Top 3 Nursing Lessons of 2014

Empowering forward thinkers, investing in education and experience, and supporting nurse-driven initiatives are the most important nursing lessons of the year.

I love looking forward to things. I'm a list-making, goal-setting planner, who is relentlessly (and maybe unrealistically) optimistic about New Year's resolutions. (I'll be running my first half marathon in 2015. And now I really have to do it, because it's in writing!)

Earlier this month, I consulted with a couple of nursing's most innovative thinkers to predict what the year 2015 would hold for the industry. We discussed big ideas, like a renewed focus on nursing ethics and the push to get more nurses into the boardroom.

But as much as I love predictions and resolutions, it's also invaluable to reflect on where we've been and what we've learned. Looking back at the 45 nursing columns I've written so far this year, a few ideas jumped out at me:

1. Empower the Forward-Thinkers
This year's HealthLeaders 20 honored nursing's answer to MacGyver: Roxana Reyna, RN, a skin and wound care specialist at Driscoll Children's Hospital in Corpus Christi, TX, who makes, or "hacks" solutions for her pediatric patients' wound and skin care by measuring, cutting, and experimenting with materials that are often manufactured with adults in mind.

I profiled her work in June, but she's just one of many forward-thinking nurses who figure out innovative solutions to patient care problems every day. "It's having to troubleshoot and come up with a solution for the problem," Reyna told me. "It's just like the nursing process."

Empowering those forward-thinkers is important, not only for advancing patient care and encouraging nurse autonomy and innovation, but also for when it's time to implement new initiatives.

"You want to look for your early adopters so they can pilot," says Linda Talley, MS, BSN, RN, NE-BC, vice president and CNO at Children's National Health System in Washington, DC. She told me in August about her hospital's LEAN initiatives pilot, which she started in units that she already knew were helped by "change agents."

Engaging the change agents not only ensures that the most forward-thinking nurses are at the forefront of changes, but also means that once a pilot is successfully completed, those forward-thinkers can help make institutional changes and "lead on behalf of the organization," Talley says.

Imagine how many change agents a hospital could have if all nurse leaders took Talley's cue by looking for, recognizing, and empowering its innovators.

2. Invest in Education and Experience
My first column of the year was titled "Experienced Nurses are Less Expensive Than You Think." It highlighted a study of children's hospitals which found that:

• The odds of death increased as the institutional percentage of pediatric critical care unit nurses with two years' clinical experience or less increased.
• The odds of mortality were highest when the percentage of RNs with two years' clinical experience or less was 20% or greater.
• The odds of death decreased as the institutional percentage of critical care nurses with 11 years' clinical experience or more increased and for hospitals participating in national quality metric benchmarking.

The study author, Patricia A. Hickey, PhD, MBA, RN, FAAN, vice president of cardiovascular and critical care services at Boston Children's Hospital, told me that older nurses aren't expensive; they're "priceless."

"There is nothing more expensive than turnover… [the hiring process] is far more expensive than the salary that you're going to pay to a senior nurse, and all nurse leaders know that," Hickey said at the time.

"I think we now, for the first time, have illustrated why nurses deserve the salaries that they get—because they are saving lives and they are rescuing patients from bad outcomes."

I revisited the subject of the monetary value of nurses in October when I highlighted a study that found that patients who receive 80% or more of their care from nurses with baccalaureate educations have 18.7% lower odds of readmission than patients treated by nurses without degrees.

Researchers estimated that increasing the proportion of BSN-prepared nurses caring for each patient to 80% or more would reduce annual readmissions by roughly 248 days, reducing costs by more than $5.6 million annually.

The cost associated with salaries for a larger group of BSN-prepared nurses was estimated to be $1.8 million for the nurses included in the study, a cost that's far outweighed by the potential savings.

It also pays to pay nurses enough money to live on.

"[I]t is essential for health care organizations to pay adequate salaries to nurses," ANA spokesperson Adam Sachs told me via email, "so they don't feel compelled to get a second job to support themselves and/or a family, since nursing is very demanding work physically, mentally, and emotionally."

Sachs's assertion was in a column about nurses needing to work multiple jobs, which can compound fatigue and contribute to decision regret and lapses in patient care.

Kathryn Hughes MSN, RN, program coordinator, nursing administration at University Medical Center in Las Vegas told me via email that as a clinical manager, she often sees nurses who have multiple jobs.

She says she's seen everything from nurses who act surly toward patients to ones who fail to double-check medication labels. She even had a nurse who arrived to work a 12-hour day shift immediately after working a 12-hour night shift at another facility.

Paying nurses an adequate salary is certainly worth the investment if it means better patient care.

3. Save Money with Nurse-driven Initiatives
Speaking of innovation and empowering nurses to make positive changes, 2014 gave us examples of the ways nurse-led initiatives help patients, improve outcomes, and save money.

For instance, a nurse-driven ambulatory initiative at Duke Raleigh Hospital's ICU saved $589,824 over six months, and was projected to save nearly $1.2 million over a year. The six-month early progressive mobility work aimed to get mechanically ventilated and post-operative patients up and moving sooner, sometimes as soon as they're admitted to the ICU, in an effort to decrease the cost and length of stay as well days on mechanical ventilator.

Nurses at Fox Chase Cancer Center implemented a delirium-prevention protocol, a risk-assessment and screening tool that creates a risk score for patients using measurements such as the confusion assessment method, and assigned certain types of interventions based on that score.

"[The interventions] decreased the length of stay in the ICU by about a half of day," Anne Jadwin, RN, MSN, AOCN, NE-BC, vice president of nursing and CNO, told me. That might not sound like a lot, but it's significant when you consider the high risks and cost of the critical care unit. In addition, pharmacy data shows that patients needed sedating drugs less often with this protocol in place.

Nurses are also discovering that they can impact the way their units are set up to improve workflow and even the way their hospitals are designed. But their feedback has to be listened to and acted on by responsive leaders.

"If they don't speak up, I keep bugging them until they do," says Irene Strejc, RN, BSN, MPH, CENP, CNO at Methodist Richardson Medical Center in Texas.

"Silence is not an option. They know they have a voice, and I expect them to use it. I respect them very much. I want them to feel that they make a difference in everything that they touch."