While questionable social media use makes headlines, nurses can use social media tools in ways to further their professional knowledge.
When I read about the recent incident where Jacksonville Naval Hospital staff members shared unprofessional behavior on Snapchat—including flipping off an infant and referring to newborns as "mini-Satans"—my reaction was, "Don't people know better by now?"
While some may be quick to blame social media for these lapses in professionalism, Robert Fraser, MN, RN, a primary care nurse, author, and digital health strategist from Toronto, Ontario, Canada, points out that bad behavior did not start with the advent of social media. Social media just makes it more visible.
"Professional misconduct is not new or [an] unusual thing," he said. "But social media incidents, I think, tend to get more coverage for a number of reasons, [in part], because the evidence is left behind related to the incidents."
And thanks to technology, that evidence can reach, and affect, a larger group of people than it would in the pre-Internet world.
"Healthcare professionals…are not always paying attention to the opportunities, as well as the risk of potential harm, that can come from [social media]," Fraser says. "I want people to understand the risks as well as the potential."
Fraser offers his thoughts on how nurses can avoid the pitfalls of social media as well as ways to use it to positively affect the nursing profession.
Clear Policies Needed
Nurse leaders and healthcare organizations need to set clear policies regarding the use of social media.
"What I encourage organizations to do is a) make sure they have a policy and b) that it's something they revisit over time," Fraser advises.
Some expectations, such as privacy rules including HIPAA, may already exist within other policies.
Fraser says there is a hierarchy of professional practice obligations and social media connects with all of them.
The highest level of the hierarchy pertains to laws, such as HIPAA, or other federal privacy legislation.
Organizations and professional organizations, such as state boards, also have their own rules and regulations regarding privacy.
Your Personal Brand
Before a nurse decides to post something on a social media channel, he or she should think about how that tool ties into professional practice.
"People should make sure they are really thinking through what behavior they're doing and how they're going forward to record that," he says. "Nurses need to be aware of the professional reputation they're creating for themselves and how they're using online tools. Social media does provide new opportunities and new ways of approaching how we communicate, but nurses need to reflect on their professional identity and their professional expectations within the workplace."
While it may be tempting to vent to your Facebook friends about a bad shift or complain about a difficult coworker, nurses need to reflect upon why they feel the need to post this type of information on a social media platform.
"Nurses need to be aware that they aren't using it for therapeutic purposes that they need a counselor for," he says. "Or a colleague who understands the unit dynamic to talk to about those issues."
Promote Positive Behavior
Rather than restricting employees' access to social media while they are in the facility (as some organizations do) nurse leaders can model positive use of these tools.
Fraser knows of a hospital that has used Facebook as an additional way of communicating information posted on the intranet or by email. They have also shared photos of nurses (taken with permission and without sharing identifying patient information) to highlight the work staff is doing.
"They were encouraging nurses to follow so that when they were looking at news updates and seeing what might be going on in their social world, they may also be able to engage around the positive professional behaviors that the organization wanted to endorse," he says.
Social media is also an excellent way for nurses to connect with other RNs across the country and internationally. For example, the Free Open Access Nursing Education community is using technology and social media to provide nurses with an opportunity to relevant healthcare topics in real time and to share best practices, new research, and information relevant to the profession.
Hospitals and health systems have not typically prioritized nurse manager training and development. But that's changing as healthcare leaders begin to recognize the critical role nurse managers play in achieving an organization's outcomes and initiatives.
Ronda J. McKay, DNP, RN, CNS, NEA-BC, vice president of patient care services and chief nursing officer at the 458-bed acute care Community Hospital in Munster, Indiana, began her journey into management as most nurse managers typically do.
"How you used to become a manager was, you were one of the best workers on the floor, so they made you a manager. It wasn't so much that you had the leadership capability, but that you were a hard worker," she says.
Nurses with strong clinical skills often find themselves hastily appointed to the role of nurse manager without the proper training and skill development to thrive in the role.
"I was appointed as manager of four units and [the previous manager] left at noon that day," McKay recalls. "I got a phone call from the finance people, and they wanted to know how many FTEs we were going to need for the next fiscal year. I said, 'You know what? I'm going to call you right back.' I called the VP [of nursing] and I said, 'What's an FTE?' "
But as healthcare becomes increasingly complex, healthcare leaders are realizing that nurse managers can play key roles in improving financial, clinical, and quality outcomes.
"[Nurse managers] are critical to the mission of the organization and meeting the strategic initiative at that point-of-care service. We need to make sure that they're competent to do the job that they're put in charge to do," McKay says. "It's really about how we are orchestrating to train these nurses to be agents of administration, to be fiscally responsible, to understand what the strategic mission and values of the organization are, and to follow those."
Fortunately, some organizations across the country are creating well-thought-out, intentionally designed programs to help nurse managers develop the skills they need to succeed in a value-based care environment.
Leadership development is lacking
Developing strong nurse managers is important for many reasons, says Paula McKinney, DNP, RN, NE-BC, vice president of nursing and CNO at Scotland Health Care System in Laurinburg, North Carolina. The healthcare system had 23,244 hospital patient days (all patients) in fiscal year 2016.
"If they don't learn how to be a good leader, and they're just managing the processes, then they [could] set their unit up to create an unhealthy work environment," she says.
Results from the decadelong RN Work Project, a multistate, longitudinal panel study of new nurses' turnover rates and their intentions and attitudes about work, highlight the importance that nurse managers have on the work environment.
According to the study's findings, poor management was one of the top three reasons newly licensed RNs gave for leaving their first jobs, and 17% reported that, because of their supervisor, at least once a month, it was difficult or impossible to do their job.
Lack of proper training affects the longevity of nurse managers as well.
"If you promote someone to nurse manager and [he or she leaves] you within 12 to 18 months, you're losing a great deal of money. It could be up to $100,000," McKinney says. "I think there's some cost savings involved in better preparing them to be leaders and managers instead of letting them be out there on their own to flounder and then they end up leaving the job."
In McKinney's recent study, "Improve Nurse Manager Competency With Experiential Learning," published in the October 2016 issue of Nurse Management, 86% of the respondents said they had no formal leadership development when they first became a nurse manager.
The study, of which McKay is a coauthor, assessed leadership and management competency in three leadership areas—the science (business management), the art (leading people), and the leader within (self-reflection)—as self-reported on the Nurse Manager Skills Inventory by 28 nurse managers at Community Hospital.
"It's a self-reported evaluation that the leader does, and they can see in what areas their deficits are," McKinney says. "Those are the ones they can focus on for professional development or finding a mentor that can help them in that area."
The majority of Community Hospital's nurse managers self-identified as less than competent in the financial management area.
To address this, a targeted experiential education module was developed to give nurse managers a better understanding of financial issues, such as the topics of expense forecasting and cost-benefit analysis.
"They understood the concept, but they had never practiced it themselves," McKinney says. "We did some experiential learning in the classroom setting with them on how to do a cost-benefit analysis—some of them had never done that before and some had—but as a group they were able to sit [together] and figure through some of that."
When the nurse managers retook the skills inventory after going through the module, their scores in the areas of unit department budget, creating a budget, monitoring a budget, and analyzing a budget increased from less than competent to competent.
Scores in the areas of understanding healthcare economics and policy, expense forecasting, concepts of capital budget, and concepts of cost-benefit analysis increased from novice to advanced beginner.
The nurse manager residency
Lancaster General Hospital, a 533-bed nonprofit hospital, part of Lancaster General Health/Penn Medicine in Pennsylvania, has been ahead of the crowd in the way it develops nurse managers.
In 2006, the organization began its nurse manager residency program to better address succession planning and knowledge transfer from seasoned nurse managers to new nurse managers.
"If they don't learn how to be a good leader, and they're just managing the processes, then they [could] set their unit up to create an unhealthy work environment."
"At the time, we had a lot of tenured nurse managers who had been in the roles for I'd say 15–20 years, and they knew that we were going to have turnover," says Valerie Adams, RN, MSN, MBA, CCRN, director of nursing at Lancaster General. "They started seeking out, 'How do we better prepare people for going into the nurse manager role?' "
Kimberly Callahan, RN, BSN, NE-BC, nurse manager for the vascular surgical unit, was one of the first participants in the nurse manager residency when it began over a decade ago.
She says the program was invaluable in helping her develop skills specific to the role.
"I think the first skill is being a visionary and actually sharing that vision so your team has a purpose and they know what they're working toward. That's really important for our goals that we have as a nursing department," she says.
To take part in the program, nurses must have a bachelor's degree and three to four years of bedside nursing experience.
Those interested in becoming nurse manager residents fill out an application for the program after they've shadowed and interviewed three nurse managers, explains Adams.
They then go through an interview process with a team of nurse managers, a human resources representative, and the nursing directors.
Candidates take a personality factors test to identify their strengths and weaknesses to help connect them with the preceptor best suited to their needs.
There are usually one to two cohorts per year consisting of two to three residents.
Each resident is assigned a preceptor. To give them the chance to observe different leadership styles, residents rotate preceptors each quarter over the yearlong program.
They meet monthly with Adams, who oversees the program.
"We talk through different things because I want to be sure they're viewing situations through a leadership level not through the staff nurse level," she says.
Since its inception, 20 nurse manager residents have gone through the program. Two relocated out of state and two were nurse managers for a short time before going back to the bedside.
"Otherwise, everyone else is in a nurse manager role or some other kind of nurse leadership role within the organization," says Adams.
Recommendations from the National Academy of Medicine may not be met this decade, but progress has been made toward achieving higher levels of nursing education.
In its 2010 report on the future of nursing, the Institute of Medicine (now the National Academy of Medicine) recommends 80% of registered nurses hold a baccalaureate degree by 2020.
That's only three years away. So how clear was the organization's vision of the profession? Well, not exactly 20/20.
"There are more nurses earning baccalaureate degrees, but by 2020 we are unlikely to achieve the 80% goal," says Chenjuan Ma, PhD, associate professor at NYU Rory Meyers College of Nursing.
Her assessment is based on data from a newly released study published in the Journal of Nursing Scholarship.
To assess the educational trends of frontline, hospital-based RNs, Ma and her fellow researchers examined nursing-unit level data from the Registered Nurse Education Indicators, part of the National Database of Nursing Quality Indicators.
The analysis showed an increase in BSN-prepared frontline nurses in U.S. hospitals—57% in 2013 compared to 44% in 2004.
Though the 80% goal may not be met within the next three years, Ma says having that concrete objective has been positive.
"From my perspective, I think it's more important to look at how much effort we have put in to increase the number of nurses with baccalaureate degrees or how much progress we have made to increase the number of nurses with baccalaureate degrees," she says.
BSNs On the Rise
The increase in BSN-preparedness began before 2010, the study found growth accelerated after the Future of Nursing recommendations were made.
The proportion of nurses with a bachelor's degree in a nursing unit increased by 1.3% annually before 2010. From 2010 on, there was an increase of 1.9% each year.
The percentage of units having at least 80% of nurses with a bachelor's degree increased from 3% in 2009 to 7% in 2013.
Based on current trends, the researchers expect 64% of hospital-based nurses will have a bachelor's degree by 2020, and the 80% goal will likely be reached in 2029.
"To help accelerate this transformation, further advocacy, commitment, and investment are needed from all healthcare stakeholders in order to advance nursing education and, in turn, improve quality of care and patient outcomes," Ma says.
Nurse leaders, in particular, should find ways to champion and support BSN-preparation.
"It's important for nurse leaders to create an environment that really values and respects higher nursing education," she says.
One way to do this to provide opportunities for nurses to perform to their full capacity and practice at the top of their license.
"It motivates nurses to pursue a higher nursing degree," Ma says. "If nurses do not have the chance to perform to their full capacity, they feel like, 'If I have a higher education, I cannot use it.'"
Investment Will Pay Off
Additionally, Ma suggests that hospitals invest in hiring nurses with bachelor's degrees. For those facing challenges with the supply of BSN-prepared RNs, Ma says there are non-traditional means to help organizations boost BSN numbers.
Online education is one option as are innovative BSN-education models include collaboration between community colleges and university nursing schools.
She also suggests that organizations provide flexible scheduling options and tuition reimbursement for RNs who wish to further their education.
Finally, nurse leaders need to educate their counterparts in hospital administration on how BSN-prepared nurses can improve quality outcomes and patient care.
"If nurses have better competency in terms of providing care,' Ma says, "I do believe that in the long term it will also help reduce the cost of healthcare."
The Emergency Nursing Supply Relief Act proposes to designate 8,000 visas for healthcare workers in shortage professions.
To help ease staffing issues, hospitals and health systems are seeking international nurses to fill vacant positions, but current visa regulations can make it difficult to ensure supply keeps pace with demand.
"My company has 1,000 open orders, and I would say that other companies within the AAIHR [American Association of International Healthcare Recruitment]are clearly in the hundreds, if not higher, of open job orders for international nurses," says Shari Dingle Costantini, MBA, RN, AAIHR.
She is chair of regulatory affairs and CEO of Avant Healthcare Professionals, a staffing agency that specializes in recruiting internationally-educated RNs.
But even though they are in demand, it can take years to bring an international nurse to the U.S. For example, there's typically a three year wait for Filipino nurses to enter the country, says Costantini.
Additionally, since the Trump administration has taken office, the process for bringing international nurses to the U.S. has slowed.
"We have been recruiting international nurses and healthcare professionals for more than 14 years. The delays we are seeing with government agencies since the change in administration are dramatic. They are truly creating a hardship for many healthcare clients in critical need of nurses," she says.
The Emergency Nursing Supply Relief Act, a house bill introduced in July by U.S. Rep. Jim Sensenbrennar, (R-WI), aims to address this problem.
Visa Criteria for International Healthcare Workers
The bill designates up to 8,000 visas in the employment-based immigration third preference category (EB-3) for nurses, physical therapists, and other healthcare professionals in critical needs categories.
The beneficiaries of these visas must meet specific requirements, Costantini says:
The profession must be on the Department of Labor's schedule A—a list of professions designated as shortage areas. Registered nurses and physical therapists are consistently on this list.
Nurses must pass an English fluency exam.
The applicants' education must be evaluated and deemed equal to a U.S. education.
Applicants must apply for and pass the NCLEX.
Foreign-issued nursing licenses must be reviewed to make sure they are authentic and unencumbered.
"Hopefully, it will allow for more nurses to come in. That's the goal," says Costantini. "Because of the requirements on nurses it's a little longer process to get them in, but knowing that you have those visas available, you'll begin to see that pipeline fill and deliver nurses."
Not All Legislation is Equal
Costantini points out that other bills addressing immigrant workers have been put forward, but not all of them would bode well for the supply of international nurses.
"If that bill was passed in its current form, you would not have any international nurses coming in for about three to five years," she says.
Still the bill has gained traction in the house and has 230 cosponsors from both parties.
Costantini understands healthcare executives have many issues vying for their attention, but she encourages them to educate legislators about effects various bills can have on healthcare worker supply.
"They don't always put together immigration and the shortage," she says.
"We know right now healthcare workers are shortage professions and highly in demand. In a lot of rural communities, patients aren't going to have access to care if they don't have healthcare workers."
A small hospital's patient-centered treatment unit designated for patients with coexisting medical and behavioral health issues is showing reductions in length of stay.
"Oh, East is East, and West is West, and never the twain shall meet." That line from a Rudyard Kipling poem is a good explanation of the way healthcare has typically viewed medical issues and behavioral health issues.
But the reality is the two do not exist in separate realms. They can, and do, occur simultaneously and each can have a profound impact on the other.
To address this reality and improve patient care, Reading Hospital in Pennsylvania opened a medical complexity unit for patients who have primary medical diagnoses and a psychiatric comorbidity.
The 19-bed unit opened on June 26, 2017 and is medically comanaged by psychiatry and the organization's hospitalist program. Ann Blankenhorn, RN, MSN, MBA, NEA-BC, is the facility's senior nursing director.
"We wanted to look at safety and efficiency, and we wanted to look at a holistic approach to care—that we were caring for the whole person not just their pneumonia or their cellulitis. We wanted to make sure we weren't missing any of the psychosocial components or the psychiatric diagnoses that they many have had," she says.
Care Criteria
The organization realized there was a need for the unit when its consult liaison team saw a 38% increase in consultations for this patient population in the main hospital setting.
"These were patients that we were seeing in our hospital," she says. "Previously the [consult liaison team members] were going all over the hospital making sure they didn't miss anybody. Now, we're able to cohort that team a little bit better."
The unit is staffed by registered nurses and patient care assistants who receive training in non-violent crisis intervention and education on being proactive with behavioral aspects of care and psychiatric illnesses as well as traditional medical/surgical knowledge, Blankenhorn says.
To be admitted to the unit, patients must have a primary med/surg diagnosis and a coexisting behavioral health diagnosis. However, they do not have to be in a mental health crisis to receive care.
"If somebody comes in and they're non-compliant with their diabetes [care plan] and their sugars are in the 500s, but they happen to have a long-term mental health diagnosis, that would be somebody that would be ideal because we can manage their medical issue while also making sure they don't backslide with their psychiatric medications or the treatment they were receiving psychiatrically," she explains.
In addition to a variety of medical diagnoses, patients may also present with behavioral health issues such as delirium, toxic ingestion, overdose, or substance withdrawal.
An active mental health crisis is not necessary for admission, however. Additionally, patients from the hospital's inpatient mental health unit who require medical intervention may also be cared for on the unit.
"We're also looking at our relationship with other facilities that send us patients with mental health diagnoses that have a medical problem so we can develop relationships and really enhance that care for the patient," Blankenhorn says.
Promising Outcomes
In addition to providing consistent, patient-centered care, Blankenhorn says the unit's goals are to decrease the need for one-to-one care and length of stay.
"Oftentimes, this patient population could have a longer length of stay if they get mixed in with the crowd," she says.
"On this unit, we have a dedicated social worker and case manager. We do daily interdisciplinary walking rounds at 8 a.m. so we're able to really focus on what the needs of the patient are and what we need to do to get them to the next step in their care."
In the unit's first three months, Blankenhorn estimates that around 15 to 20% of the patient population need to go on for inpatient psychiatric care once their medical issue is resolved.
"Our length of stay in our first two months was below six days," she says. "And on average we were seeing 11 days for this patient population. So, we've seen some optimistic results there."
Two reports find that RNs are personally and professionally affected by natural disasters.
As communities hit by Hurricanes Harvey and Irma begin the long path to recovery, it's important to remember disasters leave more in their wake than physical damage to homes and property. They also leave marks on victims' psyches.
That includes nurses.
"When both personal life and professional life are impacted by an adverse event, as occurred in Superstorm Sandy, stress can exponentially increase. The responsibilities associated with the profession of nursing add additional demands that increase the risk for role conflict when a disaster occurs," says Victoria H. Raveis, PhD.
Raveis is research professor and director of the Psychosocial Research Unit on Health, Aging and the Community at NYU College of Dentistry.
The reports were centered on nurses working at NYU Langone Health's main hospital during Superstorm Sandy in 2012. Key themes that emerged were communication—both improving channels and its importance in connecting nurses with others during a crisis—and social support.
Preparedness Training Needed
To understand how nurses at NYU Langone were impacted before, during, and after the storm, the researchers conducted interviews and surveys with 16 nurses who participated in the mid-storm evacuation of more than 300 patients at NYU Langone's 725-bed Tisch Hospital due to high water levels.
Raveis and her team explored nurses' experiences in disasters, assessed their challenges and resources for carrying out responsibilities, and uncovered some lessons.
After the interviews, an online survey was sent to all RNs assigned to inpatient units at NYU Langone on the day of the storm. The researchers received 528 anonymous responses, including responses from 173 nurses who were part of the evacuation.
While some nurses had had disaster training and experience, and a few of them reported feeling prepared during the storm and the resulting evacuation, many working the night of the storm lacked prior hands-on experience or deep knowledge of emergency preparedness.
This lack of comfort with emergency preparedness is not uncommon says Eric Alberts, corporate manager, emergency preparedness at Orlando Health.
"I've been going across the United States speaking about the PULSE [nightlclub mass shooting] incident and, unfortunately, we're finding a lot of hospitals don't have an emergency plan," he says.
"Or if they do they don't practice it. And if they do practice it, they're not really practicing it. They're just doing a flu shot campaign and calling it an exercise."
Alberts recommends that hospital and health system leaders do a thorough evaluation of their disaster readiness.
"Really look at your processes and your people and see what is available during emergencies. Emergency preparedness and healthcare looks and feels different everywhere you go," he says. "And then from that, look at what resources and people are able to help those individuals have a good, efficient, and effective plan."
The NYU researchers also call for more education and planning for future disasters and recommend FEMA's all hazards approach to disaster planning.
Personal Concerns Present
Communication was a challenge during Superstorm Sandy when access to electronic medical records, email, and phone communication was unavailable because of power loss.
RNs reported unlocking medication carts in anticipation of the power outage and handwriting medical summaries for patients being evacuated to other hospitals. Of the nurses surveyed, 72% reported their primary mode of communication was talking face-to-face and 24% used personal cell phones.
Researchers also found that nurses had personal concerns during the storm, worrying about their families' welfare and personal loss.
While many arranged for extended stays at the hospital before the storm, they reported they felt uncertain about leaving their families and later had trouble contacting loved ones.
The survey found 25% nurses had property damage or loss and 22% needed to relocate after the storm. Some respondents reported psychological problems after the storm including disturbing thoughts (5%) and difficulty sleeping (4%).
Social support from coworkers, hospital leadership, and loved ones was cited as an important resource in helping them through the stressfulness of the disaster.
"Our research also shows that maintaining good communication with peers and hospital leaders after the hurricane helped the nursing staff feel more connected and less stressed," said Christine T. Kovner, RN, PhD, the Mathey Mezey Professor of Geriatric Nursing at NYU Meyers.
Researchers hope to bring the discussion about moral distress among chief nursing officers into the open.
Ethical challenges are not left at the bedside when nurses move into leadership positions.
Chief nursing officers still experience moral distress—the disequilibrium resulting from the recognition of and inability to react ethically to a situation—it's just taboo to talk about it, finds a qualitative study published in the Journal of Nursing Administration in February 2017.
"There's shame and isolation when you do have the experience, so it can make it very difficult for people to feel like they can openly discuss it," says Rose O. Sherman, EdD, RN, NEA-BC, FAAN, professor and director of the Nursing Leadership Institute at Florida Atlantic University.
Sherman is one of the study's authors. "I think that the other piece of it is, CNOs might not always label it as moral distress. But these are uncomfortable situations where they're making decisions against their values systems."
The Causes of Moral Distress
Through oral interviews, Sherman and her co-author, Angela S. Prestia, PhD, RN, NE-BC, discussed chief nursing officers' experiences of moral distress, including its short and long-term effects. Prestia is corporate chief nurse at The GEO Group.
The study's 20 participants described their experiences of moral distress, and several said they experienced it on more than one occasion. It was often related to issues like:
Staff salaries and compensation
Financial constraints
Hiring limits
Increased nurse-to-patient ratios to drive productivity
Counterproductive relationships
Authoritative improprieties.
"For example, a physician went to someone over a CNO's head and said, 'I think you should pay a scrub tech more. She is very valuable to me," Prestia says. "And of course he was a high-admitter, high-profile physician."
The CEO approved the special compensation, creating a salary inequity among the other scrub techs.
In another scenario, six participants reported their CEOs had improper sexual relationships with staff members. Prestia points out that the CNOs did not object to these relationships because of religious or moral beliefs, but because they were harming productivity at the organization.
"In their [the CNOs'] mind' of right and wrong, these people had access to things that they should not have had access to and [those relationships] create barriers to getting the work of the organization accomplished."
Lasting Effects
The study uncovered six significant themes related to CNO moral distress:
Lacking psychological safety
Feeling a sense of powerlessness
Seeking to maintain moral compass
Drawing strength from networking
Moral residue
Living with the consequences
CNOs reported they often felt very isolated during the experience of moral distress.
"If they pushed back on a decision because they felt it was in conflict with their values they were isolated within the organization and they no longer felt safe. They weren't invited to meetings. They weren't included in decision making," Sherman says.
Even though they took steps to do what they felt was right—documenting meeting minutes, reviewing policies and procedures, and referring to The Joint Commission standards—to maintain their moral compass, those efforts were often unsuccessful.
"What happened was when they were in this situation… they were beat down at every turn," Prestia says. "Then the 'flight' started to set in. 'Maybe I need to leave? Maybe I should resign? Maybe I need to start planning my exit strategy?' Or before they could do that, they were terminated."
Moral Residue
Even once they were out of the situation, many CNOs reported the experience left them with a 'moral residue.'
"It is a lingering effect of the moral distress. I liken it to a fine talc that lingers on your skin and it manifests itself either physically or emotionally," Prestia says. "We actually had several participants say, 'When I get a call about staffing now in my new job, all of a sudden I get this feeling of impending doom.'"
Both Sherman and Prestia hope this research will open up a larger conversation about CNOs and moral distress.
"What we found in the work that we did was, clearly, collegial support from a strong network is very important in building one's resiliency and being able to deal with these situations," Sherman says.
"I think that having others who've been through it is very important, which is why forums that allow people to talk about this candidly, when a CNO finds him or herself in this situation, become critical."
Researchers studied 3,101 couples over the age of 65, each with one spouse acting as caregiver for their disabled partner. They looked at Medicare payments and ED visits for the disabled spouses in the six months after the caregiver spouses took standard tests to measure their fatigue, mood, sleep habits, health and happiness.
In those six months, ED visits were 23% higher among patients whose caregivers scored high for fatigue or low on their own health status. Over the same time frame, patients with fatigued or sad caregivers had higher Medicare costs—$1,900 more if the caregiver scored high for fatigue, and $1,300 more if the caregiver scored high for sadness.
“Informal caregivers, including spouses, enable older adults with functional disability to stay out of the nursing home and live at home where they’d prefer to be,” says senior author Deborah Levine, MD, MPH, an assistant professor of internal medicine and neurology at University of Michigan. “Our findings suggest that we need to do a better job of identifying and supporting caregivers experiencing distress, in order to help caregivers feel better and hopefully improve outcomes in older adults with disability.”
Respite Support Needed
Nearly 15 million older adults receive help with activities of daily living from spouses and other family or friend caregivers, but Medicare does not pay for or offer formal respite coverage for family or friends who regularly care for older adults.
Given the increased use of healthcare resources when caregivers are unsupported, it may make financial sense to change this policy.
“I definitely think there are specific services that could help caregivers, if we can identify those people who are highest risk and provide a basic level of support such as an around-the-clock geriatric care call line that could help caregivers feel less isolated and talk to a nurse about whether, for example, to go to the emergency department,” says lead author Claire Ankuda, MD, MPH. “This is a high-cost, vulnerable population.”
A new study challenges the wide-held belief that medical student empathy declines over the course of medical school.
His gallows humor and abrasive personality made Dr. Gregory House a television icon, but future physicians are not destined to follow in his jaded, albeit fictional, footsteps.
A new studyby social neuroscientists at the University of Chicago, calls into question the common perception that empathy declines during medical training, particularly between the second and third years of medical school. The study was published in September in Medical Education.
While prior studies reporting a deterioration of empathy during medical training relied on one self-reported assessment of cognitive empathy, The University of Chicago study, considers both cognitive and affective empathy.
"Cognitive empathy is the ability to recognize and understand another person's experience, to communicate and confirm that understanding, and to act in an appropriate and helpful manner without necessarily sharing his or her emotions," says the university’s Jean Decety, the Irving B. Harris Distinguished Service Professor in Psychology and Psychiatry, and lead author of the new study. "Affective, or emotional, empathy is being attuned to someone else's emotions, feeling what he or she feels.”
Traditionally, cognitive empathy has been emphasized as most important in a clinical setting since it enables physicians to understand how patients feel without having an emotional attunement. Affective empathy has been believed to impede a physician's effectiveness in diagnosing and treating patients. Decety and colleagues say that both facets of empathy are important in patient-physician interactions, because physicians must be able to accurately perceive and respond to their patients' emotional states.
Empathy Increases During Medical School
Researchers followed 129 medical students during their first three years of medical school. At the beginning and end of each year, students completed a series of online surveys and behavioral tasks designed to objectively assess different components of empathy.
When researchers evaluated the respondents’ answers to the Jefferson Scale of Physician Empathy, a common self-assessment questionnaire thought to primarily evaluate the cognitive aspects of empathy, they did see a decline in scores of the course of training.
But when they administered the Questionnaire of Cognitive and Affective Empathy, an assessment to distinguish the two facets of empathy, students’ scores on the questionnaire improved over time and both affective empathy and cognitive empathy increased during medical training. They also showed greater sensitivity to facial expressions of pain and progress in their ability to quickly and accurately recognize others' emotional states.
"We found that changes in empathy during medical training are not necessarily negative—the narrative appears to be much more complicated than we initially thought and illustrates how problematic it is to rely on a single, subjective measure to evaluate a complex psychological construct," say the study’s authors.
Providing the correct ratio of directors to managers is a good start toward positioning nurse managers to develop their leadership skills.
Nurse managers, 300,000 strong, represent the largest segment of the healthcare management workforce. Yet their potential to influence clinical outcomes and strategic goals has been overlooked by healthcare organizations for decades.
Now, she says, CNOs should be asking themselves this question: "What are the supports that nurse managers need to be resilient in that role?"
Make Management Manageable
Hoying says one area that leaders should evaluate is the expectations placed on nurse managers.
About seven years ago, she noticed a troubling trend among the nursing directors at her organization."What I was seeing was all the directors getting out of here at seven or eight o'clock at night and not being able to get home in a timely manner," she says.
Hoying approached the CEO at the time and successfully made the case to add nurse managers in order to support the directors. The organization also implemented a one-manager-to-25-FTE ratio.
"Depending on how many employees were on their unit, that's how many managers they got. If they had a staff of 50, there was a nurse director and then they got a nurse manager. If it was 75, they got two nurse managers and a director," she explains.
"By that [ratio] you're able to work with the staff and do all of the education with the staff that's needed and vice versa. It allows the manager to be successful and be the nurse leader that that individual could be."
Having a large amount of direct reports is not uncommon for nurse managers, but leadership needs to consider whether the practice is in the best interest of nurse managers.
"I've heard some stories where managers have had 100 people that they're responsible for. How do you begin to do 100 evaluations?" she says.
"I think for the manager to be successful, even before you do the education, you have to have realistic foundations for these folks."
Leadership Skill Development
Another benefit of the ratio is that it gives both directors and managers time for education to develop their leadership skills.
"That was really the foundational piece," she says, "making sure that we built in the opportunity for that director to go to different things and to attend sessions and help mentor and grow that nursing group that's coming up in the ranks."
This also helps to address another age-old issue in nursing management—promoting a strong clinician-to-management position without prior training.
"This way they're learning budgets, they're learning HR issues, they're learning how to mentor others," she says of the manager/director structure. "They're learning as they go and they have 25 employees that they're helping along."
Providing this type of support benefits not just the nurse manager but staff nurses, patients, and the organization.
"It's our job as leadership to make sure we've got the right resources so that they are successful and they are going to enjoy their role," Hoying says. "Because when that role turns over, that affects everybody on the unit."