Emergency medicine's unique nature makes noncompete agreements particularly ill-suited to the specialty.
Emergency physicians are clearly negatively affected—personally and professionally—by noncompete clauses, as revealed in a new questionnaire by members of the American College of Emergency Physicians (ACEP).
As such, ACEP is urging the Federal Trade Commission (FTC) to finalize its proposed rule to ban noncompete clauses in employment contracts. Doctors and other healthcare workers who work under noncompete clauses would be freed of those hiring restrictions under the FTC’s proposed rule.
“ACEP carefully monitors the emergency medicine labor market in pursuit of our overall goal to support emergency physicians and ensure that they are treated fairly by their employer and practice in an environment where they can best care for their patients,” Christopher S. Kang, MD, FACEP ACEP, president of ACEP, said in a letter to Lina M. Khan, FTC chair.
“Therefore, ACEP supports the commission’s proposal to categorially ban noncompete clauses and we urge it to finalize the regulation as proposed to help address the current anticompetitive conditions faced by many emergency physicians that limit their right to freely practice medicine in their communities,” he wrote.
Indeed, emergency medicine’s unique nature makes noncompete agreements particularly ill-suited to the specialty; emergency physicians do not have a “book of business” of existing patients with whom they have established and ongoing relationships. If they leave for another group or hospital, no patients will follow them to their new practice, so their departure does not lose their previous employer any business, Kang explained.
Professional consequences
Some 90% of the 75 emergency physician respondents to the ACEP survey said noncompete clauses make it harder for emergency physicians to switch employers, and more than half—59%—said they would seek a different job locally if they were not subject to the clause.
“This has without a doubt caused an impact on fair market value of our compensation as we have not received a raise in over five years and because leaving the company would cause all of the emergency physicians a hardship of moving, we all accept the bad conditions under which we are working,” one emergency doctor said.
Another worried about patient care: “I feel trapped, and worry every shift that this noncompete limits my ability to advocate for my patients—since a core part of the job of a good emergency doctor is advocating for patients even when it causes work for more ‘powerful’ specialists within the hospital,” the physician wrote.
Noncompetes can particularly affect rural and underserved areas that are struggling to keep doctors.
“As I am working in an area of the country that is in dire need of emergency physicians, if I leave my current job, I would be depriving this high-need area of a physician, as I would be forced to find work outside this area,” a rural physician responded. “Moreover, this area would be losing someone who has been actively putting down roots and becoming a member of the community, with a knowledge base of the local resources and culture.”
Personal consequences
Other emergency physicians revealed how noncompete clauses—being “chained to a single employer,” as one put it—had affected their personal and family life.
“My noncompete is geographically quite broad, and basically means that if I leave my current employer, I will have to move my special-needs kids out of the school system we moved here for,” one physician responded.
Said another: “I recently moved away from my hometown and my wife’s family due to a noncompete clause. This was a very trying time for my family and my children. I had to tear them away from their school, friends, and sports. After the move my children experienced bullying at school, lack of sports options, and one child developed severe anxiety requiring treatment. I then lost significant income and equity selling my house.”
Noncompete clauses also prohibit emergency physicians from “moonlighting” at other health facilities, an opportunity that can allow physicians to expand their skills, enhance job flexibility, and help them earn additional income. Of respondents who have had a noncompete clause in their contract in the past five years, 12% felt limited by their inability to moonlight.
“As a fellow in my late 30s and the only physician in my family, I have been the one to provide when my family needs money,” one ACEP member responded to the survey. “Not being able to leverage a contract or even moonlight at a nearby facility over a holiday weekend forces me into continued financial strain. No one should get to say what I do or where I work in my free, unscheduled time.”
Giving more control
“Restricting an emergency physician’s ability to choose a job can stall or upend their career, contribute to workplace dissatisfaction, and accelerate currently high rates of burnout, especially in rural or underserved communities where it is already challenging to attract and retain physicians,” Kang wrote.
“Finalizing this ban would be a fundamental step that can empower emergency physicians,” he wrote, “to take more control over their careers.”
After less than a year, the special team has improved nurse staffing, patient care, and health system finances.
Much like the U.S. Navy SEALS go to where their services are necessary, Jefferson Health’s S.E.A.L. RN team deploys to areas of greatest need.
The Jefferson Health S.E.A.L. (Service, Excellence, Advocacy, Leadership) RN Team, which launched in May 2022 with an initial cohort of 25 nurses, is a flexible staffing resource of nurses who care for patients across Jefferson Health’s 18 hospitals in southeastern Pennsylvania and southern New Jersey.
And, yes, the name is patterned after the Navy SEALS elite special operations forces.
“The name ‘S.E.A.L.’ team certainly draws on the concept that these nurses are meant to operate as a special workforce team deployed to hospitals where the staffing need is greatest on a weekly basis,” Andrew Thum, MSN, ML, RN, NE-BC, director of Nursing Workforce Operations for Jefferson Health, told HealthLeaders.
“S.E.A.L. nurses serve as leaders and ambassadors for Jefferson nursing as they work with different patient populations, nursing teams, providers, and leaders across our health system,” Thum said.
“This change is imperative in evolving how organizations balance valuing their people with meeting operational needs,” Thum wrote. “Now is the time to engage and think differently in order to recruit and retain the best talent.”
How it works
“Our SEAL nurses work primarily in one of three specialties which they select upon hire based on their experience: Medical-Surgical/Telemetry; Critical Care/Intermediate; or Emergency Services (ED),” Thum said.
Jefferson Health is exploring adding other specialties such as surgical services and respiratory therapy, according to Daniel Hudson, MSN, RN, CENP, vice president, Nursing Administration & Operations.
S.E.A.L. Team nurses are hired into one of three tiers:
Tier 1: deployed to two divisions within Jefferson Health
Tier 2: deployed to three divisions within Jefferson Health
Tier 3: deployed to all divisions across Jefferson Health
At the time of hiring, Tier 1 and Tier 2 S.E.A.L. nurses choose the divisions in which they wish to work and receive a base hourly salary that is incentivized depending on their tier selection. They also are eligible for shift differentials.
The S.E.A.L. nurses, who self-schedule in six-week periods, are required to work four weekend shifts per schedule and rotate in several holidays annually. Divisional staffing offices consult weekly with the S.E.A.L. Team leader to identify locations of greatest need and nurses are deployed divisionally based on these needs.
S.E.A.L. nurses also have full-time benefits including medical, paid time off, tuition reimbursement, and employer-matched retirement contributions.
“We offer S.E.A.L. nurses—like all Jefferson nurses—opportunities for ongoing continuing education,” Thum said. “We are in the process of launching a health system nursing clinical ladder program, which the S.E.A.L. team will be eligible for, that includes opportunities to engage nurses in their professional growth and development.”
The impact
The S.E.A.L. RN Team has positively affected staffing, patient care, and finances.
“The nature of the S.E.A.L. role—working across so many different practice environments—is naturally intellectually stimulating, or so our S.E.A.L.s tell us,” Thum said.
On a weekly basis, the S.E.A.L. Team is meeting anywhere from 12%-16% of the health system’s proactively identified staffing needs, according to Thum’s article. Prior to the team’s implementation, these needs either went unfilled or were staffed with core staff overtime, premium paid shifts, and agency staff.
“The benefit of using our own S.E.A.L. nurses in lieu of external agency nurses to meet staffing needs has not only had a positive financial impact but it has also allowed us to ensure more consistent, higher-quality care for our patients as S.E.A.L. nurses are Jefferson nurses trained to our standards of excellent nursing practice,” Thum told HealthLeaders.
Indeed, “we are projecting to save millions of dollars annually by replacing agency RNs with S.E.A.L. RNs,” Hudson noted.
As the program grows, so will those cost savings. The initial plan was to have 100 S.E.A.L. RNs, but the new program has been so successful that Jefferson Health already has plans to boost that number.
“We have identified the benefit of this flexible type of nursing workforce for staff, patients, and hospital operations and, as such, we have begun an initiative to expand the team to 150 nurses over the next several fiscal year quarters,” Thum said. “We hope to have most of these nurses hired by the end of June 2023. At present, we have hired a total of 51 S.E.A.L. nurses.”
Reaching that staffing goal appears to easily be in reach, given the program’s popularity, Thum noted.
“The overwhelming interest in this program among internal and external partners has been very encouraging,” he said. “While we expected the program would be successful to some degree, we did not expect it to receive such intense interest and praise from patients, nurses, leaders, and professional colleagues across local and national healthcare organizations.”
Inventor saw a gap in available and effective airway management tools for patients who suffer breathing complications.
A nurse anesthetist who leads a team that developed a device she invented, the McMurray Enhanced Airway (MEA), is the Nurse-led Team Award winner of the 2023 ANA Innovation Awards given by the American Nurses Association (ANA).
The ANA Innovation Awards highlight, recognize, and celebrate exemplary nurse innovators who improve patient safety and health outcomes. The award includes a $50,000 prize earmarked for further product advancements.
Roxanne McMurray, DNP, APRN, CRNA, and her team with McMurray Medical, in Saint Paul, Minnesota, developed the breathing tool to maintain adequate ventilation for surgery or other medical procedures.
Unlike other airway devices, the MEA’s longer flexible tubing reaches beyond the tongue to quickly stent open a patient’s airway, easing ventilation and oxygenation. It can be inserted quickly and easily without requiring special patient positioning or accessories.
The MEA also can be attached to an anesthesia circuit or resuscitator bag.
“New airway management tools are needed to help today’s patients breathe better during and after anesthesia is administered, especially in ambulatory and outpatient surgery centers and non-operating room procedures,” McMurray said. “The McMurray Enhanced Airway meets these needs and more in a significant way.”
Today’s patients, particularly those who are older, obese, or have sleep apnea, often have an increased risk of upper airway obstruction, according to McMurray Medical.
McMurray and her team saw a gap in available and effective airway management tools for patients who suffered from breathing complications, which led to the creation of the first-of-its-kind MEA.
“The 2023 ANA Innovation Award winners have built clinical solutions for complex healthcare challenges. Roxanne … advanced care and the resources being delivered, while simultaneously improving health quality for patients,” said Oriana Beaudet, DNP, RN, PHN, the ANA’s vice president of nursing innovation. “Advancing nurse-led solutions that create sustainable cost-effective solutions across healthcare is good business, driven by purpose and mission.”
“Nurses advance health through their work as clinicians, scientists, entrepreneurs, researchers, product designers, policy leaders, in advanced practice, as community organizers, and by providing direct care across our country in hospitals, long term care, hospice, ambulatory settings, schools, and numerous public health settings,” Beaudet said. “It’s time the innovative work of nurses is recognized.”
Violence prevention plans, wage increases, and sufficient PPE are among some of the RNs' wins.
RNs at Alta Bates Summit Medical Center (ABSMC) have voted overwhelmingly—87%—to ratify their collective bargaining agreement, concluding a systemwide contract fight with Northern California's Sutter Health that began in June 2021.
"We didn't get everything we wanted, but we made important gains to retain staff, and stop them from fleeing to other facilities," said Ann Gaebler, a neonatal ICU RN at ABSMC. "We will continue to address staffing at our hospital and fight for quality patient care."
While nurses approved contracts specific to their facility, highlights applicable across all 16 Sutter facilities include:
Patient and nurse safety protections: new workplace violence language to ensure the hospitals maintain sufficient security systems and violence prevention plans; maintenance of a three-month stockpile of PPE; and presumptive eligibility for workers' compensation during a state-declared pandemic or epidemic.
Recruitment and retention strategies: improved meal and break assurances; wage increases ranging from 21-32% over the life of the agreements, with Sutter hospitals bargaining their first contract receiving as much as 25-55% increases, with additional step increases; differentials for weekends and charge nurse duties; and tuition reimbursements.
RNS from across 16 Northern California health facilities have been bargaining with Sutter Health management for 21 months for safer staffing, pandemic readiness protections, and workplace violence protections, according to California Nurses Association/National Nurses United (CNA/NNU).
More than 8,000 nurses staged a one-day strike last April to call attention to Sutter Health's "refusal to accept nurses' common-sense proposals for improved nurse and patient safety," said the CNA/NNU.
"We have been on the front lines before and during this pandemic," Amy Erb, a critical care RN at California Pacific Medical Center of San Francisco, said shortly before last year's one-day strike. "Throughout this time, we have witnesses Sutter Health become profitable while they refuse to invest in the resources we need in order for us to provide safe and effective care to our patients and community."
The agreement at ABSMC is effective through November 2027, while the agreements at the other Sutter hospitals run through December 2026.
"I am so happy that ABSMC members have a contract," said Paula Lyn, RN and a CNA board member. "All Sutter nurses deserve our congratulations."
Still, healthcare workers generally feel safe going to work each day, new survey says.
Violent patients are a top safety concern for nurses, reveals a recent survey commissioned to better understand healthcare worker concerns.
Of the nurse respondents, 81% are concerned about patients becoming violent, which is understandable given that 59% of them reported a dangerous event at their workplace, according to the Healthcare Worker Safety Survey conducted by Motorola Solutions, which specializes in video security and access control.
The study, fielded between December 2022 and January 2023, analyzed answers from 500 respondents working in the healthcare field, including doctors, nurses, technicians, and administrators across the United States.
Hospital and healthcare system employees generally feel safe going to work each day, with 68% of healthcare workers stating they feel extremely or very safe while at work and 89% saying that they trust their workplaces to keep them safe in the event of an emergency.
Some of the biggest safety concerns healthcare workers have include patient(s) becoming violent (72%), the impacts of burnout/mental health (61%), and active assailants (42%).
Only 40% of respondents believe their workplace is extremely or very well prepared to manage an active assailant scenario.
More than half (54%) of healthcare workers noted that they would be at least somewhat likely to quit if a violent incident unfolded in their workplace.
Healthcare workers perceive staffing shortages to be one of the biggest safety concerns because they believe that loss of personnel will negatively affect the mental health of remaining workers and lead to job burnout (77%) and it will affect patient safety and care (72%).
Mental health
Widespread mental health challenges and job burnout also concerned survey respondents. More than half of them (56%) indicated that their or their colleagues’ mental health is generally worse now than during the height of the COVID-19 pandemic.
Nurses responded that mental health is “extremely” worse now (24%) while, comparatively, physicians said that mental health is at the same level now that it was during the height of the pandemic (31%).
Healthcare employees are also increasingly concerned about their patients’ mental health and the effect this may have on worker safety, the survey indicated. Almost three-quarters (71%) of healthcare workers said that patients’ mental health impacts their or their colleagues’ safety and well-being while at work.
Safety notifications
Healthcare employees would feel safer if more interconnected communication platforms were used for emergency notification, training was prioritized, and safety guidance was centralized, the survey noted.
Specifically, respondents shared that they would feel more prepared if their workplace: utilized panic button technology or another 911-alerting system (55%); conducted safety procedure training (51%); used customized text and/or phone alerts (48%); made safety plans digital and easy to access for all staff (46%); and offered a safety app with resources, plans, and emergency contacts (44%).
Those who work in hospitals or health systems must feel confident in their level of personal safety, despite a rise in violence, the survey concluded.
By taking into account healthcare employee safety concerns, consistently conducting safety training, and adopting new communication technology, health systems “can ensure that their staff is able to render the best possible patient care without unnecessary, unnerving distractions,” the survey said.
A shared leadership/professional governance mindset is key to a successful practice redesign, CNE says.
Editor's note: This article appears in the June 2023 edition of HealthLeaders magazine.
Care models had not wavered much since hospitals became medicalized in the early 20th century, and particularly since the Centers for Medicare & Medicaid Services (CMS) were created in 1965, says Jason Gilbert, PhD MBA RN NEA-BC, executive vice president and chief nurse executive, Indiana University Health.
But now, nursing shortages, increased patient acuity, and workforce pipeline challenges are requiring nurse executives to configure different care models.
Gilbert spoke with HealthLeaders about how he and his organization are approaching practice redesign and best practices to implement a redesign.
This transcript has been lightly edited for clarity and brevity.
HealthLeaders: What is your definition of practice redesign?
Jason Gilbert: I love this question, because we've had a big debate about that. There’s a lot of confusion in the literature and healthcare in general, about the difference between what a staffing model is and what a care model is. Both of these are very important, but they have a distinct focus.
Staffing plans are all the activities that are required to ensure that there's an adequate number and mix of healthcare team members to provide care. Nationally, this has been a big focus on ratios and with benchmarking—supply and demand.
But the definition we’re using for care model delivery models is the way tasks, assignments, responsibility, and decision-making authority are structured to accomplish quality patient care outcomes. These define which healthcare worker is responsible for which tasks, and then who has the authority to make decisions.
With all of that said, I don't think you can separate one from the other. There’s been a great focus nationally about staffing plans and nurse-to-patient ratio, but in my opinion, not enough emphasis on nursing care model redesigns.
We need to get away from thinking about redesign as if we’re going to be finished with this in the near future. It’s really care model evolution. These need to continue to evolve.
Both staffing models and care delivery models have that impact on quality, safety, mortality, affordability, and health equity, but you need to assess the contextual issues—geography of your units, availability of technology, your level of preparation, experience of your available caregivers, your pipeline, financial resources, licensing, accreditation, state practice acts, and then of course, patient and family.
Jason Gilbert, PhD MBA RN NEA-BC
HL: When is it necessary to re-engineer, or evolve, the way patients receive care?
Gilbert: The burning platform that's caused this necessity has been the huge supply and demand mismatch between the number of caregivers available and patient demands and acuity. We’ve been through many nursing shortages in the past but nothing really quite like this one. This has been exacerbated over the last several years with accelerating retirement rates, more work options outside of acute-care settings or in healthcare for nurses, and changing expectations in the workplace.
We have a pipeline issue with lack of faculty in nursing schools and a great number of qualified applicants are turned away every year just because there aren't enough to teach the next generation. We’re also experiencing a knowledge complexity gap in the profession. Millennials and Gen Z are now the largest portion of the workforce, which flipped in 2020 when baby boomers—and I hate those labels of generations—once were the largest sector in the healthcare workforce. They’re taking a lot of experience with them as they retire, so we have to rethink the way we provide care and onboard and partner with schools.
So, we need to continue to evolve improved quality and safety and patient care in the way it's delivered and to make care more affordable and equitable. Our past models are just not sustainable, not only for our patients, but for our direct caregivers, as well, and we saw a lot of this exacerbated during the pandemic. Our patients are telling us that they don't always like to receive care in the way that it's designed, and our caregivers are telling us they don't always like providing care in the way that it's been designed in the past.
We have lots of data on this and it's time to change our mindsets and embrace the changes that are ahead of us. As a profession, nurses have the duty to ensure that patients receive quality healthcare, so we're going to have to take a more active role in care model redesign.
HL: What does practice redesign look like at Indiana University Health?
Gilbert: As we are entering in this work, we want to be thoughtful about how this is going to be different. A lot of times we trial things, but then we don't always get good data for what works or what doesn't, or we try to wait for the perfect model before we would implement anything because, quite frankly, the stakes are high and there is that innate fear that you're going to make a mistake that's going to cause you not to give quality care.
So, we created a vision statement for care model redesign, and then associated guiding principles: we wanted to engage our frontline team members, we've encouraged autonomy, rapid testing, and frequent evaluation. We’re trying to get a little more agile and nimble with what works and what does not and spread that so we share the lessons learned across our system.
We have a lot of different pilots going on in the system and we have a research study that's going on with five innovation units across the state, so we're not waiting for perfection on this, but once we communicate the vision and the criteria, we developed some change management tools for our frontline leaders to help with how to go about this.
Part of the mindset shift for this has been to lead more through guiding principles that are not a one-size-fits-all. There were some who were probably waiting for me as the chief nurse executive to say, “This is the care model at IU Health; now everyone go out and implement this and everything will be fine.” I don't think that you can lead this way. I could have done that, but I think it would have failed miserably.
HL: What are key tips you would suggest in implementing practice redesign or evolution?
Gilbert: Balancing that structure and autonomy and not waiting for the perfect model that's going to work for everyone. Care is so complex across different patient populations, and different acuity levels that we have to lead more through guiding principles and really involve the front line and the voice of the patients and families in redesign.
It's been key to equip the frontline managers with the change management tools because there is a fear of, “What if this doesn't work?” or “What are we going to have to ask the staff to do?” It’s a shift to say that we want the staff to come up with the ideas and help with the redesign.
Leverage your professional governance structures and the Magnet principles—team empowerment, continual improvement mindset, focus on quality, safety, affordability, and equity. The biggest step is to let go of the past and challenge the status quo. Ask the “why,” and then help communicate the “why” with team members.
HL: Change in healthcare is traditionally slow, so how do you encourage others to let go of the past?
Gilbert: I have found that these initial pilots really work with the willing. There are many who want this change. They live with this every day, and they're frustrated and they want to provide care in different ways. Our frontline team members see the deficiencies, so who better to be involved in the changes?
Letting go of that traditional paternalistic command-and-control models of leadership and getting into that shared leadership/professional governance mindset is the key to the future with this. The best ideas come from our front line on how we're going to change care or do things more efficiently.
HL: What have you learned from your efforts to implement practice redesign?
Gilbert: That you can't look only within the four walls of your organization to change this, so we've taken a very active role in partnerships outside of the hospital with some of our partner universities. IU Health has given grant money to both Ivy Tech Community College and to the IU School of Nursing for expanding enrollment to help with some of the issues they have. We're also looking for community partners with high schools and vocational schools to look at pipelines for healthcare workers.
You also have to take a very active role in advocacy for public policy. You have to do a full assessment of the communities you serve, community partnerships, and if we're going to change practice, we have to work with our state and federal legislators in order to do that as well.
When 100% of the nursing faculty at one upstate New York reported incivility as a major departmental issue, they reversed course.
Incivility among nurse educators—bullying, disrespect, harassment—is growing and affects new nurses’ view of nursing as a profession, according to a new study published in NursingCenter.
Workplace incivility among faculty and students in nursing education has been known to have “detrimental effects on health and well-being, disrupt teaching and learning, and negatively impact the adequate preparation of new graduate nurses,” the study notes.
With 85% of nurses report incivility in healthcare, creating a culture of civility beginning in nursing school and extending into the workplace, is crucial to healthy environments and safe patient care, according to the study, which outlines a particular nursing program’s efforts to address incivility.
At a large nursing program in upstate New York, 100% of the nursing faculty reported that incivility was a major issue in the department. They enjoyed teaching nursing students but did not care to work together as a faculty group. Their complaints included a lack of teamwork, favoritism; undermining, demeaning comments; stealing others' joy at work; blaming each other for incivility; bullying behavior; and failure to recognize accomplishments.
As a result, faculty did not work as a team in creating new innovative projects, developing and revising curricula, or simply helping each other when needed, according to the study, authored by Maureen Kroning, EdD, RN and Sara Annunziato, MSN, RN.
However, the faculty admitted their desire for a civil environment where they could experience joy in the workplace, so in May 2019, five nursing faculty launched an effort to address incivility and identify and implement effective strategies to create a civil environment so faculty could experience joy at work, according to the study.
The five faculty members and the nursing program director developed an Incivility Care Plan by incorporating the American Nurses Association (ANA) Nursing Process and the American Psychological Association's five essential components to healthy workplace practices: employee involvement; work-life balance; employee growth and development; employee recognition; and health and safety.
“Each step in the nursing process can help address the issue of incivility,” the study says. “Care planning using the nursing process allows one to assess incivility, diagnose the human condition as a result of the incivility, plan and develop strategies or interventions, evaluate if the interventions were successful, and revise the plan of care as needed.”
The study was implemented in early 2020 and by March COVID-19 cases surged in New York. The unexpected rapid transition to remote teaching created intense challenges, but it also led to an equally unexpected, “unprecedented” level of collaboration and communication among faculty, the study says.
For example, some faculty excelled in teaching remotely and helped other faculty learn and implement the needed technology to teach remotely. And during remote teaching, faculty met weekly to share experiences and how they were doing during the pandemic, which brought joy as they collaborated to achieve the semester's teaching and learning objectives.
From 2019 to 2021, as full-time faculty retired or resigned, potential candidates were carefully chosen for their ability and commitment to work effectively in a team environment, possession of a positive attitude toward work, and zero tolerance for incivility.
Implementation
For the next two years, accomplishments, such as weddings, births, graduations, promotions, and more were announced and celebrated at faculty meetings and shared with administration and adjunct faculty.
“Encouraging open communication and acknowledging, recognizing, and supporting faculty concerns were the first vital steps in addressing incivility in the department,” the study says. “To improve communication, faculty worked hard to include all adjunct faculty in team meetings and to disseminate all meeting minutes to full-time, part-time, and adjunct nursing faculty [as well as] support and lab staff.”
Evaluation
A five-question anonymous and confidential survey indicated that 73.7% of participants responded that they were experiencing joy at work.
Asked to select from a list of strategies that might contribute to bringing joy to work, participants responded:
A positive attitude: 92.1%
Collaboration with peers: 89.5%
Being a team player: 84.2%
Working toward a common goal: 78.9%
Celebrating each other's accomplishments: 68.4%
Accountability for creating an environment of civility: 57.9%
Creating a zero-tolerance attitude for incivility: 52.6%
Hiring new faculty who are positive and team players: 50%
Speaking out against incivility: 36.8%
“To effectively work as a team, the nurse faculty need to focus on effective collaboration instead of competition to improve nursing programs and student success,” the study notes. “True teamwork requires the mindset that the success of any team member is a success for all and that a failure to achieve a goal is a failure of the team as a whole.”
New study to determine whether stress-reduction techniques can remedy nursing students' struggle to graduate.
While stress is no stranger to nurses, it frequently begins long before they start their first job.
Indeed, research indicates that nursing students experience higher stress levels compared to other majors and that these levels are on the rise. The result is a “bottleneck” or struggle to graduate, which has further effect on a dire workforce shortage.
Cathy Tierney, EdD, assistant professor of nursing at the University of Nebraska Medical Center College of Nursing’s Northern Division and her colleagues are looking into this challenge with a two-year study, “Bottleneck Reduction: Use of Simulation and Stress Reduction Apps in BSN Courses to Increase Academic Success.”
The “bottleneck” is not new, Tierney said, and faculty often recognize it.
“If students struggle in the first and second semester, usually by the third and fourth semester, you can tell the difference,” she said.
For nursing students working through their final year of attaining a Bachelor of Science in Nursing (BSN), stress comes from three primary areas, according to a 2022 nursing study:
Academic stressors: Exams, anxiety of failure
Clinical stressors: Extreme fear of failure, negative reaction to death or patient pain
Personal/social stressors: Economic problems, family issues
Additionally, demands of studying, completing didactic and clinical assignments, and doing actual clinicals leave little free time for nursing students, the study says.
Clinical placements may require nursing students to spend considerable time away from campus and the feeling of being responsible for the well-being of patients can be overwhelming—both of which remove nursing students from the normal social developmental activities of their same-age peers, the study says.
Nursing students participating in the “bottleneck” study, which began January 1, are coached on meditation and stress-reduction techniques. They also are working with faculty to develop individualized study plans.
“We’re being proactive to address student stressors and develop a plan for success by making sure students are familiar with the academic resources available,” says Tierney, who has expertise in wellness and self-care.
Tierney completed her Doctor of Education at Bryan College of Health Sciences in 2021 with a dissertation topic on how traditional nursing programs incorporate self-care practices into the student nurse experience. She has extensive experience using complementary modalities to promote self-care and holistic wellness, and has practiced as a certified hypnotherapist and healing touch practitioner.
Additionally, the study includes incorporating simulation into classroom content, which is offered to all students regardless of whether they participate in the study.
Recently developed vrClinicals for Nursing training platform ramps up the 'day-to-day unpredictability of nursing.'
New immersive virtual reality (VR) technology is transporting Herzing University nursing students to a busy hospital floor where they must handle multiple patients and frequent interruptions—just like the real world.
vrClinicals for Nursing, an immersive, VR nursing education experience, recently was developed by Wolters Kluwer, Health and Laerdal Medical. Students using vrClinicals for Nursing with a Meta™ Quest 2 headset will be engaged in an authentic, virtual clinical environment where they must navigate real challenges nurses encounter on the job: prioritizing multiple patients with varied, complex cases; colleague interruptions; and patient requests.
With the current nursing shortage and limited clinical opportunities, newly licensed nurses are increasingly managing higher patient caseloads and must refine their independent clinical judgment earlier in their careers, according to Wolters Kluwer. Metaverse-related technologies, which are being used in many nursing schools, can provide the experiences to better prepare today’s nursing students for this environment.
The new technology mirrors the “the day-to-day unpredictability of nursing,” says Leila Casteel, DNP, APRN, NP-C, a practicing family nurse practitioner and associate vice president, Curriculum & Innovation at Herzing University, a Milwaukee, Wisconsin-based private university.
Casteel spoke with HealthLeaders about how the new technology is benefiting and preparing the university’s nursing students.
This transcript has been lightly edited for brevity and clarity.
HealthLeaders: How much of the current learning is in-person clinical work and how much is virtual simulation?
Leila Casteel: About 45% to 50% of our clinical hours across all of our clinical courses are simulation and of that simulation, there's a component of campus-based high fidelity, which is a smaller component. So I would say overall, about 35% of our clinical hours are completed using a virtual clinical experience.
HL: As a practicing nurse yourself, and also as an educator, how effectively does virtual simulation prepare nurses for the real world of nursing?
Casteel: It may sound a little blasphemous to say, but in many ways it prepares students more so than some of the live placements, and that's for a number of reasons. We've recognized that something has degraded a little bit in new grad nurses, and you think, “How did we get here? How, over the last 20 years have we become less effective at the bedside when we graduate?”
Part of that is the unpredictability of where your students land, and so much is dependent upon not only the strength of the clinical instructor, but the environment itself—the patients, the staff, and the willingness and interest of the nurses. You also have nurses out there who don't know the clinical judgment model because that's not what they learned.
So, we have to ensure that our students are getting that full experience and that we have measurable outcomes. One of the best things about virtual experience is that it can be very intentional and have very specific outcomes that are assigned and aligned with whatever's happening in that course. And you can ensure that all your students are getting that experience from end to end, which feels a lot better than the uncertainty of just sending them out.
HL: Virtual learning seems to provide a less stressful environment where students can make mistakes without endangering a patient. How does this aid in their learning?
Casteel: It’s absolutely a part of their learning. That freedom to fail and the formative assessment that we can complete in this type of environment is so critical to their own self-confidence when they go out and are working with live patients, so it's almost necessary. They need to explore, because at the heart of clinical judgment is decision-making and how we determine next steps. For students to be able to think that way, they have to start thinking about not only the decisions they're making, but why they're making them, what the risks are, and making alternative decisions.
That's exactly what virtual simulation provides is the opportunity to explore and make a decision. Maybe it's not the right one, but now you've got this opportunity, this excellent opportunity, to explore that decision in a more meaningful way, so that you can try again.
HL: What does the new vrClinicals for Nursing technology bring to your students that previous platforms don’t?
Casteel: Primarily, the concept of having multiple patients, diverse patient experiences, and that idea of learning to multitask. So often, virtual products are focused on a single patient at a single time and there's a lot of limits to that. We can do a lot to enhance even those experiences and we do because we love all virtual clinical experiences.
But this is unique because it is much more like what you would expect in an actual facility or on the job: multiple patients, diverse conditions, and things to consider. They’re fully built out, so there's their story, their history, the chart, and everything else, so students get to dive in and learn a lot about the patients before coming into clinical, which is extremely important and something they can’t do currently.
The level of urgency is a little different. With most virtual experiences, the student has a little bit more control over that urgency and that feeling of stress, because they can hit a pause button and they’re focused on one single patient. This experience really does require them to be in a mode of thinking, “What is the next best thing to do if I've got 10 conflicting priorities?” They have to think that through and articulate that to their instructor. It’s so much more complex, but in a positive way.
What’s really interesting about this experience is the way it weaves in and out of clinical urgency and then into contemplation and reflection, and then back into clinical urgency and back out into reflection, contemplation, and discussion. That’s good for a lot of reasons, but mostly for the deeper learning that can occur in that guided experience.
HL: How do the students feel about using virtual simulation technology?
Casteel: For a decade or so, we've had this interesting group consisting of very experienced techies and also some who didn’t want anything to do with it. But what we're seeing now, especially post-pandemic, is even those who were a little late to the game are now accustomed to using technology for everything.
We use our phones for everything, so there’s much less resistance. They’re almost drawn to it because that is now the norm. If the experience itself is meaningful, students report that not only did they learn something, but they were given that brain space to think about what they were learning so it sticks a little bit more. And they're going to be able to go tomorrow and explain that to somebody because it was an experience and not simply following a nurse and trying to mimic behavior. So, when it's done well, students really like it.
Legislation to bolster rural hospitals includes provision to give CRNAs autonomy.
The recent bipartisan Save America’s Rural Hospitals Act includes a provision to permanently remove physician supervision of Certified Registered Nurse Anesthetists (CRNAs), under Medicare Part A conditions of participation.
That provision, along with another to include non-medically directed CRNA services as a mandatory benefit under the Medicaid program, is being cheered by the American Association of Nurse Anesthesiology (AANA).
CRNAs have been practicing without this regulation for nearly three years under healthcare flexibilities issued during the public health emergency.
"Today more than ever, rural communities must address accessibility issues, including a lack of healthcare providers, the needs of an aging population suffering from more chronic conditions, access to healthcare, and larger percentages of uninsured and underinsured citizens," said Angela Mund, DNP, CRNA, president of AANA.
"As a CRNA who grew up in a small town in far northwestern Minnesota, I know firsthand the challenges of recruiting healthcare providers and how important the solo CRNA was to ensuring that we could provide surgical services to our community,” she said.
More than 170 rural hospitals across the country have closed their doors since 2005, and 453 rural hospitals are vulnerable for closure, according to the National Rural Health Association.
"This legislation would permanently end Medicare cuts that have devastated small-town hospitals,” said U.S. Rep. Sam Graves (R-Mo.), who reintroduced the bill along with U.S. Rep. Jared Huffman (D-Calif.),to rescue rural hospitals on the brink of bankruptcy and get them back on solid ground.
"CRNAs are the primary providers of anesthesia care in rural settings and have been instrumental in delivering care during the pandemic to patients where they live and when they need it," said Mund, in encouraging AANA members to contact their local U.S. Representative to support the bill.
"Often, CRNAs serve as the sole anesthesia provider in rural hospitals, affording these facilities the capability to provide many necessary procedures," she said
The importance of CRNA services in rural areas was highlighted in a study that showed that compared with anesthesiologists, CRNAs are more likely to work in areas with lower median incomes and larger populations of citizens who are unemployed, uninsured, and/or Medicaid beneficiaries.
