Workplace violence prevention takes efforts from the health system and the community, according to this nurse leader.
HealthLeaders spoke to Mary Beth Kingston, executive vice president and chief nursing officer at Advocate Health, about how to CNOs can prevent workplace violence. Tune in to hear her insights.
The Supreme Court's decision will impact patients receiving care through Medicare, Medicaid, and CHIP.
The United States Supreme Court recently overturned the long-standing Chevron deference doctrine, which held that courts should defer to agency interpretations of statutes that fall under the particular agency's purview, when the interpretation is reasonable, and the meaning of a statute is not made explicitly clear by Congress.
Hospitals and health systems will now potentially have to wait through legal challenges to regulations that were previously determined by the many federal agencies that influence healthcare.
The 6-3 decision was made on June 28 to reverse the original ruling made in the landmark case Chevron U.S.A., Inc. v. Natural Resources Defense Council, Inc., in 1984. It is now up to the courts to determine their own interpretations of ambiguous regulatory standards.
There are many unknowns about how this decision will ultimately play out, but the impact on federal agencies such as the EPA, FDA, and OSHA and their ability to regulate environmental, health, and safety matters is undeniable.
This decision will also potentially impact the healthcare industry in two key ways.
Access to public healthcare
An amicus brief, published in September 2023, warned that "overruling Chevron would have enormous impact on the administration of federal programs, including Medicare, Medicaid, and CHIP, that are critical to public health."
According to the brief, approximately 65 million Americans receive healthcare coverage through Medicare, while Medicaid and CHIP cover 90 million low-income children and adults and seniors with disabilities.
The brief was signed by the American Academy of Pediatrics, American Cancer Society, American Cancer Society Cancer Action Network, ALS Association, American Heart Association, American Lung Association, American Public Health Association, American Thoracic Society, Bazelon Center for Mental Health Law, Campaign for Tobacco-Free Kids, Child Neurology Foundation, Epilepsy Foundation, Muscular Dystrophy Association, National Health Law Program, Physicians for Social Responsibility, The Leukemia & Lymphoma Society, and Truth Initiative.
When Chevron was still in effect, the brief stated, courts deferred to the Centers for Medicare & Medicaid Services (CMS) to make policies that the agency needed to make while "plugging the interstitial gaps that inevitable arise as it administers the health insurance statues in a myriad of every-changing real-world settings."
In a press release published the day of the ruling, the organizations said they were disappointed in the Supreme Court's decision, saying Chevron has helped those organizations ensure that healthcare laws are "interpreted and implemented appropriately."
"We anticipate that today's ruling will cause significant disruption to publicly funded health insurance programs," the contributors said, "to the stability of this country's healthcare and food and drug review systems, and to the health and well-being of the patients and consumers we serve."
The brief’s signees argued in favor of the importance of having experts interpret standards that will have that impact.
"As our amicus brief noted, large health programs such as Medicaid and Medicare, as well as issues related to the Food, Drug and Cosmetic Act, are extremely complex," they said in the press release. "So it is key that decisions about how to interpret and implement relevant laws are made by experts at government agencies."
Healthcare leaders and workers will likely feel the effects of this decision through the impact it will have on public health.
"As leading organizations that work on behalf of people across the country who face serious, acute and chronic illnesses, as well as many people who lack access to quality and affordable healthcare," the signees said, "we will continue to work to ensure that healthcare laws are implemented in ways that benefit the public health."
Virtual nursing ROI can be measured in a variety of ways, including sick time, says this nurse leader.
On this episode of HL Shorts, we hear from Clair Lunt, senior director of nursing informatics at Mount Sinai Health System, about using sick time as an ROI metric for virtual nursing. Tune in to hear her insights.
CNOs must protect and support nurses from workplace violence using methods that are tried and true, say these nurse leaders.
Nurses everywhere continue to experience high levels of violence and abuse at work on a regular basis.
In 2023, eight in 10 nurses experienced at least one type of workplace violence, according to a National Nurses United report. While prevention isn't always possible, CNOs need to make sure that nurses are getting support and assistance after workplace violence incidents occur.
Nurse leaders must advocate for using evidence-based approaches to find out what really works and what doesn't.
Prevention
According to Mary Beth Kingston, executive vice president and CNO at Advocate Health, there need to be more studies done to see what prevention methods are actually effective. For example, weapons detection systems might prevent people from bringing weapons in, but they will not mitigate the typical violence that nurses face in the workplace, Kingston explained.
"Look to see what makes sense within your organization," Kingston said, "but also go back and look for the evidence about what does work, and what truly does help keep people safe."
"Make sure staff know about all of the different things that we have to offer for them to support them," Schuetz said, "then make sure that we're assessing the environments [and] making sure we have environmental controls in place that make sense for the location."
To Kingston, prevention involves three key factors:
"I'll focus on the training and practice and preparation, partnering with safety and security, and really assessing the physical environment as well as all aspects of the environment," Kingston said.
Leaders can control environmental factors by making sure that nurses have exits that they can get to at all times, and assessing items in the room that could potentially become weapons in the midst of an incident.
Kingston emphasized that partnerships with safety and security teams, other departments in the health system, and organizations within the community are also critical. Behavioral health response teams can be particularly beneficial.
"When you feel as though a situation is beginning to escalate, you can call for support and have that show of support, as opposed to a show of strength," Kingston said, "a show of support for both the patient and for the nurse at the bedside."
CNOs can also leverage technology for workplace violence prevention.
"With some of the technology that's out there now, you can have a button or some type of alert on your badge, or on some other type of device," Kingston said, "and you can alert folks when you need help, [and] that can prevent an incident from going to injury."
Schuetz added that a zero-tolerance policy for patients behaving aggressively is essential, as well as proper procedures for removing patients when necessary.
"Our facility developed a pretty rigorous process around patient dismissal when they cannot really participate with the team in a way that's conducive for them to get better and it's abusive to our team," Schuetz said.
If patients come through the emergency department, they will still be treated as required, but patients will be discharged and dismissed from the health system if they cannot comply with the patient code of conduct, Schuetz explained.
"A number of these patients will stop coming back to the facility once they have been dismissed because they don't want the hassle," Schuetz said. "It's our hope that they find a facility where they can have a relationship with the team where they can get the care that they need."
Support after incidents
When incidents inevitably do occur, the next steps that CNOs and other nurse leaders take can make a huge difference for the nurse.
Schuetz explained the peer-to-peer support program at her health system, and their new program that involves a team of people that can provide resources to everyone involved in an incident.
"Oftentimes there's collateral damage, people that witness an event are equally as traumatized as the person," Schuetz said.
The program brings leadership, counseling, and chaplain support to the person or people involved to help them recover. Survivors of workplace violence incidents can suffer from PTSD, which can severely impact their careers if they do not receive the proper support and resources.
"We're trying to wrap our arms around those people," Schuetz said, "[by] making sure that they get some time off work if they need it, making sure they know about pressing charges and the support they can have for pressing charges."
Kingston noted that CNOs need to understand that the impact of workplace violence often lasts beyond the incident.
"I think in healthcare we've done a reasonable job of initial follow-up," Kingston said, "but we have to recognize that this can have an impact days after and weeks after."
CNOs should implement a series of responses, according to Kingston, starting with a strong employee assistance program. Organizations should have a formal support process that is not dependent on the individual manager or leader.
It's also important that other types of violence don't go unnoticed.
"If someone's being called a horrific name all day long while they're working, they may not have a strained shoulder or a bruise, but they are also experiencing workplace violence," Kingston said, "and I think we have to recognize the cumulative impact of some of the behaviors we see."
Lateral violence, such as bullying or incivility at work, are also issues that need to be addressed.
"We have to support our frontline leaders to be able to address those types of behaviors," Kingston said. "They're not something that's reported because people don't even recognize that always as another form of workplace violence."
Part one of this piece was published on Monday, June 24, 2024.
The HealthLeaders Exchange is an executive community for sharing ideas, solutions, and insights. Please join the community at our LinkedIn page.
Previous telemedicine processes are now helping this health system implement virtual nursing, says this nurse leader.
While virtual nursing programs are new to several health systems, the concept of telemedicine is not.
Kay Burke, chief nursing informatics officer at UCSF Health, shared the four areas where their virtual nursing program is having an impact, and how the health system has built off their telemedicine model to improve virtual nursing workflows.
Burke is a part of the HealthLeaders Virtual Nursing Mastermind program, in which several health systems are discussing the ins and outs of their virtual nursing programs and their goals for implementing this new strategy.
Areas of focus
According to Burke, there are four key areas where UCSF is implementing their virtual bedside virtual care program. The first pilot was completed on one adult inpatient acute care services unit. The next will be in the birth center.
"[We are] kicking off a pilot in which we are virtually proactively educating patients who are scheduled for a C-section," Burke said. "So that's an exciting use case that we're exploring."
UCSF is also expanding the program to additional adult care units and into the pediatric space.
"We are dipping our toe into the pediatric space," Burke said, "exploring one unit that is focused on the assessment of our social drivers of health."
Starting with telemedicine
Virtual nursing is not entirely uncharted territory, Burke explained.
"While the program as launched last year is targeting several inpatient units," Burke said, "we've really been doing telesitting and nurse triage via telemedicine capabilities, eICU, [and] virtual consultation for years."
According to Burke, the COVID-19 pandemic opened the door for many virtual capabilities.
"I want to always sort of demystify that this is brand new." Burke said, "And while the care model is becoming more and more well-defined, there are so many different use cases and instances of virtual nursing that have been in the clinical care setting for many, many years."
Burke explained that UCSF modified the EHR using data that was already in their production system to create a queue or work list for the virtual nurse to work off of, so that the nurse understands which patients are eligible for a virtual nurse.
One example of an eligibility criteria is that all of a patient's discharge requirements have been met. For instance, a patient could have an order to go home, a ride set up, and their medications already set up in their DNE, but they haven't had their patient education completed.
"We know that the discharge education now, through the electronic health record, signals as outstanding," Burke said, "so that falls to the work of the virtual nurse."
UCSF also configured their clinical communication platform by doing a directory design, so that the virtual nurse and the directory nurse can communicate.
"Sometimes even though there is an outstanding task that needs to be completed, the patient is not willing to connect with a virtual nurse or is just not available or ready to do so." Burke said, "So that communication configuration was also something that we need to figure out."
The last step was incorporating the technology. Burke said they already had iPads in the clinical setting as a result of the pandemic, which enabled virtual medical interpretation, visitation, and consultation.
"We just leveraged those to additionally carry out the patient-nurse interaction via video," Burke said, "and the telemedicine capability that we had in place already."
The HealthLeaders Mastermind seriesis an exclusive series of calls and events with healthcare executives. This Virtual NursingMastermind series features ideas, solutions, and insights onexcelling your virtual nursing program.Please join the community at our LinkedIn page.
To inquire about participating in an upcoming Mastermind series or attending a HealthLeaders Exchange event, email us at exchange@healthleadersmedia.com.
Nurses everywhere are concerned about AI, and here's why.
On this episode of HL Shorts, we hear from Betty Jo Rocchio, senior vice president and CNE at Mercy, about why nurses are nervous about the rise of AI in healthcare. Tune in to hear her insights.
New technologies like ambient listening are poised to revolutionize the nursing workforce.
As many health systems begin their virtual nursing journey, they must determine what technology they will use and how it will evolve over time.
Tiffany Murdock, chief nursing officer at Ochsner Health, described the current technology that the health system is using for virtual nursing, and how they plan to optimize their workforce through new innovations.
Murdock is a part of the HealthLeaders Virtual Nursing Mastermind program, in which several health systems are discussing the ins and outs of their virtual nursing programs and their goals for implementing this new strategy.
Advancing the program
Ochsner's virtual nursing initiative has been in place since 2018, and according to Murdock, the current goal is to optimize the workforce through innovation.
"We have an Innovation Ochsner lab that helps us try to find different products," Murdock said, "and then we try to develop our own, too."
So far, the technology in use ranges from iPads to fixed, in-room technology, depending on the hospital. According to Murdock, hospitals in the health system are at different stages of technological advancement, so the needs are different in each one.
Some of the technology is also being repurposed. Many of the fixed screens that were once used solely for documentation now have multiple uses.
"People can come in and out of e-consults through those as well," Murdock said. "We're just trying to figure out what works at each of our different campuses because we have different types of hospitals."
Looking to the future
The ultimate goal is to give time back to the nurse at the bedside by streamlining the extra tasks that nurses often have to complete.
"All the little tasks that take the time away from the nurse to [practice at] the very highest scope will be taken by the virtual nurse," Murdock said.
According to Murdock, ambient listening is on the list of innovations that Ochsner wants to incorporate alongside virtual nursing.
"I am so excited about the thought of even [something like] an Alexa," Murdock said, "a patient [could be] able to close their blinds, turn their lights on, adjust their air, [or] search different things."
Ochsner is also trying to incorporate devices that can take vital signs and be integrated into the rest of the technology. That way, CNAs would not have to come in and take vital signs every two to four hours, Murdock explained.
However, to Murdock, ambient listening will be the key.
"I think that will be a complete change in practice," Murdock said, "because you really will be able to document an assessment and not have to look at a screen, which I think will…change the way we practice."
The HealthLeaders Mastermind seriesis an exclusive series of calls and events with healthcare executives. This Virtual NursingMastermind series features ideas, solutions, and insights onexcelling your virtual nursing program.Please join the community at our LinkedIn page.
To inquire about participating in an upcoming Mastermind series or attending a HealthLeaders Exchange event, email us at exchange@healthleadersmedia.com.
CNOs must come up with innovative ways to prevent workplace violence.
Nurses across the country are experiencing record levels of workplace violence, for many different reasons.
CNOs are responsible for the health and wellness of their nursing workforce, and it is imperative that they implement prevention measures and prepare nurses for what they might face.
Virtual nursing is only one piece of the workforce puzzle, says this nurse leader.
On this week's episode of the HealthLeaders podcast, Clair Lunt, senior director of nursing informatics at Mount Sinai Health System, chats with nursing editor G Hatfield about the HealthLeaders Virtual Nursing Mastermind program, and what other health systems can learn about implementing virtual nursing programs. Listen to the episode here.
Proving ROI
One of the biggest challenges with virtual nursing is proving ROI and defining the metrics with which to measure progress. Dr. Lunt spoke about how timely discharges can be a tricky metric to prove, because there are so many factors that can contribute to a lower discharge time, besides the presence of a virtual nurse.
Dr. Lunt said that at Mount Sinai, they are using sick time as a metric. Virtual nursing gives nurses who are physically or emotionally exhausted the option to work in a less stressful capacity.
"Not so much the turnover of the staff," Dr. Lunt said, "but the sick time, like the mental health days that we know sometimes are just absolutely necessary for nurses that have had a day."
At the Virtual Nursing Mastermind program summit, many of the participants spoke about turning "soft" metrics like patient satisfaction into "hard dollars," and to Dr. Lunt, it's all about connecting the dots.
"Rather than just saying, 'oh, look, our satisfaction rate went up,' [you need to ask] what does that mean?" Dr. Lunt said. "It's nice to know that people like our service, but what does that mean to us in a dollar sense?"
Moving forward
So, what comes next?
According to Dr. Lunt, the conversation moves well past virtual nursing and into staffing the workforce.
"How can we sustain the staff that we have knowing that there probably aren't enough coming up in the future to replace any that leave?" Dr. Lunt said. "Technology is one way of being able to do that."
However, Dr. Lunt also made it clear that nurses will always be critical to the healthcare workforce.
"We will always need nurses," Dr. Lunt said. "Nothing will replace them, because without them, data just doesn't happen without people putting something into the system somewhere."
The HealthLeaders Mastermind seriesis an exclusive series of calls and events with healthcare executives. This Virtual NursingMastermind series features ideas, solutions, and insights onexcelling your virtual nursing program.Please join the community at our LinkedIn page.
To inquire about participating in an upcoming Mastermind series or attending a HealthLeaders Exchange event, email us at exchange@healthleadersmedia.com.
Workplace violence incidents in healthcare are seemingly on the rise. Let's take a look at why, according to these nurse leaders.
Nurses across the country are experiencing record levels of workplace violence.
According to a National Nurses Unitedreport, in 2023, eight in 10 nurses experienced at least one type of workplace violence within the past year. Additionally, 45.5% of nurses reported an increase in workplace violence on their unit in the previous year.
The nurses involved in the report cited many types of violence, with 67.8% reporting verbal threats and 38.7% reporting physical threats. Nurses experienced being pinched, scratched, punched, kicked, spat on, and groped at alarming rates. Only 18.4% of participants reported no experiences of workplace violence.
CNOs are responsible for the health and wellness of their nursing workforce, and it is imperative that they come up with innovative ways to prevent workplace violence.
Understanding the numbers
According to Mary Beth Kingston, executive vice president and CNO at Advocate Health, it's hard to say one way or another that the incidents are rising, but it has become a more publicized issue.
"I'm not sure we have a have a good baseline to even say that [incidents are] increasing," Kingston said. "With that being said, it certainly feels as though things are increasing and we’re hearing about it more and more."
However, Kingston explained that in health systems implementing basic measures to prevent workplace violence, there have been improvements. Those measures include training and better reporting processes that can help identify where issues are, so health systems can target their approach. Health systems should also have risk and assessment processes, mobile duress technology, and behavioral health response teams.
"There's a number of basic foundational things that we can put in place to help keep all those providing care safe," Kingston said, "and not just those providing care, but everybody in the whole environment safe."
"Historically, nurses sort of accepted that there was a certain amount of abuse that they would have to take as part of their job," Schuetz said, "so it was and is drastically under reported."
Schuetz also said that the lack of resources for people with mental health conditions might also be contributing to the issue.
"If someone has a challenging life situation that requires some type of care in a facility, those facilities are not always available," Schuetz said, "and so the hospital becomes kind of the de facto place to put the patients so that they're kept safe."
Identifying the root cause
CNOs and other leaders need to first identify the reasons workplace violence is occurring in their health systems. For Kingston, it's important to consider the patient's perspective.
"It could be fear of the unknown or a fear of diagnosis that causes them to react, or pain," Kingston said. "Sometimes it can result from frustrations in some of our processes, [such as] long wait times."
For other patients, it could be cognitive difficulties or behavioral health issues. However, Kingston emphasized that it's important not to stereotype those patients.
"This is not to say that it is patients who have behavioral health problems are the ones that cause violent incidents all the time," Kingston said, "and I think sometimes we do jump to that decision, but there are certainly circumstances."
Kingston also mentioned that recently, there has been a general lack of boundaries between patients and nurses. CNOs must work to reemphasize the role of the patient and the nurse in a healthcare environment, and reinforce those boundaries between the patient and their care team.
"So again, [there are] many, many reasons [that workplace violence occurs]," Kingston said, "which makes it difficult to have the formula to say here's what we can do in every situation to prevent or to mitigate."
Training the workforce
One of the best things CNOs and other nurse leaders can do for their nurses is prepare and train them properly. According to Schuetz, nurses need to know how to identify and assess patients that may be at risk for violence. It's critical that nurses use the proper assessment tools so that they can get the support they need.
"Coming into the hospital, you might have a patient that has not and does not appear to be violent or have violent tendencies," Schuetz said. "The added stress of being in the hospital often just brings out the worst in people that already have a propensity to act out in certain situations."
Nurses also need to be aware of their environments and know the proper procedures for when incidents do occur. De-escalation training is crucial, according to Kingston and Schuetz.
"We have yearly training around how to de-escalate patients that are escalating," Schuetz said. "Sometimes, we're inadvertently causing patients to be escalated."
"It's really about listening and trying to understand what's going on before something erupts," Kingston said. "Practicing with de-escalation, even having folks act in the patient role and being able to practice that, I think is important."
Kingston believes more advanced training is necessary for nurses who work in high-risk areas, including self-defense.
"I don't know that everyone needs that, but certainly de-escalation and more of a focus on trauma informed care," Kingston said, "understanding where that patient is at as they're coming in…so that we can try to understand [and] mitigate before it becomes very difficult."
Peer support training is also key, so that nurses know how to help each other in the workplace setting.
"That to me is so important because [in] these situations, if our response is elevated and the patent is not as elevated yet, they will rise up to meet us," Kingston said.
According to Kingston, training should start as soon as possible while the nurses are in their undergraduate degree programs. To Schuetz, it comes down to looking at the tools that are available to you, and utilizing both mandatory and optional training.
"For nursing, there's so many things that we have to teach and train," Schuetz said. "Healthcare workers are just inundated with information and so they don't always know what's available to them."
Ultimately, it comes down to communication and using a combination of methods to try and prepare the nurses for what they might face.
"I'm a firm believer that it's a million little things that make a difference," Schuetz said. "If there was one thing that could solve this, that would have happened many, many moons ago."
Part two of this piece will be published on Monday, July 8, 2024.
The HealthLeaders Exchange is an executive community for sharing ideas, solutions, and insights. Please join the community at our LinkedIn page.
