A 5-part series celebrating nurse leaders who have claimed their place as a strategic partner in their organization's leadership.
Editor’s note: Hospitals and health systems have seen a steady evolution of chief nursing officers taking a seat at the executive strategy table, guiding and participating in operations and policies. HealthLeaders is featuring five of those nurse executives during this special week to discuss their experience as a strategic partner in their organization’s leadership.
Part 1 of a 5-part series.
Learning has been a way of life for Kathleen Sanford, DBA, RN, FAAN, FACHE, executive vice president and chief nursing officer of CommonSpirit, one of the nation’s largest nonprofit healthcare systems with more than 1,000 care sites and 140 hospitals in 21 states.
Sanford, a contributor to the CNO Exchange Community*, built and honed her leadership skills with education—formal, informal, and continuing—and continues to learn something new nearly each day.
Sanford spoke to HealthLeaders about how a curious, innovative spirit helps prepare good leaders.
This transcript has been lightly edited for brevity and clarity.
Kathleen Sanford, DBA, RN, FAAN, FACHE, executive vice president and chief nursing officer, CommonSpirit. Photo courtesy of CommonSpirit.
HealthLeaders: When did you first become part of a health system’s operational leadership and what was that experience like for you?
Kathleen Sanford: I was selected as the chief nursing officer for Catholic Health Initiatives in late 2006 and I felt pretty prepared for the job. I'd had a variety of other leadership positions. I'd been in hospitals, I'd been in other settings and like most experienced CNOs, I’d been responsible for both the practice of nursing and operations, managing everything—inpatient nursing, home health, urgent care, admitting, registration, pharmacy—so the complexity in the system was not a big challenge to me.
I've heard people say it's a big challenge, but it really wasn't. I felt prepared for the things that you need to know as a system chief nurse, which are working through other people, partnering, teamwork, and understanding organizational politics. Those didn't bother me.
What I missed, and I didn't realize how much I would miss it when I moved to the system, was my community and state involvement with people like United Way, the YWCA, and local businesses. I still miss those sometimes, because there's an intimacy in a smaller system or in an individual university or community that you just don't have at a large national system.
The only thing that was new was the travel. I've been active in national organizations—AONE [now AONL], the Tri-Council, AAN—so I was used to travel, but I wasn't used to the extensive travel necessary in such a large system. We are in nearly half the states.
HL: Nursing schools are adapting their curriculum to prepare nurse leaders to lead organizationally, but it hasn’t always been that way. How did you accumulate the skills to step into an operational leadership role?
Sanford: I love the word “accumulate,” because it really is true; we do accumulate so many variants, and educations all along our career, and I’m still accumulating from brilliant people and colleagues, and I'm always learning something new. But the way you accumulate them is pretty similar to everyone else and that’s in three different ways: formal education, continuing education, and of course, experience.
My formal education started at the Walter Reed Army Institute of Nursing, so I was fortunate to be, from the minute I entered college, in training to become an officer in the military. Leadership and management were just something that we learned about, so that was the beginning of my accumulation. But when I graduated as a new officer, I realized I hadn't accumulated enough because I was managing people who were older and more experienced than I was, so I went back and got a master's degree in human resources management.
When I left active duty, I thought I had the right education, but I realized that healthcare in the civilian world was more of a business than in the military world, so I went back and got an MBA. I talked to the CFO about the needs of nursing and decided that I wanted to back that up with an understanding of research, so I went back and got a doctorate so I would be able to speak the research language.
Nurses have a lot of initials after their names and that's often because we believe in formal education, but we also believe in continuing education. I've continued to learn from experienced managers, I’ve been active in organizations where you can learn a lot, such as AONL, Tri-Council for Nursing, ANA, and AAN, where you can get continuing education and keep up with what's happening in healthcare.
The biggest learning of all comes from experience. I discovered that even the things you learned in school don't always exactly work the way you’ve been told, so I have made mistakes along the way, and I try to learn from those mistakes. I try doing different things. For example, I took two years away from nursing leadership and worked for strategy, so that I could learn about that. I did project management for building a new clinic and a new hospital at one time. I served as a journal editor, and it’s amazing how much you learn when you’re an editor because as you read other people's articles you learn about what's going on in their organizations.
I discovered that you can learn more when you yourself are a writer. I accepted positions with HFMA [Healthcare Financial Management Association] and with The Business of Caring, which was a nursing journal, at the same time. I wrote a column for HFMA to help finance leaders understand nursing and I wrote the column for the nursing journal to help the nurses understand finance.
So, there are a variety of things we can do to help us accumulate what we need to move into any leadership job. I’ve said several times that management is a specialty just as much as any other specialty, and those of us who practice it need to accumulate that specialized knowledge, education, and experience and learn from them so that we can support everybody else.
HL: What do you, as CNO, uniquely bring to your organization’s leadership team?
Sanford: Nursing leadership is built on experiences and growth from one job after another. We start close to the patients—the people that we serve. I think my experiences are similar to every nurse leader. I started as a staff nurse, then became a charge nurse, head nurse, nurse supervisor, CNO of a hospital, CNO of a small system, and now CNO of a large system. Each position offers a different way of looking at things at every single level in an organization.
You know what it feels like on the front lines, you know what it feels like at the executive table, and what it feels like in the middle. Those are not experiences that every executive has. I’ve had the experience of managing people who weren’t nurses; I've managed every type of clinician including physicians, and what that has taught me is that different professions can look at the exact same problem differently. This has taught me to be more open about trying to understand alternative viewpoints. I think it has made me more able to learn from others and to appreciate the different skill sets and experiences that can help us when we get to the executive table.
HL: Nurses tend to be creative and innovative. How has this served you as an operational leader?
Sanford: Because I am a nurse I have learned how to be part of innovative teams. It’s helped me understand and be willing to listen to others who may have ideas that seem a little far out. Having worked with other nurses and having to do “work arounds” in order to provide good care, I am able to understand that even when you don’t fully understand what someone else is talking about, you should listen because their innovations may be what we need. Our own experiences makes us—nurse leaders—open to listening to other people’s innovations and also enables us to think about doing things differently. It serves all of us well to be open to new ideas, to propose new things. At CommonSpirit, we’re doing virtual nursing and at one point I had something called a Private Practice Unit where I let nurses hire their own colleagues. You need to try different things to see what works best for your employees, your patients, your organizations and your communities.
Being creative helps in change management, too. If you’re innovative, you’re a little better at helping people adapt to change.
Innovation has also helped me personally. Years ago, a young pharmacist came to me and said, “Kathy, I really think that nursing and pharmacy should work together, and I want to do an outpatient infusion program with you.” We didn't have one in our community. He explained it to me, I said OK. Then we put a dyad together—a nurse and a pharmacist—and started the program.
Many years later, I went into that clinic as their patient to get a shot for osteoporosis. Nobody knew who I was. Nobody knew that I'd had the fun of starting the clinic, but I got the benefit of it as a patient. So, see? Innovation is not just what we're doing for other people; it helps us, too.
HL: How does CommonSpirit prepare its CNOs to be strategic partners within their own organization’s leadership team?
Sanford: I don’t believe that you should start teaching strategy at the chief nurse level. To help leaders think strategically, you need to help them be strategic thinkers at every level of their career. We’re starting with our new grads. We have a one-year residency program and part of that program is to spend time helping those new nurses learn how to be innovative and how to think strategically. In addition, we have a number of classes on those subjects for experienced staff nurses.
Because of COVID, we have not had the formal education programs that we had previously. We’re currently planning to get back into more leadership education. We are considering how to educate all of our leaders together because leadership isn’t just about nursing. All managers need to be educated in the specialty of management. Everybody should know about how to think strategically and understand strategy, whether they want to be the chief nurse or a top executive
The business is better off when we're all thinking of the organization’s mission and how it can best be fulfilled.
* The HealthLeaders Exchange is an executive community for sharing ideas, solutions, and insights. Please join the community at https://www.linkedin.com/company/healthleaders-exchange/. To inquire about attending a HealthLeaders Exchange, email us at exchange@healthleadersmedia.com.
Northwell Health Cancer Institute's new Cancer Care Direct program begins with diagnosis and continues until survivorship.
Patients at Northwell Health Cancer Institute who face a new cancer diagnosis now have the caring hand of an RN to expertly navigate them through the complex and sometimes bewildering course of treatment.
The cancer institute, in New Hyde Park, New York, recently launched Cancer Care Direct, a comprehensive program to connect patients at its 10 cancer centers with clinical registered nurse navigators who allow patients to focus on their health while providing expert guidance to them and their caregivers.
Nurse navigators provide such personalized services as: securing timely appointments for all specialties; attending doctor appointments or arranging telehealth visits; helping with paperwork, connecting patients to clinical trials, and assessment for pain management; palliative care; social work; physical therapy; behavioral health; and accessing support services such as nutrition counseling, financial resources, transportation, and survivorship programs.
Prior to creating Cancer Care Direct, the cancer institute offered navigation to breast cancer patients beginning in January 2022, said Rita Mercieca, RN, senior vice president and chief administrator. That service illustrated the need to offer it to patients being treated in all cancer specialties and since early 2022 nurse navigators have helped more than 1,200 patients in various cancer specialties.
Mercieca spoke with HealthLeaders about the program’s origination and the extraordinarily positive feedback it is receiving.
This transcript has been lightly edited for brevity and clarity.
Rita Mercieca, RN, senior vice president and chief administrator, Northwell Health Cancer Institute
HealthLeaders: Prior to Cancer Care Direct, a nurse navigation program originated for breast cancer patients in January 2022. How did that develop?
Rita Mercieca: I was asked to come to the cancer institute in the middle of 2021 right after COVID, and it was in November when a nurse at Long Island Jewish Medical Center (LIJ) reached out about her husband, who was having abdominal pain and went to see his primary care provider. He needed a CAT scan and when it lit up [meaning the possible presence of cancer], they told them to go to his GI doctor for endoscopy. That was 30 days out and the pain got worse. The primary care referred him to surgery and the surgeon saw him within a couple of days and requested a PET CT, but the closest appointment they could get was 10 days out, so they sent them to another site.
They went home and waited for results. Four days later, no one had called them. This was before the Cures Act was in place, where you get your results to the portal immediately, so she reached out to me and said, “I don’t understand. I'm trying to get the results. Can you help me?”
The wife did not have a good experience and she switched her care to another health system. This is our employee. She wrote a two-page email to me that ended with, “Could you please create some navigation that could help us?” And that's where we began.
Having cancer is frightening enough; just picking up the phone to make that appointment is a journey for a lot of people, so we thought about how to make this better. How could we take best practice wherever we can find it and create something that our patients will benefit from, as well as our providers?
We're a major health system. We do a lot of screening and biopsies, and we get a lot of positive findings. How are we delivering that message and how can we support our providers in delivering the message and then help the patient with the next steps?
We first took a look at breast cancer because when we call the mammogram patient with a positive biopsy, we tell them to follow up with their doctor, and often they respond with, “Who should I call? Can you recommend someone?” We thought it would be great if we could tell them to reach out to our breast navigator and actually support that patient, and that’s where we started.
We make that next appointment for them, and what’s different about what we do is our navigators are at that appointment if the patient is OK with that. Sometimes the patient is so worried and stressed they're not hearing clearly what’s going on, so we take that person through their journey of further imaging or neoadjuvant therapy or surgery or medical oncology or oral medications or radiation oncology, or whatever it is that they need. If they need support, financial assistance, or transportation, we link them to the right people.
Our coordinators who support the navigators are the ones making the appointments and authorizations, which allows our navigators and nurses to practice to the top of their license.
Other health systems and cancer centers do this, but we pulled from different models and tweaked it to be patient-centric and physician-centric. We looked at some best practices, we looked at some of the research on navigation, and we said, “Okay, that's all good, but we want to have that real personal touch where the patient feels supported.” Cancer is so complex, and the navigator knows that complexity.
HL: This program reaches across so many departments. How did you manage to coordinate with all of them?
Mercieca: I have an amazing team of people that work on this, but we also have an amazing health system with a group of chairs and their administrators that are encompassing everything a patient needs.
When we bring on colorectal, we've got our primary care at the table, we’ve got our gastroenterologists, surgeons who are doing surgical oncology, administrators, imaging, medical oncology and pathology, so we, as a multidisciplinary team in a very multidisciplinary health system, are able to pull in everyone we need—everything that’s going to touch a patient—to make this work in a very comprehensive way.
HL: What are the requirements to be a nurse navigator?
Mercieca: I'm looking for compassion and empathy first. The second piece is certification in navigation, of course. If they have a background in medical or surgical oncology, any kind of oncology that's always a plus. But we can teach this skill; it’s hard to teach the compassion, so that is the most important piece.
HL: How long does a nurse navigator assist each patient?
Mercieca: Everyone’s different, and every patient has different needs. Our navigators are there to assist until they have reached survivorship and then we have a great handoff to our survivorship team. It could be months, it could be a year—however long a patient needs to be with us, and when they’re done, and we've handed them off, if they need something they're more than welcome to continue reaching out to us.
HL: How many patients does each nurse navigator assist?
Mercieca: Our research found that a navigator can assist, in cancer, up to 230 patients at any given time, so that's the number we try to stick with. As we get close to that, we then add on another navigator or we pull a navigator from a different disease that's not quite as busy.
HL: Which patients qualify to get a nurse navigator?
Mercieca: Anybody.
HL: How much are you projecting the program to grow in the future?
Mercieca: We've just fully launched everything early this year, so we're still in the growing phase. I can't tell you what that's going to look like in the future, but we will put the resources we need to make sure that patients who want to be navigated are able to be navigated.
HL: What kind of feedback are you getting from the patients who have been assisted by a nurse navigator?
Mercieca: Feedback from patients has been absolutely phenomenal. They are grateful, but more so they feel like they've got the support they need if they have a question, if they need to change something, or if they didn't understand who they are supposed to call. They can always call that nurse navigator.
We have sent out surveys to understand, first off, if there is anything we need to improve because that's really the feedback I'm looking for. I'm glad that everything's good so far, but is there something that we need to improve on? I can tell you that with the surveys we sent out, they're rating us on a scale of zero to five, with five being the best, and we are at 4.9, so that’s tremendous.
A proactive model of rounding for inpatient cancer care is among success stories featured at the conference.
A nurse who developed a proactive model of rounding for inpatient cancer care resulting in a dramatic drop in rapid responses is among presenters at the 48th annual Oncology Nursing Society (ONS) Congress running through Sunday in San Antonio, Texas.
Evidence-based practice changes led by nurses are being highlighted at the conference, including one by Michael Martorana, BSN, BS, RN, of Roswell Park Comprehensive Cancer Center, in Buffalo, New York, that addressed reducing rapid responses and codes through critical-care nurse rounding.
Though most cancer patients receive treatment as an outpatient, some require inpatient care for treatment complications, symptom management, and complex procedures.
Martorana discussed the implications of this need for a higher level of nursing care during a poster presentation, “The Effects of Proactive Critical-Care Nurse Rounding with High-Risk Patients in a Dedicated Cancer Hospital,” co-authored by Andrew Storer, PhD, DNP, RN, NP-C, A, FAANP, Roswell Park’s vice president and deputy chief nursing officer.
Martorana developed a proactive “SWAT” model of rounding at Roswell Park, 142-bed dedicated cancer hospital, and successfully advocated for its funding, leading to a 12-hour-per-day increase in critical-care nurse staffing for high-risk patients.
Over the seven-month trial period, SWAT nurses rounded daily to each inpatient unit, where staff identified patients at risk of clinical deterioration and those discharged from critical care the previous day. SWAT nurses then assessed those patients for needed interventions.
Because of early intervention, the need for rapid responses involving staff outside the critical care unit fell from 4.5 per 1,000 patient days in the seven months prior to the SWAT program to 3.5 in the seven months after the program began, according to the cancer center.
Codes outside the critical care unit, signaling that a patient was in medical distress, dropped from 0.48 per 1,000 patient days in the seven months before implementation to 0.16 in the following seven months. The reduction in rapid responses and codes resulted in less disruption and the use of fewer resources, noted the nurse researchers.
Light intervention also results in better sleep quality after their shifts, nurses report.
Nurses who received 40 minutes of bright light exposure prior to their night shifts experienced less fatigue and made fewer errors at work, indicates a new study conducted by McGill University.
The evening light regimen also resulted in better quality of sleep following their shifts, the nurses reported.
“Healthcare workers are experiencing high levels of fatigue due to staffing shortages, difficult schedules, and heavy workloads. Further, the cost of medical errors has been estimated at tens of billions of dollars per year in North America,” says Jay Olson, senior author of the recent study published in Sleep Health.
“Our study shows that feasible changes, such as getting light exposure before the night shift, may help reduce fatigue and its effects on performance at work, something which could benefit both the nurses and their patients,” Olson says.
Indeed, growing evidence indicates that night shift work significantly affects health and performance in nurses and other medical personnel because of the change of natural and circadian sleep processes, according to a 2021 article on sleep-related problems in night-shift nurses, which can compromise safety by, as Olson says, increasing the risk of errors and workplace accidents.
The study
Building on a previous study, Olson and other researchers recruited nearly 60 nurses at McGill University Health Centre in Montreal, Quebec, Canada to work schedules that rotated between day and night shifts within the same week.
During the study’s initial 10-day observation period, nurses in the experimental group made a total of 21 errors, ranging from accidental needle pricks to giving the wrong medication dose.
Nurses were then given 40 minutes of bright light exposure from a portable light box before their night shifts. After the light intervention, the nurses made a total of seven errors—a reduction of 67%—confirming the results of a previous feasibility study where the researchers saw a similar 62% reduction in the number of errors at work, according to the researchers.
In contrast, nurses in the control group who changed their diet to improve their alertness showed only a 5% reduction in errors.
The researchers also found that nurses who followed the evening light intervention reported significant improvements in fatigue compared to those in the control group. In addition, the nurses who reported higher levels of fatigue made more errors at work.
“Interventions like the one we studied are relevant to a large population of workers, since between a quarter and a third of the world’s employees do some form of shift work,” says Mariève Cyr, the report’s first author. “Although we focused on nurses working rotating schedules, our results may apply to other types of shift workers as well.”
The researchers are conducting workshops on practical fatigue management at hospitals and other workplaces and have launched a website that shift workers can use to adapt the interventions to their own schedules.
Strengthening employee engagement and retention ranks second in critical issues that need to be addressed.
Human resources (HR) leaders and chief nursing officers (CNOs) rate quality and safety as the most critical issue to address at their organization, according to a report released Tuesday examining issues and trends affecting healthcare talent.
Other priorities include optimizing the workforce, boosting productivity, conducting strategic workforce planning, and improving recruitment. Further down the list were maintaining compliance, reducing costs, leveraging technology, and building the brand.
Of the 50 HR leaders and 72 CNOs surveyed nationwide, 84% rated quality of care and patient safety as the most critical issue, followed by strengthening employee engagement and retention (77%) and improving the caregiver experience (73%), according to the report released by Cross Country Healthcare Inc., a tech-enabled workforce solutions platform.
However, only slightly more than half of these leaders indicated their organization has effectively improved employee recruitment (53%) or strengthened employee engagement and retention (51%), the research shows.
But healthcare organizations are moving forward to address the staffing crisis, according to the survey, with leaders reporting that their top priorities include improving the efficiency and effectiveness of the hiring process, strengthening employee engagement and retention, and improving employee attraction and recruitment.
“Between mass talent shortages, burnout and resignations, health leaders are aware that they must adapt to a changing workforce landscape,” said Hank Drummond, Cross Country’s chief nursing officer. “Prioritizing work-life balance, mental health and appropriate staffing is critical to ensuring that healthcare workers have the support they need to provide care to their patients. Staff wellness trickles down into the quality of patient care.”
Other key findings from the study include:
HR leaders are investing most in improving the caregiver experience, followed by improving employee recruitment.
CNOs are investing most in employee recruitment, followed by optimizing and managing the workforce.
HR leaders (64%) feel they are most effective at maintaining staffing levels and employee development, while CNOs (54%) are most effective at employee engagement and retention.
Comprehensive workforce plans were completed by 56% of HR leaders and 43% of CNOs.
Hiring efficiency and employee engagement are the top areas for strategizing, while recruiting is getting the most investment to develop innovative solutions.
In examining which technologies the leaders want to adopt in the year ahead, onboarding, training and development, and workforce management topped the list.
Searching for solutions
Talent shortages, burnout, and resignations are requiring HR and nurse leaders to explore new staffing models. HR leaders prioritize workforce optimization in their staffing plan, while CNOs prioritize reducing reliance on staffing agencies, the report says.
“Health leaders must reimagine their approach to their workforce,” said Daniel J. White, Cross country’s chief commercial officer. “They must be nimble and innovative and explore new models to help maximize their most valuable asset—their people.”
But that’s not without challenges, said surveyed leaders who shared some of those barriers to their workforce strategy.
From HR leaders:
“Buy-in from leadership is hit or miss; it is hard to sell it to staff after all the changes recently.”
“It is keeping staff. A lot of people don’t want to work nowadays, and it’s hard to keep people interested, especially in healthcare. So, I try and make it as exciting as possible.”
From CNOs:
“Having enough RN staff available to hire. We are doing great within hiring to some extent, but at the same time still have the younger work force choosing to leave for ‘better hours,’ ‘better life balance/blend,’ etc.”
“A lack of future-ready skills in the workforce, like data literacy or multidisciplinary literacy, is caused by factors like the COVID-19 pandemic and digitalization.”
Battling racism is the Rx for safer and healthier moms and babies, educator says.
Disproportionately high mortality rates for black women aren’t caused by genetics, says an expert in healthcare disparities that affect maternal care; the cause appears to be systemic racism.
Black women can be “healthy as a marathon runner” and receive ample prenatal care, yet they still face a higher maternal risk, says Mykale Elbe, DNP, APRN, FNP-BC, director of the MSN Nurse Practitioner Program and Assistant Professor of Nursing at Maryville University in St. Louis. Elbe, also an active family nurse practitioner at Mercy Health, has devoted a large part of her practice to minority care.
Elbe spoke with HealthLeaders about these troubling numbers and what nurses and nurse leaders can do to help lower them.
This transcript has been lightly edited for clarity and brevity.
HealthLeaders: The death rate among black Americans has been substantially higher than the rate for white women for decades. What are some reasons that such an imbalance has persisted for so long?
Mykale Elbe: It's something that we have seen for generations. People in healthcare have known about it for a while, but with the pandemic data and higher death rates, it's brought some more attention to it. Studies have looked at this and we have seen that despite their socioeconomic status, their insurance status, or how many prenatal care visits they get, there is this higher risk factor for poor maternal outcomes and even fetal outcomes. They have higher rates of NICU admissions and preterm birth.
Some of that can be genetics, but some other studies have noticed if you are a first-generation immigrant from Africa, you do not have this predisposition. You are at the standard mortality risk factors as a Caucasian or other race female, so the thought is, this is an effect of the American culture around underlying bias and racism and the stress that women of color live with day to day around racism, and the underlying stress that they may not even themselves know that they're dealing with. Is that putting increased stress on their bodies and leading to increased mortality rates? They can be healthy as a marathon runner and active and have no underlying diseases, but they still have a higher risk.
Mykale Elbe, DNP, APRN, FNP-BC, director of the MSN Nurse Practitioner Program / Photo courtesy of Maryville University
HL: Unconscious bias, or maybe conscious bias, among practitioners causes some women to skip pre-natal checkups. What is the impact of that?
Elbe: It's not just for prenatal; it’s even in healthcare in general. We do see African-American women and African-American patients in general, but there is this concern that with the stress that’s put on them, maybe they’re not as vigilant on following up with their healthcare providers routinely. And, if you are living in a predominantly African-American neighborhood, you have less healthcare services available to you.
HL: Healthcare is making efforts now to increase diversity in its workforce, including nurses. What effect will that have on these disturbing outcomes?
Elbe: The hope is it will, but until we see that, it’s hard to say. When I first started as a nurse practitioner, I was the minority at the practice where I worked and most of our providers were providers of color. But it's still that access to care that creates limits. We have to get providers to open practices in areas that are predominantly serving those communities of color to see if we can increase that.
HL: What should be nurses’ responsibilities in addressing healthcare disparities, particularly when you say that it's not so much social determinants as ingrained racism?
Elbe: Making sure our programs educate about that. In my class, I have my students watch a video that addresses healthcare disparities, and it is amazing how many of the working nurses we have in our program respond with, “I'd never thought of this.” We have to make sure in our nursing programs—in our health professions—we are educating our future providers about microaggressions and how to address microaggressions that they may not even know they have. We also have to provide education about diversity, equity, and inclusion, and make sure students are doing self-reflections and are not afraid to discuss this topic.
HL: How well do nursing schools, in general, address this issue?
Elbe: Every time this comes up, even at Maryville University, the consensus is, “Oh, nursing has got this,” but do we have this? It’s one of those things where we need to be more active about, aware of, and make sure we're more diligent. I know the National Organization of Nurse Practitioner Faculties (NONPF) has a significant interest group on diversity, inclusion, and equity, and we just put out a toolkit on how to educate about microaggressions and addressing microaggressions in nurse practitioner education.
We have to be more diligent about that. As healthcare providers, we're getting better about including that in our education, but we have to make students aware and thinking about those microaggressions and diversity inclusion aspects of care—not just when it comes to race but also to gender and sexual orientation to prepare our future providers to truly be ready to help patients of every background.
HL: What can nurse leaders do now to begin lowering the maternal death rate among black Americans?
Elbe: Having open dialogues with their staff to make sure that we are aware of our own microaggressions and microbiases that we may not think about, but they can be there. We need to make sure that we, ourselves, are self-reflecting and addressing them so that we're not producing bias that make patients feel uncomfortable because if a patient feels uncomfortable with their healthcare provider, they’re not going to want to come back. That’s going to stop them from seeking healthcare.
Seasoned nurses strengthen Jefferson Health's workforce while sharing their deep expertise.
Jefferson Health is re-engaging retired nurses to support its nurses and care teams as they struggle with staffing shortages.
The Nurse Emeritus Program provides the opportunity for experienced, retired nurses to engage with, support, and mentor nurses, nursing teams and new leaders across Jefferson Health’s 18 hospitals in southeastern Pennsylvania and southern New Jersey.
The new program offers three roles for retired nurses:
Emeritus clinical nurses work at the bedside, are engaged in direct care, and support and mentor clinical nurses, including new-to-practice nurses.
Emeritus specialty nurses—educators, informatics, etc.—work at the bedside or within the department of nursing, complete staff and patient education projects, inform evidence-based practice, and support bedside learning.
Emeritus nurse leaders work at the department, regional, or health system-level on special projects to drive nursing workforce and practice strategy and to support and mentor new nurse leaders.
The program includes inpatient, ambulatory, and surgical service settings and a nurse emeritus has the choice of working on the unit they were formerly assigned to or another area of interest with similar skill sets, according to Jefferson Health.
“This program is part of a comprehensive nursing workforce optimization strategy,” said Kate FitzPatrick, DNP, RN, NEA-BC, FAAN, executive vice president/Connelly Foundation chief nurse executive officer at Jefferson Health.
“Our goal is to bring innovative approaches to support our nurses and care teams during this time of global workforce challenges in healthcare,” she said.
The program, first launched in November, recently added its first emeritus nurse leader—AnnMarie Papa, DNP, RN, CEN, NE-BC, FAEN, FAAN, previously vice president and chief nursing officer for Einstein Medical Center Montgomery in East Norriton, Pennsylvania.
“Nursing has always been more than a career; it is truly my passion,” Papa said. “Through the years, I’ve been fortunate to learn and grow from seasoned nurse colleagues. I’m excited to continue doing what I love while also being able to support the next generation of nurses.”
The Nurse Emeritus Program is a key initiative to help Jefferson Health’s nurses also learn and grow from seasoned nurses, FitzPatrick said.
“As nurses retire, we are losing a wealth of knowledge, clinical expertise and strategic leadership,” she said. “This is a wonderful opportunity to sustain important knowledge and expertise at Jefferson and support nurses across our organization.”
Organizations trying to build diversity, equity, inclusion and belonging (DEIB) are often hampered by lack of leadership support.
Only 38% of organizations offer diversity, equity, inclusion, and belonging (DEIB) learning and development programs to all employees, new research says.
The Future of Diversity, Equity, Inclusion, and Belonging 2023 report examines the DEIB landscape, including the extent to which key DEIB initiatives are developed, how frequently DEIB initiatives are funded and supported, and how employers’ use of training, incentives, communication practices, and metrics relate to DEIB.
“The objective for DEIB has to shift from just improving representation of equity deserving groups to creating environments where all employees thrive rather than just survive,” according to the report, which was issued by Circa, a talent acquisition and diversity recruiting firm.
Circa’s survey, which ran from December 2022 to February 2023, gathered 255 complete and partial responses from HR professionals in virtually every industry around the world, but primarily in the United States.
The report revealed these major findings:
DEIB in most organizations is immature and initiatives are seen as ineffective.
More than half (52%) rate the DEIB initiatives in their organizations as ineffective (that is, 4 or below on a 10-point scale). Only 15% say DEIB in their organizations are at the expert or advanced stage on the HR Research Institute’s DEIB maturity model.
One-third say women represent 20% or less of their top leadership in their organization and 73% say the same about ethnic/racial minorities in top leadership positions.
While HR is responsible for DEIB in most organizations, two-thirds spend just 20% or less of their average workweek on DEIB-related work.
In more than half of organizations, the primary responsibility for DEIB issues, programs, and/or policies falls on HR in some way.
“This is an indication of the strategic importance of DEIB. Considering the complex nature of DEIB and the multifaceted approach required to deal with DEIB issues, this amount of time seems hardly enough to be devoting to DEIB issues,” the report states.
Meanwhile, about one-third of organizations do not have a DEIB department, function, or representative.
Organizations aim to build a culture of trust through DEIB initiatives but are hampered by lack of time and leadership support.
The top barriers to increasing the effectiveness of DEIB initiatives are: insufficient prioritization at top leadership levels (44%); lack of metrics to identify insufficient DEIB (44%); lack of time (43%); and inadequate training (40%).
“Without buy-in from top management, DEIB initiatives lack strategic focus and required support,” the report says. “Metrics can help get leadership support by demonstrating how crucial DEIB is to business success. This can also help improve barriers related to lack of understanding of the potential benefits of DEIB (37%).”
Less than one-third of organizations say equitable pay is among the top five priorities in their organizations.
Despite legislation advocating pay transparency and equitable pay, more than one-fifth of respondents say equitable pay is not an organizational priority for executives.
In about a third of organizations (32%), it is among the top five priorities and in just 9% of organizations it is the top priority for executives.
“Pay inequity has been a long-standing issue and organizations who do not focus on these issues are likely to miss out on talented candidates,” the report says.
Organizations use specific DEIB initiatives infrequently and rely on benefits to incentivize equity deserving groups.
The most commonly cited initiatives are: emphasize DEIB in the talent acquisition process (25%); consistently communicate the importance of DEIB throughout the organization (23%); and include DEIB-related training during onboarding (22%).
More than half of organizations offer these benefits/work arrangements to make it easier for diverse employees to work there: paid time off (82%); remote work options (78%); flexible work options (69%); and paid parental leave (60%).
“However, when seen in the light of other results, this brings into question if some of these benefits are offered to all employees as a way to hire and retain good talent in general or if these benefits were designed specifically to help improve DEIB,” the report says.
Recommendations
The report offers eight recommendations for organizations to improve their DEIB:
1. Look at DEIB as a journey and not a destination.
Organizations very often incorporate policies, procedures and systems to improve DEIB as a means of feeling assured that they have done their best to check the DEIB box. However, in reality, undoing years of discrimination and oppression is rarely a short-term goal.
2. Hold critical and vulnerable conversations around DEIB.
Truly moving toward equity requires having vulnerable conversations around discrimination, belonging, and equity. This may require extensive training for managers and other DEIB professionals who hold these conversations to employ active listening, empathy, and help employees feel safe to share their stories.
3. Get help with DEIB initiatives.
Organizations often require help from specialized consultants or employees who have expertise in DEIB to assist them with these initiatives.
4. Utilize DEIB-related data and metrics.
Consistent and holistic measurement of DEIB allows organizations to first determine where they stand, and then measure improvements they make on this baseline.
5. Build inclusive leadership.
Leadership buy-in is critical to any initiative. Top leaders who act as sponsors for DEIB initiatives help increase credibility, remove roadblocks, and increase exposure across the organization.
6. Allow employees to bring their authentic selves to work.
Studies show that minorities often face greater pressure to conform to "white ideals" of professionalism. Employees cannot check their identities at the door when they enter the workplace. Rethink policies around appropriate dress codes and behavior at work.
7. Focus on visibility for underrepresented groups.
One approach to improve visibility for minorities at work is coaching and sponsorship. This provides resources and training to underrepresented groups that helps bring them to a level playing field.
8. Be accountable and focus on specific actions.
Actions could include exploring non-traditional pathways for sourcing a more diverse applicant pool (such as all-women coding camps), creating inclusive job descriptions, training recruiters to look beyond candidates’ academic credentials, and communicating clear career paths for minorities and women.
'We are committed to making a PhD accessible and attainable for talented individuals from all backgrounds,' dean says.
A new PhD program at Johns Hopkins School of Nursing (JHSON) is answering the call for a more diversified nursing workforce.
The Pathway to PhD Nursing Scholars, designed to accelerate diversity within PhD-prepared nurses, will be an eight-week intensive program to recruit and prepare students from groups underrepresented in nursing with mentorship, resources, networking, and career guidance.
The pathway program will focus on post-baccalaureate nurses and address structural inequities in PhD education, according to JHSON.
“We are committed to making a PhD accessible and attainable for talented individuals from all backgrounds,” says Sarah Szanton, PhD, RN, FAAN, dean of the nursing school. “The urgency of the nursing shortage, and the even greater nurse faculty shortage, make this vital opportunity that directly aligns with our mission to develop a diverse pipeline of nurse leaders.”
The program’s design is based on recommendations from the American Academy of Colleges of Nursing and the 2021 report from the National Academies of Sciences, Engineering, and Medicine, which says nursing over the next decade will demand a larger, more diversified workforce prepared to respond to future public health emergencies and address systemic inequities that have fueled health disparities.
The report identified several priorities to meet the needs of the U.S. population and the nursing profession for the next decade, including promoting diversity, inclusivity, and equity in nursing education and the workforce. Nursing students and faculty not only need to reflect the diversity of the U.S. population but also need to help dismantle structural racism prevalent in education and the workforce, it said.
Nurses selected for the pathway program will learn about the nursing research process, how to apply for a PhD, and how to conduct community-engaged research. They will also learn the principles of health equity and social determinants of health. They also will receive special networking opportunities, research shadowing experiences, and multiple levels of mentorship from faculty, current PhD students, and researchers within and outside the Johns Hopkins network.
“We hope to demystify the process of applying for a PhD and show nurses that they not only have the vision, but also the support, to achieve a PhD,” says a lead faculty member, Jennifer Wenzel, PhD, MS, RN.
The Pathway to PhD Nursing Scholars program will run for five years with 10 scholars selected each year and is funded through a $5 million investment by Johns Hopkins University.
Ena Williams, PhD, RN, Yale New Haven’s chief nursing officer and senior vice president, spoke with HealthLeaders about how she and her colleagues have encouraged nurses to question the status quo and use their experience and skills to improve their practice to benefit patients.
This transcript has been lightly edited for clarity and brevity.
HealthLeaders: What are some innovations that have come from Yale New Haven Hospital nurses?
Ena Williams: During the pandemic, one of the first things they did was develop an innovation page on the nursing website where they could enter any issues that were impeding their ability to deliver care from a practice or a workflow perspective. Out of that came several innovations.
For example, they noticed that patients were not getting their meals in synchrony with their blood glucose testing, because patients would call for their meals at different times. But with COVID, we wanted to minimize going in and out of the room. So, within 24 hours, they had completely changed the practice of how meals were being ordered and how they were arriving to the unit. They partnered with the diabetes consultant, the dietary folks, and physicians—a real interdisciplinary team—to synchronize the testing of the blood glucose, the administration of medication, and meal delivery.
One innovation resulted in an alternative care model that stratified the nurses by color code according to their expertise, but also allowed other nurses who may not have that level of expertise to support those nurses. For example, if I'm an ICU nurse, I was a red nurse. But if I was a nurse from a step-down unit who had not delivered care to the same level of acuity as an ICU nurse but I could do 70% of what that intensive care nurse will do, I became the pink nurse.
When a nurse arrived on their unit, they wanted to know what level of competency they had and out of that came this alternative care model which has become embedded as part of the standard way we operate. When we have surges in patient volume, we can modify that model.
Ena Williams, Yale New Haven Hospital chief nursing officer and senior vice president / Photo courtesy of Yale New Haven
For example, when we had a spike in volume in the maternity space last year, nurses from medical-surgical units volunteered to go to the maternity unit and they used this model to create safety. We've used it in the emergency department and when we had a lot of pediatric RSV, so it’s an alternate staffing model that creates flexibility and elasticity in our care.
We also support nurse practitioners who care for students in what we call our school-based clinic. We fund nurse practitioners and embed them in our inner-city schools, and one of them realized that there was not a way to evaluate children and their risk for Type 1 diabetes. Because there’s a large population of African-Americans and Asians who have a high risk for diabetes, a lot of these kids would end up getting into a diabetic crisis.
So, this NP decided to start a screening process and, with grants, bought a small machine to test the A1C of the schoolchildren and worked with our pediatric primary care physicians to refer them. To date, about 25% of the school-based clinic’s population met screening criteria and had the opportunity for early interventions.
I gave you those different examples to show that innovation is not embedded in just one location. One of the most recent ones came out of our very dynamic nursing research-based program: After surgery, there has been this long, traditional belief that you should not be given water to drink for eight hours.
A group of our nurses said, “I don't know if that still stands and maybe we should challenge that.” And through their practice, they began to offer early fluids to patients post-operatively and in fact, were able to significantly reduce the post-operative nausea and vomiting that a lot of patients had.
HL: Why are nurses such natural innovators?
Williams: Nurses are problem solvers. It’s taught to us as part of our training. We’re taught to assess a situation, to use the information that we gather to come to some early conclusions about what we are seeing, hearing, feeling, sensing, touching, and then to come up with a plan—and not to just to put the plan in place but to continually evaluate that plan.
It really is a part of the way nurses practice, but what amplifies it is when you create an environment where nurses can what I call, “play in the sandbox,” where they can challenge the status quo, and say, “How can we make this better?” As nurse leaders, we emphasize that this is expected, that this is supported, and that this is validated and celebrated when those things happen.
HL: What are some specific steps that nurse leaders, in particular, can do create and then foster a culture of nurse innovation?
Williams: It is a journey, and I would encourage a nurse leader to be very patient and give themselves much grace, but you also have to be very intentional about this. You need structures, processes, and clarity, and you need to educate the community of nurses and leaders. Sometimes leaders are the toughest to let go because we think we need to own everything.
You have to be willing to truly listen and respect nurses’ voices. Sometimes they may get it wrong, and you may have to guide them a little bit, but you have to trust them. We trust our nurses to take care of the most acute patients—the sickest of the sickest—so why can't we trust them to make decisions about their practice? That's our belief here at Yale New Haven.
HL: Innovation requires a level of comfort in exploring creative solutions, risk-taking, and a willingness to fail. What are ways that nurse leaders can support these characteristics?
Williams: By helping nurses to understand that innovation can be very simple. For example, nurses recognized that they wanted to do something when a patient on a unit is dying and one of our units decided that they were going to light a candle and put it at the desk so everyone on the unit would understand that somebody is in transition, and that there would be a level of respect, tone of voice, and support for the team that is supporting that family.
Out of that came a practice where they created a keepsake box that is now part of the supply chain at our hospital that any unit can order. Included is the candle, a poem written by a nurse that is sent to the family, a condolences card, and mementos. It came out of a nurse thinking, “How can we be respectful?” So innovation doesn’t have to be big; you can make a change where you live.
The other lesson is that it doesn’t have to be perfect because perfection can be your greatest enemy. Begin small and then pull your colleagues in. The other thing that's important is providing expertise. A nurse will have an idea, but they don't necessarily have the skill set to see it through, so providing them with individuals like nursing professional development specialist teams or even project leaders can help them to structure programs.
HL: What can a healthcare system, beyond the nurse leader, do to sustain a culture of nurse innovation?
Williams: Allow time for nurses to innovate, or to work together in teams to lead research projects. We invest in our research teams and provide funding. We also have a librarian from the Yale medical school that helps our nurses with evidence-based and research articles to help them think through issues. She’s very integrated in the work that we do, and that’s another innovation—having a librarian available to us.
It’s really about investment and framing the environment in terms of what we expect of nurses and how nurses can practice within the environment. You have to invest in the environment; it doesn't come just by chance.
