students through the nursing programs fast enough because we don't have the faculty," Zangerle says. "I would like to see some type of enhancement to nursing faculty growth. Either through compensation, incentives for direct faculty, or programs that may promote formal practice appointments and practicing nurses who also serve as faculty."
If the Trump administration boosted support for nurse faculty development, either through Nursing Workforce Development Programs contained in Title VIII of the Public Health Service Act or via newly created programs, it would be a major win for nursing.
Learn from the Past, Plan for the Future
Before he moves forward on any healthcare reform, however, Trump would be wise to take situations like this under consideration while making a thoughtful assessment of what parts of the ACA have worked, what parts haven't, and what parts are somewhere in between.
"It's really [a matter of] dissecting it, learning from issues that came up in Obama's rollout, and not making it partisan," Houlahan says. "I think he needs to share the playbook with us along the way so people can be prepared and really understand what the changes, or the things that he repeals— what the impact of that is going to be,"
Improvements in patient safety, quality of care, and organizational processes are fostered by work environments that empower and engage frontline nursing staff, nursing leaders say.
Creating an organizational culture that emphasizes quality, safety, and continuous process improvement is a must in order to provide value-based care.
More than two dozen nurse executives discussed nursing's in role providing high-quality patient care along with strategies to reduce errors, promote best practices, and support process improvement during nursing quality roundtable sessions at HealthLeaders Media's invitation-only 2016 CNO Exchange at the Bacara Resort in Santa Barbara, CA in November.
According to the group discussions, high-quality nursing care hinges on three components:
Frontline engagement
Empowerment
Accountability
1. Engagement
When she began her role at Montefiore Health System's Wakefield campus in Bronx, New York, Joan O'Brien, MSN, RN, NE-BC, director of nursing, intentionally focused on ways to boost staff engagement as a means to improve the facility's HCAHPS scores.
"We created a list of 'nine elements' of how staff could [positively] connect with and engage patients and colleagues—namely by showing courtesy and respect," she says.
Knocking on the door before entering a patient's room, introducing oneself to patients and families, and asking for permission before assessing a patient are visible ways to communicate respect.
"Can I take your blood pressure? Which arm would you like for me to use? By asking, you're connecting with the patient," O'Brien says.
These interventions may sound simple, but they are effective. Over a four-year timeframe, the Wakefield campus' patient satisfaction scores rose and it received a patient satisfaction award from Press Ganey.
2. Empowerment
To sustain and continue quality improvements, it's crucial to tap into the wisdom of the frontline staff, O'Brien says.
"Now, whenever we have a problem, we go to the frontline staff and say, 'This is the issue. How can we make a difference?' When people take [on] ownership and accountability, things begin to change."
An empowered staff is critical to ensuring patient safety. When staff members have the confidence, authority, and support to raise concerns about safety and patient care, nurses can stop harm before it occurs.
At Anne Arundel Medical Center in Annapolis, Maryland, some clinicians were hesitant to escalate a concerns, says Barbara Jacobs, MSN, NEA-BC, RN-BC, CCRN-K, vice president of nursing and CNO.
To address this, she has provided a "resource nurse," an RN with critical care training, dedicated to responding to staff concerns. In addition, Jacobs trains staff on the steps to take and language to use to ask for help and resolve issues before defaulting to the route of rapid response.
"A nurse needs to be able to articulate her concerns," she says. "It's OK if you're not exactly sure what the problem is [and] you need someone more experienced to [assess the situation]."
3. Accountability
Accountability and team work are instrumental in driving consensus on best practices, nurse leaders say.
Baptist Medical Center Jacksonville in Florida holds hospital-acquired incident meetings, led by a chief medical officer and chief quality officer, who are both physicians, and a nurse from the quality team to discuss compliance, says Tammy Daniel, DNP, MA, RN, NEA-BC, vice president of patient services.
At the meeting, a nurse manager, nurse director, nurse navigator, and several staff members bring up a recent incident and discuss how it could have been prevented. The directors from nursing and other departments are in attendance so information can be disseminated throughout the organization.
"The CMO has the difficult conversations with the physicians. "You've got to have that physician partner with your nursing team to drive those metrics."
Nurse leaders say the standard recruitment and retention methods of sign-on bonuses, pay increases, and retention incentives won't be effective in improving the current nursing shortage.
Nursing shortages are like bad pennies—they keep turning up.
Imbalances in RN supply and demand occurred in the 1980s, the late 1990s, and the early 2000s. Now hospitals and health systems across the country are starting to see the effects of another shortage.
During nursing workforce roundtable sessions at HealthLeaders Media's invitation-only 2016 CNO Exchange at the Bacara Resort in Santa Barbara, CA, many of the more than two dozen nurse executives in attendance said they are dealing with a very real nursing shortage at their facilities and systems. But this shortage may be quite different than those past.
"I'm looking across the whole country, from the East Coast to the West Coast, watching what's happening in our different markets, and I do believe that the nursing shortage we're going through now is unlike any we've seen before," said Kathleen D. Sanford, DBA, RN, FACHE, FAAN, senior vice president and CNO at Englewood, Colorado–based Catholic Health Initiatives.
CHI operates in 18 states and includes 103 hospitals, community health services organizations, accredited nursing colleges, home health agencies, living communities, and other facilities and services that span the inpatient and outpatient continuum of care.
What Makes This Nursing Shortage Different
By 2020, nearly half of RNs will be at traditional retirement age, the U.S. Department of Labor reports. As these seasoned professionals retire, their experience, knowledge, and skills, which are essential to achieving the goals and outcomes of an increasingly value-based healthcare industry, will go with them.
Add to the mix a multitude of new nursing opportunities created by changing care delivery models and the career philosophies of younger nurses who crave change and typically move on to new opportunities every one to three years, and there is cause for concern.
"I believe, and my team believes, that unless we do something totally disruptive, our communities are going to be harmed very shortly by this shortage," Sanford said.
Money Isn't the Answer
At the Exchange, there was much discussion about what works and what doesn't when it comes to recruitment and retention. There was agreement that the old standbys of sign-on and retention bonuses aren't necessarily the best solutions to address this new shortage.
"We just keep trying to throw money at ways to retain staff, and that is not retaining Millennials," said Barbara Jacobs, MSN, RN-NEA, RN-BC, CCRN-K, vice president of nursing and CNO at the 415-bed Anne Arundel Medical Center in Annapolis, Maryland.
"We're going to have to think of something completely different around retention, because what motivates the millennial nurse is not really pure dollars."
What does motivate nurses to at least stay in an organization?
"Relationships, feeling valued, knowing that you're doing work that's meaningful," said Pamela Dunley, MBA, MS, RN, CENP, who recently transitioned to president and CEO at Elmhurst Memorial Hospital in Illinois.
Autonomy Matters
Dunley has given Elmhurst's nurses a sense of independence and control by using shift bidding to fill open shifts. "It was really a big [change] for the nurses because they got control over what they wanted to do versus you either floating them or asking them to work another shift," she said.
In addition to the autonomy and shift differential, nurses can also earn points for covering a shift. "It's like your credit card. You can gain points and you can buy things with your points," Dunley said.
"It helps the nurse feel a sense of control, and they don't mind signing up for extra shifts because they feel like, 'Oh, I'm in charge here. I can decide what I want to do.' Some of my nurses have gone to Europe on the points. They've saved them up."
More of the discussion from the CNO Exchange sessions on the nursing workforce can be found in the CNO Exchange 2016 Insights Report.
RNs are questioning whether the University of Michigan Health System's new name, Michigan Medicine, truly reflects the organization's mission.
The University of Michigan Health System has changed its name to Michigan Medicine, but nurses at the academic medical center are not thrilled with the new moniker.
"The money spent on implementing and marketing the new name would be better spent on patient care," Katie Oppenheim, RN, Chair of the University of Michigan Professional Nurse Council, an affiliate of the Michigan Nurses Association (UMPNC/MNA), said in a media release.
"The term 'medicine' is almost exclusively associated with physicians, yet so many other professionals contribute to the treatments and breakthroughs here," Oppenheim said.
"We are concerned that time and resources are being squandered on a marketing ploy that ultimately diminishes the contributions of a diverse and dedicated staff."
The news release issued by the Michigan Nurses Association states that nurse managers raised concerns that the name change did not reflect the health system's broad mission.
"To me and others, 'medicine' has negative connotations. You only seek medicine once you are already sick," said Heather Roe, RN, UMPNC/MNA Vice Chair.
"UMHS's mission is broader than that. We deserve a name that makes it clear that we support health comprehensively, not just through medicine but also with prevention, research, education and other professional supports including nursing."
A Three-part Mission
The name change better reflects the organization's three-part mission of patient care, education, and research, Marschall S. Runge, MD, PhD, dean of the University of Michigan Medical School, executive vice president for medical affairs, and CEO of Michigan Medicine, said in a media statement last week.
The new name is also an attempt to reflect recent organizational changes, including Runge's combined role as leader of both the U-M Medical School and Medical Affairs for the University of Michigan.
"We expect Michigan Medicine will help generate a better understanding of the strengths of our academic medical center and will energize all our faculty and staff," Runge stated.
But not all are in agreement with this rationale.
"I can't help but wonder what the other UMHS facilities outside of Ann Arbor think of this," said MNA President John Armelagos, RN, who is holds the title of UMPNC/MNA grievance chair.
"A statewide network was built on the current name and branding. Isn't an obvious association with U of M's prestigious academic resources part of what other hospitals were hoping to gain through affiliation?" Armelagos said.
"MNA commends the nurse managers who pointed out some of these concerns before the rebranding was announced. We only wish the administration had listened."
An online petition urging UMHS to reconsider the change has received 1,153 signatures, more than double the goal of 500.
Frontline managers play an important role in improving patient experience, safety, and quality of care. If you don't believe it, look at these numbers.
If a top-down push for quality improvement isn't working, try something that does.
At its annual conference in December, the Emergency Nurses Association recognized Brentwood, TN-based LifePoint Health's Emergency Department Nurse Director's Council with its Team Award for 2016.
The ENA gives the award to a group or committee that has made contributions to patient safety and excellence in emergency nursing through the development of sustainable projects or programs.
The idea behind creating the council was to "bring in the frontline leaders, to get input and feedback on any process changes, policy changes, supplies, equipment, and best practices," says Pam Booker, RN, MSN, western group chief nursing officer for LifePoint Health and executive sponsor for the emergency services team.
"It was an understanding that promoting change at the facility level always has to be patient-focused and employee-owned," says Sue Atkin, RN, MSN, regional director of emergency services for LifePoint Health.
"Having a corporate, top-down push on initiatives never seems to be successful. So we said, 'let's listen to our leaders at the local level and see what their input is on how best to leverage best practices throughout all of our facilities.' "
Listening to frontline leaders has paid off, says Booker.
Since its inception in 2012, the 12-member council of ED nurse directors from LifePoint's 72 hospitals helped drive improvements in patient experience, safety, and quality of care by:
Reducing time-to-provider times by 43%—from to approximately 46 minutes to 26 minutes
Reducing the time-of-arrival to receiving appropriate pain medication by 41% for long bone fracture patients—from 55 minutes to 32 minutes
Reducing the number of patients leaving without treatment by 48%—from 2.4% to 1.3%
Finding Focus by Polling and Listening
The council determines where to focus improvement efforts by reviewing core measures for ED care, CMS regulations, and input from the front line.
In addition to connecting via conference calls, the ED nurse director council members have an onsite meeting once a year. Prior to the meeting, a survey is distributed to all of the organization's ED directors, chief nursing officers, and ED medical directors, Atkin says.
The survey asks questions such as these:
How did we do last year?
Did we accomplish your goals last year?
What do you see on the forefront for emergency care in the upcoming year?
Have physician practices changed for a specific patient group?
What new patient problems could present in the ED during the year?
"Our ED council then gets together, reviews the results of those surveys, and then says, 'OK, this sounds like it's really important to all of our teams,' or, 'There's a new regulation coming down that we're going to have to focus on for the year,'" Atkin says.
"And the council says, "We have very specific items that we're going to work on that fit into our strategic priorities of quality and service high performing talent, operational excellence and growth.'"
Site-specific experiences are used to help drive the development of organizational best practices.
The council members share what works and where they need help in meeting their goals.
"We have hospitals that are doing better, and then we have hospitals that are still struggling [to meet the goals]," Atkin says. "They compare their practices amongst each other… and the 12 council members are liaisons to their facilities to say, 'This is what we talked about in our council meeting. Why don't you try this and see if it helps.' "
If healthcare leaders want to achieve similar results, it's important to recognize the integral role frontline managers and staff play in meeting those goals.
"With buy-in from the frontline, there's ownership and with ownership comes pride and successes," Booker says.
The VA declines to give certified nurse anesthetists full-practice authority, claiming there is no issue with access to anesthesia care. Nursing organizations disagree.
The final rule will allow the VA's certified nurse midwives, clinical nurse specialists, and nurse practitioners to practice to the full extent of their education, training, and certification. The agency declined, however, to grant full practice authority to certified registered nurse anesthetists.
In a news release, the VA said it did not have immediate and broad patient access challenges to anesthesia care across its health system and therefore chose not to finalize the provision which included CRNAs as one of the APRN roles receiving full practice authority.
Some in nursing are disappointed with this decision.
"The AANA is terribly disappointed by the VA's decision to not grant full practice authority to CRNAs because now veterans will continue to deal with long wait times for needed healthcare procedures that require anesthesia services," AANA President Cheryl Nimmo, DNP, MSHSA, CRNA told HealthLeaders Media via email.
"And the solution to the problem is right there—a highly educated, qualified, motivated, and proven CRNA workforce that is currently being underutilized due to practice barriers imposed by physicians to benefit physicians. Let me be clear: Veterans are not the beneficiaries of this decision."
Nimmo points out that while the VA says there is no issues with access to anesthesia care, the VHA Independent Assessment in 2015 identified numerous access problems such as:
Delays in cardiovascular surgery due to lack of anesthesia support
Increasing demand for procedures requiring anesthesia outside of the operating room
Slow production of colonoscopy services in comparison with the private sector
"This clearly speaks to the underutilization of CRNAs, and it also raises questions about anesthesiologists who spend their time supervising CRNAs rather than actually providing hands-on patient care," she wrote.
"Just imagine how many more veterans could be cared for if start times for surgical and other types of cases requiring anesthesia were no longer delayed unnecessarily while waiting for supervising anesthesiologists to become available."
While The American Association of Colleges of Nursing acknowledges the VA allowing three APRN roles full practice authority is progress, it agrees the policy needs to be extended to include CRNAs.
"AACN believes the full cadre of clinicians will not be maximized within the VHA if CRNAs are excluded," the organization said in a news release.
"AACN appreciates the opportunity that the VA has provided to allow for an additional 30-day comment period on full practice authority for CRNAs. We stand firm in our view that CRNAs would increase access, and will submit additional comments to the VA in collaboration with our colleagues in the community."
Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN, president of the American Nurses Association echoed those sentiments.
"The American Nurses Association is pleased with the VA's final rule allowing APRNs to practice to the full extent of their education and training," she said in an official statement.
"However, ANA is concerned with the final rule's exclusion of CRNAs, which is solely based on the VA's belief that there is no evidence of a shortage of anesthesiologists impacting access to care. We join with our colleagues in continuing to advocate for CRNAs to have full practice authority within the VA health care system."
The AANA plans to continue to advocate for full practice authority to be extended to CRNAs at the VA.
"We are charging full steam ahead. A grave injustice has been done to our nation's veterans, who deserve much better. I'm a veteran, so I can sympathize," says Nimmo. "CRNAs are ready to help change the VA culture that long wait times for care are OK. They are not OK. We plan to keep delivering that message until the VA finally gets this right."
Comments on the final rule and full practice authority for CRNAs can be submitted to the VA until January 13, 2017.
The hottest nursing topics this year were patient experience, job satisfaction, and the wellbeing of nurses.
With an unusual presidential election under our belts, and the fate of the ACA uncertain, it's safe to say that 2016 was a perplexing, at times chaotic year for healthcare leaders. Which means you may not have had a chance to delve into all the content, news, and information HealthLeaders Media has to offer. So, in case you missed it, here are our most popular nursing centric stories of 2016.
Hoping to counter stress and compassion fatigue, Cancer Treatment Centers of America at Midwestern Regional Medical Center in Zion, IL, created private spaces for its nurses to process their emotions before returning to their patients.
More and more studies are linking nurse work environments to better patient outcomes and improving nurse work environments will likely be on the radar for many nurse leaders in 2017.
But even in the face of state budget cuts and closures of city-run behavioral health clinics, one nurse leader was able to develop an innovative and cost effective program that decreased behavior health patient length of stay in the ED by 40%.
3. The Hidden Patient Experience
Ensuring patients have an outstanding patient experience can be tricky since what is most important to a patient varies from individual to individual.
Often it's these personal preferences, rather than clinical care (even if it is amazing), that influence whether a patient reports having a good experience at an organization.
Nurse leaders at Cleveland Clinic and Mount Sinai Health System, talk about how they are trying to improve patient experience by better understanding these "invisible" patient preferences.
The major takeaway: A single-minded focus on HCAHPS scores is a missed opportunity to improve quality, safety, and patient engagement through a broader, more multifaceted approach to patient experience.
Nurses bring a wealth of clinical understanding to the chief executive role, but they have to master business skills and a wider focus if they want to succeed.
When Leah A. Carpenter, RN, MPA, went into nursing 30 years ago, she did not intend to follow a career path to administration. In fact, early in her career, she was pretty skeptical about the folks in the C-suite.
"I had no desire to be a suit whatsoever," says Carpenter, who is now Administrator and Chief Executive Officer at Memorial Hospital West in Pembroke Pines, FL.
"There was a very big disconnect between the C-suite—and even middle management—and the rank-and-file staff. I really didn't have a great deal of respect for or want anything to do with a leadership at that time."
Then a bit of what she calls "divine intervention" nudged her into the administrative realm. "I lost my hearing progressively over the last past 20 years, so I'm virtually deaf in one ear," she says.
"I had to make a decision whether I wanted to go into management or education, because that's pretty much the two paths that a nurse can take if she's not going to be at the bedside."
Despite that unconventional beginning, Carpenter has risen to the top as a CEO. Now she has some insights and advice for RNs who are considering a CEO role.
Q. What talents, skills, and insights can a nurse bring to the CEO role?
A. Besides the obvious, which is the clinical background and really understanding what it takes to give safe, quality care that is service-oriented, I think I understand the struggle and what the staff needs to be able to deliver that.
That allows me to garner a certain level of respect from the team because they know I've been where they are.
Q. Do you think nurses who become CEOs face unique challenges?
A. Yes, in some respect. It's been easier for me personally in terms of mastering the role because I have the advantage of understanding the intricacies of the clinical world. I think it has been difficult—I've accomplished it but it's taken a while—to garner the respect as a businesswoman as well as a clinician.
Not every nurse leader or CNO can transition from the clinical world into the administrative world.
Q. Do you think there's a major difference between CNO thinking and CEO thinking?
A. Absolutely. You have to still have the understanding and the insight of the CNO, but there's a completely different skill set that you have to master in order to be a CEO.
You have to learn that balance. You can't look at it from just the eyes of a nurse. You're everyone's voice and you represent everyone—the clinical side, the dietary side, the environmental side, the construction side, the legal side.
There's a whole scope of skills and negotiation abilities that you need to have to balance all of that.
Q. What advice do you have for nurses interested in becoming CEOs?
A. It shouldn't be about the title or about the money. It needs to be about the impact: What do you hope to achieve and deliver? What's the end product?
For me, the end product was having an impact on safety, quality, and service, but at a table where I could really make a difference by having the experience as well as learning the business end of it.
I would steer [prospective nurse CEOs] away from a graduate degree in nursing. I think it limits your scope. They have to look at a business or administration type master's degree.
Also, mentors are key. You have to find people who are really good at this, attach yourself to their hip, and learn everything you can from them.
Not everybody's not going to be a great leader, but you can still learn from bad leaders. You can learn what not to do, and you can develop yourself into the kind of leader you want to be, knowing the things that don't work.
In a letter to the president-elect, the American Nurses Association calls for an equitable health system that supports increased access to cost effective, high-quality care.
"ANA is calling on you and your administration to prioritize the health of the nation, which is foundational to progress and economic growth," ANA president Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN, wrote in a letter issued Dec. 5 to the president-elect.
The association, which has advocated for healthcare system reforms to improve access to high-quality care in the past, also detailed its principles for health system transformation in the letter.
The ANA calls for a standard package of health care services for all citizens and residents. The package would contain many features already in the Affordable Care Act, such as health insurance coverage despite pre-existing conditions, the ability of children to continue receiving health insurance coverage through their parents' plans until they are 26, and expansion of Medicaid.
A transformed health system would optimize primary, community-based, and preventive services that encourage patients to develop partnerships with their healthcare providers. In turn, primary healthcare would include preventative curative, and rehabilitative care coordinated by the healthcare team.
Healthcare costs would be reduced through effective use of care coordination services to improve outcomes.
The association also advocates for way to stimulate "economical" use of healthcare services while supporting those who don't have the means to share in costs through government-private sector partnerships, payment systems that reward quality and stewardship of resources, elimination of lifetime caps or annual limits on coverage, and federal income-based subsidies to assist individuals in purchasing insurance coverage.
A Call to Strengthen the Workforce
Finally, the ANA says there must be support for the development of a highly skilled healthcare workforce.
ANA calls for increased funding for programs and services focused on increasing the primary care workforce, increasing nursing faculty, and improving workforce diversity. Barriers and restrictions that prevent RNs and advanced practice registered nurses from making full contributions to patient care should be removed.
"ANA looks forward to working with you and your administration to address our nation's health care challenges. We look forward to sharing the expertise of nurses throughout your transition period and presidency to improve the health care system and the health of the nation," Cipriano wrote.
New policies developed by nursing leaders at three Chicago-area hospitals guide hospital staff in caring for behavioral health patients and keeping them safe.
Caring for behavioral health patients is a major challenge for nurse leaders. When it escalates to elopement—the unauthorized departure of a patient from a hospital—patient safety becomes an immediate concern.
Patients with behavioral health needs often present to hospital emergency departments or, because of medical co-morbidities, are admitted to a medical-surgical unit where staff may not know how to care for this patient population.
But nurse leaders at Weiss and three other Tenet Health Chicago-market hospitals have worked together to develop standardized polices regarding patient elopement.
Creating policies to guide staff in caring for behavioral health patients can improve both quality and safety of care, says Mary Shehan, DNP, RN, NEA-BC, chief nursing officer at Louis A. Weiss Memorial Hospital in Chicago, part of Tenet Health.
Shehan spoke at the recent HealthLeaders Media Chief Nursing Officer Exchange at the Bacara Resort & Spa in Santa Barbara, CA.
The Problem
Patient elopement is a very real problem that most organizations have experienced at one time or another, but it is rarely discussed. About 20% of adults in the U.S. experience mental illness in a given year. About 4% experience a serious mental illness that interferes with life activities, according to the National Alliance on Mental Illness.
"Preventing patient elopement is a concern we all face, especially for those patients who are at risk for harming themselves or others," Shehan says.
Patients elope in a number of ways. Some will leave the building if they do not have constant supervision when they are sent to a have a test or procedure done, or while using the bathroom. They may also exit out an open door after another person leaves, which Shehan calls "tailgating."
No matter how elopement occurs, there are consistent, proactive ways to better prepare an organization and its staff to better deal with the issue.
The Solution
Shehan recommends identifying patients at risk for elopement—including those with severe psychosis, dementia, or drug and alcohol withdrawal—and reviewing current practices as well as best practices in the literature.
She also suggests performing a gap analysis and getting answers to these questions:
Where are the opportunities to reduce the risk of elopement?
Once patients leave, how do you take them back?
If they leave and are not found, how is that handled?
Is there a "safe room" in the emergency department?
Is there enough staff to have a constant patient observer or are patient care technicians being pulled out of care to act as sitters?
It is also important for nursing supervisors to know how many patients are in restraints hospitalwide and how many are in need of constant observation.
The Outcomes
Shehan says the biggest innovation that has come out of this work is the creation of a psychiatric program director position at Weiss.
When she came to the organization over a year ago, there was a half-time manager/half-time staff position open for the 11-bed psychiatric unit. The two openings were combined to create the full-time psychiatric program director position.
"With an 11-bed unit, the average daily census is about nine, but I have a greater average daily census [of behavioral health patients] when one factors in the rest of the house—in my emergency department and on my med/surg floors—where patients are being medically cleared to go to the next level of care," she says.
Instead of being responsible for just the 11-bed unit, the psychiatric program director has responsibility for the continuum of behavioral healthcare across the organization. The director oversees behavioral health nursing care in the ED, on the med/surg units, as well as in the psychiatric unit.
The director conducts daily rounds on all patients with behavioral health concerns, including those with restraints and those who need a constant observer. In addition, he does on-the-spot education with nursing staff.