Care coordination has been called the "missing link in healthcare." Now the Registered Nurse Ambulatory Care Coordinator Association has formed the first national organization to support nurses and other population health management professionals in care coordinator roles.
Here's another sign that care coordination is gaining traction in the healthcare industry: Care coordinators at Ohio-based Mercy Health have formed what it says is the first national organization to support nurses in care coordinator roles and members of population health management teams.
The new, non-profit Registered Nurse Ambulatory Care Coordinator Association (RNACCa) aims to "support and strengthen evidence-based practice among nurse care coordinators and other population health management professionals," according to its website.
"We've already done some of the legwork; why not share it?" one of the association's co-founders, Teaera Roland, MSN, RN, population health nurse care coordinator for Catholic Health Partners, told me. "We want to get nurses the education that they need to provide the education and tools that the patients need."
Although care coordination is a relative newcomer in the healthcare world, the stats supporting its value are already making a big impact. For example, Mercy Health's nurse care coordinators helped drive a 51% reduction in hospital admissions, a 35% reduction in readmissions, and a 37% reduction in emergency department visits over the course of a yearlong pilot.
Roland says she and her team have learned that it's worth it to spend time upfront with patients, getting to know them and understanding the very personal barriers that they face when it comes to staying healthy.
"We've done studies," she says. "Patient outcomes are improved when you take that one-on-one time."
It's not only Mercy Health's studies that point to the benefits of care coordination. In June 2012, the ANA released a white paper called "The Value of Nursing Care Coordination," which examined recent reports and studies about care coordination and the role of RNs.
For example, one study cited found that care coordination leads to better care at a lower cost, particularly for populations with multiple health and social needs.
Care coordination also got a boost from a new Medicare rule that will pay nurses when they help patients make the successful transition from hospitals to other settings. The rule calls for paying RNs for services that aim to manage patients' transitions from hospitals to other settings and to prevent complications and conditions that cause hospital readmissions. It creates new payment codes for care coordination activities performed by RNs.
"Other organizations are catching onto care coordination," Roland says. "This is the missing link in healthcare."
In the 2012 HealthLeaders Media Industry Survey, 30% of CEOs said care coordination is their greatest strategic challenge. Roland says that the new RNACCa aims to ease that challenge for people and organizations that want to give care coordination a try.
When she first started her work in care coordination, Roland says she "learned that I didn't know nearly as much as I thought I did," even though she was a master's prepared nurse with a lot of critical care experience.
Instead of starting out without a lot of direction, like Roland did, new care coordinators can look to the RNACCa for guidance, helping them skip the trial-and-error phase and letting them "get down to the nitty-gritty" of care coordination right away.
The RNACCa will provide educational materials for nurses and help for identifying resources for patients. It also plans to host a conference within the next several months and has partnered with Cincinnati's Xavier University to provide a certification program in population health management starting later this year. The program will count toward a Master's of Science in Nursing. Roland also says that the RNACCa would love to partner with other organizations, such as the ANA, to expand.
Nurse care coordinators' day in the limelight has arrived, Roland believes. "I really think that this is the time," she says. "Nurses have the opportunity, and the tools, and the backing to change healthcare."
Three healthcare institutions that rely on advanced practice registered nurses prove that a little innovation can go a long way in improving not only access to care, but also the care itself.
Advanced practice nurses are the most clutch players in the healthcare game, there to fill the gaps when primary care providers are in short supply. Three institutions show the innovative ways that APRNs can provide care, despite a number of significant hurdles.
The eight-page brief also identifies three of the most significant barriers to APRN's practice and touts statistics showing their effectiveness. In this regard, it's a lesson we already know: APRNs can help expand access to care; the types of APRNs; the licensing, training, certification, and education required of them; and stats about the way APRNs improve care.
The brief also outlines the three main barriers to APRNs' practice: legal/regulatory barriers (such as laws requiring APRNs to work with a collaborating physician and lack of reimbursement from government and private insurers); institutional barriers (restrictions from individual healthcare organizations); and cultural barriers (patients' notion that doctors provide better care).
But what I found the most interesting about this report were the three institutions that were spotlighted as APRN innovators.
The first profiled institution is the US Department of Veteran Affairs, which the brief says employs more than 5,000 APRNs "to deliver primary, specialty, acute, ambulatory, telehealth, and home healthcare services." The VA plans to implement a new, system-wide policy this year that will allow all APRNs who meet certain criteria to practice without direct physician supervision, even in states that don't allow it, using its federal status to override state laws, the brief says.
The policy aims to standardize rules across different VA facilities so that APRNs who work at several facilities won't encounter differing rules about the ways they can practice. The VA will also issue guidance about an expanded list of APRN core privileges including signing admission and discharge orders, making patient rounds, and preparing progress notes.
Another example highlighted in the brief is the Transitional Care Model (TCM) at the University of Pennsylvania Health System, which uses APRN specialists to develop and execute wide-ranging discharge plans. Trials of the effectiveness of the program in high-risk, high-cost, high-volume patients found that it resulted in everything from reduced costs for at-risk pregnancies and preterm infants to improved outcomes and satisfaction among chronically ill older adults. Experts say that use of the TCM in the broader healthcare system could have amazing results.
"If brought to scale, the TCM could accelerate efforts within the U.S. to move from a fragmented health care system to an integrated, high-performing one," Mary D. Naylor, PhD, RN, FAAN, Marian S. Ware Professor in Gerontology and director, NewCourtland Center for Transitions and Health at the University of Pennsylvania School of Nursing, is quoted as saying in the brief.
Finally, the brief points to Duke University Health System's Department of Cardiovascular Medicine, which "leverages interprofessional teams to increase access to care and improve patient satisfaction." In other words, physicians and APRNs tag-team with patients, dividing duties between them.
Physicians develop care plans for new patients; NPs and PAs see returning or acutely ill patients; and RNs coordinate follow-up care, schedule procedures, and respond to triage calls. They also consult with each other as needed.
Such a model "requires a cultural shift," says Allison Dimsdale, DNP, RN, NP. But the effort to make the shift seems to be worth it: A pilot showed that patients like the model and that the average wait time for appointments dropped 57% for new patients and 75% for returning patients.
I found the examples in this brief heartening and exciting. Yes, there are things standing in the way of APRNs, but as these institutions show, a little innovation can go a long way in improving not only access to care, but also the care itself.
Male nurses face all kinds of prejudices when they enter the workforce. Those preconceived notions and misjudgments are not only harmful to them, but to the nursing profession as a whole.
"There's a real interesting thing about men in nursing," Connie Curran, EdD, RN, FAAN, told me a few weeks ago. "They go to the top."
Research seems to back up her assertion. Data released earlier this year shows that even though men represent less than 10% of the nurse workforce in the United States, they are paid more than their female counterparts.
Full-time female nurses earned 91 cents for every one dollar earned by their full-time male colleagues. For both full-time and part-time nurses, the survey found that men earned an average of $60,700 per year and women earned $51,100.
That's why I was skeptical about the need for the new book Man Up! A Practical Guide for Men in Nursing. A part of me felt a savage sense of satisfaction that nursing is the one, last bastion of female domination. So what if there aren't as many men as women in nursing? So what if men feel like they're outnumbered and less influential at work? Welcome to how many women feel all the time.
But I had a change of heart when I actually started reading the book. Male nurses face all kinds of prejudices, ranging from the idea that they're inherently not as caring as women, to the notion that nursing is a "womanly" discipline, the book says.
For example, the book's lead author, Christopher Lance Coleman, PhD, MS, MPH, FAAN, wrote about how disappointed his father was in his choice to become a nurse.
"My family perceived nursing as a woman's profession," he wrote. "My parents worried that a man choosing nursing would face obstacles such as stigma, limited opportunities, and low pay… the word 'bedpan' kept creeping into conversations."
Just think about what that implies: That changing bedpans—i.e., real, hands-on, down-and-dirty caregiving—is a woman's domain. Such prejudices and stereotypes are not only potentially harmful to male nurses, but to female nurses and to the nursing profession. The belief that men are too masculine for nursing implies that nursing itself is weak.
The book also made me more aware of the gendered language that so often accompanies nursing. Coleman writes that in textbooks, classrooms, and conferences "she" is always the pronoun of choice when describing nurses.
I'm guilty of this, too, something that a reader of this column recently pointed out to me in an email. She wrote to complain about the headline and gendered language in the article, "When Mean Girls Wear Scrubs."
"A full 20% of my nursing staff is male," wrote Lynne Beattie, RN, MSN, Interim Manager Telemetry at Seton Medical Center in Daly City, California. "As sensitive as I was to being left out of the usual "he" and "him" communication in the late 70's, I'm equally sensitive today to articles [and] discussions that imply all nurses are female."
"A full 20% of my nursing staff is male," wrote Lynne Beattie, RN, MSN, Interim Manager Telemetry at Seton Medical Center in Daly City, California. "As sensitive as I was to being left out of the usual "he" and "him" communication in the late 70's, I'm equally sensitive today to articles [and] discussions that imply all nurses are female."
Her email also stuck a fork in the savage satisfaction I once felt about women dominating nursing. When someone knows what oppression feels like, they should do all they can fight it elsewhere.
The IOM's report on the future of nursing calls for more diversity in the nursing profession, including more gender diversity. For men who are in the nursing profession or want to pursue it, Man Up! seems to provide a good primer for navigating the field.
The book covers nearly every aspect of work along the entire nursing continuum, from the decision to become a nurse, to "breaking" the news to families, to moving through school, to finding a mentor, to becoming a nurse leader or entering academia.
And it provided this little nugget, which really struck a chord with me: "Research shows that men enter nursing for the same reason as women: They hold personal values (like caring for others) that are consistent with the holistic approach in nursing. Men who are nurses and seek leadership roles must be aware and sensitive to the fact that inequities on social and professional levels still exist for both male and female nurses."
No one wins when one group of otherwise equal workers is perceived and treated differently than another.
Some hospitals believe they can't afford investing in assistive technologies that improve patient safety and protect nurses from injury. Can they afford not to?
"If you think education is expensive, try ignorance."
That saying, generally attributed to former Harvard president Derek Bok, comes to mind when I think about how some hospitals view spending on tools for safe patient handling.
Technology, such as ceiling lifts, to assist in moving, lifting, and repositioning patients can prevent injuries among nursing staff and enhance the patient experience, yet some hospitals are reluctant to implement them.
The American Nurses Association contends the investment is well worth it.
Nurse safety was identified as one of the top five nursing issues for 2013 and ANA president Karen Daley told me back in January that the association was leading the way in developing national interdisciplinary standards for safe-patient handling. True to her word, they were released last week.
Suzy Harrington, DNP, RN, MCHES, the director of the ANA's Department of Health, Safety and Wellness, who moderated a conference call previewing the standards, hinted that the voluntary standards might soon have some teeth, saying, "We are anticipating some national legislation based on these standards very soon by congressman John Conyers (D-MI)."
The standards are:
Establish a culture of safety
Implement and sustain a safe patient handling and mobility (SPHM) Program
Incorporate ergonomic design principles to provide a safe environment of care
Select, install, and maintain SPHM technology
Establish a system for education, training, and maintaining competence
Integrate patient-centered SPHM assessment, plan of care, and use of SPHM technology
Include SPHM in reasonable accommodation and post-injury return to work
Establish a comprehensive evaluation system
During the call, Daley and other speakers made a strong case for the use of technology, such as ceiling lifts, to assist in moving, lifting, and repositioning patients. She said that musculoskeletal injuries are a primary reason healthcare workers leave direct patient care, adding that often healthcare workers don't get injured by a single event.
Rather, most injuries are the result of the cumulative effect of lifting heavy loads day in and day out for years, which can lead to long-term disorders and disability, Daley said.
She also cited 2011 U.S. Bureau of Labor statistics showing that nursing professions are among the top five occupations in the number of musculoskeletal disorder-related on-the-job injuries or illnesses that require missed days from work. In fact, nursing assistants topped the list, beating out laborers, janitors, and truck drivers.
"We can't afford these losses and still meet the rising demands for healthcare services," Daley emphasized.
The idea that losses from injuries add up financially for hospitals and the healthcare system at large is an important one for demonstrating the business case for implementing the new standards, including the use of technology.
Robert Williamson, MS, BSN, RN, CWCP, director of associate safety at Ascension Health and the current president of the Association of Safe Patient Handling Professionals, said that the constant shuffling of work schedules to adjust for workers who have been injured takes not only a physical and emotional toll, but a financial one. He argues that the cost of lost worker productivity is much greater than the cost of technology to help prevent it.
"We know that the resources that are spent managing and caring for these injuries are great," he said.
Beyond the physical and financial benefits of technology, Ronda Fritz, MA, BSN, RN, Safe Patient Handling Facility Champion at the VA-Nebraska-Western Iowa Health Care System, says that tools such as ceiling lifts and seated slings can help preserve patient dignity—and likely improve their satisfaction, too.
"Instead of calling four or five staff into a room to position or lift a patient of size, the healthcare worker simply uses a technology to safely and discreetly move them," Fritz said. "The first time we used the lift and sling to assist with an ultrasound procedure for a 640-pound patient, she cried tears of relief and thanked us for not embarrassing her by bringing in six extra sets of hands to position her and expose her. She stated that the technology used was comfortable and much more dignified."
Hospitals might bristle at the idea of investing much money in these kinds of technologies if they're already struggling financially. But the ANA says the investment is worth it. It also points to alternative, lower-cost technologies such as air-assisted lifting devices that are not as expensive as ceiling lifts.
I'd also argue—and so do the ANA and other organizations—that healthcare workers have spent too long being the exception among industries that don't expect their workers to manually lift unreasonably heavy loads.
"Science tells us that a healthcare provider should not lift more than 35 pounds of a patient's weight under the best of circumstances," said Mary Matz, MSPH, CPE, CSPHP, chair of the SPHM Working Group and national program manager for patient care ergonomics at the Veterans Health Administration. "We all know that there are few patients that fall into that category."
Anyone who's ever spent any time in a warehouse knows that although there's certainly lifting involved, workers regularly employ the use "technologies" to move heavier loads. I doubt whether any warehouse owner would object to buying a forklift because they're too expensive.
"As nurses we've traditionally accepted manually moving patients as part of the job," Daley said. "In what other profession would a worker say, 'Let me boost up or move that little pile of hundred pound boxes?' They wouldn't. They would use some sort of technology to do the lifting."
Hospitals that fail to stamp out verbal abuse among RNs and those that demand 12-hour shifts risk losing valuable employees to other organizations where working conditions are more favorable.
New nurses, especially if they are young, are classic victims of nurse-on-nurse bullying. But while the practice may have been viewed as a rite of passage in the past, hospital leaders can no longer afford to let it go unchecked.
One reason is financial. Cheryl Dellasega, PhD, RN, CRNP, an expert on bullying among nurses told me that left unchecked, it can result in good employees leaving an organization.
New research adds more evidence to Dellasega's point. A study of newly licensed registered nurses finds that nurses who are verbally abused by nursing colleagues report lower job satisfaction, unfavorable perceptions of their work environment, and greater intent to leave their current jobs.
The study, "Verbal Abuse From Nurse Colleagues and Work Environment of Early Career Registered Nurses," was conducted by the RN Work Project and published online in the Journal of Nursing Scholarship.
Researchers surveyed 1,407 newly licensed registered nurses about how often they were verbally abused by nurse colleagues:
Never (low level);
One to five times in the past three months (moderate); or
More than five times in the past three months (high)
Almost half (49%) experienced moderate verbal abuse and 5% said they had experienced high levels of verbal abuse. The most commonly reported experiences involved being spoken to in a condescending manner and being ignored.
The authors of the study say that it's this kind of passive/aggressive abuse that's the most "insidious."
"Rather than yelling, swearing, insulting or humiliating behavior, most early career RNs reported that the abuse they experienced involved condescension or lack of acknowledgement," Wendy Budin, RN-BC, PhD, FAAN, adjunct professor at the College of Nursing, New York University, one of the study authors, said in a statement.
"This kind of subtle abuse is less likely to be reported and more likely to be overlooked as a problem, which makes it all the more insidious and it is all the more important that hospital administrators work to confront and prevent it."
Indeed, Dellasega told me a few weeks ago that such behavior is common when nurses form cliques and gang up on or exclude other nurses. For example, nurses who are part of a clique often make rude or sarcastic comments to or about newcomers, and even go so far as not sharing supplies.
Part-time, agency, or floater nurses are another group of nurses that Dellasega says often experience bullying. The RN Work Project study appears to support this claim: It found that staffing shortfalls were also correlated with higher levels of abuse.
Another finding had to do with shift length, with RNs working day shifts saying that they experienced higher levels of verbal abuse than those working evening and weekend shifts. RNs working eight-hour shifts were less likely to experience abuse than RNs working 12-hour shifts. Unmarried nurses reported higher levels of verbal abuse, too.
The consequences of bullying and verbal abuse are wide ranging, from spurring nurses to call in sick more often, to causing post-traumatic stress disorder, anxiety, depression, or insomnia in victims. Patient safety might also be in jeopardy when nurses are working in a toxic, abusive environment.
But a striking finding of the new RN Work Project study is that nurses who are verbally abused are more likely to jump ship.
The study shows that intent to leave a job is highly correlated with the levels of abuse new RNs experienced.
RNs who reported no verbal abuse were least likely to plan to leave in the next three years. But those who experienced moderate to high levels of abuse were most likely to say they intended to leave in the next 12 months.
It's also important to note the finding that these new RNs didn't want to leave the field of nursing, just their current, poisonous environments. This means that hospitals that allow verbal abuse to occur are likely losing valuable employees to other organizations.
The authors of this study recommended a course of action similar to the one Dellasega calls for in her book, Toxic Nursing: Managing Bullying, Bad Attitudes, and Total Turmoil. They say hospitals should implement mandatory organization-wide programs for all employees about the impact of verbal abuse and other disruptive behaviors, as well as zero-tolerance policies.
And if your organization hasn't taken the time to train its nurse leaders in conflict resolution, now's the time to do it.
Why don't more nurse leaders go after hospital CEO jobs? Too many nurses underestimate their potential and believe that landing a chief nursing officer position means that they've reached the pinnacle of their career.
Connie Curran, EdD, RN, FAAN, hears a common refrain among chief nursing officers who are frustrated with their hospital's top leadership: "How many CEOs do I have to teach to do their jobs?"
Curran has ready reply: Why don't you apply to be a CEO?
Most often, though, nurses don't go for it. In a profession where more than 90% of the workforce is female, nurses are still seriously underrepresented in CEO positions.
Why is this? Although there are certainly external factors that hold women back from pursuing executive-level positions—sexism is still alive and kicking, folks—there are also internal factors that hold them back. Curran says female nurses who move up the ranks into hospital leadership positions most often end up in chief nursing roles—and then stop there.
"I think that a lot of people really underestimate their potential, and if we don't see somebody else doing it we think it can't be done," Curran says.
Her challenge to chief nurses? Dream of being the CEO.
Curran is CEO of Best on Board; a faculty member of the American College of Healthcare Executives; a member of the boards of directors for Hospira Inc., DeVry Inc., and DePaul University; and former chairman of the board of Silver Cross Hospital.
Nurses—most of whom are women—don't dream big enough, Curran says. "She should stop and think about where she is in her career and is that as far as she wants to go?" she says. "Has she reached the pinnacle of her dreams?"
Becoming CEO someday isn't an aspiration for many nurses, not simply because they're contented in their current role, but because it never occurs to them that they could be the CEO.
"I do think lots of times we set our bar, or our goal, or our dream too low," Curran says. Plus, many nurses are dedicated to patient care and don't want to move out of that realm. But she counters that nurses who move into chief executive roles can exercise great power and influence over improving patient care.
In fact, the desire to be a CEO "really comes from the very thing that makes you want to be a nurse," she says: Wanting to help people. She says nurse managers should ask themselves, "'Why wouldn't I want to run the hospital or be on the hospital board?' It's kind of an extension of your core mission."
Curran says successful nurse executives possess the fundamentals skills a CEO needs. They know how to set priorities and delegate responsibility. They also understand the importance of building good networks and positive relationships, as well as always learning new things and broadening their skills by doing everything from reading articles to attending webinars and workshops. They have a firm grasp on finances, something many women are convinced they're ill-equipped for, despite routinely and competently managing their household finances. But that's a column for another day.
Risk-taking is also important.
Of those who have ventured forth, Curran says, "They all kind of stuck their nose out there and tried something that they had never tried before and never thought of trying." And maybe more importantly, they don't let fear of failure keep them from trying new—and maybe scary and intimidating—things. If you've never made a fool of yourself, now's the time to do it, she says.
"This is about taking a risk with your own abilities, taking a chance," she says. Don't be afraid of mistakes—they're inevitable—and don't linger over them. For example, if you use wrong terminology in a meeting, get over it and move on.
Nurses should speak up when they're underrepresented on hospital boards, Curran says. She points out that the ratio of nurses to physicians on hospital boards is incredibly skewed when compared to the ratio of physicians to nurses who work in hospitals. Only a very, very small percentage of hospital board members are nurses, yet the majority of the workforce consists of nurses.
"I really believe nurses need to be on board for the sake of the patients as well as the sake of the other caregivers, but I don't see if happening," Curran says. "Who knows how the place runs on Christmas Eve? Nurses." Why wouldn't you want nurses who literally run the place on the board, she asks?
Although hospital executives and board members should work to inject a new and critical perspective into the good-old-boy network and make a conscious effort to get more nurses on their boards, Curran says nurses should take the initiative here and advocate for themselves, too.
She tells chief nurses to get in front of CEOs and tell them they need a nurse on the board. Many times they'll get an "oh yeah" kind of response from the current board members. As in, "oh yeah, I never thought of that."
Here are six strategies for nurses who aspire to the corner office:
1. Step out of your comfort zone: Get on a committee that you may not be entirely comfortable with. For example, if you're intimidated by numbers, join the finance committee.
2. Develop relationships: Have a broad view and understanding of your entire organization, not just your little slice of it. Cultivate relationships with people who work in the lab and housekeeping, as well as with physicians and other nurses.
3. Find a mentor: When you encounter someone you admire and who does something really well, make an effort to learn from that person.
4. Get a coach: If you want to be a better tennis player, you wouldn't hesitate to get a coach; why should developing leadership skills be any different? "It's worth the investment to get a coach to help you," says Curran.
5. Understand the numbers: It's not enough to be a good clinician; you have to understand the financial aspect of healthcare, too. Curran believes deans of nursing schools should require finance classes for students. If you didn't take one while you were in school, though, it's not too late to take one now.
6. Value your work: If you're working unforgiving hours, day in and day out, maybe surrounded by people who appear not to appreciate you, it's easy to forget the just how important your work really is. "When someone diminishes the significance of what you do over and over again you start to lose appreciation for it," Curran says. "You lose the awe about how miraculous it is."
A California ruling that would allow non-licensed adults to administer insulin in schools cheapens and devalues not only the practice of nursing, but also the clout of its own licensing authorities.
My daughter has a spinal cord defect and because of that, the law says the school district must provide her with physical therapy. But what if she got to school at the beginning of September and I found out that rather than getting PT from a licensed physical therapist, she'd receive it from the school secretary instead?
It's a ridiculous scenario, and one that wouldn't ever happen, right? But in California, there's something similar afoot, something that threatens to devalue nursing and that the American Nursing Association is fighting hard to prevent.
Here's the issue: The California Department of Education wants to allow unlicensed personnel to give insulin [PDF] to children in schools. Two lower courts have already ruled that this violates the state's Nursing Practice Act, which says that administering medication is a nursing function that cannot be performed by unlicensed individuals.
The American Diabetes Association, however, and others have appealed to the California Supreme Court, arguing that the law puts students' safety at risk because not all schools have nurses. Oral arguments began on May 29.
Maureen Cones, associate general counsel for the ANA, tells me that the implications of this case could extend way beyond what happens in California schools.
"With budgets being what they are, schools and school districts are quick to eliminate nursing positions," she says. For that reason, this case is being watched by many states experiencing the same issues. "If the ADA prevails and the decision is overturned, it will give license to any state to allow unlicensed personnel to administer insulin."
Moreover, the ANA believes that overturning the previous rulings would set a dangerous precedent: Cones says it will be the first time anywhere that a healthcare licensing law would be preempted in favor of a federal disability law.
"That would have very far reaching implications nationally," Cones says.
The ANA says its position doesn't mean that federal disability laws don't apply; they're simply saying that the two laws need to work together. In fact, the ANA says that the courts' rulings "do not prevent students with diabetes in California's public schools from receiving the health services to which they are entitled. California law permits several categories of individuals to administer insulin in the school setting, including parental designees." Moreover, nursing positions in schools shouldn't be on the chopping block because of budget constraints.
The ADA says this on its website:
[F]amilies of children with diabetes and diabetes health care experts not only disagree with the idea that you need a health care license to administer insulin, but know that this position puts students with diabetes at risk. There is only one school nurse for every 2,200 students in California and a budget crisis with school personnel being laid off across the state. And even if there was a full-time school nurse in every school, the nurse wouldn't be available for all extra-curricular activities and field trips.
The ADA position says that "because there's not a nurse in every school, effectively the licensing laws should be ignored," Cones says. "What's next? If a nurse doesn't have to provide medication in accordance of state law are gym teachers going to be providing physical therapy?"
That "what's next?" statement gets to the heart of the real issue that should be worrying to nurses everywhere: Ruling that anyone can administer insulin cheapens and devalues not only the practice of nursing, but also the clout of its own licensing authorities.
"The hallmark of any true profession is the ability to regulate itself. If the ADA prevails, the board of nursing will no longer be able to decide who is qualified to administer any medication," Cones says. "It erodes the profession of nursing."
Nurses are naturally protective of their turf and are trying to preserve school nursing jobs. Some people might see irony here because this fight is being waged at the same time that nursing unions and advocates are lobbying to extend scope-of-practice laws in many states. Nurses with advance practice licenses rail against physician groups who want to keep them from practicing without physician supervision.
However, in my opinion, this isn't it's an accurate parallel. Secretaries and teachers and janitors aren't healthcare professionals like doctors and nurses so it's like comparing apples and oranges. I know how to do my daughter's PT stretches and I'm sure lots of people could be taught how, too, but I still expect a licensed physical therapist to provide her PT her in school. She's entitled to that under law.
The more disordered a nursing unit is with its staffing, the more turnover and costs will go up. A thorough assessment and overhaul of scheduling, tracking, and staffing policies can put an end to the chaos.
It seems like a simple thing: If you hire a nurse to work 36 hours per week, you expect her to actually work those 36 hours. But what if he or she isn't always doing that? What if sometimes the nurse puts in a 32-hour week?
And what if you found it that it's been happening more often than you think, among nurses who are regularly just a few hours shy of their full-time status?
What if a-few-hours-shy was the norm across several units or even across many sites in a multi-hospital system? "That doesn't happen, does it?" wondered Mary Lou Wesley, senior vice president and chief nurse executive for WellStar Health System, based in Marietta, GA.
Oh, yes it does. In fact, "It's pretty amazing how much it does," she came to learn.
Wesley says the more chaotic a unit is with its staffing—when shifts perpetually seem to be short-staffed, and nurses are continuously on call—the more turnover will go up and staff satisfaction will go down.
Switching to scheduling software that allows managers to see who's working what hours has allowed managers at her hospitals to be alerted when nurses aren't working enough hours, or in some cases, too many hours.
It's also allowed managers to see other, smaller things, such as which nurses are regularly punching in a little early and out a little late.
Jolene Goedken, senior vice president and CNO at Mercy Health System, says making sure nurses work a full workweek means "you don't have the reliance on needing to fill those hours with other contingency resources."
"Any time you're using contingency resources," she says, "that's where you start to get some of the premium costs associated with that."
Yet identifying the problem is only half the battle. Wesley says making sure nurses work when they're supposed to be working has required more than simply knowing who was working when. Part of improving scheduling at WellStar involved doing a complete review—and in some cases, revamp—of hospital policies related to staffing, scheduling, and attendance.
Some policy changes were simple. For example, the review revealed a wide variation in starting and end times for staff nurse shifts within the five-hospital WellStar system. Sometimes the differences were between different facilities, but some were actually between units at same facility.
"If we want to utilize resources more effectively… we really need standardized shift start and end times," Wesley says. WellStar also made policies about punching in and out of shifts on time more explicit; when hundreds of nurses do that every day, the costs associated with it really add up.
"There were no consequences for the staff who continued to do that day after day after day," she says. "We really need our policies in some cases to have a little more teeth in [them], and have more ownership on the employee side."
Other changes involved making sure nurses don't work too many hours. This helps to prevent fatigue and reduce overtime costs.
After revamping the hospital's policies, WellStar put together a communications strategy to alert nurses to the changes in policies. Shared governance groups were invited to explain the new policies to nurses at each facility to make sure that everyone was aware of and onboard with the changes.
Wesley acknowledges that there will certainly be "some folks who might not be too happy" with new rules. But she insists that so far, feedback from the vast majority of nurses has been positive.
Strong, streamlined policies means scheduling will be more organized and less chaotic. "We really believe that most of the staff are going to feel very relieved" by the changes, Wesley says.
For many nurses, leaving high school doesn't mean leaving the bullies behind. Bullying has been called nursing's "dirty little secret," but judging by the numbers, it's hard to believe it could be kept secret at all.
Cheryl Dellasega, PhD, RN, CRNP
Most women can relate in some way to the 2004 Lindsay Lohan movie Mean Girls, in which her character encounters a group of bullying high school girls who say things like this: "Half the people in this room are mad at me, and the other half only like me because they think I pushed somebody in front a bus."
But while most women can leave memories like this behind when they graduate from high school, for those who enter nursing and become victims of nurse-on-nurse bullying, leaving high school hasn't made the mean girls disappear; they're just wearing scrubs now.
Bullying has been called nursing's "dirty little secret," but judging by the numbers, it's hard to believe it could be kept secret at all.
Twice as many nurses as other Americans have experienced bullying in the workplace. According to study of 612 staff nurses in theJournal of Nursing Management, 67.5% had experienced bullying from their supervisors, while 77.6% had been bullied by their co-workers. Compare that to the 35% of Americans outside healthcare who've reported workplace incivility, says the Workplace Bullying Institute.
Not only is bullying among nurses an issue, it's one that most nurse managers aren't equipped to handle properly, according to Cheryl Dellasega, PhD, RN, CRNP, co-author with Rebecca Volpe of the new book Toxic Nursing: Managing Bullying, Bad Attitudes, and Total Turmoil.
Bullying "is a huge problem now in the workplace," Dellasega tells me. "I think a lot of nurse managers don't get a lot of training in conflict resolution."That's especially true when they have little more management experience than any of their co-workers but were promoted to the role because they have a bachelor's degree and a few extra years of seniority, Dellasega says.
In order to write the new book, the authors not only conducted a literature review, but also reviewed hundreds of blogs written by nurses about situations of conflict. By doing so, Dellasega and Volpe were able to identify key themes and scenarios that are common to bullying, as well as which groups of people were commonly involved in bullying.
Finally, the authors interviewed nurse management experts to give insight into dealing with such situations. "There were different pockets of nurses who seemed to be really engaged in the situation, as either a victim of the aggressor," Dellasega says. For example, new nurses are often victims.
"I think that brand new, young nurses [are] sort of the classic targets," Dellasega says. Often, these nurses are idealistic about their work and excited about how they're going to make a difference, but the older, established, more jaded nurses engage in bullying to knock them down a little. In fact, Dellasega says, sometimes the young nurses' preceptors are the ones who are doing the bullying because they feel like the role is a thankless one.
"I know that even…the literature…supports that preceptors often don't feel well prepared to do the job and often don't want to do the job," she says.
Another group of nurses who are often bullied are part-time, agency, or floater nurses who are picked on because they're not part of the regular nurses' clique.
Yes, clique. Dellasega says the regular nurses who are in the clique often make rude or sarcastic comments to or about the new person, or even go so far as not sharing supplies. Even nurses who come in from other floors can be left of out, even though they're just there to help.
Dellasega says that the cliques and bullying in a hospital comes with the same kind of baggage that most of us thought we left behind in high school. But for nurses, there's the added stake of patient safety. Although studies haven't explicitly linked increased bullying to decreased patient safety, research does say that happier nurses do their jobs more effectively. (Conversely, nurse burnout is linked to higher healthcare-associated infection rates).
"It's not a big leap to figure that when you go into work… if there's a toxic environment… you won't be able to give your full attention to patient care," Dellasega says.
Bullying also leads nurses to call in sick more often in order to take mental health days. Abusive behaviors can even cause nurses to develop post-traumatic stress disorder, anxiety, depression, or insomnia, a Joint Commission survey has found. Hospitals can also lose valuable employees to bullying and many nurses have left their jobs because of it.
"Things get to a point where they just can't take it," Dellasega says. Sometimes nurses feel like they're "going into the battle zone every day."
Nurse managers shouldn't let things get to that point. Managing relationships should be day-to-day work, not something that only happens during moments of high tension.
"Don't wait for it to get to the point that there's explosive conflict," Dellasega says.
Just as Dellasega discovered which nurses and situations tend to breed bullying, she and her co-author also discovered which environments are healthy. Bullying is rarer when there is a sense of teamwork, collaboration, and authentic communication with coworkers.
Dellasega says the ideal nurse manager is transparent, letting the staff ask questions and answering honestly, even if the answer is "I don't know, but I'll find out."
Feelings of empowerment are also important to reduce bullying and satisfaction. And upper hospital management should provide appropriate training for new nurse manager about how to effectively and positively deal with bullying.
Finally, Dellasega says nurses managers should monitor their own behavior to ensure that they're not engaged in bullying themselves, even if inadvertently. For example, sighing heavily after someone speaks could be interpreted as negative. Other behaviors to watch out for are favoritism, certain body language, gossiping, and speaking in a raised voice.
"I think nurse manager have to really monitor their own behavior and be cognizant of anything they might do," Dellasega says. "The nurse manager sort of sets the standards."
Because higher patient satisfaction scores translate to higher Medicare reimbursements, how nurses interact and talk with patients has a demonstrable and significant impact on a hospital's bottom line.
When a patient in pain cries for help, it's almost always a nurse who responds. But how swiftly that response comes and how effectively the interaction that follows satisfies the patient's needs has repercussions far beyond the bedside.
The way nurses interact and talk with their patients could have an impact on a hospital's bottom line, concludes a new study. It finds that how hospitals perform on the "communication with nurses" dimension of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey strongly influences several other "Patient Experience of Care" dimensions.
And as we all know, higher patient satisfaction = higher reimbursements.
The Press Ganey study aimed to find out which of these measures influenced each other. Researchers used data from a sample of 3,062 acute care hospitals to conduct what's called a "hierarchical variable clustering analysis" on the HCAHPS dimensions. This analysis identifies multiple measures that are consistently grouped together and pinpoints which measures lead the others.
It found that communication with nurses, pain management, communication about medication, responsiveness of the hospital staff, and the overall rating of the hospital were consistently clustered together, and that communication with nurses leads the way.
Translation? Efforts to improve scores in the area of communication with nurses will likely lead to higher scores in the other dimensions within that cluster, too. It's for this reason that the study calls nurse communication a "rising tide measure;" something for hospitals to focus on and improve that will set off a chain reaction of improvements in multiple areas.
This study uses appropriately rigorous methodology, but really, connecting the dots on these quality measures is just common sense.
Think about it. Nurses ask patients to rate their pain and are the ones who keep the pain meds coming, so it makes sense that quality measures connected with pain management and communication about medicines would be associated with nursing quality.
Also, when patients need help, nurses are the ones who answer their calls and pages with a visit to the bedside. Therefore, having nurses who are very responsive to those requests will likely help improve the "responsiveness of hospital staff" measure, too.
Plus, among all hospital staff they encounter, patients interact most frequently and regularly with nurses. Surely the quality of those nurse interactions color patients' overall perception of their hospital experience.
Research has consistently shown that nursing quality influences quality of care across wide measures of quality, and better nurses result in better quality.
For example, one study found that higher levels of RN hours per patient day (nurse staffing ratios) were associated with lower central line-associated blood stream infections (CLABSI); catheter-associated urinary tract infections (CAUTI) rates. It also found that critical care units with higher percentages of RNs holding national specialty certifications had lower CLABSI and CAUTI rates.
Here's the clincher: The reverse is also true. A different study showed that nurse burnout is linked to higher healthcare-associated infection rates (HAIs), and as a result, higher costs.
According to the Press Ganey study [resgistration required], the closer a measure is statistically to the "communication with nurses" measure, the more it will improve after the nursing measure is improved.
Another example: "responsiveness of hospital staff" follows communications with nurses very closely, and will improve more and at a faster clip than other measures, such as "overall rating" which is further behind.
The study calls for investing significant time and resources into improving the "communication with nurses" measure, and recommends several best practices for hospitals: "Consistent and purposeful hourly rounding, bedside shift reporting, use of scripts, post-discharge phone calls, hiring nursing candidates who exhibit strong interpersonal skills, and providing service skills training with periodic reinforcement."
Are you managing your nursing staff in a way that's consistent with preserving reimbursements?