Nebraska's move brings to 20 the number of states allowing nurse practitioners full practice authority, puting it "in line with the future of collaborative models of health care," according to one state lawmaker.
Nebraska has enacted a law that scraps the previously required integrated practice agreements for nurse practitioners, becoming in March the twentieth state to grant full practice authority to NPs.
Tay Kopanos, DNP, NP, vice president of state government affairs for the American Association of Nurse Practitioners calls the move "tremendous."
"By retiring the written collaborative agreement, Nebraska has just said, 'We are going to utilize our nursing workforce to their maximum capacity,'" Kopanos says.
Now, 20 states and the District of Columbia allow NPs full practice under the exclusive licensure authority of the state board of nursing. Kopanos says the states where NPs have full practice authority have seen more NPs working in rural and underserved areas and those states are better able to provide earlier preventive healthcare services and access to primary care.
"As states are struggling to address expanding Medicaid populations, an aging population, and increased people living with chronic diseases… states that are utilizing NPs will be ahead of the curve," Kopanos says.
Although that number represents less than half the states in the nation, the trend is moving toward allowing NPs full practice authority. Kopanos says it's "telling" to look at the number of states that have enacted such laws in the just the past few years, as well as the number of states currently introducing legislation to grant full practice authority to NPs. (See AANP's state practice map here).
"In the last four years we have had six states retire the condition of physician involvement," she says, pointing to North Dakota and Vermont in 2011; Nevada in 2013; Minnesota and Connecticut in 2014; and Nebraska so far this year.
Several states have already introduced legislation this year, and there are others that will likely do so later in the legislative session. Maryland, Texas, Illinois, South Carolina, Pennsylvania, and Kansas have all introduced language that would grant full practice authority to NPs. California has placeholder bill waiting for formal language, and a handful of other states are looking act, too. Should all of these states enact laws, the balance would tip toward the majority of states allowing NPs full practice authority.
"States are looking at right-sizing the regulations around nursing practice," Kopanos says.
The notion of "right-sizing" state laws is gaining traction as the NP role marks its 50th anniversary this year. In the decades since it was first established, the NP role has evolved, but in many cases, legislation hasn't evolved with it, creating a disconnect between the high level of care that NPs can provide and the limited care that outdated licensure laws allow. Some laws have been on the books since the 1970s or 80s, Kopanos says.
"Nowhere else in healthcare would it be acceptable to offer the best of what could be offered of the 70s or 80s," she says.
Kopanos points to several organizations, such as the National Governors Association and the AARP, which have supported reexamining scope-of-practice rules to allow for more NPs to practice primary care.
There is opposition, however, from the American Medical Association. In a January 15 letter to Kathy Campbell, chair of the Nebraska Legislature's Health and Human Services Committee, the AMA argued that expanding NP scope-of-practice would "compartmentalize and fragment healthcare delivery. "The AMA said it was "concerned that the changes proposed" by the legislation "may undermine the delivery of patient-centered, team-based care in Nebraska."
In the AMA's view, that team-based care should be led by physicians. In an emailed statement to HealthLeaders, the AMA said:
The American Medical Association encourages physician-led health care teams that utilize the unique knowledge and valuable contributions of nurse practitioners, physician assistants, and other health care clinicians to enhance patient outcomes. Innovative physician-led team models by some of the nation's top health care systems across the country are achieving improved care and patient health, while reducing costs. The AMA looks to these systems as evidence that physician-led, team-based models of care are the future of American healthcare. Patients win when each member of their health care team carries out the role for which they are educated and trained.
But as a recent Supreme Court decision about dental services providers and scope-of-practice laws underscores, the NP scope of practice issue boils down to competition, not patient safety.
"Over four decades of research have consistently demonstrated that there is no safety concern, and quality of care has been high, and in some cases, better than the profession that they have been benchmarked against," Kopanos says.
A "landmark" Supreme Court decision about teeth whitening service providers and scope of practice laws has national implications for nurses, too, says the American Nurses Association.
What do inexpensive teeth whitening, the Supreme Court, and antitrust laws have to do with advanced practice nurses? A lot, says Maureen Cones, associate general counsel for the American Nurses Association.
Maureen Cones
Associate General Counsel,
American Nurses Association
It all starts with the North Carolina Board of Dental Examiners, which didn't like that non-dentists were offering cheaper teeth-whitening services than they were. To put a stop to it, the board issued "official cease-and-desist letters to non-dentist teeth whitening service providers and product manufacturers, often warning that the unlicensed practice of dentistry is a crime," according to a Supreme Court opinion about the case.
The threats worked. But after the non-dentists stopped offering teeth whitening, the Federal Trade Commission stepped in, filing an administrative complaint that the dental board's actions were anticompetitive and unfair. On February 25, the Supreme Court agreed.
So again, the question: What does this have to do with APRNs? According to Cones, this ruling essentially means that state licensing boards can't engage in conduct that limits the scope of practice for other professions "unless their actions embody the clearly articulated policy of the state and is done with state supervision."
Scope of practice. State policy. Sound familiar?
An ANA statement about the ruling drew parallels to the nursing profession, saying that this "anti-competition case has far reaching implications beyond dentistry and will have a significant, positive impact for nursing practice: It ensures nurses can work to the full extent of their education and training, unrestricted by unlawful anti-competitive interference."
"I would call this a landmark ruling," Cones says.
There are unmistakable echoes here of physician claims that limiting APRN's scope of practice is a patient safety issue. The North Carolina Board of Dental Examiners claimed that its teeth-whitening battle was about patient safety, but the FTC rejected that notion, pointing to "a wealth of evidence… suggesting that non-dentist provided teeth whitening is a safe cosmetic procedure," according to the Supreme Court opinion.
"It's not a patient safety issue, people do teeth whitening at home," Cones says.
It's really about financial stakes and competition.
Cones says boards are intended to regulate their own professions. Although the ANA believes this to be an incredibly important function, scope-of-practice overlap can cause substantial friction when one profession thinks another is cutting into what it considers its exclusive practice. But "the intent is for regulatory boards to regulate themselves, not other professions," Cones says.
The million dollar question then, is who gets to decide on the exclusive practice for one profession or another.
"The state gets to decide, the elected officials," Cones says. She says states will need to establish a supervisory structure so action taken by boards can be reviewed.
This is good news for consumers because those responsible for articulating the policy of the state have electoral checks and balances in mind, rather than the best interests of a certain profession. If action someone is taken against, it will truly be in the best interest of patient safety, rather than the financial interests of a certain profession, Cones says.
And that's where this decision will have national implications: There are medical boards and nursing boards in all 50 states, and scope of practice overlap battles are occurring with increasing frequency.
"The Supreme Court decision protects patients' right to have access to healthcare providers of their choice," Cones says. "That's really important at a time when we have countless folks entering the world of the insured."
Patient satisfaction scores only modestly improve after hospitals are remodeled, research shows. What matters more is communication between providers and patients.
Picture yourself walking into a glitzy, gorgeous hotel that was designed entirely with beauty and comfort in mind. Everything—from the lobby, to the beds, to the food, to the view—is simply beautiful, looking like a spread in a glossy high-end travel magazine.
But what if, after a couple of days, you discover that the service at this gorgeous, dream locale is just mediocre? What if it's downright bad? Would you give the hotel a glowing online review and recommend it to all of your friends?
Zishan Siddiqui, MD
Assistant Professor of Medicine,
Johns Hopkins University
School of Medicine
I'm guessing that the answer is probably no. As it turns out, the same is true for hospitals, too.
According to a new study led by Johns Hopkins researchers, patient satisfaction scores only modestly improve based on the effects of a remodeled/redesigned hospital.
The bottom line?
"Healthcare leaders should not blame suboptimal environments for poor satisfaction scores," says the study's lead author, Zishan Siddiqui, MD, assistant professor of medicine at the Johns Hopkins University School of Medicine. He also believes that nurses and other frontline caregivers will emerge as the research leaders in this area.
Patient-centered hospital design has gotten a lot of attention over the past few years, being touted as a way to improve patient satisfaction scores. In 2011, for instance, I wrote about a hospital that took cues from Disney World and health resorts with the design of its brand-new, $211 million facility.
Siddiqui agrees that the hospital/hospitality analogy might be an apt one—to a point. He concedes that "a fantastically clean room and a great view" at a hotel might somewhat make up for bad service.
But that "halo effect" doesn't seem to apply in the healthcare setting.
"Very few things, if anything at all, can make up for poor communication from a healthcare provider," he says. "The kind of care that [patients] get is so much more supremely important."
Siddiqui and colleagues found themselves living within a "very interesting natural experiment" in which some of the care at Johns Hopkins Hospital was moving to a gorgeous new building, while some care stayed in an older facility. This allowed researchers to compare results of HCAHPS and Press Ganey patient satisfaction surveys between the new and old facilities.
Although there was a significant improvement in facility-related satisfaction scores, there wasn't a significant change in care-related satisfaction, or even overall satisfaction.
"I was surprised," Siddiqui says. "We looked at the data and we said, 'We have to write this up.'"
There are certainly hospital design elements that can help improve patient care. For instance, one hospital undergoing a redesign got advice from its nursing staff about the functionality of showers and how patients would flow through the facility.
But Siddiqui says he imagines that his research will inform leaders' decision-making about how much they really want to invest in lovely—and likely expensive—design elements that might not actually provide a return on investment.
Siddiqui adds that his team's research spotlights two additional aspects of patient satisfaction research in general. First, he notes that patient satisfaction surveys don't capture every patient's experience.
"Only 20–25% of our patients respond to our surveys," he says. Therefore hospital leaders could be making decisions based on an unrepresentative sample.
"We have to figure out a way of getting these non-responders to tell us what they think," Siddiqui says.
He also believes that there is a big opportunity for bedside nurses and other frontline caregivers to lead the way in patient satisfaction research, especially since funding is limited. Doing so can help leaders discover evidence-driven, local solutions for what will work in their own hospitals, and then share that knowledge more broadly.
"I think healthcare leaders need to find out a way of supporting researchers within their hospitals," he says. "I think they will be the critical players in advancing research in this area."
A framework for compassionately connecting with patients is likely to ease patients' suffering and to lift HCAHPS scores, clinical quality measures, and reimbursements.
Fifty-six seconds.
That's how long it takes to make a connection with a patient. It could be something as simple as asking about her family, whether she has any pets, or what she likes to do when she's not stuck in the hospital.
The patient might talk about just one thing during those 56 seconds, but anything she says can be built upon throughout the course of her hospital stay. As a result, she patient feels more in control, acknowledged, and is likely to give her healthcare provider more information, allowing for better care.
Christy Dempsey
HCAHPS scores, clinical quality measures, and reimbursements are likely to rise. All because of a 56-second effort to make a personal connection.
A report from consulting firm Press Ganey, "Compassionate Connected Care: A Care Model to Reduce Patient Suffering," details the firm's model for connecting with patients. First and foremost, connecting with patients and improving care requires acknowledging that patients are, indeed, suffering.
"We started talking about suffering a couple of years ago. The word suffering is emotional; it doesn't feel good, and certainly, as a nurse, it's a call to action," says Christy Dempsey, Press Ganey's CNO. "We needed to have an action to help our organizations to reduce suffering, and that's where Compassionate Connected Care came from. It's a framework to help to reduce suffering."
Although all healthcare providers should aim to provide this kind of care, nurses have always treated the whole person and provided holistic care.
"That's why I think this is really resonating with nursing leaders," Dempsey says.
The Compassionate Connected Care framework includes six main themes. Within those themes are actions that healthcare providers can implement immediately, and others that will take more time and effort.
But doing so pays off. Dempsey points to a nursing unit at one hospital in Missouri which saw its HCAHPS score rise from the 50% to 90% percentile after piloting some of these tenets.
"There are things in each one of these tenets that [providers] could do this afternoon that would improve the patient experience," Dempsey says. "There are things that you can do today and build from."
They are:
Acknowledge Suffering "We have to acknowledge suffering and show our patients that we care," Dempsey says. Simply doing that can actually reduce the suffering all by itself, she adds.
Body Language Matters Nurses and other providers should sit down and make eye contact with patients while they're talking with them. Dempsey says doing so makes the patient perceive the interaction as longer and more meaningful—even if it's not—than if the nurse stands in patient's doorway, for instance. That compassionate connection will have a ripple effect: For instance, call light frequency goes down and requests for pain meds go down. "It's actually going to save us time," Dempsey says.
Anxiety is Suffering Dempsey says that hospitals and healthcare providers are actually "instilling anxiety" when they do things like make patients wait a long time to get pain medication or to see a provider in the ED. Because of this, improving patient flow is critical. "It's hard work," she says. "But we have to do it."
Coordinate Care "There are so many touch points that a patient has to go through," Dempsey says. "For the patient, it seems like the left hand doesn't know what the right hand is doing." Simple things like a physician telling the patient that she has read the notes from the patient's nurse, talked with their physical therapist, or had a meeting with their oncologist lets the patient know that the people on the care team are actually talking to each other.
Caring Transcends Diagnosis "Real caring goes beyond the diagnosis of the patient. The patient is not the gallbladder in 202. It's Mrs. Smith who misses her dog, has a family," Dempsey says. "We have to get back to taking care of the whole person, not just the reason that they're in the hospital."
Autonomy Reduces Suffering When patients check into the hospital, their clothes are taken away and they're told when they can walk, eat, go to the bathroom and go home. "We take away all control," Dempsey says.
Therefore any control nurses and other healthcare providers can give back can feel hugely significant. For instance, nurses might ask patients which arm they'd like blood pressure taken on, what time they'd like to take a walk, and whether they'd like to turn left or right out of their room when they take that walk.
"I think nurses have so many competing priorities that it's very difficult to focus," says Dempsey. "What I see is a very task-driven approach to patient care. We've got to get past that because we will never achieve the kind of patient care we want to deliver… if we don't connect."
Alerting the general public to the problem of safe patient handling might put pressure on hospitals to finally implement—and stick to—already widely dispersed guidelines that aim to protect nurses.
During a pre-surgery visit last week, an orthopedic surgeon picked up my 45-pound, five-year-old daughter off the floor and lifted her onto an exam table so he could take a look at her hips and knees.
"My wife read an article that said doctors and nurses can hurt their backs lifting patients," he commented. His wife didn't think he should do it anymore after reading the article.
"Yeah, I think Chloe might be heavier than the recommendations," I said of my daughter.
"Oh," he said. "You read the article, too?"
No, I didn't read the article, but I write about nursing, I explained, and lifting patients safely is something that nurses talk about a lot.
I did see the NPR.org article last week in my Facebook newsfeed, but have to admit, I didn't click on it. To me, this was old news. But I did note to myself how it sometimes takes a while for news that's big in the nursing world—or any specialized world—to reach the ears of the general public.
A former editor of mine used to say these kinds of articles were for the "spectators," not the "players," to use a sports analogy.
I'm sure this wasn't new information to the surgeon. He was simply making conversation after lifting my daughter (who is heavier than the 35-pound recommended limit for safe lifting). But after talking with him, I did go back and search for the article so I could read it myself. In doing so, I realized that although this information isn't new to nurses, it might be new for the general public, and that's incredibly important.
Turns out, the article was the first in a series about the dangers of nursing (read the second part here). After recounting an anecdote about a nurse who suffered a career-altering back injury while helping to lift a 300-pound patient, the article ticked off alarming musculoskeletal injury statistics among nurses and the recommendations for safe lifting. All familiar territory for those with knowledge of the conversation around safe-patient handling.
Despite these statistics, though, the article went on to say that:
[A]n NPR investigation reveals [that] studies by university and government researchers began to show decades ago that the traditional way hospitals and nursing schools teach staff to move patients—bend your knees and keep your back straight, using "proper body mechanics"—is dangerous.
"The bottom line is, there's no safe way to lift a patient manually," says William Marras, director of The Ohio State University's Spine Research Institute, which has conducted landmark studies on the issue.
I was a bit confused. I didn't think the healthcare community needed an NPR investigation to tell them something they've known for years (check out the "myths and facts" section of this safe patient handling brochure from the ANA).
But that's what I got wrong in my initial reading of these articles. Although this NPR series didn't break any new ground when it comes to what nurses already know, I'm sure it did break new ground for consumers who might have never before considered that the nurses who care for them might get injured in the process.
And alerting the wider public to this problem might put pressure on hospitals to finally implement—and stick to—already widely dispersed guidelines that aim to protect nurses.
Because let's face it: Hospitals know about the risk of nurse injuries already; they're simply ignoring it, or brushing it off, or not consistently following through with needed changes. Apparently it's not enough for millions of nurses and hospital administrators to already know this information. Those of us who follow this topic know that hospitals often simply overlook nursing injuries because investing in making change isn't a big enough priority.
These NPR stories made me realize that it's incredibly important for the mainstream media to report on issues that are already well-known within the healthcare community. The headline on the first article in the series says it all: "Hospitals Fail To Protect Nursing Staff From Becoming Patients."
Perhaps exposing this kind of negligence could be a crucial part of correcting it.
Legislation aiming to restore "decimated" student loan funding could help incentivize nurses and healthcare professionals to practice in rural and underserved areas of Washington State.
APRNs and other highly trained nurses are among the health providers that Washington State is trying to recruit with loan-quashing legislation introduced in December.
Molly Belozer Firth
The bill, SB 5010 introduced by Senator David Frockt (D), aims to alleviate the state's primary care shortage by helping to ease the financial burden of massive student loan debt that healthcare providers are saddled with when they leave college.
Such debt leads to a vicious cycle that affects everyone from the providers themselves to the patients that get left behind. When faced with massive debt, new grads have no choice but to work in settings that can pay them higher salaries, leaving community health settings and underserved areas such as rural Washington State unable to recruit desperately needed providers.
"If they add on all this debt, they need to know they're going to have a way to pay [it down]," says Molly Belozer Firth, director of public policy for the Community Health Network of Washington, one of the organizations working in coalition to support the legislation. Also supporting it are the Washington State Nurses Association, Washington State Hospital Association, Washington State Medical Association, Washington State Dental Association, and Washington Association of Community & Migrant Health Centers.
SB 5010 would allocate $8 million in the 2015–2017 biennium for Washington's Health Professional Loan Repayment and Scholarship Fund, which encourages healthcare students and healthcare professionals to practice in underserved areas by helping pay down their student loans. The program has been in existence for years, but it was, as Firth says, "decimated" in 2011, when it was cut by 87%.
The program's current funding are "not enough to be able to support the number of providers that are out there that are looking to work in community health settings," Firth says. For example, in 2008 the program issued 84 loan repayment awards. In the most recent cycle, it only issued 25, she says.
The coalition believes that restoring funding to the program would allow it to fund 118 additional loan repayment awards, which could translate into 36,000 more medical patients being served.
Recruiting nurses, especially ARNPs, can go an extremely long way in alleviating Washington State's—or any state's—primary care shortage, especially when they're allowed to practice independently.
In Washington State, "Advanced Registered Nurse Practitioners (ARNPs) are independent in their scope of practice including full prescriptive authority. No collaborative agreements are required," states the Washington State Department of Health website.
"[Supplementing] with nurses is very important to increasing access to care," Firth says. There's also an emphasis on recruiting nurses of all kinds, especially since Firth says the state's community health centers believe strongly in team-based care.
Moreover, she says Washington State is a leader in trying to address the needs of nurses and trying to make sure they're present in healthcare decision making. "For the state overall… we've been a longtime supporter of nurses," Firth says.
She notes that although the Medicaid expansion in Washington State is good news for patients, it can only go so far; health coverage doesn't mean much if there aren't health professionals to provide care.
"This is a really smart investment that Washington State could make," Firth says. "It could really help ensure that we could help meet the needs of tens of thousands additional patients."
Restoring funding to the loan repayment program is a great way to address the primary care shortage without trying to solve longer-term pipeline issues, she adds.
"We can dramatically increase the number of providers in these rural and underserved areas with this investment, and it's an immediate investment. You see results pretty fast. This is an immediate solution."
Preventing two of the most common healthcare-associated infections reduces the cost of patient care by more than $150,000. The cost of running an infection prevention program in the ICU is about $145,000.
Preventing infections in the ICU not only saves lives; it also saves money, finds a new study published in the American Journal of Infection Control.
The study found that elderly patients admitted to ICUs are about 35% more likely to die within five years of leaving the hospital if they develop an infection during their stay.
Preventing two of the most common healthcare-associated infections (HAIs) not only increases their survival odds but also reduces the cost of their care by more than $150,000.
Those two HAIs—central line-associated bloodstream infections (CLABSI) and ventilator-associated pneumonia (VAP)—are preventable, says senior study author Patricia Stone, Centennial Professor of Health Policy and Director of the Center for Health Policy at Columbia University School of Nursing.
Patricia Stone
A report released by the Centers for Disease Control and Prevention last week shows significant reductions at the national level in 2013 for nearly all HAIs. Still, "just one HAI is one too many," Stone told me via email.
This new study shows that it pays to prevent infections, finding that on average, the ongoing cost of running an infection prevention program in the ICU is about $145,000. Those prevention efforts reduced ICU costs by $174,713 per patient for each instance of CLABSI, and by $163,090 for VAP.
In addition to cost-effectiveness, the study found that proper CLABSI prevention efforts resulted in an estimated gain of 15.55 years of life on average for all patients treated in the ICU. Efforts to prevent VAP resulted in an estimated gain of 10.84 years of life.
But just because prevention protocols are in place doesn't mean they're being followed. For instance, another study that Stone lead last year showed that when it comes to CLABSI, 92% of ICUs had a policy for an insertion checklist, but only 52% of the healthcare professionals were seen to adhere to that policy.
For VAP prevention, the results were similar: 74% of ICUs had a ventilator bundle checklist, but only 52% of those treating patients adhered to it.
HAIs are nurse-sensitive outcomes, but nurses aren't alone in the need to adhere to prevention protocols. They can, however, act as leaders in adhering to protocols, and can use the new study findings to bolster or implement HAI prevention programs. I chatted with Stone via email to learn more.
HLM: What surprised you most about the study findings?
Stone: While I thought infection prevention and control would be cost-effective due to the high attributable costs associated with these infections, I was surprised at how cost-effective multifaceted infection prevention programs were. I was also surprised how robust these finding[s] were to a number of assumptions.
HLM: What would you say are the most significant findings and why?
Stone: The most significant findings were that infection prevention not only saves lives, it also saves money. In the current constrained economic environment in hospitals with many cost-cutting measures being put in place coupled with the focus on quality, it is important to know that investments in infection prevention pay off in terms of decreased HAIs and improved economic outcomes.
HLM: What lessons or takeaways are there for nurse leaders and nurse executives? Are there lessons for charge nurses on units, or nurses specializing in infection control, or for nurses in the higher ranks of executive leadership?
Stone: Nurse leaders and executives should know that investment in infection prevention should remain a high priority. Nurse managers should be supportive of infection prevention efforts. Nurses specializing in infection control may want to use these findings in reports to administration and hospital boards to ensure investment in their departments.
HLM: What should nurse leaders have staff do differently based on these study findings?
Stone: Many hospitals are already investing in infection prevention and have well developed programs that help bedside nurses provide the best-evidence based care at the bedside. If the hospital the nurse works in doesn't [have such a program] they [nurse leaders] should try to make sure it [gets one].
They could use these findings to try to get the investment in infection prevention showing how it pays off in the end. But, even in the hospitals with well developed programs, there are still HAIs occurring and just one HAI is one too many.
Furthermore, the HAIs are increasingly caused by emerging or resistant organisms. We need to emphasize the need for compliance with guidelines to deliver the highest quality care.
HLM: What findings do you think might be most surprising to nursing executives?
Stone: How cost-effective infection prevention can be!
Often the only nurse in the executive suite is the CNO, but the new president and COO of the University of Vermont Medical Center, an RN, has spent years in executive leadership positions without ever being CNO.
"The first thing I did last Friday [January 2] was spend four hours on the patient care ward," she says. "It's really important for me to listen and learn, and that's what I've been doing this week."
So often, the only nurse in the executive suite is the CNO, but Whalen has spent years in executive leadership positions—as chief executive of Harborview Medical Center in Seattle and executive vice president at the University of Arizona Medical Center in Tucson—without ever having been a CNO. She says nurses in the c-suite are uniquely prepared to see patient care throughout the entire healthcare continuum.
It's "really looking at the care of the patient from a more holistic approach, from start to finish," Whalen says. "I think the nurse sitting at the table really has the education and qualifications and background to really look at the entire perspective of patient care." She adds that nursing is the only discipline at the table with that level of training.
This training has taught Whalen to always think about the patient in her executive decision making. She says her entire commitment and passion is putting patients first, directly thinking about how every decision she makes will impact patient safety and quality.
"I think that was ingrained in me as a nurse," she says.
Whalen notes that executives like her—nurses who step into non-CNO executive positions—are becoming more common, especially as organizations expand the breadth of executive roles beyond the traditional ones, which "makes great sense given the complexity of organizations," she says. (I'm thinking of roles like Chief Patient Experience Officer).
But that's not to say nurses don't have a long way to go. "Do I think we have enough? Of course not," Whalen says. Like many other nurse leaders, she also sees a great need for more nurses in board roles.
In the meantime, though, Whalen will be focusing on her new role as COO and president, with several initiatives on tap. For instance, she says the medical center is about to undertake a large bed replacement project, and after spending time on the patient care unit, "boy do I understand how necessary that is," she says. "We have significant need to do some replacement. The staff are very excited, and I think our patients will be very excited."
There is also a move toward single patient rooms, which she anticipates will also greatly improve quality of care and patient experience.
In addition, UVMC will be starting a national search for a CNO, aiming to recruit someone who will not only sit on the operations team at the medical center, but also play an important role within the school of nursing.
"I'm tickled about that opportunity," Whalen says.
When I asked her about the education and training needs of future nurses, Whalen had a lot of ideas, especially around technology and the ever-changing and always-more-complex demands that the health industry puts on its nurses.
"The technology that we ask our nurses to manage on a daily basis is really amazing," she says. "We don't train nurses to be engineers, and some of these 'smart' things require significant technological wherewithal."
She worries about the balancing act between performing hands-on, personal patient care and managing technology, and sees an opportunity to address this in nursing school.
Whalen also believes in interdisciplinary learning and the need to look across educational systems to do more team education.
"When nurses come out of nursing school they're working with a team of phenomenal practitioners," she says. "We ought to be educating them as a team."
Whalen is clearly excited about her new role and working at a place where nursing experience is so important; her predecessor was also a nurse.
"It was very clear that nursing expertise was extremely desirable in the recruitment process," she says. "It's really an honor to serve here. I'm thrilled that I can bring the expertise of nursing in the program, but this is an organization that really valued that all along."
The American Nurses Foundation is launching new efforts, and its executive director says CNOs and other nurse leaders can act now to increase board participation.
The nurse leadership world lost one of its luminaries when Connie Curran, EdD, RN, FAAN, passed away at the age of 67 in November 2014. I had the pleasure of interviewing Connie a couple of times, most recently in August, when we talked about the lack of nurses on hospital boards. She told me about the time she was dismissed as a "dumb blonde" by a hospital CFO when she was appointed to the board's finance committee.
Connie was a shining light of knowledge, compassion, and enthusiasm, the kind of person who not only strove for leadership, but inspired it in others; who always challenged herself and those around her; who always asked, "Why not?"
She was a former chairperson of the board of Silver Cross Hospital in Lenox, IL, and served on numerous other boards of directors, including for Hospira, Inc., DePaul University, and the University of Wisconsin Foundation. She was an amazing example of nurse leadership and was passionate about the critical need for more nurses on hospital boards.
"We have felt a deep loss in Connie's death and are really working very hard to continue this work in her memory," Kate Judge, executive director of the American Nurses Foundation, told me last week. "She is a stellar example of what is possible."
The work that Judge is referring to that of getting more nurses on boards of directors. The American Nurses Foundation recently received a $150,000 grant from the Hillman Foundation to do just that. Judge says the grant will emphasize getting nurses on boards of national health systems, philanthropies, and for-profit healthcare entities. The money will go toward hiring dedicated staff whose sole focus is this work.
Part of that work includes a board membership survey (you can take it here) for nurses to fill out to identify who has served or is serving on boards, as well as those interested in serving on boards.
The foundation is also developing a database to identify nurses who are serving or who would like to serve. So far, there are roughly 800 to 1,000 pilot profiles in the database, Judge says, adding that such a repository not only will help executives who want to recruit nurses for boards, and also will track whether the foundation's efforts to increase board membership are working.
"I think one of the roadblocks [is] that nurses haven't [often] been on boards, so they're not considered part of the regular pool," Judge says.
That seems to be changing, at least a bit. Judge says that, increasingly, younger nurses are viewing board involvement as part of their career trajectory. In addition, older nurses wish they had started building their resume with board experience when they were younger.
"They didn't see role models there," Judge says.
Other ways that the foundation will be working to increase the number of nurses on boards of directors will be to by developing workshops about board service, as well as other educational resources that will be available in print and online.
"Our goal is to share everything that we develop as widely as possible," Judge says. "The word that this is an important venture is being spread in so many different ways."
In addition to using educational resources from the foundation, Judge says there are things that CNOs and other nurse leaders can do now to increase board participation.
"They can look to themselves and say, 'Can I serve on a board in my community?' " she says, whether that's on a school board, corporate or nonprofit board, hospital board, or non-healthcare-related board. Nurse leaders can also encourage their senior nursing staff to serve.
"The desire to serve is so rich in nurses but often is focused on the bedside," Judge says. "We hope that this work will help nurses step into new leadership positions in ways that help patients overall."
Judge says she's grateful that the grant will allow the American Nurses Foundation to do this work with dedicated resources.
"This is something that is going to take great effort and people coming together and working for something that is beyond anyone's single capacity," Judge says. "If they don't have resources to devote to something, they can't move the needle, and we must move the needle on this."
A predictive analytics tool uses EMR data to trend whether patients are getting better or worse by using more than 30 different variables, such as cardiac rhythms, labs, vital signs, nursing assessments, and shift data.
Back in October, we saw a vividly frightening example of how EHRs are no substitute for nurse-physician communication, when nursing notes entered into the medical record for an Ebola patient were either overlooked or ignored.
Relying too much on technology certainly can be dangerous, but Virginia-based Riverside Health System is showing that technology can also be powerful when it's combined with interdisciplinary care.
For the past year, Riverside has been using a predictive tool from PeraHealth that uses EMR data to trend a patient's condition over time, using more than 30 different variables, such as cardiac rhythms, labs, vital signs, mental status, fall risk, and pressure sore risk. The data automatically flows into the tool from EMRs, requiring no additional input, and a score is calculated with each data point.
"Anytime there's new information that flows in, it creates the calculation," Susan Tanner, MSN, RN-BC, Riverside's System Director Clinical Informatics, says of the tool.
Tanner says a challenge of EMRs is their disparate data fields. For instance, nursing assessments aren't necessarily presented with labs. Also, looking at individual nursing assessments at individual points in time doesn't tell you much.
The predictive tool combines several variables over time to trend whether the patient is getting better or worse.
The most heavily weighted of those variables are nursing assessments and shift data, Tanner says, and watching those trends could allow caregivers to find subtle changes in conditions that may otherwise be missed.
"The research has demonstrated that nursing assessments are very early indicators of patient decline," she says. "It could create a system where we could be proactive in our intervention."
Tanner says it will take several years of data before Riverside will be able to perform a deep analysis of how well the predictive tool works in terms of finances and patient outcomes, but already, she believes, "it's been a worthwhile investment." That's because of what she calls their "catches."
These "catches" are individual patients that caregivers were able to help because of the early predictive indicators. For instance, when an elderly woman's son was concerned that his mother wasn't ready to be discharged from the hospital, he contacted her care manager who took a closer look at the patient's trend scores and noticed a subtle decline.
"It opened up a discussion, it opened up additional investigation," Tanner says, and it also delayed the patient's discharge until she was really ready for it.
In another instance, a nurse noticed that a patient seemed less alert during rounding, so the nurse took a look at the patient's trend and saw a significant decline. That prompted the provider to order studies, which showed that the patient had pleural effusion which hadn't yet been picked up on, Tanner says.
The data is visible in all nursing systems throughout the health system, and the link to trend data is available in EMR. It's also visible on large kiosk monitors throughout units. A large TV shows an anonymized, color-coded graph for all of the patients on a unit, allowing nurses to instantly see where the sickest patients are, and helping caregivers to prioritize their rounding.
Patients and families can see it, too.
"In the spirit of transparency, we do have it visually displayed," Tanner says, adding that caregivers could share the trend data with patients and family, which could be especially useful in discussing transitions of care.
"It is something that you could share with the patients and families… and help support the appropriate transition of the patient," she says. "It could be used as a way to communicate."
The data is not only used to improve communication with patients and families. Tanner hopes it is also improving communication among caregivers. The patient trends data is part of the discussion during daily interdisciplinary rounding; during shift hand-offs; and prior to discharge.
So far, nurses have been strongly onboard with using the new tool.
"The implementation and optimization has been nurse-led, nurse-driven," she says. "The challenge really is not with our nurses, our challenge has been the physician adoption piece."
Ultimately, as with all technologies, adoption will depend on whether it becomes routine for everyone to use it.
"We really are trying to hardwire this into our culture," Tanner says. "I'm extremely passionate about this technology."