Nurse union cites the growing Delta variant, which already is dominant in the United States.
Noting that the "COVID-19 pandemic is far from over," with most states seeing increasing cases, National Nurses United (NNU) sent a letter Monday to the Centers for Disease Control and Prevention (CDC) asking the agency to once again recommend that masks be worn in public to reduce the increasing spread of the virus.
"NNU strongly urges the CDC to reinstate universal masking, irrespective of vaccination status, to help reduce the spread of the virus, especially from infected individuals who do not have any symptoms," wrote NNU executive director Bonnie Castillo, RN, in the letter. "SARS-CoV-2, the virus that causes COVID-19 disease, spreads easily from person to person via aerosol transmission when an infected person [even if they're asymptomatic or pre-symptomatic] breathes, speaks, coughs, or sneezes."
The United States is seeing a 16% increase in daily new cases over the previous week and more than 40 states have an increase in daily new cases over the previous two weeks as well as 25 states seeing an increase in hospitalizations, according to NNU.
The rise in cases is not surprising due to "the rapid reopening of many states and the removal of public health measures, including the CDC’s May 13, 2021, guidance update that told vaccinated individuals they no longer needed to wear masks, observe physical distancing, avoid crowds, or get tested or isolate after an exposure, within only a few exceptions," the letter states.
The "CDC’s guidance failed to account for the possibility—which preliminary data from the United Kingdom and Israel now indicates is likely—of infection and transmission of the virus, especially variants of concern, by fully vaccinated individuals," the letter continued.
The Delta SARS-CoV-2 variant is already dominant in the United States.
The CDC’s May 13 guidance "also failed to protect medically vulnerable patients, children, and infants who cannot be vaccinated, and immunocompromised individuals for whom vaccines may be less effective," Castillo wrote.
The vaccines effectively prevent serious illness and death from the virus, but no vaccine is 100% effective. Additionally, the emergence and spread of variants may reduce vaccine effectiveness. In response to the spreading Delta variant, the World Health Organization on June 25 urged fully vaccinated people to wear masks.
"Masks are a simple and effective tool, especially when used in combination with other measures to reduce the risk of COVID-19," Castillo wrote.
NNU also called on the CDC to update healthcare infection control and other COVID-19 guidance to fully recognize aerosol transmission; require tracking and transparent reporting of COVID infections among healthcare workers and other essential workers; and track infections in people who are fully vaccinated, including mild and asymptomatic infections.
The Kentucky nursing school has tripled its student of color population in the last decade to provide racially concordant care.
While hospitals and other healthcare organizations work to rectify the health disparities and inequities revealed by COVID-19, one Kentucky nursing school has steadily contributed toward a more diverse, culturally competent healthcare system for more than a decade.
Frontier Nursing University (FNU), in Versailles, Kentucky, has strengthened its nationally recognized Diversity Impact Program to triple its student of color population from 9% to 28% in the last decade to better provide racially concordant care, or having a shared racial identity between a healthcare provider and patient.
Studies on racially concordant healthcare are a mixed bag. Associating positive health outcomes for minorities with race concordance is inconclusive, some studies say. However, other research indicates that disparities in patient-healthcare provider communication may create challenges in care delivery.
Conversely, Black men in Oakland, California, were more likely to get a preventive health screening when offered by a Black doctor, according to a 2019 study.
FNU's Diversity Impact Program, which recruits and retains underrepresented students and employees, contributes to the university's mission to provide accessible nurse practitioner and nurse-midwifery education to serve all individuals, but with an emphasis on women and families in diverse, rural, and underserved populations.
That program recently was bolstered with a $2.2 million Nursing Workforce Diversity grant from the Health Resources and Services Administration (HRSA), an agency of the U.S. Department of Health and Human Services, which is the primary federal agency for improving healthcare to people in rural areas or who are economically or medically vulnerable. In 2017, Frontier received that grant for just under $2 million.
HealthLeaders talked with FNU's chief diversity and inclusion officer, Geraldine Young, DNP, APRN, FNP-BC, CDCES, FAANP, about how the 2,500-student nursing school is doing its part to contribute toward a more diverse healthcare system.
This transcript has been lightly edited for length and clarity.
HealthLeaders: Frontier Nursing University started working on disparities more than a decade ago. What was the impetus back then to create a program to begin addressing it?
Geraldine Young: Frontier knew that race concordant care would help improve disparities, so they wanted to put out more nurse practitioners and nurse midwives into the communities in which they live and serve to combat these issues, particularly in rural and underserved areas. We were able to increase numbers because we received a HRSA grant in 2017. That HRSA Nursing Workforce Diversity grant was instrumental in helping create different, innovative ways of recruiting and retaining students of color, as well.
HL: Frontier’s student of color population has tripled in the last decade and is now at nearly 28%. What are some of the strategies the nursing university has used to create that growth?
Young: When you have programs that focus in on diversity, equity, and inclusion, then you create an atmosphere of belonging, and you're doing things for diversity that are intentional. Also, Frontier changed to a holistic admissions process and added in measures to ensure the inclusion or admission of students from a diverse backgrounds and rural and underserved areas.
One way we do it is through intentional recruitment of diverse populations. We go to different, diverse conferences like the National Black Nurses Association or The National Association of Hispanic Nurses to recruit nurses to become advance practice nurses such as nurse practitioners or nurse midwives. The holistic admissions process is a big piece of it, too, to have those inclusive metrics to ensure that you are admitting students of color.
Then there's the issue of making sure you retain them once they get into the program, so there's some things that we've done through the Diversity Impact Program and through the grants, such as mentoring programs for students of color, and we've offered scholarships through the Nursing Workforce Diversity Grant for students of color. We've also offered academic support, such as tutoring and peer mentoring to make sure we can retain the students of color. Not only do we look at bringing them in, but how we can assist them in making sure they sustain throughout the process to be able to successfully graduate.
HL: What is the retention rate on your students of color?
Young: Retention of students of color is at 84%, and our goal was 80%, so we're exceeding our goal.
HL: What are Frontier's percentage goals as far as the students go and what is the timeline for getting there?
Young: The goal we're shooting for is 30% for students of color, but at the same time, we do recognize that our nation is changing. By 2045 or 2050 the people we consider minorities in the United States will become the majority, so this is something that we will continue to look at and probably eventually try to match that population. Because in order to address health disparities and inequities and improve health outcomes, we have to have culturally competent healthcare being delivered by people who we know and trust or that understand us.
HL: You all are working on faculty diversity as well, correct?
Young: Yes, with this new HRSA grant, one of our main focuses is to increase recruitment of faculty of color and to retain faculty of color. The last percentage that we have for faculty is at 14% and we're looking to increase it to around 20%. Eventually we want to make sure it matches our student population. Right now, the students of color are at 28% so we are trying to eventually get to that number. We want our leadership, our faculty, to be representative of our student population.
HL: For health systems or hospitals that want to address health disparities, what are some of the first things they need to do?
Young: They need to make sure they educate themselves first. They can see what is going on around this nation with health disparities and health inequities, but I think education is the first step. Next step, I would say for an organization, diversity, equity, inclusion, and anti-racism work has to be at the core of what you're doing, so it has to be a part of the mission. It has to be a part of the vision. It has to be a part of the strategic planning and the goals. It has to be at the core of what you're doing, and it has to be threaded throughout everything that you're doing, if we're going to make everything right.
72% don't follow through on expected charity commitments, resulting in $17B in unrealized community investment, new study says.
Cleveland Clinic, Massachusetts General, Vanderbilt University Medical Center, and several other nonprofit blue-chip providers enjoy large tax breaks, but fall short in making appropriate community health investments, says a new study from the Lown Institute, a healthcare think tank.
Nonprofit hospitals collectively failed to invest nearly $17 billion in their communities, says the analysis released today from Lown Institute's 2021 Hospitals Index.
The Lown Hospitals Index 2021 Community Benefit ranking examined 3,641 hospitals based on their Medicaid revenue, charity care spending, and other investments that have direct benefit to the community—health clinics, housing, and food security. Data sources include hospital cost reports filed with the Centers for Medicare and Medicaid Services and IRS 990 forms, both from 2018.
The institute, for the first time, calculated “fair share deficits” for private nonprofit hospitals, by comparing each hospital’s spending to the value of its tax exemption. Of the 2,391 hospitals included in this part of the study, 72 percent were found to have a fair share deficit, ranging from a few thousand dollars to $261 million.
Hospitals that dedicated at least 5.9 percent of overall expenditures to charity care and meaningful community investment were considered to have spent their fair share. The 5.9 percent threshold is based on established research into the valuation of the nonprofit tax exemption.
Largest fair share deficits
Except for Vanderbilt University Medical Center, the 10 hospitals with the largest fair share deficits all appear on US News & World Report’s 2020-2021 Honor Roll. These hospitals account for more than 10%—$1.8 billion—of the nation’s total fair share deficit:
NAME
FAIR SHARE DEFICIT
Cleveland Clinic (Cleveland)
-$261 M
New York-Presbyterian Hospital (New York)
-$237 M
UCSF Medical Center (San Francisco)
-$208 M
Massachusetts General Hospital (Boston)
-$179 M
U. of Michigan Health System (Ann Arbor)
-$169 M
NYU Langone Medical Center (New York)
-$163M
Vanderbilt University Medical Center (Nashville)
-$157 M
Brigham and Women's Hospital (Boston)
-$142 M
Hospital of the U. of Pennsylvania (Philadelphia)
-$142 M
Cedars-Sinai Medical Center (Los Angeles)
-$138 M
Performance varied widely, even among hospitals in the same city, where hospitals face similar tax rates and their communities have similar needs and similar rates of uninsurance, the study said. In Boston, for example, Boston Medical Center had a fair share surplus of $11 million. Massachusetts General Hospital (MGH), by contrast, had a community benefit spending deficit of $179 million.
"The MGH has long been committed to supporting the needs of our diverse communities, improving the health and well-being of those we serve, and working within the community to address social determinants of health," according to a statement from Joseph Betancourt, MD, MPH, senior vice president for Equity and Community Health at MGH.
"During the past decade, the MGH has earned major national recognition from the American Hospital Association and the Association of American Medical Colleges for its work in and contributions to community health and health equity," he said. "The MGH has not yet seen the Lown Institute’s most recent report, but when it is available, we will be reviewing the methodology and findings to determine how the rankings were compiled."
HealthLeaders reached out to all hospitals on the deficit list. These are the statements, edited for length, of those that responded:
University of Michigan Health System
“University of Michigan Health has a strong tradition of supporting and directly providing programs in our communities. Michigan’s Medicaid expansion and other programs under the Affordable Care Act have enabled us to accelerate our efforts to get more patients covered for their health care, which led to improved healthcare access for the most vulnerable Michiganders and a reduction in our charity care expenditures."
"Many of our community investments to increase health equity—such as school-based health centers (safety net clinics) and older adult services—are not reflected in this methodology."
Vanderbilt University Medical Center
“For the most recent fiscal year, Vanderbilt University Medical Center provided more than $829 million in charity care and other community benefits in service to the citizens of Tennessee. These funds support direct patient care and a range of initiatives that positively impact Tennesseans in other ways through improvements in community health."
"The analysis by this organization allows only certain financial measures to be counted while intentionally excluding other beneficial activities traditionally supported by academic medical centers like VUMC that require considerable financial commitment.”
Brigham and Women's Hospital
"Brigham and Women’s Hospital is committed to its surrounding communities and investing in the people, neighborhoods and businesses that comprise them. An essential part of our mission, this commitment is reflected in many initiatives across our Center for Community Health and Health Equity which are informed by an extensive Community Health Assets and Needs Assessment process."
"These include grants to local nonprofits, prevention and wellness activities that address the social factors that contribute to poor health outcomes, programs aimed at reducing violence and at improving birth outcomes, supporting young parents and their families, and advancing educational, employment and career development opportunities for young people."
Cleveland Clinic
"Cleveland Clinic remains committed to the communities we serve. In 2019, our total community benefit increased 12% to $1.16 billion, representing the highest level in our reporting history. Community benefit is a measure of a hospital’s investment in its community through education, research, financial assistance and Medicaid shortfall, subsidized services, and outreach programs."
"As a 100-year-old nonprofit hospital system, Cleveland Clinic is a community asset with no owners, investors, or stockholders. Any and all extra funds from operations are invested back into the health system to support patient care, research, education, and long-standing charitable efforts."
Cedars-Sinai Medical Center
"The study ignores many of the most important community contributions of independent, nonprofit academic medical centers, and does not accurately reflect how we serve our communities. For example, the study excludes all academic medical centers’ financial contributions to research and education; the report’s conclusion that “these investments do not have a direct impact on the health of its community" would come as a big surprise to the millions of people in underserved communities and communities of all types around the country and the world whose lives were saved or improved because of the research funded by academic medical centers."
"Nor does it account for the impact that the educational mission of academic medical centers have in addressing the chronic shortages of health professionals. Also, it neglects to account for the fact that Medicaid and Medicare cover only a fraction of an academic medical center’s actual cost of care. When these community benefit contributions are appropriately included, Cedars-Sinai’s total community benefit contribution for Fiscal Year 2020 was $723,512,000 (18% of total expenses)."
Best performers
The 10 hospitals that performed the best overall in community health investment were:
Paradise Valley Hospital (National City, California)
Elmhurst Hospital Center (Elmhurst, New York)
Queens Hospital Center (Jamaica, New York)
Metropolitan Hospital Center (New York, New York)
Woodhull Medical and Mental Health Center (Brooklyn, New York)
Leonard D. Chabert Medical Center (Houma, Louisiana)
NYC Health + Hospitals Coney Island (Brooklyn, New York)
Lallie Kemp Medical Center (Independence, Louisiana)
Zuckerberg San Francisco General Hospital (San Francisco, California)
The University Hospital (Newark, New Jersey)
"Hospitals say they want to be great community partners, and the ones at the top of our list have followed through," said Dr. Vikas Saini, president of the Lown Institute. "With the pandemic shining a light on health inequity in America, we need more hospitals to give back as much as they take in tax breaks."
Additional information, including an explanation of methods, is available at the Lown Institute Hospitals Index website. A launch of the full 2021 Lown Institute Hospitals Index, including rankings across more than 50 metrics, will take place in the early fall.
Limiting staffing to no more than 10 patients per nurse would have health and financial benefits, Penn study says.
Establishing safe nurse staffing standards in hospitals in Chile, where some patient-to-nurse ratios reach as high as 24 patients per nurse, could save lives, shorten hospital stays, and reduce readmissions, says a new study conducted, in part, by the University of Pennsylvania School of Nursing.
Researchers looked at 40 hospitals throughout Chile and found large variations in patient-to-nurse staffing, which was significantly better in private hospitals versus public hospitals.
Lower staffing levels in public hospitals were found to be associated with avoidable deaths and higher-than-necessary costs, according to the study.
"Nursing has been overlooked in Chile as a solution to healthcare quality and access problems," Aiken says. "This study shows investments in improving hospital nurse staffing would result in higher quality of care and greater productivity which could improve access to public hospitals."
The researchers collected extensive data from 1,652 nurses practicing in 40 Chilean complex general acute hospitals and analyzed outcomes for more than 761,948 patients. They found:
Nurse staffing in Chilean hospitals is much worse than international standards. On average, nurses in Chilean hospitals care for 14 patients each, compared to 5 patients each in the United States, where legislation sets safe nurse staffing standards. Some public hospitals have patient-to-nurse ratios that reach as high as 24 patients per nurse.
Variation in hospital nurse staffing results in avoidable deaths. Patients in hospitals where nurses were responsible for 18 patients each had 41% higher risk of death compared to patients in hospitals where nurses cared for eight patients each.
Better hospital nurse staffing would reduce costs of care enough to fund additional needed nurses. In poorly nurse-staffed hospitals, the average length of stay was significantly longer and more patients were readmitted after discharge because of complications. Improving nurse staffing to 10 patients per nurse could save more than $29 million USD annually from avoided hospital days. That savings would more than pay for the costs of employing the 1,118 additional nurses needed.
Availability of hospital beds was adversely affected by poor nurse staffing. If Chilean public hospitals staffed at levels where nurses cared for no more than 10 patients each, more than 100,000 days of inpatient care could be avoided annually from shorter stays and reduced readmissions, resulting in reducing hospital admission waiting lists.
Chile has a sufficiently large supply of nurses to staff hospitals at much improved levels. Chile has an excellent nurse education system which graduates more than 6,000 nurses a year, all with bachelor’s degrees.
"The findings from this study suggest that Chile has the resources and the means," says Marta Simonetti, PhD, RN, the lead researcher at the University of the Andes, "to improve nurse staffing in public hospitals to enhance access to high-quality hospital care in the country."
Caregivers gathering at Tenet's Dallas headquarters for a direct appeal to corporate executives for safer staffing to end the decade's longest nurse strike.
A delegation of workers from a Tenet Healthcare hospital in Southern California will join striking Massachusetts St. Vincent Hospital nurses at noon CDT Wednesday to take their complaints directly to Tenet's executives in Dallas and deliver a 16-foot signed petition to Tenet CEO Ronald Rittenmeyer.
Caregivers from Fountain Valley Regional Hospital, Orange County's largest for-profit hospital, said their departments are under-staffed and lack the resources to adequately provide for patients. Many employees, they said, cannot afford health coverage.
"St. Vincent isn't the only Tenet hospital that is dangerously understaffed and under-resourced," said Jasmine Nguyen, a pharmacy technician at Fountain Valley Regional, who is planning to be in Dallas Wednesday. "We're always understaffed and our patients are left waiting too long for their medications."
Early in the pandemic, Fountain Valley caregivers, represented by the National Union of Healthcare Workers (NUHW), accused the administration of understaffing and refusing to properly isolate COVID-19 patients.
Responding to a NUHW complaint, the California Department of Public Health last year issued a 33-page report last year that described "systemic" infection control violations, including failure to isolate COVID-19 patients in designated COVID-19 units.
Congresswomen Katie Porter, D-Calif., and Rosa DeLauro, D-Conn., referenced the report in a May 21 letter asking the Biden Administration to investigate whether Tenet and other major hospital companies used federal COVID-19 relief funds to bankroll mergers and acquisitions.
NUHW members picketed Fountain Valley Regional as well as nearby Tenet hospitals in Los Alamitos and Lakewood, Calif., in June to support the congresswomen's request for a federal investigation.
In a June 15 letter supporting that request for a federal investigation, NUHW president Sal Rosselli noted that Tenet ended 2020 with a $399 million net profit and $2.5 billion in cash reserves, more than double its cash balance in any quarter during the past 10 years. The company also purchased 45 surgery centers from SurgCenter Development for $1.1 billion and used nearly $500 million in cash to pre-pay debt not due for four years.
"There is ample evidence to suggest that Tenet Healthcare used COVID-relief funds to improperly expand its business, enrich its executives and shareholders, and prioritize the company's bottom line over patients and caregivers," Rosselli wrote.
NUHW also is demanding that Tenet stop subcontracting housekeepers and food service workers, leaving many without health insurance during the pandemic.
New study finds mobility practices nonexistent for ICU patients deemed ready to begin out-of-bed activities.
Critical care nurses frequently did not mobilize intubated patients receiving mechanical ventilation because the patient was uncooperative, according to a new study published in American Journal of Critical Care.
Competing demands from other patients or concerns about patient safety or potential adverse events also kept nurses from mobilizing intubated patients, according to Nurses’ Perceptions of Barriers to Out-of-Bed Activities Among Patients Receiving Mechanical Ventilation, which explores the mobility practices of critical care nurses in a 56-bed medical intensive care unit (MICU) at Yale New Haven Hospital in Connecticut.
If a unit has no designated mobility team, efforts to get patients out of bed are integrated into nurses’ individual patient care responsibilities. Although all 105 patients examined in the study met early mobility criteria within eight to 173 hours after intubation, none were mobilized for out-of-bed activities.
For the study, the definition of mobility was narrowed to nurse-initiated interventions that helped patients get out of bed to stand, sit in a chair, or walk.
In mechanically ventilated patients, bed rest can decrease skeletal muscles by 12.5% over the first week in the ICU, that report said, and for every day of additional bed rest in the ICU, they can lose 3-11% of their muscle strength.
In this newest study, patients were deemed ready to begin mobility activities within an average of 41.5 hours after oral endotracheal intubation. The authors believe the study is the first to report how soon patients were in stable-enough condition after intubation to begin mobility based on a defined set of parameters.
"Creating a unit culture that embraces early mobility practices requires collaboration, education, and a commitment that patients who can do out-of-bed activities are actually mobilized," said co-author Dawn Cooper, MS, RN, CCRN, CCNS, a clinical nurse specialist at the York Street Campus of Yale New Haven Hospital.
"Most nurses in our study reported that they never or rarely got intubated patients receiving mechanical ventilation out of bed, and clinicians infrequently entered mobility orders for these patients," she said.
Though patients, medical issues, and patient safety concerns provided the most barriers to mobility, the environment of care posed very few barriers; nurses rarely mentioned that lack of help from other nursing staff, physical therapists, or respiratory therapists, or lack of a clinician’s activity order impeded mobility, the study said.
Most nurses indicated they had received training on portable lift equipment, but just 58% reported feeling comfortable using it. Six rooms in the unit have a ceiling lift, but only 17% of the nurses reported being trained on its use and only 12% felt comfortable or very comfortable using it.
Units should review their mobility criteria and protocols for patients with complicated medical conditions, the authors recommend, take inventory of the factors unique to their unit that create barriers to early mobilization, and then apply an interdisciplinary protocol-driven mobility program to overcome those barriers.
The COVID-19 pandemic dominated most of her term, impacting healthcare at every level, but Thomas ably guided the association through substantial membership growth—it has 118,000 members today—and legislative successes, as nearly half the states now allow nurse practitioners (NPs) full practice authority.
Thomas talked with HealthLeaders on the last day of her term about the road ahead for NPs and what she considers her most important accomplishments.
This transcript has been edited for clarity and brevity.
HealthLeaders: AANP considers nurses "the future of healthcare." What does that mean?
Sophia Thomas: We're meeting the needs of healthcare patients living in areas where they really don't have access to care. And while the profession is experiencing double-digit growth, the number of primary care physicians continues to decline as physicians opt for more lucrative specialties.
It's important that we realize that by 2025, as the US faces a shortage of as many as 90,000 physicians, nurse practitioners are really growing and really working to meet the needs of the underserved communities. After COVID, it's an opportunity for us to look at the future of healthcare and redefine healthcare.
HL: COVID altered the course of NPs regarding full practice authority. How likely is it that American NPs eventually will be able to practice without physician oversight?
Thomas: In 24 states now, the District of Columbia, Indian Health Services, and the whole [Veterans Administration] healthcare system, nurse practitioners do practice with what we call a full practice authority. We practice many times in clinics and hospitals with physicians.
We don't believe that a nurse practitioner needs a written piece of paper, or agreement, to say we collaborate with Physician X, because we collaborate with healthcare providers of all specialties, including physicians, every day without written agreements. [Physician oversight] is an outdated practice model and more and more states are choosing to shift to allow nurse practitioners to practice to the top of their education and training without the regulatory restrictions.
HL: Along the same lines, how likely is it that Medicare will increase the NP reimbursement rate to 100% of the physician pay rate?
Thomas: It's important for us to look at clinical outcomes and certainly the data is there to suggest that nurse practitioners' clinical outcomes are equal to physicians' on many levels, and certainly more and more research is being done.
It's about equal pay for equal work. We're not paying healthcare providers based on how much they spent for their education, we're paying for a service. And there are specific guidelines for the service—how much time you spend with the patient or how complex the diagnoses are—and that's what's billed. So, it really should be about equal pay for equal service.
HL: More clinicians than ever before are choosing the nurse practitioner path. Why do you think that's happening?
Thomas: I can tell you that for me, when I became a nurse, I loved my contact with patients and making a difference in their lives. I was at a hospital, and certainly for me, it was a calling to provide more comprehensive care and to look into prevention because I was seeing patients in the ICU who had very preventable conditions.
It was a calling to get higher education, get my master's and doctorate degrees, get that national certification, and be able to practice with patients on the outpatient level to work on preventive strategies. More and more people are choosing it because they see the healthcare disparities in this country, and they want to be able to provide more care to patients and educate them to really improve the healthcare and the outcomes of our country.
HL: Your term has been quite unlike your predecessors', particularly with the challenges of COVID and all that came with it. What do you consider your most important accomplishment?
Thomas: I worked throughout my presidency to really connect with our members and educate them on all the changes with COVID and as the guidelines kept changing, we thought it was important to really shift our focus to provide our COVID resources to our members, as well as PPE. People were having a hard time getting access to PPE and so we provided PPE access to our members as well as COVID education. Then we realized very quickly that burnout was happening in the healthcare community, so we again quickly shifted to provide resources.
Most of all, [I've enjoyed] engaging the grassroots, providing them more educational opportunities from within our Continuing Education Center, listening to our members, and meeting their needs.
Certainly, I had some highlights, like getting to visit the White House and being a consultant for Operation Warp Speed [the public-private partnership to accelerate development and distribution of COVID-19 vaccines], but all of that is about elevating the role of the nurse practitioner to create more awareness.
NPs really stepped up to the plate. We now have 325,000 nurse practitioners in this country, which is amazing, and that's 325,000 solutions to healthcare as long as nurse practitioners are able to practice to the top of their education and training.
University of Missouri nurse's research links congregational support and forgiveness with neuroimmune biomarkers.
As a 20-year nurse practitioner, Jennifer Hulett, PhD, APRN, noticed breast cancer survivors often credited God or a divine being for being alive. Results from her new study suggest that may not be a coincidence.
Spiritual beliefs and religious practices are associated with neuroimmune activity, adding credence to a spiritually based psychoneuroimmunology (PNI) model of health, according to Hulett's study, which was published in Supportive Care in Cancer and funded in part by the National Institute of Nursing Research.
Hulett, now an assistant professor at the University of Missouri (MU) Sinclair School of Nursing, is researching the benefits of spirituality on improving immune health and reducing stress, as well as the chances of cancer reoccurrence, among breast cancer survivors, according to a press release.
Hulett collected and froze samples of saliva from 41 breast cancer survivors at MU’s Ellis Fischel Cancer Center.
She identified breast cancer survivors' reports of practicing forgiveness and receiving positive social support from their church congregation or other social support network and linked them with two specific biomarkers—alpha-amylase and interleukin-6.
The findings lay the foundation for further examining the role spirituality plays in the health and well-being of both cancer survivors and individuals managing chronic disease.
"Breast cancer survivors are often a highly spiritual group given the trauma they have been through, and we found they often have more positive spiritual beliefs in a loving God or higher power rather than a punitive, punishing God," Hulett says.
"This confirmed what I had previously experienced anecdotally as a nurse," she says. "Breast cancer survivors would often express gratitude and contribute their health and well-being to a higher power, and they tended to have better health outcomes as well."
Hulett’s research builds off previous findings indicating positive spiritual beliefs are associated with healthier levels of cortisol, a biomarker commonly associated with stress, among breast cancer survivors.
"Cortisol and stress suggest chronic inflammation, and anything we can do to lower levels of stress and inflammation will have a good effect on a patient’s longevity, health outcomes, and reduced risk of reoccurring disease," Hulett says. "We often hear about diet and exercise in promoting physical health, but we rarely hear about the importance of managing stress, and all three are connected with well-being."
One in eight women develop breast cancer, and previous studies show chronic stress in breast cancer survivors is linked with increased inflammation and risk for cancer reoccurrence.
"We know cortisol is linked with stress, and elevated levels of the immune biomarker interleukin 6 suggests inflammation," Hulett says. "By first finding out which biomarkers are meaningful to look at, we can then see how they are potentially influenced by various spiritual or mindfulness practices aimed at reducing inflammation."
Hulett’s research adds to the body of knowledge evaluating effectiveness of spiritual and mindfulness interventions, including daily prayer, mediation, yoga, and relaxation, on health outcomes among cancer survivors and individuals with chronic disease.
"We already know these interventions improve mental health, but they might also improve physical health as well, and we can try to prove it by looking at these physiological biomarkers," Hulett says.
"These spiritual interventions are what nurses can use at the bedside to quickly implement if they see patients struggling to cope with their illness," she says. "Any evidence-based solutions we can equip nurses with will help improve patient health outcomes, and that is where these mind-body interventions can play a role going forward."
Regular 1:1 meetings with new nurses foster engagement and solve problems before they arise.
With newly licensed RN turnover rates ranging between 17% and 30% their first year, and 30% to 57% by their second year, according to different studies, one nurse leader has taken a vigorous approach to handling her nurses' concerns long before they become disenchanted enough to leave.
Brigitte Nastally, MSN, RN, clinical operations manager for Indiana University Health, schedules regular and frequent one-to-one meetings with first-year nurses, going beyond the number of meetings recommended by the health system's human resources (HR) department.
The regular meetings serve to counteract factors that contribute to increased turnover. Among those factors are feelings of vulnerability, limited support from their healthcare organization, and a stressful working environment factors, according to a research article in the American Journal of Nursing Research.
Many newly graduated RNs not only have trouble organizing, prioritizing, and delegating their nursing work, but they report feeling poorly prepared and frustrated that the work environment does not match their expectations, the research article says. As a result, they feel incompetent, stressed, and overwhelmed.
For those reasons, Nastally implemented the frequent one-to-one meetings.
"During the tumultuous year of 2020, I anticipated that new nurses may need ongoing support, coaching, and development conversations," she says. "Beginning at orientation, we set up a meeting schedule between the new nurse, clinical educator, and unit manager."
The roll-out to schedule monthly one-to-one meetings with each first-year nurse was tricky, because patient needs were so great, Nastally says.
"However, I made an effort to touch base as frequently as possible to ensure new nurses were adapting to the needs of patients during COVID surges," she says. "I also made sure to keep an eye on each nurse to check on their own well-being and overall mental health."
Those one-to-ones have become more regular as working conditions begin to return to normal.
IU Health's HR department's onboarding roadmap includes 30-, 60-, and 90-day meetings with managers in addition to other touchpoints along the employee's first year, says Nastally.
Nastally does much more than that with her new nurses. She extends that onboarding roadmap out to four, five, and six months, and beyond, and follows annual performance reviews with additional post-reviews at three months and six months, she says.
She uses a conversation guide supplied by HR for those discussions, but the chats are informal, she says.
"We often have unstructured conversations where I ask about what is going on in the new nurse’s home life, what struggles or successes they have had," she says, "and I try to find opportunities for continued learning and development."
Costs of turnover
Nurse turnover is costly on several levels. The average time to recruit an experienced RN ranges from 66 to 126 days, depending on specialty, according to the 2021 NSI National Health Care Retention & RN Staffing Report, and turnover has a profound impact on diminishing hospital margins.
That includes vacancy costs, such as overtime, paying for agency nurses, closed beds, advertising and recruitment, orientation and training, and decreased productivity.
Based on these estimates, each percent change in nurse turnover is worth $337,500 in either direction, the report says.
Turnover's patient care costs are also high.
Hospitals with low turnover rates, ranging between 4% and 12%, had lower risk-adjusted mortality and lower patient lengths of stay than organizations with moderate (12% to 22%) or high (22% to 44%) turnover rates, according to an article in the The Online Journal of Issues in Nursing.
Furthermore, nurse turnover creates negative effects in illness exacerbation, medications management, communications, and follow-up, the article states.
One-to-ones are 'priorities'
For her part, Nastally is working to decrease turnover at her health system by making the time to maintain close contact with 21 first-year team members, including those who may be less vocal.
"We schedule these meetings as priorities in my calendar," she says. "These are not 'extra' meetings in my mind, as it's so important to get to know my team and their strengths."
If a meeting must be canceled, rescheduling is imperative, Nastally says.
"We have to be flexible to the ever-changing needs of the patients and the hospital, so if we don’t get the opportunity to meet on the scheduled day, then I do my best to reschedule or at least have an informal touchpoint," she says.
From these one-to-one meetings, Nastally has forged meaningful relationships with her newest nurses, gaining insight about their career aspirations, impactful moments with their patients, accomplishments, and work struggles.
She has also learned the names of their children, spouses, and family members, how they like to spend their time away from work, and their important life events.
Measurable results of Nastally's one-to-one meetings with first-year nurses may not reveal themselves in data numbers, aside from her belief that it helped to reduce departures during COVID-19 surges, but she knows, as a leader, that the effort is working.
"While we did not measure the metrics of these meetings, the benefits of these practices went beyond metrics," she says. "I’ve developed positive, strong relationships with my team members and benefited from hearing about the valuable relationships our team members have developed with their patients."
Racial bias against Asian Americans has grown during the COVID-19 pandemic, with harassment directed at Asian nurses and other healthcare workers, despite their effort to stop spread of the virus in hospitals.
The AAPI Student Nurses members are using their experiences as minorities within the healthcare system to give voice to AAPI clients and increase awareness of the health disparities unique to these populations, according to a press release from Vanderbilt University School of Nursing in Nashville, Tennessee.
"As frontline workers, these race-related harassments from patients are disheartening and greatly impact AAPI healthcare professionals’ abilities to carry out their roles as patient advocates," the article reads. "In addition to anti-Asian harassment encountered in the workplace, AAPI healthcare professionals are dealing with increasing harassment in their daily lives and safety concerns for their loved ones."
Health organizations have a responsibility to address bias, for both their employees and patients, the student nurses write.
"Acknowledging that racism and xenophobia are major public health issues is a necessary first step," the article reads. "Racial discrimination is recognized as a social determinant of health. Studies have shown that experiences of racism are linked to poor physical and mental health outcomes, both short and long term."
It also suggests healthcare institutions should:
Support healthcare employees through intolerance for racial prejudice;
Hold perpetrators accountable and take prompt, appropriate actions to protect vulnerable employees when discrimination occurs within the workplace;
Provide mental health resources and support groups for AAPI employees to process, grieve, and heal from race-related stress and traumatic discriminatory events;
Partner with local antiracist organizations to better understand the role of racism within their communities and resultant health disparities;
Provide transparency in policies, diversity efforts in hiring procedures, and cultural competency training within healthcare organizations.
“Through their work and this experience," says Ginny Moore, associate professor of nursing and director of the women’s health nurse practitioner specialty, "these students are shaping the future of nursing for the better."
