Healthcare executives are eager for solutions to the many challenges of running their business. But in their quest for answers, they may be overlooking a large and effective group of change agents already in their midst: nurses.
This article first appeared in the March/April 2018 issue of HealthLeaders magazine.
Nurses can improve quality and outcomes, enhance an organization's culture, and build relationships with patients, colleagues, and the community—yet to do so, healthcare leadership needs to see them as more than just a cost center.
Three nurse leaders share their thoughts on how nurses can influence change in healthcare and, if given the opportunity, be drivers of innovation.
Profit margins, mergers and acquisitions, reimbursement: There's an enormous focus on these issues in the industry, but they are not the ultimate goals of healthcare.
"When all is said and done, our mission is caring for people, and the ones who care for people, primarily, are the nurses," Maggie Fowler, RN, BSN, MBA, NEA-BC, system vice president and chief nursing officer for St. Louis–based SSM Health. "It's not saying that our physicians, pharmacists, respiratory therapists, and all the other disciplines don't—in an acute hospital setting, it's definitely a team effort—but when most people go home, the nurses are still the ones there who are assessing the plan of care. They're the primary communicator in most situations."
Nurses also maintain near-constant contact with patients. Fowler says there are about 40,000 employees at SSM, with nurses making up one-third of the total workforce.
"When all is said and done, our mission is caring for people, and the ones who care for people, primarily, are the nurses."
Maggie Fowler, RN, BSN, MBA, NEA-BC, system vice president and chief nursing officer, St. Louis–based SSM Health
In SSM's hospital settings, 50%–60% of the workforce are nurses. This connection lets nurses understand the challenges patients face and develop solutions to promote optimal care.
"Nurses are problem-solvers. The cycle of change in healthcare over the last couple of years has been so rapid. We need [nurses'] eyes and ears to help us recognize how we can improve not only the care in a hospital setting, but in an ambulatory setting and all the places where care is going to be delivered going forward," Fowler says.
Solving the problem of falls
Fowler has seen firsthand how nurses can improve patient care and outcomes and, subsequently, an organization's bottom line.
"In a healthcare environment, falls can be devastating," she says. "They can lead to a negative perspective for patient morbidity if they're injured during the fall, and have a negative impact to the organization on a cost-of-care perspective."
Recognizing this, the organization's nursing practice councils, which facilitate evidence-based decisions regarding nursing practice standards, policies, and procedures, identified a fall risk assessment tool—the Hester Davis Scale—to help reduce falls at SSM.
SSM worked with Amy Hester, one of the creators of the tool, and its EMR vendor to launch a pilot project in spring 2016 at one of the organization's hospitals.
The pilot occurred on two units, and based on its results, SSM determined that the assessment tool had efficacy for the healthcare system. The pilot had validated the value of implementing the tool systemwide, with investment on the front end being recouped by savings on the back end.
"The outcome of that pilot clearly demonstrated that this assessment tool allowed us to more clearly recognize patients who were at risk for falls," says Fowler. "The Hester Davis
algorithm—once you make this assessment—identifies the steps you take to decrease falls."
The practice was then rolled out to the rest of the SSM system (although Fowler says one hospital still needs to be onboarded to the new procedure). Training was done via "waves" across the system, with three to four hospitals per wave, Fowler explains.
Each wave took three weeks and included webinar and online training. There was also coordination with the supply chain to ensure facilities had the correct equipment (including low beds and fall mats) to address fall risk.
The organization took a whole-hospital training approach that included RNs, physicians, physical therapists, environmental services, and others.
Based on nearly a full year of data from the facilities where the fall risk assessment has been implemented, total falls have decreased by 30% per 1,000 patient days. That reduction should have a big payoff and save the organization an estimated $2.5 million annually, based on industry cost standards.
Additionally, there has been a 5% reduction in falls with injuries per 1,000 patient days, which equates to a savings of $500,000.
Fowler says SSM Health recognizes that healthcare delivery is changing and that nurses are integral to redesigning and transforming the industry.
The success of the fall risk assessment project has both empowered bedside clinicians to influence change and driven system leadership to increase its focus on the key priorities of safety, quality, and service.
"For you to be able to impact your nurses at the grassroots level, you need to be able to be at the table as a nurse leader and impact decisions, because in a lot of organizations nursing is the largest resource."
Katie Boston-Leary, RN, MBA, MHA, BSN, CNOR, NEA-BC, chief nursing officer at University of Maryland Prince George's Hospital Center in Cheverly, Maryland
"One of my priorities with nurses is that we have to translate the value [of nursing] and have the ability to translate the work into the bottom line. That is personally a passion of mine," she says. "It's translating it into dollars and cents. We're dealing in an environment with reduced reimbursement, so anything that we do, in turn, should have a positive outcome to lower the overall cost of care. We need to be advocates to help connect the dots for executives and other employees in the organization."
The shift to value-based care, while necessary, is also posing a challenge for nurse leaders.
"The value-based approach to care, which is a much-needed change, has many challenges for leaders and organizations as we are making tough changes with declining reimbursement and the financial penalties that come with it while we continue to care for very sick patients," says Katie Boston-Leary, RN, MBA, MHA, BSN, CNOR, NEA-BC, former chief nursing officer and senior vice president of patient services at Union Hospital in Elkton, Maryland, and chief nursing officer at University of Maryland Prince George's Hospital Center in Cheverly, Maryland.
"And when we do meet our targets, in most cases, we never see rewards or they don't come in a very tangible way," she says.
Likewise, leaders are tasked with how to best utilize nurses in this updated care model.
"We are now recognizing that we are appropriately in the business of maintaining wellness, so how do or will our bedside nurses fit into that strategy? Strategies should not be constrained to providing care within the four walls, but well outside of that, and we should be able to measure impact on outcomes," she says.
Nurse leaders may feel like they have one foot in two boats as they try to manage a dual reality—the long-standing fee-for-service models still in use, plus the outcomes-based models that are increasingly being adopted.
"We have a lot of people in nurse leadership roles that are still using the approach of yesteryear where it is the top-down approach. It's a little bit of managing what was and what should be versus what is," observes Boston-Leary.
Instead, she says nurse leaders should be taking a proactive approach and creating solutions that will move nursing and healthcare into the future. "It's that adage of skating to where the puck is going."
CNOs: Advocates in the C-suite
The key to moving forward is having strong nurse leaders who are willing to advocate for nursing in the C-suite.
"It is really being able to have nurse leaders that can stand with their finance person, with their CEO, and work to get proper data analytics or IT resources to better utilize and manage nursing resources. When our frontline nurses are stretched with managing volume and high acuity, nurses barely have time to perform value-added care that is meaningful versus what we see today—less critical thinking and largely computer-driven protocols, which is 'color by numbers' nursing care," she explains.
In addition, she notes, "in many organizations, nursing productivity and [patient] acuity is not measured well. Yet in most cases, staffing decisions are being based on singular data points that are forcing nurse leaders to make decisions that will hurt their team and will cause them to lose top talent."
Boston-Leary points to the hospital census as an example of this. When one of Union Hospital's pediatric units had issues with patient volume and nurse retention, instead of relying on the traditional low-census day model of nurse staffing, Boston-Leary came up with an alternative solution.
"At Union Hospital, we had a small pediatric unit challenged with declining volumes and occasional spikes without having enough staff to care for patients. We also had high turnover and low retention with nursing," she says. "A quick phone call from me to the large reputable pediatric hospital, pitching an idea for that hospital to run our pediatric unit, resulted in a management service agreement with that hospital two years later. Nurse leaders need to take the lead with these types of collaborative strategies with the support of their peers in the C-suite."
Boston-Leary advises nurse leaders to look at data trends and put together a proposal for their C-suite peers on how they plan to manage workforce and labor expense.
"That innovation and taking that entrepreneurial approach and using analytics is what we need to do in a more proactive way," she says. "Otherwise, of course your CFO or CEO is going to need answers and implementation of changes that nurse leaders will not be comfortable with, and you're not going to be left with much choice. Then you're sunk. When you're in the red in terms of your variances, that doesn't leave enough lead time to try new innovative ideas without the financial pressures for an immediate turnaround."
Fostering bedside innovation
C-suite level support for nursing innovation is necessary to effect organizational change. "For you to be able to impact your nurses at the grassroots level, you need to be able to be at the table as a nurse leader and impact decisions," says Boston-Leary, "because in a lot of organizations nursing is the largest resource."
And nurses can come up with amazing solutions when they have support, she says.
"Empowerment reveals the goldmine of talent and innovation you have within your building that we typically don't take advantage of. I think taking that lid off and being less oppressive with our policies and empowering people breeds innovation," she says.
That is why Union Hospital stresses empowerment during its nurse residency program. "That's the one thing that we impress upon folks when they come in here new to practice—that you are a leader at the bedside. That is important for people to know early in practice," says Boston-Leary. "There's no submission here. You have a voice, these are your avenues, and we want you to be an innovator, too."
In fact, each nurse residency cohort at Union Hospital puts forth a research-based idea that the hospital can implement. "We have a major presentation at graduation that we also turn into actionable items for change in our organization," she says.
One example is the creation of a tranquility room where staff members can go when they need to de-stress during a shift. "We saw marked improvement with our RN satisfaction scores in almost every domain in comparison to two previous years, as nursing felt that they were being listened to," she says.
Another nurse resident found data that nurses who work nights don't eat healthfully during their shifts. On a SurveyMonkey questionnaire, nurses remarked that they were not eating healthfully and that they would like five-minute exercise routines to help boost their energy levels at night. As a result, the vending machines now have much healthier options, and the organization is in the process of distributing "fit kits" on every unit with quick and easy exercise routines.
A third nurse resident researched how to reduce chaos during codes and found evidence that labeling team members' roles using visible IDs would make code resolution more efficient and improve outcomes. The hospital is in the process of implementing that project
"These ideas were initiated by nurses who were relatively new to practice," Boston-Leary points out. "That speaks to empowerment at all levels because the incumbents may feel inspired by the fact that if a new entrant is implementing these great evidence-based ideas, I can certainly do something, too."
Jonathan B. Bartels, RN, BSN, CHPN, palliative care liaison nurse at the University of Virginia Health System in Charlottesville, may not be a nurse executive, but he's a prime example of how nurses can have a major effect on the culture of healthcare.
His concept of "The Pause," where care teams take about a minute after a patient's death to stop and honor the life that has left them, has garnered national and international interest.
The practice, Bartels says, gives healthcare providers permission to stop and honor loss, and it's a movement away from what he describes as "the industrialized / scientific / professional detachment" that healthcare practitioners have been trained in.
In short, it reconnects patients, family members, and providers with the essence of healthcare: humanity.
The ground for the "The Pause" was laid around 2010, after Bartels attended a retreat that focused on developing resilience. Participants were challenged to go back to their healthcare facilities and create changes. At the time, Bartels was working in the emergency department, and he noticed how staff handled an unsuccessful resuscitation.
"During one of our intense resuscitations, I had noted that when we were done, we kind of just walked away from the situation," he says. "I realized that we had lost a ritual of honoring, so I knew that's where I could possibly [have] influence."
"Leaders are not just the leaders who are identified by the institutions. These are leaders who are identified by their peers. Use them as change agents."
Jonathan B. Bartels, RN, BSN, CHPN, palliative care liaison nurse, University of Virginia Health System in Charlottesville
After losing a patient, Bartels took inspiration from the actions of a hospital chaplain who once requested the care team stop and pray after an unsuccessful resuscitation. "I emulated what a chaplain had done, but instead of offering a Judeo-Christian prayer, I asked that the room stop and honor the patient in humanistic language."
His example of such language: "Could we stop and honor this patient who was alive prior to coming in here, who was loved by others, who loved others, who had a life—and also take the moment to honor all the efforts we put into caring for the patient? I ask that we hold the space, to honor this patient in your own way and in silence." This allows staff to own the practice and honor a patient's last rite of passage when a chaplain is not available, he says.
The response to Bartels' action was positive. "People who were not necessarily religious per se came up to me and said, 'You gave me space to do this, and I thank you for that,' " he recalls. "It opened the door for others to imitate it, and others started to practice it. That's really how it took off—it was just people seeing it done once and then being empowered to do it themselves."
Thus, "The Pause" was born. It began to spread beyond the ED into UVA's other care areas. Trauma surgeons and anesthesiologists requested care teams to take part. It has spread to other healthcare facilities and settings, both nationally and internationally, as well.
"Other institutions have formalized it. Cleveland Clinic is now using it across the board," Bartels says. "It's being done for organ transplants in South Africa. When patients are donating, they do it for the donor and they do it for the recipients. In hospices, they're doing it, and they're also doing it out in the field for EMS care providers."
He adds that the University of Virginia's school of nursing is working on a preliminary national/international study to look at both the spread of The Pause and how different areas/cultures define it.
Anecdotally, those who take part in the ritual have had favorable experiences. "The results of that have been mostly qualitative reporting. 'This made me feel better; it felt right; it helped the family to see us do the practice,' " he says. "EMS [staff] and healthcare providers tell me [The Pause] shows that you really care. It's not just enough to try and save a life; it's that extra demonstrative of compassion."
As direct care providers, nurses are in a prime position to identify areas that need improving and, like Bartels, come up with solutions.
"Nurses are not only implementing the instructions and the guidance of the physicians; they are the eyes and ears of healthcare. They provide a huge portion of the direct hands-on care 24/7, and that affects outcomes," he says. "The way I see nursing really influencing is in helping to look at what outcomes are being worked [toward] for our patients. It's not just healing the disease, it's healing the whole patient. It's not just stating 'I'm offering compassionate care'; it's actually giving compassionate care."
Bartels encourages executives to look to those nurses who are "informal leaders" to facilitate change.
"Leaders are not just the leaders who are identified by the institutions," he says. "These are leaders who are identified by their peers. Use them as change agents."
Editor's note: This story has been updated to correct the name of the organization where Katie Boston-Leary, RN, MBA, MHA, BSN, CNOR, NEA-BC, currently works. Boston-Leary is chief nursing officer at University of Maryland Prince George's Hospital Center in Cheverly, Maryland.
Jennifer Thew, RN, is the senior nursing editor at HealthLeaders.