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.
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."
A revised position statement from the American Nurses Association calls for stronger collaboration between nurses and their employers to curb nurse fatigue and its clinical consequences.
Nurse fatigue is frequently linked to patient safety issues, from decision regret to poor hand hygiene compliance. Now, the American Nurses Association has released a revised position statementon the topic that calls for stronger collaboration between nurses and their employers to reduce fatigue.
It statement outlines evidence-based strategies for doing so and makes these recommendations:
Involve nurses in the design of work schedules
Use regular and predictable schedules
Limit work weeks to 40 hours within seven days
Limit work shifts to 12 hours
Eliminate the use of mandatory overtime
Promote frequent, uninterrupted rest breaks during shifts
Enact official policy allowing nurses to accept or reject a work assignment based on preventing risks from fatigue. It should include the conditions that a rejected assignment does not constitute patient abandonment, and that RNs should not suffer adverse consequences in retaliation for refusing the assignment.
Encourage nurses to manage their health and rest
The position paper was developed by a 15-member Professional Issues Panel on Nurse Fatigue, as well as an advisory committee made up of about 350 additional ANA members.
Among the people on the Professional Issues Panel was Linda D. Scott, PhD, RN, NEA-BC, FAAN, Associate Dean for Academic Affairs at the University of Illinois at Chicago College of Nursing. Scott and I spoke last year about herresearch linking decision regret with nurse fatigue. I caught up with her via email this week to hear about her experience developing the new position statement and its notable changes.
HealthLeaders Media: Why is this new position paper exciting?
Linda Scott: In 2006, the ANA published 2 separate position papers on the need to manage nurse fatigue. While each of these position papers spoke to the responsibilities of nurses and employer[s], the 2014 position paper emphasizes the collaborative and reciprocal responsibilities that each have in ensuring a safe, well-rested and vigilant nursing workforce.
HLM: What are some of the most important new additions, changes, and/or differences in the new position statement?
Scott: The rationale and strategies that are included are strongly grounded in research evidence that supports the need for fatigue management in health care.
There is an emphasis on the ethical responsibilit[ies] of both registered nurses and employers to consider the need for adequate rest and sleep when deciding to offer or accept work assignments, including on-call, voluntary, or mandatory overtime.
It recognizes the importance of inadequate sleep and the impact that sleep impairment and fatigue can have on the ability of nurses to deliver optimal patient care, all of which can have adverse effects on patient outcomes.
HLM: You were one of 15 people tasked with contributing to the position paper. Where can we see your influence?
Scott: My influence can be seen in the evidence for nurse fatigue, the need for fatigue management, and the impact on nurse and patient safety.
HLM: Is there anywhere that the position paper doesn't go far enough?
Scott: The position paper speaks to the importance of fatigue management, and the risks associated with long work hours. Without adequate sleep and intershift recovery, shiftwork will always be problematic.
The position paper emphasizes the need to address all aspects, makes recommendations for maximum work hours, and reiterates the need for nurses to be fit for duty…that is, they are accountable for getting enough sleep before starting a work shift. I think that there will still be nurses who think that they are immune to the impact of sleep loss and fatigue.
HLM: Now that the position paper is released, what are the next steps for implementation?
Scott: Next steps include dissemination, dialogue, and hopefully policy and practice changes.
A rising awareness of ethical issues, a push for better representation in the boardroom, and initiatives to raise education levels among RNs will be top-of-mind topics for nurse leaders next year.
The Ebola virus. Nurse staffing battles. ED violence.
Like any year in recent memory, 2014 was a turbulent one for the nursing profession. But it was also an exciting one, and 2015 promises more of the same. I touched base with a couple of nursing leaders to get their take on some of the top issues that are in store for the profession.
A Navy nurse faces possible discharge for refusing to participate in force-feeding detainees. It's a test case for nurses in all practice settings who are faced with ethical issues every day.
Nurses have the right and an obligation to an ethical practice. With it should come the right to speak up without punishment when that ethical practice is threatened.
But possible punishment is exactly what's at stake for a U.S. Navy nurse who refused to continue force-feeding hunger-striking detainees at Guantanamo Bay Detention Camp. Although the Navy has opted not to press criminal charges, it is still considering requiring the nurse to show cause for remaining in the Navy, which could lead to his discharge, the end of an 18-year Naval career, and the possibility of no retirement or veteran's benefits.
Moreover, a discharge would send a "message from the Navy that nurses who refuse to participate in force-feeding could lose their careers," the nurse's attorney, Ron Meister, said during an media call last week led by the American Nurses Association.
The ANA has taken up the fight on behalf of the Navy nurse, who hasn't been publicly identified, arguing that he should be able to refuse to participate in force feedings without punishment.
"Professional registered nurses have the right to make independent ethical judgments, regardless of the setting in which nursing care is provided, even if this causes the nurse to experience conflict arising from competing loyalties," ANA President Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN, said during the call.
The other people on the call—Vincent Iacopino, MD, PhD, senior medical advisor for Physicians for Human Rights, and Albert Shimkus, retired Navy captain and associate professor at the U.S. Naval War College—argued not only the rights of the nurse, but also against the unethical practice of force-feeding these patients, who are protesting indefinite detention. Many of these detainees, the experts noted, have been approved for release.
Whether or not force-feeding is ethically unacceptable is only part of what's at stake here.
"In many ways this is a test case," and not just for the military, Cipriano said, but also for nurses in all practice settings who are faced with ethical issues every day.
The case of the Navy nurse "parallels in some ways the very issues that came up in the nursing ethics summit," Cynda Hylton Rushton, PhD, RN, FAAN, the Bunting Professor of Clinical Ethics at the Johns Hopkins School of Nursing and Berman Institute of Bioethics, and lead organizer of the summit, told me last week.
"I think we really need to take seriously these examples," she says.Issues ranging from nurses going on strike to end-of-life care to the decision not to participate in force-feeding are "really are symptoms of this more fundamental issue: Do we actually have a culture where it's safe for nurses to speak up and speak out about their ethical concerns?" she says
In preparation for the conference, organizers reached out to nurses to find out what keeps them up at night (encapsulated in a video) and heard about issues such as balancing quality and safety with efficiency; navigating respect for patients, especially at end-of-life; balancing the burdens and benefits of technology; and respecting individual patient choices in the context of their culture, religion, and values.
These are all ethical issues; yet Rushton notes that the IOM's Future of Nursing report was "largely silent on the ethical issues, and the roadmap for the future hast to include this ethical dimension."
She says the summit and report represent the first time that multiple stakeholders—collaborating partners include the ANA, American Academy of Nursing, American Association of Critical-Care Nurses, and many other groups—have come together to create its ethics blueprint, which includes recommendations in the following areas:
Clinical practice: Create tools and guidelines for achieving ethical work environments, evaluate their use in practice, and make the results easily accessible
Education: Develop recommendations for preparing faculty to teach ethics effectively
Nursing research: Develop metrics that enable ethics research projects to identify common outcomes, including improvements in the quality of care, clinical outcomes, costs, and impacts on staff and the work environment
Policy: Develop measurement criteria and an evaluation component that could be used to assess workplace culture and moral distress
"It's one thing to deal with these issues in the theoretical, but when the rubber hits the road is when nurses are confronted with these issues in the moment," Rushton says. That's why it's so critical for nurses to have a strong foundation from which they can raise and act on these ethical concerns without fear of reprisal, as in the case of the Navy nurse. The summit has also sparked an online pledge campaign to support ethical nursing practices.
"Some of the issues we confront we are meant to struggle with. …The values that underlie these issues are fundamental to who we are as people and who we are as a society," Rushton says. "Do we have space for people to request not to participate in actions that they find morally objectionable? There are no easy answers, and that's the point."
Hospitals are increasingly adding patient experience positions. Elevating the job to the senior executive level speaks to the growing importance of patient experience in healthcare.
The Mount Sinai Health System in New York has added a senior executive to its C-suite, and it's a nurse: Sandra Myerson, MBA, MS, BSN, RN, who's taken on the newly-created position of Senior Vice President and Chief Patient Experience Officer.
Serving the Mount Sinai Health System and the Joseph F. Cullman Jr. Institute for Patient Care, Myerson had been on the job "all of nine days," when we talked on the phone last week about her short- and long-term goals, as well as the scope of the brand new role.
Although hospitals have increasingly been employing directors of patient experience, elevating the job to the senior executive level speaks to the growing importance of patient experience in healthcare.
"It's not just about how we're communicating with patients, but how they're moving through their hospitalizations," Myerson says.
Consistency Whether patients are visiting one of Mount Sinai's seven hospital campuses, its 12 minority-owned ambulatory surgical centers, or its 45 ambulatory care practices, Myerson says the patient experience should consistently be of the same high quality.
She plans to "work with the executive leadership and the president and CEOs of the hospitals to really define the patient experience across the system, and integrate all of the programs and initiatives so there's consistency."
At the top of her to-do list as she settles into the brand-new job? First is assessing where each facility is in terms of patient experience and their understanding of opportunities to improve it. She'll also work to identify where faculties might be struggling and what they're doing to address those shortcomings.
"I can't be everywhere," Myerson says, calling the job "an elephant" that requires tackling "reasonable pieces," rather everything all at once. The big, system-wide scale of the job means that Myerson can't do it alone, so a big part of her work will be about maximizing employee engagement, providing support to hospitals and their leadership, and making sure employees feel valued.
Room for Improvement "A lot of work is being done," she says. "I'm not creating anything new. I'm trying to foster what's already here."
That's not to say there's no room for improvement. For instance, she says surveys indicate that patients think the clinical care is good, but they want "consistent compassion."
"Patients want to be heard, they want to be showed that someone is listening to them," Myerson says. "I think we need to get to the basics around reducing patient anxiety."
One way to achieve that is by implementing purposeful hourly rounding by nursing staff, a process that is in various stages of implementation throughout system, with various degrees of success, Myerson says.
Also on the agenda is improving processes to enable patients to move through their visits more seamlessly, reduce wait times, and eliminate redundancy. "That really is a foundational process that helps patients feel safe," she says. "It's touching everything that the patient comes in contact with."
Making patients feel safe will also come with training about how to communicate with compassion and empathy.
"No one really taught us how to do that," she says. "We trust people who are listening to us and are taking care of us."
I mentioned to Myerson that focusing on "soft" nursing skills like these—rather their clinical expertise—makes some nurses bristle. But clinical expertise and great bedside manner aren't mutually exclusive; they're both necessary for excellent patient care.
Myerson says that for patients, clinical expertise is an expectation; patients don't ask nurses about their certifications, and they take it as a given that their nurses are experts.
An Emphasis on Communication "Patients can't judge our clinical expertise," she says. "The only way they can judge us is how we interact with them. Yes, you have to have great clinical skills," but "the only thing that can differentiate with us is how we communicate with the patient. That's what patients are looking for."
Because of her background with patient care as a nurse, Myerson feels uniquely positioned to take on the patient experience role at Mount Sinai.
"I think that a nurse has the clinical background to be able to relate to the nursing staff, who are the ones who are primarily interfacing with patients," she says. And the fact that her position is an executive leadership one "gives me some credibility and clout."
A year from now, Myerson says, she hopes the health system will gain some traction in patient experience scores in hospitals where they're lagging. She also wants to help hospital leaders implement foundational programs around employee engagement, as well as empower employees to feel positive about their work and feel like they're making a difference. Her success will depend on the relationships she builds, something that Myerson says is already looking good.
"People are so excited to meet me," she says. "So excited, delighted that someone will be there to organize and orchestrate this work."
A new standard of care for reducing delirium, based on nursing interventions and developed by nurses at a Philadelphia hospital, is better for patient outcomes and for nurses.
For Anne Jadwin, RN, MSN, AOCN, NE-BC, vice president of nursing and CNO at Fox Chase Cancer Center, in Philadelphia, getting the chance to participate in the American Association of Critical-Care Nursing's Clinical Scene Investigator (CSI) Academy was a little like serendipity.
Anne Jadwin
RN, MSN, AOCN, NE-BC
VP of Nursing and CNO,
Fox Chase Cancer Center
She and the ICU committee had just been discussing the need to do more delirium prevention in their ICU, since literature shows that delirium among critical care patients can not only be debilitating in the short-term, but also lead to long-term cognitive impairments.
The following week, Jadwin got an email about the CSI Academy, a 16-month, hospital-based nurse leadership and innovation training program funded by the AACN. Immediately, her mind traveled to that ICU committee meeting, and she knew the delirium project would be perfect.
Once Fox Chase was selected as one of the seven hospitals to participate in the Pennsylvania cohort, "we had no trouble finding four staff nurses that wanted to participate in this project," she says.
At the core of the project was 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 assigns certain types of interventions based on that score.
The ABCDE bundle was used: Awakening, breathing trial (to see if patients can be moved off of ventilators sooner), care coordination, delirium monitoring, and early exercise and mobility.
"They're all, for the most part, nursing interventions, so this is very much an independent nursing protocol," Jadwin says. "A lot of the interventions to prevent delirium are nurse-driven… these are things they can do without a physician order."
For instance, nurses can prevent delirium by getting patients up and walking around earlier in their ICU stay; orienting them to time and place; promoting better rest and minimizing sleep interruption; and encouraging passive range-of-motion exercises.
The nurses even recommended the purchase of a stationary bike that can attach to the bed, allowing patients to exercise while they're still in bed.
Ripple Effect Delirium's ripple effect can be felt beyond the patient's health and cognitive outcomes.
"In addition to the cognitive impairment that patients can have long term…it's very distressing to patients," Jadwin says. It's also tough on patient families and the nurses themselves.
"From a nursing standpoint, it's very difficult to care for somebody" with delirium, Jadwin says. People who otherwise would not be problem patients become hard to care for because they're confused. They might even thrash around and hit nurses; Jadwin says nurses have even been injured.
"There was a lot of good reason to try to minimize this experience for patients," she says.
At first, the nurses at the helm of the project faced the challenge of getting the staff nurses onboard with this new protocol, Jadwin says. "They see this in some ways as creating more work for them," and one of the things the nurses learned from the program was: "How do you sell this idea to your peers?"
They sold it by sharing the evidence, which spoke for itself.
"I think that made sense to nurses. They saw that this is something that we need to make time for because this is better for patients," she says. "That was what really sold it for them. They recognized that this is better care."
It also demonstrates the importance of communicating evidence and literature with staff nurses when making changes like these, rather than issuing top-down directives.
Outcomes The program's outcomes spoke for themselves, too.
"[The interventions] decreased the length of stay in the ICU by about a half of day," Jadwin says. That might not sound like a lot, but it's significant when you consider the high risks and cost of the critical care unit, she adds. In addition, pharmacy data shows that patients needed sedating drugs less often with this protocol in place.
Anecdotally, the nurses are more comfortable providing care to these patients and also feel good about their accomplishments. Now, it's the standard of care for the critical care unit.
"It's very powerful for them to develop those tools where they can really influence the practice change," Jadwin says. "That's just really very exciting for them to know that they were able to do this."
Researchers find 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.
The patient safety benefits of having a greater percentage of bachelor-prepared nurses have been well-established, but the business case for raising education levels among nursing staff has remained a bit more nebulous.
Olga Yakusheva, PhD
Hospitals certainly put patient safety first, but they also have to pay attention to their bottom lines. Now, a study published in the journal Medical Care is adding more evidence to the argument that investing in nurses' baccalaureate educations can make good business sense, too.
The study's lead author, Olga Yakusheva, PhD, associate professor of nursing at the University of Michigan School of Nursing and one of the lead researchers on the study, isn't a nurse. She's an economist.
"As an economist, I always think about financial incentives," she says.
"Ultimately, better patient outcomes are important," but "hospital administrators are the ones that are stuck with the bill," she points out.
That's why making the business case for having at least 80% of the nursing workforce hold bachelor's degrees is going to be so critical if the nation wants to reach the Institute of Medicine's goal for doing so by the year 2020.
"They want to make sure that they have their ends meet financially," Yakusheva says. "For people who are actually responsible for moving this forward, it is important for them to know that they do not have to make a huge finance sacrifice to improve patient outcomes, if they're investing in nurse education."
And according to Yakusheva's study, investing in nurse education does seem to improve both patient outcomes and the bottom line. Other studies of the relationship between nurse education and patient outcomes have examined hospital-level data.
A Close Look at Patient-Level Data
But Yakusheva and her research team examined patient-level data, comparing outcomes among patients in the same hospital, on the same unit, and with the same diagnosis.
The researchers found that patients who received 80% or more of their care from BSN-prepared nurses had 18.7% lower odds of readmission and 1.9% shorter lengths of stay. Researchers also found that a 10% increase in the proportion of BSN-educated care was associated with a 10% reduction in the odds of mortality.
"Simply based on how educated the nurses are… it's putting some patients at risk inadvertently," Yakusheva says.
Dollars Saved
What does this translate to in dollars and cents? A lot, the researchers found. They 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.
Yakusheva says she was expecting to find a difference in outcomes and costs, "but not quite as palpable a difference."
Perhaps that palpable difference will help get the ball rolling on meeting that 80% by 2020 goal, which the nation currently doesn't seem to be on track to reach. Currently, data shows that only about 55% of nurses are baccalaureate prepared.
Despite the patient safety evidence for increasing the number of baccalaureate-prepared nurses, and despite the landmark IOM report, there doesn't seem to be enough momentum toward reaching that deadline and goal: The percentages just aren't ticking up quickly enough.
The question is why not? Yakusheva says maybe the momentum hasn't been there because the business case for it has been lacking.
Make it Sustainable
"In the realities of healthcare delivery, as much as we want to focus on patient outcomes… you have to make it sustainable," she says. By looking at these patient-level data within the same hospital, "that makes a credible statement when you see the difference in outcomes."
Yakusheva warns against regarding this new study as definitive "proof" that increasing the number of nurses with BSNs will save money for hospitals and the healthcare industry.
But it does provide some might strong evidence toward that theory. And maybe it'll be the incentive that healthcare leaders need to invest more in nursing education.
"Protocol breaches" are inevitable when nurses aren't properly trained on working with patients infected with Ebola and hospital supplies are lacking.
"Stop blaming nurses. Stop Ebola."
Those powerful words appeared on banner during a National Nurses United press conference over the weekend. As the Ebola crisis reaches a fever pitch here in the United States in the wake of the nation's first diagnosis and ultimately first death from the virus, it's becoming clear that we aren't prepared at the hospital level to deal with the disease.
As usual, nurses have taken the brunt of both the blame and the consequences.
First, a nurse was involved in the mishandling of Thomas Eric Duncan's initial ED visit when he was sent home, despite having been told of his symptoms and that he just traveled from West Africa. Commentators (including me) questioned that judgment: Why didn't the nurse tell a doctor in person?
Certainly he or she should have known that simply noting such information in the EHR wasn't sufficient.
But protocol breaches do seem to be easy to make. The protective gear not only has to be worn, but also removed in a certain order, and with meticulous attention to detail. Even one, inadvertent slip-up in the removal of the gear can spread the disease. In fact, experts recommend using a "buddy system" so healthcare workers will be more likely to do it correctly.
Did the nurse who's now infected with Ebola have a chance to practice and "ritualize," as Johns Hopkins Medicine recommends, the right way to remove the protective gear? Was there adequate training for the nurses before the virus reached their hospital?
It's easy to blame nurses and other healthcare workers for breaches in protocol that could potentially spread this disease, but how can they be blamed if they don't know what the protocol is?
National Nurses United says nurses aren't prepared to deal with Ebola crisis. It says that not only are nurses not properly trained, but that they often don't even have the right protective equipment or facilities to deal effectively with the disease.
"Nurses and other frontline hospital personnel must have the highest level of protective equipment, such as the Hazmat suits Emory University or the CDC themselves use while transporting patients, and hands-on training and drills for all RNs and other hospital personnel. That includes the practice putting on and taking off the optimal equipment," RoseAnn DeMoro, the group's executive director, said at a press conference Sunday.
She added that NNU has received "steady reports from nurses at multiple hospitals who are alarmed at the inadequate preparation they see at their hospitals."
What's more alarming are the results of a NNU national survey showing that a staggering 76% of nurses still say their hospital has not communicated to them any policy regarding the potential admission of patients infected by Ebola.
Really? Nothing?
The survey of 2,000 RNs at more than 750 facilities in 46 states and the District of Columbia also shows that even the availability of protective gear is sorely lacking. More than a third (37%) of respondents said their hospitals have insufficient current supplies of eye protection, and 36% say there are insufficient supplies of fluid-resistant/impermeable gowns in their hospitals.
A greater number, (39%) of respondents say their hospitals do not have plans to equip isolation rooms with plastic-covered mattresses and pillows and to discard all linens after use. Only 8% said they were aware that their hospitals have such plans in place at all.
NNU's demands for nurses and other healthcare workers are so basic, that it should be embarrassing for the United States healthcare system. They want:
Full training of hospital personnel, along with proper protocols and training materials for responding to outbreaks, with the ability for nurses to interact and ask questions
Adequate supplies of Hazmat suits and other personal protective equipment
Properly equipped isolation rooms to assure patient, visitor, and staff safety
Proper procedures for disposal of medical waste and linens after use
Protocols can only be adhered to if nurses know what they are. Protective gear can only be worn if it's readily available. And procedures can only go smoothly if they've been communicated and practiced. When that fails to happen, it's a recipe for disaster.
How nurses and doctors communicate—or don't communicate—using health information technology is the focus of a multi-year study funded by the federal Agency for Healthcare Research and Quality.
The life-and-death importance of nurse-physician communication and the use of electronic health records came to a frightening, critical head last week when a nurse noted in a sick patient's EHR that the patient had recently traveled to the United States from Africa.
Milisa Manojlovich, PhD, RN, CCRN
Despite the note, the patient was sent home. He later returned to the hospital and was eventually diagnosed with the Ebola virus.
Revising an earlier statement that blamed the bungled incident on a "flaw" in its (Epic) EHR system, Texas Health Resources backtracked last Friday saying, "As a standard part of the nursing process, the patient's travel history was documented and available to the full care team in the electronic health record (EHR), including within the physician's workflow. There was no flaw in the EHR in the way the physician and nursing portions interacted related to this event."
In either event if the nurse used the EHR alone to communicate that critical piece of patient information, it obviously didn't work. According to Milisa Manojlovich, PhD, RN, CCRN, associate professor at the University of Michigan School of Nursing, it's a case of the medium not matching the message.
Leaving too Much to Chance "The Ebola example is a great example of communication technology not being used appropriately," she says. "There needed to be a sense that the medium of the electronic health record is not the best for this."
An EHR note alone leaves too much to chance. In cases like this, the communication medium should be more direct, such as a phone call, a page, or face-to-face.
"On the other hand, why is it that nursing notes are not routinely read?" Manojlovich asks. Physicians were obviously to blame here, too, since they it seems they either didn't read the nurse's note or disregarded its importance.
How nurses and doctors communicate—or don't communicate—using health IT is what Manojlovich will spend the next four years studying. She is the primary investigator using a $1.6 million grant from the federal Agency for Healthcare Research and Quality to explore how communication technologies such EHRs, email, and pagers are being used and where common failures occur, focusing on nurse-physician communication.
The study began this month, and in light of the Ebola miscommunication, not a moment too soon. According to Manojlovich, electronic communication's increasing prevalence has resulted in decreased face-to-face communication between practitioners, resulting in situations like the one in Texas, where important information wasn't conveyed, perhaps because it was inappropriately communicated.
A Critical Miscue In the announcement of the study, Manojlovich pointed to another such instance of the medium not matching the message, describing previous research in which physicians were observed putting STAT orders in the computer, but not notifying the nurses in any other way. The nurses, it turned out, were only required to check the computer for orders every two hours.
As health IT gets rolled out around the world with unprecedented speed, it's critical that the healthcare industry figures out when it's helpful and when it's unhelpful or even dangerous.
Manojlovich points to a perspective piece in the Journal of the American Medical Informatics Association titled "The Dangerous Decade," in which the authors posit that health IT is "at roughly the same place the aviation industry was in the 1950s with respect to system safety" and that related harms are sure to increase as health IT becomes more prevalent.
This combination of venturing into uncharted territory and a great potential for harm makes the patient safety stakes very, very high.
"We know there's going to be more health IT than ever before," Manojlovich says. "We really need to understand how it is being used in healthcare."
Study Methodology Manojlovich's study will include three components. First, the researchers will survey hospitals to get information about whether they have an EHR; whether nurses and doctors have computers; whether the hospitals use devices such as pagers, email, and electronic whiteboards; and other basic usage information.
"We want to just get a lay of the land," Manojlovich says. "We need this information because it's crucial to establishing how key clinical information is exchanged."
Next, the researchers will divide the respondents into two subsamples, depending on their level of technology usage. Via phone interviews, researchers will ask about how the technology influences their work, its impact on how nurses and doctors talk to each other and their relationships, and whether and how technology has changed their workflow.
The last stage will involve the researchers visiting four hospitals and observing the doctors and nurses as they work and use technology, as well as conducting focus groups. Researchers will also ask the hospitals for technology usage updates through the duration of the four-year study.
In the end, Manojlovich and her team aim to use their findings to make some recommendations about the use of health IT in nurse-patient communication, and also perhaps design technology to support the multiple decision-making that goes on in a hospital.
Manojlovich says that technology is becoming pervasive everywhere, more quickly than society can understand its effects.
"It's changing the way we live our lives in general, so it's not unusual then to think that it also has an influence in healthcare," she says. "But it might be more critical in healthcare because you're dealing with patient lives."
Home health agencies that provide supportive work environments for nursing staff have the best patient outcomes, a new study finds.
It's not only nurses who work in inpatient settings that suffer from unsupportive work environments. A new study from University of Pennsylvania School of Nursing shows that the same is true for nurses working in home health agencies.
Olga Jarrín PhD, RN
Moreover, research shows, those unsupportive work environments can result in worse patient outcomes.
The study, which claims to be the largest of its kind, shows that home health agencies that provide supportive work environments have the best patient outcomes.
"Agencies with better work environments had lower hospitalization rates, and higher community discharge rates than agencies with poor environments," the study's lead author, Olga Jarrín, PhD, RN, of Penn Nursing's Center for Health Outcomes and Policy Research, told me via email. "This effect was more pronounced in agencies where nurses reported higher levels of emotional exhaustion."
Stress and emotional exhaustion often plague home health nurses when they feel that something is preventing them from providing the best care. Sometimes factors outside their control, like patients' social and economic challenges or a lack of community resources, get in the way of patient care.
But other times "it is because a home health agency does not have the resources to support optimal nursing care," Jarrín says. "Where emotional exhaustion is caused or compounded by factors within the home health agency, outcomes are worst."
Allowing nurses to focus on patient care, rather than non-care responsibilities like administrative duties, is a major lesson from the study. In fact, she says documentation of care, driving, and making phone calls take up the majority of a home health nurses' time.
So who should do these activities instead? Jarrín says that the use of a scribe and/or driver "might dramatically increase the efficiency, safety, and satisfaction of home health nurses." For instance, she points out that interruptions from phone calls during patient care and while nurses are driving is very common.
And although home health nurses are often expected to do their documentation in patients homes, Jarrín says that "many nurses spend hours completing their charting after seeing patients, creating the potential for less accurate documentation, and long days for nurses."
But the study's overarching message is that nurses need supportive work environments to do their jobs to the best of their ability and training. Such environments provide enough time and staff to provide quality care; involve nurses in organizational decision making; provide opportunities for education and advancement; foster good working relationships between nurses and physicians; ensure continuity of patient care assignments; and offer good management and leadership, says Jarrín.
Her description of a supportive work environment should sound familiar to readers of this column because they're factors that are important for nursing and its leadership no matter the setting. Likewise, the critical lessons that Jarrín says nurse leaders can learn from this study are the same:
Involve direct-care nurses in identifying areas of care delivery that could be improved, and work together to make the changes
Ensure workloads are manageable
Ensure issues with documentation systems are addressed
Ensure nurses have access to knowledge and information needed to provide great care, such as: medication teaching and safety information, timely access to lab results, evidence-based assessment and decision-support tools, and expert/advanced practice nurses who can be consulted when needed regarding chronic disease management, wound care, and pain management, or end of life care
Learn about and consider the organization's readiness and progress towards being recognized as a place where nurses thrive and are supported in providing the best patient care possible
"The work environment, especially good nursing management and leadership, and the foundations of nursing care… are strongly associated [with] the national priority area of reducing preventable hospital admissions." Jarrín says.