The use of interim nurse leaders is common, but information on how-to help them transition to their roles is not. Mayo Clinic's nurse administrator Dale Pfrimmer shares advice on how to support interim leaders.
A certain level of uneasiness is natural when there's a change in nursing leadership. While the new leader is busy trying to get his or her arms around a new positon and develop a mission, vision, goals, and priorities, staff must adapt to a new leadership style and new initiatives.
And if this weren't complicated enough for both parties, adjusting to a new captain of the ship is even trickier when the leadership position is for an interim period.
Dale Pfrimmer, RN, MS, NE-BC
Having been in an interim position in the past and also having hired interim nurse leaders, Dale Pfrimmer, RN, MS, NE-BC, nurse administrator at the Mayo Clinic in Rochester, MN, recognizes there are certain nuances to being an interim nurse leader. But, while using interim leaders is a common practice, information on how to help those taking the positions achieve success is sparse, he says.
"I had utilized interims a number of times and when I did a literature search [so I could] give them articles to help them prepare, [but] there just wasn't much out there at all," he says.
So armed with the hope of sharing success strategies, Pfrimmer and his co-authors wrote the article "Interim nursing leadership: A win-win opportunity," which appeared in the September 2015 issue of Nursing Management. He recently spoke with me and offered his thoughts on interim nurse leadership.
One-Size Doesn't Fit All
It may be assumed that those stepping into interim roles have their eyes set on winning permanent leadership positions, but Pfrimmer says that's not always the case.
"Usually, people are interested in the role, and this is a nice way to take it out for a test drive," he says. "I do think that there are probably about one-third of individuals who aren't interested in the role, but [they take it because] they want to see a smooth transition for the sake of the unit and for the patients."
When Pfrimmer took a role as an interim unit director in a neuroscience ICU, he was in the latter group. He went in with the intention of keeping the ship steady until a permanent unit director could be found and when he realized nursing leadership and administration was the career path for him, he was surprised.
"That was a turning point in my career. I loved being an ICU bedside nurse, so that was kind of an eye-opening experience," he says. "Becoming the nurse manager, I realized I could help the unit function smoothly for all shifts. It just felt like I could do greater good."
When hiring for an interim position, Pfrimmer looks for candidates who will also place a value on furthering the greater good.
"I look for someone who has the qualities of servant leadership; who says, 'I'm here for the unit and I want to support the staff and ensure a smooth transition,' vs. 'I've always wanted to be in charge,'" he says.
A Need-to-Know Basis
Though putting the team ahead of yourself is admirable, Pfrimmer does not recommend jumping into a position without first getting more details. Potential interim leaders need to be informed about exactly what they're getting into.
Some questions Pfrimmer recommends an interim job candidate ask before accepting a position include:
What's the anticipated length of tenure?
What are the expected challenges?
What kind of orientation is available?
What are my motives for pursuing this?
How will my relationships with coworkers change?
Staff nurses contemplating a move to a leadership role should be especially mindful of the answer to that last question.
"I think this is really difficult for staff nurses stepping up into this role because oftentimes you're stepping into a role of supervision with colleagues who perhaps have a lot more experience than you do or are a lot older than you are," he says.
Support for Success
To help establish an interim leader's credibility and authority, it's wise to set up a leadership buddy system.
"From the organization's stand point, even though this is an interim leader, they still need a structured orientation and an assigned preceptor and a lot of support in the role," he says. "At least, here's your contact and, ideally, here's a few people you can call when you have questions."
This is especially important if a staff nurse is filling the position as he or she may not know the ins-and-outs of leadership's day-to-day responsibilities.
"A big piece of the pairing is just the socialization into the role—introducing them into key stakeholders, making sure they know what meetings they're supposed to be at and where they're supposed to go," he says. "Much of our costs in nursing are related to staffing, so part of that structured orientation should be having them meet with the individuals from finance to explain the basics, 'Here's the bottom line. Here's what you need to know. Here's what we're watching closely.'"
Physical presence is another way to help show support. Pfrimmer suggests administrators do patient and unit rounds with the interim leader.
"We really have to be in close communication from my position, from the administration side, to make sure we're still in lockstep with the interim until there is the formal passing of the baton," he says. "It is a huge change for a work area and that causes angst among the other staff," he says.
"You want someone in there that can calm the waters and give a sense of sense of relief that, 'We're in good hands here until we know the next step.'"
The shift to value-based care could lead to expanded hospital-level acute care in patients' homes.
This article appears in the October 2015 issue of HealthLeaders magazine.
For patients in need of the level of care and interventions given in an acute care setting, the hospital is often the only option. And while necessary to handle acute exacerbations of illnesses, hospital admissions can lead to the development of a host of other problems for patients.
"We all know that hospitals can be very dangerous places for older adults," says Amy Berman, BS, RN, senior program officer at the John A. Hartford Foundation, a New York City–based private philanthropy working to improve the health of older Americans. "They commonly experience things like functional decline, complications, and other adverse events when they're inpatient," she says.
Amy Berman, BS, RN
According to data collected by the Department of Health and Human Services Office of Inspector General, in 2008 an estimated 13.5% of Medicare beneficiaries experienced adverse events during hospitalization, and an additional 13.5% experienced adverse events that resulted in temporary harm.
The John A. Hartford Foundation has been working to find a solution to hospital-induced complications among geriatric patients since 1995, when it began working with the Johns Hopkins School of Medicine and dedicating funds and other resources to support the creation, study, and dissemination of a safe, high-quality, cost-effective alternative to inpatient acute care that is now known as the Hospital at Home model.
Though two decades show Hospital at Home—which brings inpatient-level acute care for specific diagnoses to a patient's home—delivers outcomes equal to or better than and at lower cost than those obtained in the hospital, the program's adoption has been limited due to constraints in reimbursement. But as the healthcare industry shifts to new payment models spurred on, in part, by the Patient Protection and Affordable Care Act, Hospital at Home may finally have a shot at becoming a mainstream mode of delivering care.
Care and candidates
Geriatrician Bruce Leff, MD, professor of medicine at the Johns Hopkins University School of Medicine in Baltimore and director of geriatric health services research, is one of the founders of the Hospital at Home concept. In the mid-1990s, he noticed inpatient acute care admissions were contributing to poor outcomes among his elderly patients, specifically those with multiple chronic conditions.
"They would often experience bad outcomes just for having been taken care of in the hospital," he says. The patients were "developing confusion or delirium, developing functional impairment, having adverse drug reactions, losing functional capacity, and needing to go to a nursing home because they were operating just on the margins of functional capacity."
Even though there were times when his patients needed the care and interventions that could be provided only in a hospital, Leff says he felt conflicted about recommending hospitalization knowing it could cause his patients to deteriorate. So he began to contemplate what an alternative to an inpatient acute care stay would look like. Along with colleagues from Johns Hopkins and the John A. Hartford Foundation, he developed the Hospital at Home model to allow providers to bring the essential elements of acute care to a patient's home.
To be clear, Hospital at Home is not home care. The interventions and level of care are equal to that provided on a general medical-surgical unit at a traditional brick-and-mortar hospital. Patients with specific conditions deemed in need of hospitalization by an emergency department or clinic physician can receive necessary interventions like oxygen therapy, nebulizer treatments, IV infusions, or diagnostic test like x-rays in the comfort of their homes. They also receive extended nursing care for the initial portion of their admission, and then at least daily nursing visits, based on clinical need. The physician makes one or more home visits per day and is available for any urgent or emergent situation.
Bruce Leff, MD
A set of admission criteria developed by Leff is used to assess whether the patient is a good candidate for Hospital at Home. "You don't want people who need an ICU," he says. "You don't want people who are going to be unstable and probably have to go to an ICU. In truth, you like to be able to identify people who are not going to have very high tech–driven admissions."
The original model focused on those with diagnoses of community-acquired pneumonia, heart failure, chronic obstructive pulmonary disease, and cellulitis but has now evolved to also include patients with dehydration, urinary tract infections, deep vein thrombosis, and pulmonary embolism. "The reason we focused on those conditions was because they were common reasons for admissions to the hospital for older adults," Leff explains, "and they are conditions which are usually readily diagnosable at the start of an episode of care."
Cost and quality results
Since its inception in 1995, there have been multiple studies showing the Hospital at Home model delivers quality care while decreasing costs. That's what Albuquerque, New Mexico–based Presbyterian Healthcare Services wanted to achieve when it implemented the program in 2008. PHS is an integrated system with eight hospitals, a health plan, and a medical group, and reported 2013 total operating revenue of $2.5 billion.
"We felt that this program would give us the opportunity to improve clinical outcomes for patients who were sick and that were hospital-appropriate patients," says Karen Thompson, OTR, CCM, director of hospice and Hospital at Home at PHS. "We felt that if we could provide that same level of care in their home, the outcomes would be better, they would be more satisfied—not only the patient but also the caregiver—and have a reduction in cost overall."
A study by Melanie Van Amsterdam, MD, who served as lead physician for PHS' Hospital at Home and House Calls program for the past decade, as well as Johns Hopkins' Leff and others, that was published by Health Affairs in June 2012 includes metrics that demonstrate the success of the PHS effort.
The 323 patients enrolled in PHS' Hospital at Home program from January 2009 to December 2010 had an average length of stay of 3.3 days versus 4.5 days in a comparison group receiving treatment in an acute care hospital. In addition, the PHS group had no reported falls versus 0.8 in the comparison group, and a mortality rate of 0.93% versus 3.4%.
The Hospital at Home group was at 100% compliance for five core metrics while rates in the comparison group ranged from 91% to 99% depending on the specific intervention. The patient satisfaction rate for the Hospital at Home group was 90.7%, while it was 83.9% for the hospital group. All of these outcomes were achieved with a 19% cost savings. The current patient satisfaction rate is now more than 97%, and the program has seen more than 1,000 patients since it began at PHS. Van Amsterdam (who continues to practice in the program, but gave up her lead physician role in July) attributes some of the savings to the necessity of using resources more wisely in a home setting.
"Patients are paying their own room and board," she says. "Also, we have limited diagnostic tools in the home. We don't have CT scans in the home, which means we don't use them. And how many times have you seen someone go into the hospital and they get a CT scan for indications that, normally, in the home we wouldn't think about it?"
A new era
Despite its solid patient outcomes, adoption of the Hospital at Home model has been limited in part because of the way traditional reimbursement structures are designed, Leff says. "There's no payment mechanism for this in Medicare fee-for-service yet."
Organizations with alternative payment models, such as the Veterans Health Administration, or integrated systems such as PHS, have more flexibility and incentive to adopt Hospital at Home.
"The reason you're able to build a Hospital at Home at a place like Presbyterian is because they have an integrated delivery system and they are the payer for and provider of care," Leff explains. "So they provide Hospital at Home for people who are enrolled in their own Medicare Advantage and Medicare Managed Care plan. For those patients that they insure and pay healthcare costs on, if they can provide high-quality service at a lower cost, it behooves them to do that."
Through its Innovation Center, the Centers for Medicare & Medicaid Services is evaluating whether it is beneficial to support delivery and payment of care through a Hospital at Home–style program. In 2014, the center gave the Icahn School of Medicine at Mount Sinai in New York City a three-year $9.6 million award to create and test a Mobile Acute Care Team to provide hospital-level acute care in patients' homes. The Mount Sinai Hospital is a 1,171-bed, tertiary care teaching facility.
While it is still early in the program, the MACT has seen 40 patients as of August 2015. Linda V. DeCherrie, MD, clinical director of the MACT has been seeing patients in their homes for the past 12 years as part of the Mount Sinai Visiting Doctors program. That program provides home care for about 1,200 patients under a traditional fee-for-service model, but has not involved hospital care at home. DeCherrie says she has hope for expansion of acute care in the home.
"I really think that this is the way of the future. That there are these certain diagnoses that we can care for safely at home," she says. "It's just that there's been no payment mechanism to do that."
The John A. Hartford Foundation, which supported the original development of the model, is hopeful, too. The organization gave Mount Sinai an additional $1.6 million grant for further analysis of the results.
"If we assume a similar experience with the MACT," says the John A. Hartford Foundation's Berman, "we might expect nationally that about 611,000 discharges for persons 65 and over might potentially be eligible and would want the Mobile Acute Care Team. If they were even able to reach half of those people who were eligible and receptive and we assumed 20% savings over usual care, that would be a savings of around $1 billion per year. If we were to make it available everywhere, we could reasonably assume that it would be over $2.9 billion a year."
Leff is cautiously optimistic about the model's proliferation.
Mount Sinai is leading the demonstration under the CMS Innovation Center challenge grant, "and I think that will potentially inform the development of a payment mechanism," he says. "I'm not sure if that happens in five years or 10 years. That's really at some level the million-dollar or trillion-dollar question. Will Hospital at Home get out there? I think it will. There are reasons to think that the demo will be successful and then move forward. It will probably be a slow process until it becomes a fast process."
Rebecca Freeman's IT background and real-world nursing experience will help inform her agenda as CNO for the Office of the National Coordinator.
Nurse leaders often feel frustrated, flummoxed, and frazzled by the government rules and regulations that affect the healthcare industry. After all, we went into nursing to help people, not to decipher legislative jargon created by bureaucrats who aren't clinicians and don't understand what nurses do.
Well, nurses have a new voice in the federal government who understands those sentiments.
On Sept. 8, Rebecca Freeman, RN, PhD, PMP, became chief nursing officer at the Office of the National Coordinator for Health Information Technology, the federal government agency responsible for coordinating implementation and use of health IT and the electronic exchange of health information. And even though she has been in the role for only "two seconds," she took time to speak with me about her background, her goals, and her thoughts on how health IT affects the nursing profession.
Rebecca Freeman, RN, PhD, PMP
Going Full-Circle
Freeman's background makes her particularly suited to understanding nursing's needs as they relate to health IT.
"My first career was in information technology, just straight up IT, and the last ten years or so I worked in networking," she told me. "Ironically, I was really tired of playing with computers, and I thought I would never touch another computer again. I wanted to do something really meaningful and nursing school was a perfect fit for that."
Freeman got her BSN in 2008 and went to work providing bedside care in the emergency department.
It soon became apparent her IT skills were something that could be used to benefit the nursing profession and patient care.
"I realized there were not a lot of highly technical people working in the nursing arena, and I pretty quickly got pulled back into health IT," she says. "I loved the bedside, and I miss that, but I feel like I'm helping nursing, patients, and allied health in a really different way. There are a lot of amazing emergency nurses so they could suffer the loss of me, but I think I can really provide a unique skill set to nursing informatics."
In addition to providing clinical bedside care, which she did up until 2013, Freeman has also held positions as chief nursing informatics officer and manager of nursing informatics at the Medical University of South Carolina in Charleston, and as assistant vice president and Epic national nurse champion at Nashville-based HCA.
The Ugly Duckling that is Data
Freeman has seen how health IT affects bedside nurses, clinical providers, and hospitals, and she understands its use can be akin to either unlocking a Pandora's box or a treasure chest, depending on how it's implemented.
"I saw first-hand the impact of poor implementation on patient outcomes, data, and all of the bedside clinicians' work," she says. "One of the things I like to talk about is quote, unquote, 'ugly EHR implementation' because it does make things very difficult for lots of folks at the bedside."
We all know how this type of IT implementation plays out in real life. Decreased time at the bedside. Increased time documenting. Interrupted workflows.
But the blame can't solely be placed on health IT and EHRs Freeman says.
"The EHR kind of blows things up," she says. "The EHR is just highlighting lots and lots of issues with workflow and communication." Freeman points to documentation standards as one problem that may be unearthed by EHR implementation.
"Documentation standards aren't always standard. Scales and screenings are a good example," she explains. "If we have ten scales and screenings for something, and they're all evidence-based, is there a clear one that is the best? If we could all agree to use that one….now we have the exact same data across all facilities so the interoperability piece is made much easier because a score of seven at one hospital is actually equal to a score of seven at another hospital."
Refining data is something that needs to be done in order to strengthen its usefulness, Freeman says.
"The first thing we have to look at, in the short term, is cleaning up the data sets so that we have valuable data," she says.
"We're gathering all kinds of data, just every data variable imaginable, and a lot of those data inputs haven't really proven their worth. So for many of the higher-level decision makers, they have some quality data they can use to impact nursing practice, but they also frequently have more data than they really know what to do with."
While there now seems to be an overabundance of data, Freeman still sees the potential it has to influence nursing practice.
"I think once we have a really purposeful design of a data set, then absolutely, we can make things more efficient," she says. "We can improve outcomes, we can figure out what nursing does—so quantifying nursing work— and that includes workloads tied with patient acuity. Once we get a really solid, clean, valuable data set, we can impact practice at the bedside for everyone—nursing and everyone else—especially as we go towards these more creative payment models."
Getting Started
Like anyone starting a new job, Freeman is busy getting her feet under her and learning the lay of the land.
"I have a lot of things on my docket but, being brand new to the federal government, I'm really in listening and learning mode right now," she says. "I have a whole lot of nursing interest just within the federal government across agencies—even just within the ONC—it's very reflective of the nursing community at large."
Freeman's role also extends beyond the federal government.
"I'm going to be meeting with lots of external groups and individuals to get a feel for how to pull all of their interests and all of their wish lists together and match it with the ONC initiatives," she says. "Folks say it's hard to jump through all of the hoops, especially when they aren't in alignment."
Nurses can have a profound effect on the health of patients, residents, and communities. But they need to be empowered to make connections and share their innovations, says the Robert Wood Johnson Foundation.
With all the attention it's been getting in recent years, population health may seem like it's a newfangled idea. But I, and probably any other nurse you ask, will let you in a little secret. It's nothing new.
Nurses have been immersed in population health for over a century. In 1893, nursing pioneer Lillian Wald coined the term public health nursing, which the American Public Health Association now describes as "the practice of promoting and protecting the health of populations. Wald's work with immigrant women living in New York City's Lower East Side spawned the Vising Nurse Service of New York and the Henry Street Settlement, which is still helping New Yorkers with social services and healthcare programs.
Lillian Wald
Nurses everywhere have been serving patient's needs out in the community ever since. Community health nurses, parish nurses, school nurses, and nurses in nurse-led clinics have all extended patient care beyond the confines of the hospital walls.
"With this new mission on building a culture of health, I can't think of a more perfect agenda for nurses," said Susan Hassmiller, RN, PhD, FAAN, senior nursing adviser at RWJF, during the event. "There's a lot of factors that are attributable to a person's health status and nurses really understand that."
The mission she refers to includes the action areasof making health a shared value, fostering cross-sector collaboration to improve well-being, creating healthier, more equitable communities, and strengthening integration of health services and systems.
What I took away from the discussion was that to facilitate RWJF'smission of developing a culture of health, nurses need to make authentic connections with patients, residents, and community members and to drive innovation. But in order to do this, they must feel empowered.
Making Connections
Patricia Gerrity, RN, PhD, FAAN, professor and associate dean for community programs in the College of Nursing and Health Professions at Philadelphia's Drexel University understands how making connections with community members furthers a culture of health.
When she founded what is now known as the Stephen and Sandra Sheller 11th Street Family Health Services Centerin 1996, the nurse-led center's target population of low-income residents in four of North Philadelphia's public housing developments let her know they wanted someone who would be committed to the community for the long-haul.
Patricia Gerrity, RN, PhD, FAAN
"When we went there, the community members clearly told us that they were tired of being assessed and surveyed and interviewed by people who would come in and then leave," Gerrity said during the Hangout. "So what we did was develop longterm relationships and worked with the community to find out how we could—the term wasn't used at the time—build a culture of health to help them get healthy."
This includes providing services beyond just nursing care. The residents' wish list included a teaching kitchen, a fitness center, and a place to get dental care.
"We have everything you need to work with families to make them strong and resilient," Gerrity said. "Many people talk about healthcare delivery. Health really isn't delivered. It's created, and it's created by the interaction of people and their environments."
Being Innovative
Speaking of creating, nurses have an undeniable creative streak that they use to improve patient care. Anyone who's seen a patient positioned comfortably in bed with custom-made bolsters crafted from rolled up bath towels and medical tape has seen the innovation of direct-care nurses at work.
MakerNursethe two-year-old initiative supported by RWJF was created to promote this type of innovation in nursing and to give nurses the tools they need to create solutions to improve patient care. Anna Young, co-founder of MakerNurse, explained that the program gives nurses "tangible fabrication and materials" to help them improve patient comfort and care and nurse workflow.
In September, the program opened its first maker space for healthcare providers, MakerHealth, at The University of Texas Medical Branch at Galveston and Young says over 100 nurses have come through the space and 15 different prototypes have been made.
"Everything from wound care to NICU," she said. "[Nurses are] making custom bandages on a vinyl cutter that are actually the appropriate size for patients. Another nurse from the burn unit is building an irrigation structure with 3D printed clips that snap onto the bed."
These creations are far more than just novel solutions.
"We're seeing tremendous opportunity to document value that is created for the hospital, for the system, and for the patients," she said. "Whether that is cost savings because you're able to do something in-house or whether it is better patient outcomes and reducing the time before discharge because you're able to 3-D print a clip that attaches the ventilator to a walker so patients are getting out of bed that much faster."
Becoming Empowered
Even though nurses are vital to promoting a culture of health, they often have to be prompted to remember their value as change agents and influencers.
"Sometimes nurses have to be reminded of how innovative they are and that they do have the solutions," Hassmiller said. "They need to be tapped on the shoulder and told. 'You've been doing this for a very, very long time.'"
And just how does this empowerment happen?
"I think it does start in school when we're learning nursing and how to care for people," she said. "It comes from the faculty, it comes from leadership, it comes from the deans really empowering those students right at the get-go so, when they hit the ground running, they know how valuable they are to the team in coming up with those solutions and delivering the best care possible."
Nurses working at the bedside can also benefit from leadership support and recognition.
"Take nurses aside and say, "We know that you have a lot of people to listen to and a lot of regulations, but you're with those patients, you're with those residents 24/7, and it is you they count on,'" Hassmiller says. "It is really empowering them in that way to step forward and be the leaders that we know that they are."
"When nurses go to nursing school, not many of them go in saying, 'I want to be a CNO,'" says Dawn Pevey Mauk, RN, MBA, BSN, NEA-BC, and the system vice president of service lines at Ochsner Health System in Louisiana.
Rose O. Sherman, RN
I thought back to my classmates in nursing school and realized how spot-on Pevey Mauk was. I went to school in the late 1990s and the bulk our class was Gen Xers—those born between 1965 and 1984. We wanted to become nurse practitioners, certified registered nurse anesthetists, and certified-nurse midwives, not nurse executives.
But, as Bob Dylan (born 1941, Greatest Generation) has said, the times, they are a-changin'. Research by Rose O. Sherman, RN, EdD, NEA-BC, CNL, FAAN, professor and director of the Nursing Leadership Institute at Florida Atlantic University's Christine E. Lynn College of Nursing in Boca Raton shows that members of the newest age-related demographic to join the nursing profession—the Millennials, sometimes called Generation Y, who were born between 1982 and 2004—see themselves as leaders and say they would consider taking on leadership roles.
This doesn't mean, however, that we can count our next generation of nurse leaders before it's hatched. Sherman has identified factors that influence whether Millennials embrace or reject moving into nursing leadership. If we want to grow future nurse leaders we need to keep these factors in mind.
'Y' of Course I'm a Leader
In 2013, the Health Resources and Services Association projected that over the next 10 to 15 years, one third of the current nursing workforce will reach retirement age. That's about 1 million nurses who could be out of the workforce in the next decade. And it's not just bedside nurses who will be hanging up their stethoscopes.
"Baby Boomer leaders still hold a significant percentage of nurse leader roles," Sherman says. "Many nurse leaders derive great satisfaction from their work and are reluctant to leave their positions. But the reality is that you cannot work forever, and we are beginning to see growing numbers of Baby Boomers make the decision to retire."
So who will replace these vital positions? Quite possibly the Millennials.
It's estimated that by 2020 they will make up 50% of the workforce, and, according to Sherman's study, 78% of the Millennial nurses surveyed said they would consider a leadership role. They reported that the top two incentives for becoming nurse leaders are the ability to "make a difference/inspire meaningful change" and "personal growth."
"Generation Y nurses believe, that given an opportunity, they would bring new ideas and creativity to healthcare," Sherman says. "They also think they bring a spirit of teamwork and cooperation that could improve work cultures."
Fear of Failure
It's worth pointing out that the Millennials' view of nursing leadership isn't all sunshine and rainbows.
There are specific factors that could dissuade them from pursuing this career path.
First off, the feedback they've received about leadership roles from current nurse leaders is not always glowing. The Millennials surveyed by Sherman reported that they heard nurse leader positions had a high-level of responsibility and accountability and that budget constraints were a major challenge to being an effective leader.
"I think that leaders don't always put a positive face on what they do," Sherman says, "and all [Millennials] see are either negative comments being made or what they see as pretty negative body language."
This may feed into what Sherman found to be the Millennials number one concern about taking a nurse leader position—fear of failure.
"The American Psychological Association has looked at the different generational cohorts, and this cohort is the most stressed," Sherman says. "We're seeing extreme anxiety levels among Generation Y because they fear failure."
This fear plays into whether they ultimately decide to step into leadership roles. "It's at the top of their minds when they think about [if they are] going to make this move or not make this move, she says.
Growing Leaders From the Ground Up
This is a generation that thrives on success and feedback, so the traditional "out of the frying pan into the fire" method of developing nurse leaders may not work for them. "You just can't fling them in there and let them sink or swim," says Sherman. "They need the mentorship. It's a challenging role and they need a lot of development and support."
Some may point to this need for feedback and mentorship as validation of the stereotype that Millennials expect to be coddled in the workplace. In their defense, Sherman points out that nursing leadership positions have become more challenging and intense over the past decade.
"Because of the changes in the economy and the pressures on hospitals, these leadership roles are very different than they used to be," she says. "There's a lot more pressure… and these leaders have been given more and more responsibility including multiple unit management in some situations."
Sherman suggests that leaders be on the lookout for nurses with "high-leadership potential." In other words, people who ask good questions, demonstrate good judgement, want to get involved in committees, are naturally curious, and attend continuing education opportunities.
"Those are the kinds of nurses that we really need to plant the seeds early," she says. "Many organizations today, when they identify nurses like that, are trying to look for ways to develop what they call the emerging leaders category of staff."
There also needs to be a commitment to mentorship and development of these new leaders because if support seems to be lacking, the Millennials are likely to balk at taking on a leadership role.
"[We need to look at] what we can do to begin to professionally develop them so they will start to see themselves as leaders and will be ready to move into charge nurse roles and will be ready, willing, and able to move into management positions if they're available," Sherman says.
For action plans, advice, and strategies for improving communication and engagement of your intergenerational nursing team, see the book, Managing the Intergenerational Nursing Team, by K. Lynn Wieck, PhD, RN, FAAN, and Kimberly D. Moss, PhD, RN.
Vanderbilt's executive CNO describes how the medical center made patient-centered care an integral part of its organization's culture rather than just a buzzword.
I once had a manager who declared that, "taking it to the next level," was our new departmental goal. When I asked for specifics on what the effort would entail, I was met with a deer-in-the-headlights look.
We use clichés, and their shorter, snappier cousin the buzzword, because making vague generalizations is quicker and easier than the laborious process of fleshing out the specifics of big concepts.
Take, for example, the idea of patient-centered care, which the Institute of Medicine defined in its 2001 report, Crossing the Quality Chasm: A New Health System for the 21st Century, as being "respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions."
Marilyn Dubree, RN, MSN, NE-BC
Many organizations boast that they follow patient-centered care models, but as the authors of this 2011 piece from the Annals of Family Medicine point out, what some call patient-centered care is really just the addition of hospitality industry amenities such as designer wallpaper, complimentary manicures, and eye-catching lobbies.
These enhancements may boost patient satisfaction scores, but if an organization fails to make changes to its clinical and organizational infrastructures and care models in addition to aesthetic improvements, then that's not true patient-centered care, it's—to use another cliché—just putting lipstick on a pig.
So what does an authentic model of patient-centered care look like? Marilyn Dubree, RN, MSN, NE-BC, executive chief nursing officer at Vanderbilt University Medical Center in Nashville, TN, was able to answer this for me during a recent conversation. The transcript below has been edited for clarity and brevity.
HLM: Sometimes I hear leaders say, "We're really focusing on the patient," but when you talk to the rank and file they think it's a lot of lip service. How do you make patient-centered care genuine and get staff on board?
Dubree: Most nurses, physicians, and other clinical staff would say that we have, for many decades, placed patients at the center of what we do. So the new focus that comes out of regulatory and financial models can sometimes be seen as false to them.
The way I think you make [the emphasis on patient centered care] genuine is to say, "You're already doing that; you already put the patient at the center of what you do."
The reality is that this is a space where, nurses in particular, have a very high value focusing on patients, focusing on their families, and understanding in a very intimate way the challenges that an individual has.
That's something that nurses are very close to. The ability or the need for us to measure it, or measure it in a different way, may be new. And to have it expressed as something that people are monitoring and that's being shared publicly— that's very different than what any of us on a care team experienced in the past.
Yet, if it helps to bring our work to a higher and better level, then that's a good thing.
HLM: Organizations sometimes say they put the patient first but, if they truly did we probably wouldn't have half the challenges that we have in healthcare today. What are your thoughts on this?
Dubree: I think, individually, people put the patient first, but perhaps the systems don't do that. For example, if you ask someone if they have had an experience with a nurse, they'll recount a fabulous interaction with a nurse. But they may [also] say, "I had to wait in the clinic. I couldn't get an appointment. The hospital wasn't as clean as it needed to be."
Individual interactions can be very patient-centered, but the systems that surround the care may not be experienced in quite that way. We still have work to do in that space.
I talked to someone the other day about how nurses have been [ranked] the most trusted profession, except for [2001] the year of 9/11, since Gallup's been doing the poll [on honesty and ethics in professions].
I think that's because individuals who've encountered nurses see them coming to their work without a motivation for money, without a motivation for status, but with a great motivation for caring for individuals and their families with compassion.
That's the way most people interact with nurses. And it's magnificent. That's why it's a magnificent profession. And yet some of these other things that swirl around us—like billing systems and insurance—things that are really important to making the systems work, are a little bit more difficult and challenging when you're interacting with that.
HLM: At Vanderbilt, what does putting the patient at the center of care look like? What are some things that make that happen?
Dubree: We have a lot of strategies to do that. We have a very robust collection, not just one, but a collection of patient and family advisory councils. We look at those councils as our board. They give us feedback about what we do well and what we should or could do better.
We use them for reviewing our healthcare portal, evaluating choices of new furniture for patient care rooms, and reviewing patient education material. [Our council members] are very important to us and we try to use them in a way that is not superficial, but in a way where they can be deeply involved. They have work plans and we report out on that work. Most of our big committees, like the nursing quality committee, have patients or family members on them.
We try to make sure that we are not just listening at the intersection of care or the intersection of service, but that we also have built systems and processes to involve them in how we plan care or plan changes. I think that's been very powerful.
We have patient care centers [a configuration of the individuals that provide care to a diagnostically coherent group of patients] and service lines throughout our medical center and those streams of work are led by a physician, a nurse, and an administrator.
We call this a paired leadership model. We believe that the best work outcomes are achieved when they are led by those three individuals.
We structure ourselves so that every patient care center has those roles. The individuals that lead those patient care centers are responsible for the entire continuum of care and looking at how to achieve value in clinical, financial, and quality outcomes across the continuum.
It's a model that makes a lot of sense, and people see the logic in it, but they haven't see it quite so robustly implemented. I think it's reflective of our collaborative culture. It reflects the parity of the importance of their roles and it lets us get to much better outcomes. I think our performance is much better because of that.
Do Millennials act entitled? Are Baby Boomers old-fashioned? Nursing workforce demographics are changing. One St. Louis-based hospital has changed its practices to meet this younger generation's needs.
This is the first column in a two-part series on Millennials in the healthcare workforce.
Kids these days! Perhaps you've heard these words or maybe even said them yourself. I know I've been guilty of muttering them on occasion, and probably at some point in my life have had them said about me. It's nothing new. As long as there have been adults, there have been judgements made about the generations who follow in their footsteps.
In their youth, Baby Boomers were called hippies. Gen X (to which I belong) was labeled slackers. And today Gen Y, also known as Millennials, is often described as entitled.
As this last group—defined by the Pew Research Center as those ranging in age from 18 to 34 as of 2015—establishes itself in the nursing workforce, the differences between generations should start to become even more apparent, due in part to shifting demographics.
While the Baby Boomers have long been the dominant age-related group in the U.S, Millennials are projected to surpass them in number this year, reports the center. Gen X, which is a smaller cohort in general, will be sandwiched between the other two.
As the make-up of the working population shifts, the nursing profession will have to change as well. But will a multigenerational group with a reputation for eating its young be able to do this? Possibly, but it will require give and take from all groups involved.
Leslie Neal-Boylan, PhD, RN
Respect Your Elders
Incivility, lateral violence, and workplace bullying have been and continue to be problems in nursing. In fact, just last month the American Nurses Association set a zero tolerance policy for workplace violence and bullying.
Leslie Neal-Boylan, PhD, RN, dean and professor of the College of Nursing at the University of Wisconsin-Oshkosh and author of The Nurse's Reality Shift: Using History to Transform the Future, agrees that aggressive behavior towards colleagues is unacceptable, but she points out that it may, at times, stem from generational differences.
"There is absolutely no excuse for incivility no matter what," she says. "But I do think that part of this is because we have new graduates who are coming out of school who very often—and this does not go across the board—come out thinking they know everything they need to know and also expect immediate responses. This is the email/Twitter age."
That need for immediate information and lack of recognition of other's expertise may rub some experienced nurses the wrong way.
"We have to make sure that students who are graduating understand that they are entering a world that, in some ways, is old-fashioned," she says. "You have to earn respect, and you're not going to get it unless you show that you are willing to listen to those who are more experienced and you're willing to learn and do your homework."
For example, a major Millennial faux pas is expecting other nurses to give you an answer to a question without first trying to find the solution on your own. Given the pace of today's nursing units, such hand-holding, for lack of a better word, may feel like a burden to other busy nurses.
"There's a need to be respectful and not expect that everybody is going to wait on you hand and foot when [they've] got seven patients to take care of," Neal-Boylan says.
New Nurses' Needs
While nursing, and healthcare in general, may have old-fashioned standards (for an excellent example, read the column of my colleague Lena J. Weiner on dress codes), that doesn't mean organizations have to be sticks-in-the-mud and not change to meet some Millennial preferences.
"They come in here, they know what they want, they know how they want it," says Kathy Bonser, MS, RN, vice president and chief nursing officer at SSM Health DePaul Hospital in St. Louis. "They have an expectation that they will hear from leadership and be involved."
Feedback from new hires led SSM DePaul to retool its onboarding practices in June, says Bonser.
"They want feedback and they want a lot of it," she says. "So our onboarding has changed in that we've created a path for our leaders to follow."
SSM DePaul now clearly lays out the frequency with which managers must meet with newly hired new graduate nurses.
"The first three months, six months, at those 30-, 60-, 90-day touchpoints and even out to that first year, you're constantly giving them feedback," she says.
Bonser, who herself is a Baby Boomer, says the organization has also reassessed its communication techniques with the Millennial cohort of nurses.
"They like text messaging," she says. "For me, I want to pick up the phone, I want to talk to somebody, or go see them in person. But these kids, they won't answer the phone, but they'll text you back and forth in a heartbeat."
To support this communication style, SSM DePaul now provides leaders with a cellphone stipend because they were using their personal devices to connect with the staff.
Bonser has made a commitment to create a workplace that supports Millennials. In June, the organization hired 54 new graduates, and she wants to hire 50 more this month, she says.
While changing communication styles may seem like a lot of effort to some, Bonser says adapting to generational needs is just part of being a leader.
"I don't know if [Millennials'] expectations are unrealistic; I think their expectations are what they know," Bonser says. "Our job is to figure out who's working for us, what they need, and [give that to them] within the limits of what we can actually provide."
An Ohio hospital trains liberal arts college students as community health workers. After the first year, patients enrolled in the program had a 26% reduction of ED use and 51% reduction in hospital readmissions.
When I was working as an RN, I had a unit director who used to say, "There's three sides to every story—her side, his side, and what really happened, which is usually someplace in the middle."
She applied that concept to mediating employee squabbles, but the idea relates to patients, too. It could be said there are three sides to every admission (and readmission)—what's observed in the inpatient setting, what the patient says, and what's really going on in the patient's home.
AlexSandra Davis, RN, BSN
AlexSandra Davis, RN, BSN, recently experienced this when a patient was referred to Wooster (OH) Community Hospital's Community Care Network, a program that trains and uses college students as community health workers. Both the patient and her case manager said she was safe to go home, but when Davis, who is manager of the Community Care Network, got to the woman's residence she saw the third side of the story.
"I got in the home and she didn't have her medication, she didn't have her breathing treatments, she didn't have a nebulizer, she didn't have a glucometer to check her blood sugar," says Davis. "But when you asked her if she was OK to go home, she'd say, 'I'm fine to go home.'"
If left unchecked, those issues could have led to a hospital readmission. Wooster's Community Care Network, a partnership between the hospital and The College of Wooster, was launched in 2013 to prevent situations like this.
The Beginnings of an Idea
"I was interested in doing some things with transition of care and really looking at readmissions and patients bouncing back to either readmission or to the ED," says former Wooster CNO Loraine Frank-Lightfoot, RN, DNP. "We already had a good readmission rate, but this was something that could reach even more people and make more of a difference."
Frank-Lightfoot, now CNO at Parkview Regional Medical Center and Affiliates in Ft. Wayne, IN, knew that as manager of Wooster's home health and private duty divisions, Davis had done some preliminary work with the organization's cardiologists to prevent readmissions among heart failure patients. She had also heard about how Barry Bittman, MD, was using college students as community health workers in Meadville, Pa.
"We went and saw what he was doing there… and said, 'You know we think that's something we could really implement at Wooster,'" Says Frank-Lightfoot. So Davis reached out to the college to talk about collaborating on a similar program to train Wooster students as health coaches.
"I met with the dean of the program that they have there for exponential learning. We talked about this program and Barry Bittman's concept and what we were going to be doing," Davis told me. "At that time we really didn't have a good understanding of exactly how we were going to pull this off."
Developing the Curriculum
Davis and her counterpart from the college, Carol Sedgwick, worked with Bittman and his staff to develop what is now Wooster's Community Health Network. Sedgwick oversaw specifics on the college's end such as course registration logistics while Davis developed the course's clinical components.
Loraine Frank-Lightfoot, RN, DNP
Students, usually sophomores at the liberal arts college, start with a general overview of the program including a description of the role and responsibilities of a health coach. Davis then covers the clinical aspects, including pathophysiology, of the various diseases students may encounter out in the field like diabetes, COPD, heart failure, and hypertension.
Students review disease-specific discharge booklets which all Wooster patients receive upon discharge. They help patients set goals, ensure patients have the proper resources to maintain or improve their health, and report any issues to the patients' primary healthcare providers.
Each student is assigned two patients who they visit once a week. The program awards students 0.5 credit hours toward fulfilment of the college's volunteer service requirement.
Spelling Success
The two-year-old program has had success. Currently, 35 students and 80 patients are enrolled, says Davis, and by January 2016 she expects over 100 patients to be part of the program. As enrollment, which is always voluntary, has gone up, hospital use has gone down. According to data collected a year ago, patients enrolled in the program had a 26% reduction of ED use and 51% reduction in hospital readmissions, Frank-Lightfoot says.
As the program has grown, it has also undergone some changes.
At first it was about readmissions and hospital utilization, but as time passed, "we found that most of the patients we were getting into the program were not coming through the hospital," Frank-Lightfoot says. "These were, in many cases, patients that physicians had in their office practices that were very fragile and needed more care and attention than they could provide."
Another recent change Davis has made to the program is focusing on patients with frequent readmissions to keep them out of the hospital for at least 31 days.
"We're reviewing patients that have been admitted to the hospital for CHF, COPD, and pneumonia," says Davis. "We're working with those case managers and those patients and finding out if they're appropriate for our network or not."
Essential Considerations
Frank-Lightfoot says that while the program is definitely of value, those wishing to start a similar program should consider a few factors. First, consider funding. Wooster's program is free to patients, but interestingly, the program has never been supported by any grant money.
"The grants either pigeon-hole you too much, or the grant is over and you don't have any money to fund it," she explains. "We made the commitment when we started… that we were going to do the funding through the hospital. That way we had control, we could partner with who we needed to partner with, and we knew the money wasn't going to dry up after a year."
Davis says one way to keep costs in check, is to be savvy about staffing. Volunteers aside, the program's staff consists of Davis, one full-time LPN and one part-time LPN. "You don't need to have a whole bunch of RNs out there," she says.
Understanding the community's needs and resources is also key to developing a productive program, says Frank-Lightfoot. "Be open to doing this in a non-traditional way," she says. "You have to find what works in your community and tailor it with the resources you have available. You may not be able to find a college or university that's willing to partner. You may have to pay people to do it."
Bedside nurses and nurse executives will be less affected than others by the advent of ICD-10 coding on October 1. It may take time for their organizations to adjust, but ICD-10 will eventually give nurses the data to make timely adjustments to healthcare delivery rather than simply being reactive.
For all of the wailing and gnashing of teeth over the impending conversion to ICD-10, you would think the fate of the entire U.S. healthcare system hinges solely on this update of diagnostic codes. But as far as nurse leaders go, it's safe to pack up "The End is Near" signs.
Susan Marino, RN
"I think that the good news is, for nurse execs, it's not a direct hit unless they have ownership of their advance practice nurses or they are, obviously, managing large physician practices," says Susan Marino, RN, chief nursing informatics officer at Hartford (CT) HealthCare. "In a hospital scenario, it will be fairly seamless to direct care nurses because [ICD-10] is really about two groups—the providers who are doing the documentation and then the coders."
Still, nurse executives should be aware that there could be some short-term operational bumps in the road as their colleagues get their arms around ICD-10 requirements.
"One of the key elements of ICD-10 is that it's a fairly significant learning curve for our providers. It means a lot more detail in their documentation," Marino says, "which means chances are good at go-live that there's going to be a curve of learning that will potentially hit their productivity."
Marino, who is also co-chair of HIMSS' nursing informatics executive workgroup, explains that nurse executives should be aware of patient flow in areas like the emergency department, nursing units, and operating rooms so they can identify any issues arising from the new requirements in provider documentation.
"We don't want our patients' length of stay to increase because our providers can't discharge as quickly and get their documentation done," she says. "You don't want a drop in our revenues because we're not documenting as well or it's taking longer."
Encouraging interprofessional unity is one way to help soften the edges of the stress brought on by the ICD-10 documentation requirements, says Marino.
"[You want to be] making sure that the folks out on our floors and our different areas are aware that the physicians may be frustrated at some level," she says.
She also recommends other disciplines step up their documentation game during the transition. "The more that we all play well with our systems and document more accurately, the better off our physicians will be in their ability to achieve their goals," says Marino.
And nurse executives would do well hold off on launching their own major projects until ICD-10 has become part of the documentation norm.
"Making sure that [ICD-10] is successful within the confines of your operational areas is important," says Marino. "So any major initiative that a nurse executive knows is coming down the pike, you want to make sure that you don't have competing initiatives going on so that any one thing won't be as successful as you'd like it to be."
Long-term Gains
Is all the ICD-10 angst necessary? Most likely not.
An analogy, Marino says, is "Did we freak out when we got our new iPhones and we stopped using the phone book? You know, you bring in new things, we change in our environment, and there's just natural transitions that are going to happen."
Despite the trepidation, there are benefits to doing things in a new way. In the case of ICD-10, Marino says the specificity of the diagnosis codes will help collect stronger data.
"This all kind of relates back to where we're headed in relation to our dependence on data, and accuracy in data in particular. … [We are] trying to catch up with medical terminology and really getting to a different granularity in data so that our data can help us drive improving quality of care, measuring our outcomes, the cost of care," she says. "If you don't have good data, you just can't plan, you can't improve upon on your environment."
Marino says ICD-10 has the potential to support the federal meaningful use incentives for healthcare IT, the move towards value-based purchasing, and payment reform.
For patient care, ICD-10 can help healthcare professionals better understand a condition, possible interventions, length of stay, and outcomes. Take, for example, a patient with a pressure ulcer.
"There'll be a lot more data in how a wound is measured, how it's treated, the cost of our wounds, and whether we, upon admission, were able to identify whether the patient had a wound or not," she says. "And so we can watch all these interactive pieces of data day-to-day and be much more able to make immediate impact on changes that are necessary rather than waiting a month or a quarter out to receive our data and say, 'Oh geez, we've lost a quarter in the opportunity to fix things quickly versus retroactively reacting to things.'"
Marino looks forward to having the flexibility to make clinical changes based on more robust data.
"We're in an environment now that anything we can do to make changes quickly helps every one of us," she says. "It's all these little things that add up to the ability to get us to better managing populations of our patients and being able to better manage the risk within our healthcare environment. That's really how we're going to be successful long-term. That should be on the minds of all of our nurse executives."
A dean of nursing, a CNO, and a former staff nurse share their thoughts on issues that have long plagued nursing, and discuss how to create a more cohesive profession.
Cherry Ames, The English Patient, and Nurse Jackie are all well-known, fictional works that depict nurses. Yet, if I had to choose the one that most accurately represented our profession, I'd actually go with a write-in candidate— the movie Groundhog Day. Yes, the Bill Murray movie. Yes, I know none of the characters are nurses.
I'd choose it because Murray's character is forced to repeat the same day over and over until he's finally able to learn from his mistakes and break the cycle. I think the nursing profession suffers this same fate at times. For decades, we've been going around and around on issues such as educational preparation, staffing levels, and even proper hand washing.
Unlike Bill Murray's vexed, but persistent character, we can't seem to come to a resolution that will break the cycle of repetition.
I spent the majority of my nursing career as a staff nurse, with a brief foray into management, so when the book, The Nurse's Reality Shift: Using History to Transform the Future, crossed my path, I was eager to talk with its author, Leslie Neal-Boylan, PhD, RN, to get some insight on how nursing can move forward to the future rather than continuing to be bogged down by the past.
For our discussion, Neal-Boylan, who is dean and professor of the College of Nursing at the University of Wisconsin-Oshkosh (my alma mater), we focused on a few issues that persist in nursing: staff shortages and disunity.
After we spoke, I caught up with Kathy Bonser, MS, RN, vice president and chief nursing officer at SSM Health DePaul Hospital in St. Louis, to get a nurse executive's take on the same issues:
Shortages: A Thing of the Past, and of the Future
Since the 1930s, nursing has gone through cycles of shortages and surpluses. While the RN shortage predicted to occur around 2014was muted by the 2008 economic crash that prevented seasoned nurses from retiring, the Health Resources and Services Administration says about one-third of the nursing workforce is approaching typical retirement age. If this group does retire, we'll need to educate new nurses to fill the open positions.
Fortunately nursing school enrollment is up, says the American Association of Colleges of Nursing. However, qualified candidates are being turned away—68,938 from baccalaureate and graduate programs in 2014—and one of the contributing factors is a shortage of nursing faculty. According to the association's surveyon vacant faculty positions, there were 1,236 vacant full-time faculty positions for the 2014–2015 academic year.
"In academe, shortages of qualified faculty are a big challenge," says Neal-Boylan. "More and more people want to be nurses, which is wonderful, but having doctorally prepared nurses is a challenge. And certainly the DNP has helped with that, but it really was not designed for a nurse educator per se in academe."
While Bonser has not yet seen a large shortage of nurses at her facility, she says that a faculty shortage could indeed affect the number of nurses coming into the pipeline. And if hospitals choose to go the route of only hiring BSN-prepared nurses, they may feel the pinch sooner rather than later.
Leslie Neal-Boylan, PhD, RN
At SSM, they've "been pretty successful recruiting the graduate nurses because some of our competitors in the market made that choice to only hire BSN," she says. "We've stayed committed [to hiring ADN nurses] because of relationships that we have with many of our community colleges that surround our hospitals."
I graduated with a BSN in 1998, at the beginning of a nursing shortage. My career advice to new nurses is to be flexible and be willing to move to find a job. My advice to nurse executives looking to fill nurse vacancies is to extend your recruitment efforts nationwide rather than just locally.
Disunity: 3.1 Million Nurses Can't Agree
Nursing administration and staff nurses often don't see eye-to-eye on major issues and a gap the size of the Grand Canyon has opened between them.
"Because of how we've set things up in nursing, there's not a lot of opportunity for those two groups to interact and to appreciate and understand what the other is doing for nursing and to really maximize what we could do if we were much more cohesive," says Neal-Boylan.
This can result in "…people who are very much in the position of making a lot of decisions for the profession and might not necessarily be close anymore to what the actual needs are of the nurse who's taking care of the patient," she says.
Bonser says she does not feel this disconnect at SSM DePaul, but she agrees that nurse executives need to stay attuned to what direct care nurses need. She even encourages giving those at the point- of-care the power to make decisions. "From an organizational perspective… I've got to have the people at the bedside making decisions about how the work is done because I can't possibly know that," she says.
In addition to a shared governance model, executives at SSM DePaul do monthly leadership rounds in all of the hospital's departments. "That's how we stay connected to our front line staff and understand and learn from their perspective what is satisfying them in their work, what's making their work harder, and what barriers do I, as a leader, need to help remove for them."
I have to say that this topic cuts both ways. I've heard many staff nurses say they have never felt valued by a CNO or nurse manager, but I also wonder if these same nurses extend the respect they crave to their executives.
When something does go right or a good decision is made do they thank their unit director or other nurse executives? Do they have the moral courage to speak up and articulate a problem in a professional way so it can be solved? If not, they probably should, because as I learned from a CNO I once worked with, "a closed mouth cannot be fed."
In order for things to change, you have to ask for what you need in a respectful, articulate manner. Working to make respect flow back and forth among nurses of all positions is one way I think we can to start building a united profession.
Think of all that nurses could accomplish if they could set a unified agenda and speak with a unified voice. We could truly change the health of the nation if all 3.1 million of us acted as one.