Investing in technology and services is a crucial step for healthcare organizations that need to be ready for anything, including unfamiliar infectious diseases, says a CNO who speaks from experience.
Anthrax, SARS, Ebola. While they're frightening, and at times deadly, the likelihood of a patient presenting at a U.S healthcare facility with one of these diseases is low.
Yet, as we know from recent history, it's entirely possible.
"I don't think anyone can ever realize the kind of stress an organization is under when this type of event occurs," says Ronda McKay, DNP, RN, CNS, chief nursing officer and vice president of patient care at Community Hospital in Munster, IN, a 427-bed not-for-profit facility.
McKay speaks from experience. It's been just over a year since Community earned the distinction of caring for the first person in the U.S with a confirmed case of Middle Eastern Respiratory Syndrome. There have been only two confirmed cases of MERS in the U.S. The other one was in Florida.
Despite the virus being novel to the U.S., Community thwarted any further transmission and prevented widespread panic by creatively using existing technology to gather data and then carefully communicating it to public health authorities, staff members, and the public.
'Life as You Know it Will Change'
"The impact of the disease is one thing," says John Olmstead, MBA, RN, CNOR, FACHE, director of surgical and emergency services at Community. "The impact to the community emotionally and, frankly, businesswise, is the what-ifs." In other words, fear of the unknown can often be more infectious and do greater, more lasting damage than the disease itself.
"We're very up on infectious disease processes, and we do a great job of identifying those patients that are at risk for, whatever it may be, from its inception," says McKay.
Because the patient presented with flu-like symptoms, he was quickly placed on isolation precautions as is standard protocol. But the situation grew more complicated. Based on the patient's history—he had recently traveled to Saudi Arabia—the EMR triggered an alert for further testing to rule out the MERS virus.
"You go on along your happy day and all of a sudden you get a phone call that a patient is going to be tested for the MERS virus," McKay says. "And a lot of people in the organization were unsure of really what that was."
And for good reason. The virus has only been on the epidemiological scene since 2012 when it emerged in Saudi Arabia, and, according to the CDC, it's only been linked to countries in or near the Arabian Peninsula. In May 2014, the death rate for patients with the disease was 50%, though it has since dropped to about 30%, Olmstead says.
The fact that they were heading into unknown territory hit home when, during a conference call, McKay asked Indiana State Department of Health officials what would happen if the patient tested positive for the MERS virus.
"There was a pause on the phone call and [the] exact words were, 'Life as you know it will change,'" McKay says.
Strength in Numbers
Once the patient tested positive for MERS, hospital leadership knew they had to act quickly to minimize harm by determining who had been exposed to the patient while inside the hospital. "We started putting things in motion because what you have to consider is the patient, the patient's family, the other patients inside your organization, all your employees, and the community at large," McKay says.
This was no small task. Community is not a tiny hospital out in a cornfield. It's a 445-bed facility in the northwest portion of the state and is close enough to Chicago that it's considered part of the city's greater metropolitan area. As far as they knew, failure to contain the disease could wreak havoc both within the hospital and across a large, highly populated geographic region.
Thanks to some creative thinking, they realized they could pinpoint which employees had been exposed to the patient by using reports generated from the EMR, the real-time locating system on the employee badges, and security camera video footage.
"In maybe 40 minutes, we knew through our videotape exactly where that patient had been—the waiting room, hallways, room—and every staff member that had been in that room," Olmstead says.
The 50 employees that had direct exposure to the patient were placed on furloughs until it was determined they had not contracted the virus.
The security footage was also used to establish which other patients or visitors had or had not been exposed to the patient while in the hospital which was a huge factor in reassuring the public.
"It became very apparent that we had things under control," McKay says.
Advice From Those Who Have Been There, Done That
The graceful way Community handled this event has not gone unnoticed. McKay says the hospital often gets requests to speak about the experience. She shared some pointers for nurse leaders:
"This is going to sound simple, but you always need to stay prepared," McKay says. "You've got to make sure that your process flows are where they need to be to sustain an event."
Clearly communicate those processes so your staff is educated and understands them, then test, and fine-tune the workflows through regular safety drills. If something doesn't work during a drill, address it promptly. It's far better to have a misstep during dress rehearsal than it is when you are thrust onstage under a national spotlight.
McKay also recommends investing in technology and infrastructure to increase safety and quality of care. As Olmstead points out, none of the technology they used to determine exposure was created exclusively for MERS surveillance.
"If our driving force was, 'Gosh we need to make sure we do the best job we can when this one in a billion chance of a guy from Saudi Arabia coming over [with MERS] happens,' we wouldn't have invested all this technology," he says. "We invested in it to help patients. And it worked."
Get the Most Out of HIT
McKay makes another important point about technology—investing in it means more than just purchasing it. You need to know what you have, understand its capabilities, and ask how you can use it to maximize your current process. It's because they knew their technology systems so well that they were able to use the existing features to track the MERS exposure.
McKay recommends using the same individual to provide updates to the media and the public. "You have to send a consistent message," McKay explains. The more representatives that speak to the media, the more likely it is that they will contradict each other. This can make it seem like the hospital does not have a handle on the situation and that can create anxiety in the community.
Finally, when a crisis hits, it's important for nurse leaders to be visible and communicate with bedside staff says McKay.
"You can't just sit there in your dome and say, 'Bring me the information,'" Mckay says. "You need to keep in touch with what's really going on within your organization."
McKay sums up what she learned from what she hopes was a once-in-a-lifetime event: "I think that you need to prepare for the unpredictable, invest in technology and services for your organization, and invest in education and collaboration of your employees."
Patients are encouraged to become engaged in their healthcare, but they can't do it unless providers give them the tools and information they need to actively participate.
Everyone agrees that patient engagement is important. No one agrees on what, exactly, the term means. A 2012 study published in the Journal of Participatory Medicine, "The Many Faces of Patient Engagement," concluded that there is a lack of "consistency in terminology and definitions around the concept of patient engagement."
The presenters of a session at the HIMSS 2015 conference last month, "Shaping the Frontier of Patient Engagement: A CNO/CNIO Perspective," grapple with the nebulous nature of patient engagement. Laura J. Wood, DNP, MS, RN, who is senior vice president for patient care service and chief nursing officer at Boston (MA) Children's Hospital, and Mary Beth Mitchell, MSN, RN, BC, CPHIMS, the chief nursing informatics officer at Texas Health Resources in Arlington, TX, discussed the CNO and CNIO perspectives on the evolution of patient engagement.
Despite the debate over definition and application of patient engagement, Mitchell boils it down to a single, simple description: "It's how patients become invested in their own health."
Patients like OpenNotes
One method Boston Children's is using to increase patient engagement is OpenNotes, the national initiative from the Robert Wood Johnson Foundation. The effort began in 2010 when primary care physicians at three healthcare institutions began sharing visit notes online with their patients. The sites were part of a year-long study to explore how sharing clinician's notes affected care. The results found that patients frequently accessed visit notes, reported a greater sense of control and understanding of their medical issues, had improved recall of care plans, and adhered better to medication regimens. Almost all patients wanted the practice to continue, and no physicians had opted out after a year. There are now 30 hospitals and health systems participating in the OpenNotes initiative.
"OpenNotes is a wonderful example of patient and family participation in their care, and what I think may be a harbinger of really meaningful activation," Wood says. "There's kind of a no-turning-back once you move on this, it seems."
Engagement requires transparency
In my opinion, providers need to be more proactively turning towards the type of patient engagement that, like OpenNotes, fosters healthcare transparency. Healthcare professionals play an enormous role in cultivating patient engagement because they're the ones who provide the tools and information necessary for patients to participate in their healthcare. Patient engagement is a two-way street, and I've personally seen how a providers who don't foster engagement can negatively influence a patient's health.
In the spring of 2012, my dad discovered a mole on his neck. (He gave me permission to talk about this, so I'm not violating HIPAA) He had it removed by a dermatologist who said the pathology report showed nothing to worry about. We were never offered the chance to see his chart or the pathology results.
A year later, a mass appeared in that same area on his neck and he had a second biopsy. The ENT and pathologist who did the second biopsy thought something was suspicious and sent slides to a large teaching hospital for further analysis. It turned out that the "nothing to worry about" mole and mass were a rare form of skin cancer called spindle cell melanoma. The cancer had infiltrated one of his lymph nodes.
I hadn't read my dad's medical records until he had obtained them to send them to a melanoma specialist, but once I finally did read them I was furious. The words "spindle cell" were all over the original report. How could that dermatologist have said everything was fine? To this day I question whether he read the report in its entirety.
At the advice of a melanoma expert, my dad had an excision of the abscess and removal of multiple lymph nodes. He now goes for serial PET scans and frequent follow-up visits with his oncologist but, thankfully, he is cancer-free.
For safety's sake, give us our records
During a recent RWJF First Friday Google Plus Hangout on improving healthcare value through OpenNotes, I was pleased to hear the participants talk about how transparency and patient engagement can improve patient safety.
"Another really important part of patients reading their notes is the fact that they can contribute to safety monitoring," says Jan Walker, MBA, RN, co-director of OpenNotes and assistant professor at Harvard Medical School. "Care is really complicated, we're all human, we all forget things, and having another set of eyes on what's going on can probably help people avoid errors."
This is exactly how our family would have benefited if my father's dermatologist had engaged us through a tool like OpenNotes. We could have asked questions to clarify the situation and made sure all parties—provider, patient, and family members—had reviewed the necessary information.
For clinicians who are resistant to sharing notes and providing transparency in their healthcare practice, it's time to rethink that stance.
"There's absolutely no reason to hold off," Connie B., a patient who uses OpenNotes, said in the Hangout. "From a patient perspective, I can't understand why anyone would knowingly not have it available to their patients."
And as my family learned, when it comes to your healthcare, what you don't know can hurt you.
Dawn Pevey Mauk, who became CNO of Ochsner Medical Center at age 28, discusses how being open to opportunity and willing to be uncomfortable helped her rise to COO and system nursing chair by the time she was 35 years old.
I'd describe Dawn Pevey Mauk, MBA, BSN, RN, NEA-BC, as a nurse leader who is ahead of the curve and ahead of her time. She holds a leadership trifecta of chief nursing officer, chief operating officer, and system nursing chair at Ochsner Medical Center in Baton Rouge, LA. What's impressive about this is that Pevey Mauk became CNO at age 28 and rounded out her resume with the rest of these accomplishments by the time she was 35 years old.
To put that in perspective, in its "2011 Nurse Executive Role Delineation Study," the American Nurses Credentialing Center reported that 85% of its nurse executive respondents were between the ages of 45 and 64 and only 1.7% were between the ages of 25 and 34.
Dawn Pevey Mauk,
MBA, BSN, RN, NEA-BC
Pevey Mauk recently spoke with me about her faster-than-average career trajectory, her experience as a young CNO, and her thoughts on developing future nurse leaders. The transcript has been edited for brevity and clarity.
HLM: What type of nursing did you go into right out of college? Did you always know you wanted to go into management?
Pevey Mauk: I went to work at the critical care unit at Charity Hospital in New Orleans straight out of school. I worked there from 2003 to the end of 2005 when Hurricane Katrina came through New Orleans and the facility closed.
I thought [I was going to go the] CRNA route. In those two years, I had a mentor in the unit who was very open with me. He felt that I was made for management and that I would not enjoy CRNA school. [He said] I had the ability to be collaborative with people, but to be in charge when needed and to make decisions quickly. I was 15 months out of school when [I was] asked to serve in a charge nurse capacity so I was exposed to the management path very early in my career.
HLM: How did your career path lead you to become a CNO?
Pevey Mauk: Hurricane Katrina was in August of 2005. At that point Charity Hospital shut down, so I came to Baton Rouge. I worked as an agency nurse for four months, not knowing what the outcome of the Charity Hospital situation was going to be, and then was hired at Ochsner Baton Rouge (Summit Hospital at the time) as a staff nurse in the critical care unit.
After about a month of being a staff nurse here, the telemetry director asked if I would be charge nurse on the telemetry unit. I was a little apprehensive about that because I did not have telemetry experience. But it was where the organization needed me most, so I [became] charge nurse in the telemetry unit three months after coming on staff here.
A couple of months into that the telemetry director left, and I was asked to serve in a director capacity. I did that for about two years, and when Ochsner bought the facility they needed a chief nursing officer. The plan was for it be an interim role. I served as interim CNO from January 2008 to April 2008 when it became permanent.
HLM: How did you feel when you were asked to apply for the CNO position?
Pevey Mauk: I was a little apprehensive because being a CNO was not a goal I had set. It wasn't on my radar. I knew I had a lot to learn to be a CNO. I was one of the least clinically experienced leaders here and had been with the organization for the shortest amount of time. I was nervous about how my peers would receive that.
I did it for four months with the mindset of, "this is going to be a great experience, I will learn a lot, but I know I'm not ready for a CNO job." In April, the CEO came to me and said, "I've interviewed a number of people for the CNO role, and I believe you have the ability to do it."
I feel like he was extremely supportive and took a leap of faith. I know that a lot of people questioned the decision he was making—at the time I was 28 years old. But here we are.
HLM: What did you most need to learn during the interim?
Pevey Mauk: I had not been [in a role that] involved in strategic planning, budget development, the economic side of what we do, and had never been in a position to hire or fire anyone. I recognized that I had a lot to learn as a leader around managing people, setting a vision for the staff, and being fiscally responsible.
HLM: How did you go about learning those skills?
Pevey Mauk: I took the approach [that I just had to jump in]. I worked closely with the finance team and asked a lot of questions that I knew, to many, would be perceived as dumb questions or something I should know. But they were very supportive.
I took classes to try to help enhance that skill set. When I had the opportunity to sit with someone to teach me, I would take lots of notes and I would try to apply it to a situation I had been in before to [help it] make more sense for me. Along the way I recognized that I obviously needed to get a master's degree and believed getting an MBA would help fine tune some of that skill set. I completed my MBA in 2012.
HLM: How do your CNO peers react to you being as young as you are?
Pevey Mauk: When I [travel to] conferences, people are a little bit taken aback by that and then they begin to ask questions about the facility. Internally, I think there was a little apprehension initially, but now I have a great relationship with the CNOs across the health system.
It was actually the CNOs in our health system that suggested I serve in the chair capacity. People are positive about it now but they will still tell me, "When they named you the CNO, I questioned what was happening."
HLM: What's been your biggest challenge becoming a CNO?
Pevey Mauk: My background was in critical care and telemetry, so having responsibility for areas that I had really never been exposed to was a significant learning curve. Early on, I didn't have the benefit of past experiences to build upon, so I had to talk to people and do a lot of research. I had to spend a lot of time in the details to learn about the business.
HLM: What do you think your biggest asset was?
Pevey Mauk: The flip side of not having past experience to rely on was that I was able to think about things in a different way. When you have a learning curve, you learn to be more collaborative and work with people in a different way than when you have all the past experience and you just know the answer. I think it allowed the team to be a little bit more innovative and challenge each other to think differently.
HLM: Do you have any advice for your CNO peers about getting nurses interested in the administrative path?
Pevey Mauk: You have to look for leadership ability in people early on and understand that when nurses go to nursing school, not many of them go in saying, "I want to be a CNO." We have to help identify leadership traits that they have, work with them, serve as mentors, give people autonomy, and allow them to hone their leadership skills.
I think we have a lot of nurses who demonstrate leadership ability. They just need someone to work with them to help show them the way. Many times we wait and won't fill a position until we find the perfect candidate. I know in 2008 I wasn't the perfect candidate, but it's turned out to be successful for me and for the organization. We have to look at the abilities of people and what we can teach them, not what they come in the door knowing.
HLM: What advice do you have for nurses about becoming a CNO?
Pevey Mauk: I think people need to be open to opportunities that may not feel like [they are happening at] the perfect time. Also, find the area they're passionate about, get a mentor, and really challenge themselves to take assignments that are going to take them out of their comfort zone. I tell my leaders, and people who are interested in being in leadership, part of being in nursing leadership is learning to be comfortable with being uncomfortable.
In celebration of National Nurses Week, four leading CNOs reflect on the most meaningful gifts they've received during their nursing careers.
National Nurses Week. In an act of authenticity and transparency, I'll admit I have mixed feelings about the annual event. It was definitely started for the right reason—to recognize nurses for their valuable contributions to healthcare—but sometimes Nurses Week celebrations can come across as frivolous and insincere. "Thanks for saving lives. Here's a pen," doesn't really speak to the magnitude of the work nurses do each day.
There's data to back me up. In a 2008 survey "An Evidence-Based Approach to Nurses Week," which appeared in the Journal of Nursing Administration, 727 RNs at the University of Michigan Health System said they preferred educational opportunities (65%) over gifts (16%) as Nurses Week celebration options. I thought the article's authors came to an accurate conclusion when they wrote, "Nurses want public acknowledgement and recognition that their work is valued. They want substance not trinkets."
Now before you label me "The Grinch Who Stole Nurses Week" (though you must admit all those Whos down in Whoville would qualify as a population health cohort), let me clarify that gifts and substance are not mutually exclusive. Anyone who's received a finely crafted macaroni necklace from a preschooler knows gifts can be a way to represent the enormous amount of love and appreciation someone has for you. And sometimes gifts of a more intangible nature—like the gifts of time, thoughtfulness, and kindness—are the most meaningful. These are the types of gifts we should focus on during Nurses Week because they can genuinely affect a nurse's career or personal life for the better.
In the hopes of honoring the true meaning of National Nurses Week, I asked four nurse leaders to share the most memorable gifts they've given and received during their nursing careers. Their answers are thoughtful and inspiring, and I encourage all nurses to dedicate some time this week to reflect on the gifts your fellow nurses have given you. Happy Nurses Week!
The Gift of Compassion Linda Burnes Bolton, DrPH, RN, FAAN Vice President, Nursing and Chief Nursing Officer, Cedars-Sinai Medical Center, Los Angeles President, American Organization of Nurse Executives
Linda Burnes Bolton, DrPH, RN, FAAN
"One of my most memorable gifts was the compassion provided during my first year as a staff nurse," Burnes Bolton told me in an email. "The engagement and support as I learned how to apply the knowledge from my nursing program was truly exceptional. I recall the nurse manager taking me into her office after a patient's death and saying, 'It is okay to cry and show concern for the family's loss. You also experienced a loss!' I have comforted many nurses during my career about their experiences with [the] death of a patient. It is important to demonstrate human caring at all times, and that may include sharing in the grief process with family members. It is very important to model the values we expect others to uphold. Human caring across the lifespan with dignity and respect for all includes the provision of care from birth to death."
The Gift of Listening Susan Campbell, DNP, RN Senior Vice President, System Chief Nursing Officer, Advocate Health Care, Downers Grove, IL
Campbell told me she's been fortunate to have a few outstanding mentors during her life, but one who gave her the particularly valuable gift of listening was her former CNO and COO Sue Wozniak.
"I had gone from being over a division to being over 1,500 nurses at the time, and they were all looking to me for leadership," says Campbell. "She said, 'You have to develop that vision for where you want to take them, and the only way to do that is to really listen to what their needs are and understand where they're at.'"
Campbell says Wozniak, who is now interim president at Children's Hospital of Illinois in Peoria, gifted her with the understanding that listening to others is essential to becoming a successful nursing leader.
"At [the CNO] level, it's not about directing or telling people what to do," Campbell says. "It's really about listening to the true issue and really figuring out which problem you're trying to solve and then moving forward."
Listening has served Campbell well in her career. Despite initially resisting a move from the ambulatory care setting to the acute care realm, she has gone on to be a system CNO at two different healthcare organizations, something she says she would have never done without Wozniak's encouragement.
Susan Campbell, DNP, RN
"She saw something in me that I didn't see—which is always the case with the best mentors."
In addition to listening to her own staff, Campbell hopes to give other nurses the gift of inspiration, especially to pursue further education. Campbell began her nursing career with a diploma in nursing at age 19 and, though she had a degree in health care administration, eventually went on to get a BSN and an MSN while she was CNO. Other nurses took notice of how she was able to pursue her education while maintaining a busy career and family obligations.
"I've had multiple nurses come up to me and tell me that they had been inspired by my story to go back to school," Campbell says, "and I think any sort of education is a gift."
The gift of Mentorship Donna Giannuzzi, MBA, RN, NEA-BC Chief Patient Care Officer and Chief Administrative Officer, HealthPark Medical Center, Fort Myers, FL, part of Lee Memorial Health System
Donna Giannuzzi, MBA, RN, NEA-BC
Early in her nursing career, Giannuzzi received the gift of mentorship from her then director of surgery, Mary Nilan, whose support and encouragement started her down the path to becoming the nurse leader she is today.
"I had no intention of ever wanting to be in leadership," Giannuzzi says. "I saw myself always being the person in surgery at the bedside."
But Nilan saw potential in Giannuzzi and took the time to help her develop her leadership skills.
"As a young, new nurse, she would challenge me with new projects and she would place me in positions of leadership," Giannuzzi says.
She describes Nilan as a "wonderful coach" who mentored her from the beginning to the end of an assignment or project. Eventually, Nilan gave her leadership of the PACU.
"From there is really where I started my leadership journey," Gianuzzi says.
Giannuzzi admired many of Nilan's attributes like her communication, listening, clinical, interpersonal, and coaching skills, as well as her optimism.
"She always focused on the individual no matter what was going on around her. You were the only person that she was focused on," Giannuzzi recalls. "She had a gift to pull the best out in people."
Nilan's mentorship could be described as the gift that keeps on giving.
"Although I haven't seen her in well over ten years," Giannuzzi says, "every so often, if I'm struggling with something, she will call me out of the blue."
Giannuzzi strives to pass along the gifts she's been fortunate to receive to other nurses.
"Based on that example, I hope that [what] I've done for nurses around me is to give them that gift of time, the gift of listening, the gift of caring about them, and helping them develop to be the best they can be."
The gift of Being Genuine Kelly Hancock, MSN, RN, NE-BC Executive Chief Nursing Officer, Cleveland Clinic Health System, and Chief Nursing Officer, Cleveland Clinic Main Campus
Hancock says she has been blessed to receive many gifts over her nursing career but one that really stands out is the gift of being genuine. She explains there are multiple components to behaving in a genuine manner, like being present and acting with authenticity.
"I've met some great nursing colleagues who've given me the gift of learning how to be passionate, to continue to be that advocate, to practice with determination and grace," says Hancock.
"I think those gifts really remind me that our profession is filled with more passion and joy and self-fulfillment than, in my biased opinion, any other profession that I can think of," she says.
Nurse leaders can receive some of the most meaningful gifts from the nurses they lead, Hancock says. "I continue to learn from them each and every day. It's really shaped who I am as a leader, and I am so honored and humbled to lead this dynamic group of nursing caregivers."
Hancock received an unexpected gift from the group of frontline caregivers planning the National Nurses Week celebration at The Cleveland Clinic. When it was time to select the annual trinket to be distributed to the staff, they chose to go forgo it completely.
"This group of frontline caregivers that represented our whole health system said, 'It's much more than a lunch bag or a mug,' " she says. Instead, the group decided to give the gift back to their own caregivers.
Rather than purchasing a physical gift, the group decided to donate money to the health system's caregiver hardship fund, which is available to assist caregivers in times of need.
"That gift for me was reinforcing that nurses are selfless because of what they do each day for our patients, but also because of what they do for one another," she says.
The clinical nurse leader role, introduced more than a decade ago as way to improve patient outcomes, patient safety, and quality of care, has been delivering promising, but mixed results in one Florida hospital system, which was an early adopter.
The more things change, the more they stay the same. Cliché? Some might say so, but at times it seems more like a universal law of healthcare.
Diane Raines, DNP, RN, NEA-BC,
Senior VP and CNO,
Yes, technology has changed immensely in recent years and the Patient Protection and Affordable Care Act has introduced some new challenges since its passage in 2010, but we're still grappling with many of the same issues that we were two decades ago.
Take medical errors, patient safety, quality of care, and patient outcomes, for example. Those are hot topics these days, but they've been around for a long time. In fact, those were some of the very reasons the American Association of Colleges of Nursing introduced the clinical nurse leader role in 2003.
The History of the CNL
The CNL is a master's-prepared advanced generalist who works at the point of care and applies evidence-based information to influence patient care methods and outcomes. Because the focus of the CNL is on coordinating care across multiple disciplines, The Clinical Nurse Leader Association likens the role to that of an air-traffic controller.
The CNL role began taking shape in 1999 shortly after the Institute of Medicine released its report "To Err is Human," which highlighted the need to improve healthcare quality by reducing medical errors. In response, the AACN created two task forces to determine how to improve the quality of patient care and how to best prepare nurses to provide high-level care in a changing healthcare system.
After much research and discussion, the CNL role—the first new nursing role in 35 years—was born.
Diane Raines, DNP, RN, NEA-BC, senior vice president and chief nursing officer at Baptist Health in Northeast Florida, says her organization saw the value of the CNL role from the get-go.
"In our children's hospital, we were early adopters," says Raines, who credits her colleague Carolyn Johnson, RN, with having the vision to use CNLs as soon as they became available clinically. "She really grabbed on to that role because she saw a need for a coordinating generalist on the unit."
Care Coordination a Key Skill
The CNL role eventually expanded beyond the children's hospital and there are now 30 CNL/navigators across five Baptist Health hospitals.
"When we were looking for ways to improve the patient's experience, to improve care coordination and meet our quality measures, that role reemerged in our discussion," Raines says. Their broad education and focus on care coordination made CNLs appealing. "For what we were trying to do, which is coordinate care of complex patients to make sure their discharge went better, the CNL role was an ideal preparation," Raines says.
Finding CNLs to fill the new positions was not an easy task, however, and the nurse leaders at Baptist Health had to get creative. When the organization realized that there weren't a lot of CNLs out there waiting to be hired, it "converted some of our advanced practice nurses or educators to that role," she says.
Now the job is called CNL/navigator. Those with CNL preparation are called CNLs, and those without the certification, such as APNs, are called navigators. They are responsible for helping coordinate interdisciplinary rounds and working with the nursing staff, social services, physicians, physical therapy, and other members of the care team. They help staff plan for difficult discharges so patients are educated appropriately and medications are reconciled correctly.
They also assist with the "hand-off into the community" by making the patient's appointment with the physician for follow-up care. If the patient doesn't have a physician, the CNL will help to find one.
"They're kind of the glue that keeps the care moving forward," Raines says. "We're trying not to have these complex patients just leave without that follow-up care because, of course, what happens is they come back," Raines says. Finally, the CNL/navigator can also function as a preceptor and mentor to new staff on the unit.
When I asked Raines if the CNL role created the results Baptist was hoping for, she responded, "Yes, and we still have plenty of opportunity." Metrics have shown that when it comes to quality of care, readmission rates, and patient satisfaction rates, improvements have not been consistent across the board and some units been successful while others have "struggle[d] a little bit more."
And while quality markers improved significantly, surprisingly, the CNL role did not seem to affect patient satisfaction rates.
Despite the understandable bumps along the way, Baptist Health has seen strong improvements in its quality metrics. "Those continue to improve on an annual basis," she says.
According to Raines, bloodstream infections and pressure ulcers are practically at zero. As a system, there's been a gradual trending downward of readmissions rather than a sharp decline. "We'd like to see that stronger," Raines says.
Falls continue to decrease, and though they still have more than they like, the numbers are the lowest they've ever been. UTI rates have not improved, so a navigator and an infection prevention specialist are now focusing on ways to decrease those rates.
"We were having inconsistent methods for [catheter] insertion and that gives the navigator on their unit the opportunity to focus on technique," says Raines.
One point to keep in mind is, that the nurse navigator or CNL "does not work in a vacuum," she says. "So part of the success of a program like this is [that] you've got to have a strong physician partnership, you've got to have committed social workers, etc. We still have a ways to go."
Informatics nurses are seen as having great influence over workflow, patient safety, and user acceptance of clinical systems and processes, results from a HIMSS survey reveal.
Informatics nurses are increasingly recognized as valuable assets to healthcare organizations according to data from HIMSS' 2015 Impact of the Informatics Nurse Survey. The results were released in conjunction with the nursing symposium at the 2015 HIMSS Annual conference in Chicago this week.
Maureen McCausland, DNSc, RN, FAAN,
Senior VP and CNO
Of the 576 respondents, which included C-level executives, (one in five respondents said their organizations employ a chief nursing informatics officer) clinical analysts, and informatics nurses, 60% reported that informatics nurses have a "high degree" of impact on quality of care.
More specifically, informatics nurses were seen as being most valuable during the implementation and optimization phases of clinical systems processes, and were said to have great influence over workflow, patient safety, and user acceptance.
Maureen McCausland, DNSc, RN, FAAN, senior vice president and chief nursing officer, MedStar Health, set the tone with her opening keynote session: Transforming the Vision of Nursing. "Nursing is not a binary profession, she said. "Innovation is essential to our practice."
McCausland predicted that because of new care models, big data, and other changes in healthcare delivery, nursing would move from using "evidence-based practice to practice-based evidence."
One example:At San Diego County's Palomar Health, a community-based health care services provider serving communities in an 850-square-mile area, informatics nurses are heavily invested in improving nursing workflow by addressing the issue of alarm fatigue.
When the health system opened its new hospital in Escondido, CA, it went to a distributed nursing model where there was no central nurses' station and nurses were kept close to the patients' bedsides. This called for alarms to be routed directly to staff members.
Because the number of alarms could easily become overwhelming, the informatics nurses asked questions about what the alarm parameters should be, what type of staff (nursing assistants, respiratory therapists, etc.) alarms should be routed to, and the alarms' escalation paths. The key takeaway: Always monitor the process before making changes.
Leading the Way
Stephanie Poe, DNP, RN-BC, chief nursing information officer, The Johns Hopkins Health System, got her start in informatics by coloring in bar charts with colored pencils. "I've always been fascinated by data," she said.
Pamela Cipriano, PhD, RN, NEA-BC, FAAN
The memory of sharing her early, handcrafted graphs with surveyors from The Joint Commission may make her cringe, but it was this dedication to using data and technology to make improvements in patient care that earned her the CNIO title.
Poe said CNIOs are valuable because they can be a bridge between education, quality, practice, research and IT. And while nothing has changed about the way she thinks or implements projects, she believes a title lends clout. "[It] changes the way people react to you and what you say."
In her closing keynote address, American Nurses Association President Pamela Cipriano, PhD, RN, NEA-BC, FAAN, focused on how nursing informatics is necessary to meet the demands of the changing healthcare landscape.
"In order to accomplish so many of the lofty goals we have in healthcare and health policy today," she said, "we have to have that enabled by health IT." Among those goals are improving patient safety and healthcare quality and decreasing adverse effects.
"Information technology is the steel thread running through achieving most of these goals. We have to be able to harness the ability and the technology we have to have data."
She finished her address by encouraging informatics nurses, and nurses in general, to become active and involved to help improve healthcare. She emphasized that change will only take place if nurses speak up and talk with leaders, colleagues, and other nurses about important issues.
Men represent less than 10% of the nursing workforce. The number of men in nursing programs is slightly greater, but there is still much work to be done when it comes to creating a diverse nursing workforce.
When Dale Beatty, BSN, MSN, RN, NEA-BC, went to nursing school in the 1980s, he was the only man in his school's nursing program. And, because of social stigmas attached to being a man in the nursing profession at that time, he withheld the fact that he was enrolled in nursing school from his father.
"I'm not proud of it, but for the first six months I was in the College of Nursing, I never shared it with my father," he said. "I love my father dearly, but he said, 'Don't go into that profession. You will never have a good income, and you will never have a good life.'"
But following his heart rather than his father's advice turned out to be the right decision for Beatty, now CNO at University of Illinois Hospital and Health Sciences System in Chicago. "I've got a fabulous life, I've worked with great people, and I've got a terrific career," he says of his 30 years in the nursing profession.
Beatty shared his story this month at a Men in Healthcare panel discussion during Resurrection University's Thinking Out Loud speaker series. Seven other men with careers in nursing, radiography, and health information management joined Beatty at the university's Chicago campus to share their experiences working in healthcare.
Breaking Down Stereotypes Various surveys report men account for about 7%–9% of the nursing workforce, and the American Association of Colleges of Nursing states that in 11% of students enrolled in baccalaureate and graduate nursing programs in 2013 were men. At 17%, Resurrection University's College of Nursing boasts a higher than average enrollment of men.
Though the Resurrection panelists are a part of the growing number of men in the profession, the majority of the five nurses said they had not initially considered nursing as a career option. "I couldn't visualize it for myself because I was constrained by social biases," says Beatty, whose mother and sister are also nurses.
To help break down the stereotype of nursing as a career exclusively for women, Beatty suggests consciously changing the words we use when we talk about the profession. "Even today, I hear us using the language 'male nurses,'" he says. "When I hear it within my own healthcare setting I stop people and say, 'Do we define attorneys that way? Do we say she's a female attorney? We don't.'"
Labeling nurses according to gender needs to stop if we hope to foster inclusivity within the profession.
"Sometimes we unintentionally, through lack of education and lack of good words, turn people away," Beatty says. "If we want to attract more men into healthcare, we have to use language that makes it interesting and inviting for men to participate in it."
Drawing more men, as well as people from different cultures and ethnicities, to nursing is necessary in order to meet the needs of patients and society.
Aric Shimek, RN
"When you think about getting rid of healthcare disparities, we have to have a workforce that mirrors that of our patient population," he says. "We have to continue to explore how we can attract all types of diversity within the healthcare profession so we can provide the best care to our patients."
Connecting Through Caring
While our culture may perpetuate stereotypes the panel members said they have been welcomed into the profession by their fellow nurses.
"My mentors have all been women," said Beatty. "I've never felt discriminated against from a female nursing colleague. In fact, I've felt the opposite, like there's a hand to help me along the way."
Perhaps this is because nurses know that, regardless of gender, people who choose nursing do it because they share common values like wanting to make a difference in society and a [having a] desire to help others.
Aric Shimek, RN, says it was seeing the images of the devastation caused by the 2010 Earthquake in Haiti that inspired him to give up a career in international real estate to become a nurse.
"Watching the video footage of that [I thought], 'I just wish I could get on a plane, and I wish someone would take me there because I can do something that could help someone,'" he said. Shimek now works in the cardiac intensive care unit at the Ann and Robert H. Lurie Children's Hospital in Chicago.
Beatty's decision to pursue a nursing career occurred when he began working as an orderly in a nursing home. "I loved connecting with people, I loved working with families," he says. "When I became a registered nurse and worked at the bedside, I loved it because I felt on most days I could come in, care for a patient, and that patient would be in a better place after my care."
Now, as a CNO, Beatty continues to help others by furthering their professional development. "My role is to help people develop to be the best that they can be at what they do and to work with groups of people so they can get outcomes that improve care for their patients."
To be a successful leader, Beatty advises being authentic and following your passion. "The best advice I received from one of my mentors," he said, "was to be true to yourself, to find your own style, and that will be your best reward. No truer words were said."
To better adapt to changes in the healthcare industry, Lakewood Health System adopted a dyad leadership structure pairing administrative and clinical leaders.
Teresa Fisher, RN, MA, BSN
If you think farm fields, cows, red barns, and silos are synonymous with the Midwest, a conversation with Teresa Fisher, RN, MA, BSN, will change your mind. Since joining Lakewood Health System in Staples, MN, a year ago, Fisher has been committed to getting rid of silos—the organizational kind, that is—through use of a dyad leadership structure.
A siloed organizational structure—defined in this case as clinical leaders heading up clinical operations—"works very well in traditional healthcare models, but it does not work when you're trying to move as a system and be system-thinking," says Fisher, COO/CNO at Lakewood, a small, independent health system comprising a 25-bed critical access hospital and five clinics.
To be successful in today's fast-changing healthcare landscape, healthcare organizations must embrace a culture of cooperation and move away the insular and narrow perspective that silos foster.
"You can't do it on your own," she says of tackling the challenges presented by healthcare reform, changing payer expectations, and new quality requirements.
Instead, an organization's executive leaders, physician partners, and other stakeholders must follow a unified vision and strategic plan. The dyad leadership structure, which pairs an administrative leader with a clinical leader, can help facilitate the partnership and cooperation needed to achieve shared goals.
A modest proposal: moving to the dyad structure
Before coming to Lakewood in March 2014, Fisher worked at Centura Health in Denver where a dyad leadership structure had been in place for three to five years. She had seen how this leadership model could help an organization adapt to the cascade of changes brought on, in part, by healthcare reform, and she thought Lakewood could benefit from implementing a similar leadership structure.
"The dyad model really allows that administrative team, along with the physician team, to be equally represented in decision-making," she says.
"My experience was that [with a dyad model] we might have better and more deliberate traction without all of the uproar, dysfunction, and debacles that can happen when you have your traditional administration leadership not partnered with the physicians," Fisher says.
Though the dyad model would be an adjustment for everyone at Lakewood, its use would actually make it easier to cope with changes in the future.
After a few months as CNO, Fisher proposed that a dyad model be implemented at Lakewood, and President/CEO Tim Rice agreed. As part of the restructuring, Fisher's original role of CNO was expanded to a dual position of CNO/COO, and she was paired with CMO John Halfen, MD, to form the "system dyad." The pair have been working together to run day-to-day operations at Lakewood since August. The other dyad teams of "clinical services" and "growth and development" were rolled out last month.
Opening the channels of communication
Even though she previously had worked in a dyad structure at Centura, Fisher faced some new challenges when implementing the model at Lakewood. One major difference was the fact that Lakewood does not employee its physicians. This means that physicians working in Lakewood's system are basically independent vendors.
"You can imagine all the things we need to do as a system … will be much more challenging if we do not have a partnership between the physicians and the administration," says Fisher. "We have to get us all together on the same page with the same common goals and align as system so we're working together and not resisting change."
Change is always difficult but in an employed model, leadership has more leverage to get physicians to comply with organizational standards and initiatives. At Lakewood, mandates like that aren't an option. Instead, leaders there must rely on building trust and creating relationships, both internally and externally, in order to achieve their goals and mission.
That's not necessarily a bad thing.
"The biggest benefit is that we're openly communicating. We're building trust all around the organization," says Fisher. "Having aligned, common goals is critical and the dyad model helps us get there."
The cohesive problem-solving fostered by the dyad model has enabled Lakewood to tackle big changes such as joining an ACO and implementing Epic's EMR. Another example is the creation of an 18-month strategic plan aimed at maintaining Lakewood as a successful independent facility that meets the needs of patients and the community. The plan was posted online for anyone to view.
"The benefits [of the dyad approach] outweigh the traditional model of 'us, them, we, they,' " says Fisher. "We talk about everything and I meet daily with my partner. We don't make decisions independent of each other."
The number of RNs with doctorates of nursing practice is growing, but CNOs are still unclear about how DNP-prepared nurses can apply their skills and knowledge to benefit their organizations and the healthcare system.
In 2004, the American Association of Colleges of Nursing released a position statement recommending that "entry into practice" education for advanced practice nurses be raised from a master's degree to the doctoral level by 2015. Nurses with practice doctorates were rare at that time. According to AACN data, only three schools offered doctorate of nursing practice programs and there were only seven DNP graduates when the statement was released.
Catherine Nichols, DNP, APRN, BC,
Barbara Ann Karmanos
Though the 2015 goal hasn't been met—many schools still educate APRNs at the traditional master's level—the number of DNP programs and graduates has increased enormously over the past decade. In 2014 there were 269 schools with practice doctorate programs and 3,065 DNP graduates, while another 18,352 students were enrolled in DNP programs, reports the AACN.
As the number of DNP-prepared nurses continues to grow, many healthcare professionals are asking, "What are we supposed to do with them?"
Nichols surveyed CNOs at public and teaching hospitals in Michigan to assess their views on the use and effect of DNP-prepared nurses at their various facilities. She asked about DNP nurses' practice settings, employment of the four types of APRNs, chief nursing officers' satisfaction with DNP-prepared nurses' organizational impact, and their opinions on DNP nurses' influence on achieving patient-centered outcomes. Her study findings, which were published in the February 2014 issue of The Journal of Nursing Administration, were quite telling.
A lack of knowledge about DNPs
Nichols' study found gaps in CNOs' knowledge about the expectations, competencies, and projected outcomes of DNP-prepared nurses. After reading the study and speaking with Nichols, I'd characterize CNOs' views of the role of nurses with DNP degrees to be nebulous and narrow. They think hiring DNP-prepared nurses might be a good idea, but they're foggy on the specifics of how these nurses could contribute to their organizations. What's more, they don't fully grasp that DNP-prepared nurses can fill a broad range of roles.
For example, in Nichols' study, CNOs reported they'd most likely hire a DNP-prepared nurse as vice president for patient care, while the least likely role was CEO.
"I think that speaks volumes about a lack of knowledge about who we are, what we do, and what we can bring to the table," Nichols says.
The CNOs' responses to an open-ended invitation to share their thoughts about the DNP degree and employment of DNP-prepared nurses seem to validate Nichols' observation.
She shared some responses from the study:
"Having a DNP [prepared nurse] would be wonderful, however, we don't require that level of preparation for any of our current positions and given the uncertain state of healthcare reimbursement, we'll not be creating positions requiring DNP-prepared nurses."
"So far there is not a good understanding by other disciplines of what makes this different or better than MSNs."
Confusion about DNP-prepared nurses "is a real issue," she says. "We as DNPs need to be able to articulate what we bring to the table above and beyond an MSN-prepared nurse and why we're going into this doctorally prepared realm."
As someone who began her APRN career with an MSN, Nichols understands the differences between the two degrees. DNP students obviously face more hours of theory, research, and clinical time than their MSN counterparts, but they also start to assess patient care and the healthcare system's needs in a new way.
"I used to think, 'This is what I do: I diagnose and I treat,' " she says. "Now I have to ask, 'Where else does this patient go? What other kind of direction can I give them?' "
Her expanded perspective goes beyond getting the most appropriate care for her patients.
"I have a far better grasp now, coming out the other end, of what it means to be an APRN than did I going in," says Nichols. "Now I see myself working within a healthcare setting that's part of a much larger setting, as well as the whole piece of who we are as Karmanos Cancer Institute in relation to the rest of the healthcare system in the Detroit Metropolitan area, the state, and the nation. I pretty much never thought of that before and never connected with it before."
Karen Goldman, MSN, RN, AOCN
Senior VP and CNO
Nichols describes her thinking as more global and holistic now since she completed her DNP.
"I see DNPs being leaders within healthcare, definitely in nursing, guiding our nursing discipline through this maze we call America's healthcare system," she says. "I see DNP-prepared nurses increasing access to healthcare and being leaders and developing programs."
DNPs: The role of the future?
So does Karmanos' senior vice president and CNO, Karen Goldman, MSN, RN, AOCN. While Nichols' study found that employers had some uncertainty about DNP-prepared nurses, Goldman is a CNO with a very clear vision of what those nurses can do.
Even though she does not have a DNP herself—she is an MSN-prepared nurse practitioner with a minor in administration—Goldman has incorporated DNP-prepared nurses into the nurse leadership team at Karmanos. In addition to Nichols, Lisa Chism, DNP, GNP-BC, NCMP, FAANP—who wrote a book titled The Doctor of Nursing Practice: A Guidebook for Role Development and Professional Issues—is clinical director and nurse practitioner at Karmanos' Women's Wellness Clinic. Goldman also encouraged Karmanos nurse practitioner Lisa Zajac, MSN, APRN-BC, OCN, to go back to school to pursue a DNP to better prepare her to achieve her goal of becoming a CNO.
"To me, [the DNP] is the perfect role to take nursing leadership to the next level," says Goldman. "I'm at the end of my career right now, but [there were things] I had to learn and pick up on my own, and I see [DNPs] coming out with a much better skill set than I had when I started this role."
Goldman says that because DNP-prepared nurses are educated in complex leadership issues, they are able to contribute to organizations and to healthcare in several ways, including as educators, clinicians, consultants, healthcare policy experts, and advocates.
"I look at the breadth and depth of this degree and I feel it will bring a new era into nursing," she says. "It's going to be the role of the future."
First-person accounts of clinical experiences help MGH nurses reflect on and apply new knowledge to their clinical practice. The hospital even includes written clinical narratives in employees' annual performance evaluations.
Nursing is often called an art and a science. But what, specifically, makes nursing an art? If you ask a few nurses they'd likely say that the art lies in the use of soft skills like interpersonal communication, empathy, and active listening, while the application of clinical knowledge makes it a science.
When I was in nursing school two decades ago, I learned it was important to find a balance between those two sides of the caregiving coin. Nursing has evolved since then, and today there's a much greater emphasis on evidence-based practice, tracking clinical outcomes, and synthesizing data into patient care. Throw in the increased use of technology and it can seem like the science of nursing has trumped its art.
But at Massachusetts General Hospital in Boston it's a different story—literally. Clinicians there have been practicing the art of storytelling since 1996. That's when Jeanette Ives Erickson, DNP, RN, FAAN, senior vice president for patient care services and chief nurse at MGH, spearheaded the use of clinical narratives as a way to help clinicians in nursing, occupational therapy, physical therapy, respiratory therapy, social work, and speech-language pathology articulate their contributions to their patients, their colleagues, and the organization.
Ditomassi, executive director of patient care and Magnet recognition at MGH, and Smith, professional development manager at MGH in the Institute for Patient Care, explained to me how they use clinical narratives to enhance nurses' clinical skills and further their professional development.
Details bring clinical situations to life
"A clinical narrative is a first-person story from a clinician regarding a patient situation that has meaning to them," says Ditomassi. Recognizing the right story to tell is easy, as a rule. "It's usually the [one] that stays with you no matter what."
Struggles and triumphs alike can present opportunities for deep learning about the clinical process.
"We ask [clinicians] to tell us about what was happening, what they were thinking, and what stood out to them," she says. "When you engage them in what happened by asking questions, the story moves to become something larger and much more involved."
Small details bring the big picture into focus and help the manager and clinician understand the nuances of the situation.
Small details bring the big picture into focus and help the manager and clinician understand the nuances of the situation.
"Our practice is much more than the facts," says Smith. "It's contextual."
Once the story has been told verbally, the clinician writes it down. This helps him or her reflect on what occurred, why and how it happened, what they could have done differently, and what was done well.
Setting a course for staff development
The clinical narrative isn't just a chance for sharing and understanding an experience. At MGH, written clinical narratives are included in employees' annual performance evaluations.
"The clinical narrative serves as a platform to discuss the clinician's practice and professional development goals moving forward," says Ditomassi. "The director and CNS [clinical nurse specialist] can hone in and understand challenges in a new way."
This helps identify specific areas of practice where clinicians can grow their skills. "In the past when you had an appraisal, those areas for continuing development may not have been as clear," says Ditomassi.
The stories help managers tailor a professional development plan to meet the unique needs of staff members. "There can be individual coaching, education, or time spent with a clinical expert," says Ditomassi.
If there was any skepticism from clinicians about sharing their stories during a performance evaluation, that uneasiness has long since resolved.
"Staff realize this is the most powerful conversation they will have this year, because it's about their practice," says Smith.
Changing nursing practice
MGH's experience illustrates the many ways nursing science can benefit from the art of storytelling. The authors say the use of clinical narratives helped create a reflective practice environment that has contributed to improvements in patient safety, nursing care, interprofessional communication, and patient and staff satisfaction.
"It's had a critical impact in making our work visible," says Smith. "Through dialogue with the writer you get to appreciate the clinician's critical thinking and expertise in practice."
"It brings a depth to practice that sometimes others, nurses included, overlook," says Ditomassi.
Ditomassi says after hearing or reading a colleague's clinical narrative, nurses begin to critically assess their own practice.
"They might ask questions like: 'Why is she good with that patient? How is she able to do that? What's in her toolbox?' " she says.
When they find themselves in a similar situation, nurses can recall what they learned from their colleagues' clinical narratives and apply that knowledge to their own situations.
"It gives me a landmark in country that is new to me and helps me find my way," says Ditomassi.