If nurse leaders want staff to practice self-care, they must act as role models.
"Lead by example," and "Actions speak louder than words," are two sayings that imply authentic leadership. Yes, they may be cliché sayings, but there is a ring of truth to them, especially when it comes to healthcare workplace wellness and dealing with nurse stress and burnout.
The nurse executives often cited issues in nursing such as staff salaries and compensation, financial constraints, hiring limits, increased nurse-to-patient ratios to drive productivity, counterproductive relationships, and authoritative improprieties as contributing factors to moral distress.
"From the leader's perspective, with so much focus on finance and outcomes and all these mergers and acquisitions, you [become] worried about job security," says Adele A. Webb, PhD, RN, FNAP, FAAN, Assistant Dean, External Relations & Partnerships at Capella University. "There's a lot of things that are contributing to raising the stress level in the workplace. So, [how can we protect] ourselves [from stress] and then protect the people that are important to us and work with us?"
Self-care actions speak louder than words
"About wellness or self-care, I think the most important message is that [nurse leaders] need to model the behavior that you want your staff to adopt," says Webb.
Webb shares an example of a time when, as a nurse leader, she may have unknowingly sent the wrong message to her staff.
"On Sundays, I would sit and send a ton of emails because I had time. But my staff came [to me] and said, "We feel like we have to respond. You're taking away our day off," Webb recalls. "I was putting so much pressure on them to respond to these emails that didn't need an immediate response. It was just that I had time."
Webb took the feedback to heart and stopped sending Sunday emails, so the staff didn't feel like they needed to be checking their email and responding on their day off.
"I encourage leaders to be self-aware and look at your own behavior," she says. "Is this what you want for your staff? And if it isn't the behavior you want for your staff, then you need to find a way to adopt the behavior that you think is going to help them because it's going to help you, too."
In a recent interview with HealthLeaders, Webb shared some specific ways nurse leaders can quickly bring down their stress levels in minutes without even leaving the building.
"Sometimes we say, 'I know I should exercise, but I have to drive to the gym. I have to pay the fee. I don't have the shoes," Webb says of reasons many people don't participate in stress relief habits like exercise.
But, as she points out, breathing is free, and "you're already breathing."
This technique has been promoted by integrative medicine physician Andrew Weil, MD, to combat anxiety and aid with relaxation.
Webb describes the method as inhaling the breath for four seconds, holding it for seven seconds, and then exhaling for eight seconds.
"You can repeat [this technique] as many times as you need, but you need to do it at least three times," she says.
"With 4-7-8 breathing, some people get dizzy, so the belly breathing is an option to do the same thing in a way that's less constrictive," Webb says.
To perform belly breathing, put one hand on your chest and one hand on your stomach. Breathe slowly through your nose as your stomach expands.
"Feel your stomach go down as you breathe," Webb says. "That helps you concentrate because your hands are involved. Now you're concentrating, not just through your breathing, but also with touch."
3. Meditation
Some may bristle at the thought of meditation, but as Webb points out, the practice doesn't have to be a spiritual exercise.
"It's really just concentrating [on something]," she says. "Many hospitals now have quiet rooms. They'll have a picture on the wall and you can just focus on the picture."
In 2013, a room like the one Webb describes was created at Cancer Treatment Centers of America (CTCA) Chicago in Zion, Illinois. During the first three months it was open, the room was used by nurses over 422 times, and 96% of nurses surveyed said their anxiety levels decreased after they left the room.
Webb says intentionally humming a song can help leaders' shift stressful thoughts out of their minds.
"When you're humming, you're not really thinking about anything else. It's a really good thing to do if you're walking down the hall. It just clears your mind," she says. And she encourages picking a song that has a connection to joy.
5. Dancing
Studies have found that physical activity in general, and dance in particular, can lower stress and anxiety.
"If you see a nurse having a hard day, twirl them around," Webb suggests. "Have a little dance party or tap out a rhythm at the nurses' station. Before you know it, everybody's doing it."
6. Yoga
Studies have found that yoga has benefits specific to nurses including reports of higher self-care and less emotional exhaustion and depersonalization compared to control groups that did not take part in yoga.
"If you have an office, you can get into one of these poses," Webb says.
When it comes to self-care, stress management, and wellness, Webb says its time to push pride aside for the good of nurses and patients.
"So many people say, 'I can [deal with stress]. I'm tough. I can push through,'" she says. "But we're hurting ourselves [because it] is trickling down to your family and trickling down to your staff. [And nurses] trickle it down to their patients. It's really our opportunity to recognize that our wellness is important, to respect ourselves enough to take a minute, and to model that for our staff."
Editor's note: This story has been updated to reflect Cancer Treatment Centers of America (CTCA) Chicago's most recent name. The previous version of the story listed the organization's prior name Cancer Treatment Centers of America at Midwest Regional Medical Center.
Nursing homes only met nurse staffing requirements less than 60% of the time, a new analysis finds.
When patients are admitted to a nursing home, it's usually because they're unable to care for themselves at home. While it's a difficult choice, families often make the decision to ensure their loved ones get the care and assistance they need.
But a new analysis of payroll-based staffing data for U.S. nursing homes, uncovered large daily staffing fluctuations, low weekend staffing, and daily staffing levels that often fall well below the expectations of the Centers for Medicare and Medicaid Services.
The study, published in the July issue of Health Affairs, found that when compared to weekday staffing there was a large drop in weekend staffing in all staffing categories, based on CMS' data resource, the Payroll-Based Journal.
In fact, the average weekend staffing time per resident day was just 17 minutes for registered nurses, nine minutes for licensed practical nurses, and 12 minutes for nurses' aides.
Additionally, using PBJ data from more than 15,000 nursing homes, researchers discovered that 54% of facilities met the expected level of staffing less than 20% of the time during the one-year study period. For RN staffing, 91% of facilities met the expected staffing level less than 60% of the time.
CMS does not mandate a staff-to-resident ratio standard for nursing homes, but it does require that an RN must be present for eight hours a day, and an RN or LPN must always be present at a facility.
To meet a requirement of the Affordable Care Act, CMS has been collecting data from nursing homes since 2016. PBJ data have been used in the federal Five-Star Quality Rating System for Nursing Homes since April 2018.
"Staffing in the nursing home is one of the most tangible and important elements to ensure high quality care," study co-author David Stevenson, PhD, a Health Policy professor at Vanderbilt University Medical Center says in a news release. "Anyone who has ever set foot in a nursing home knows how important it is to have sufficient staffing, something the research literature has affirmed again and again. As soon as these new data became available, researchers and journalists started investigating them, and the government now uses the PBJ data in its quality rating system."
Unlike previous nursing home staffing data that was self-reported by facilities and covered only a narrow window of time around a facility’s annual recertification survey, PBJ data are linked to daily payroll information for several staff categories and cover the entire year.
"We found that the newer payroll data showed lower staffing levels than the previous self-reported data," says co-author David Grabowski, PhD, professor of Health Care Policy at Harvard University. "The lower levels in the PBJ data likely reflect both the fact that they are based on payroll records as opposed to self-report, and also that staffing levels were abnormally high around the time of the inspection. In fact, the PBJ data clearly show this bump, followed by a return to normal after inspectors leave."
Stevens says he hopes families and future nursing home residents become aware of and push back against these staffing practices.
"Hopefully, the general public will gain a broader awareness of the information that is available, not only on staffing but on other aspects of nursing home care," Stevenson says. "The only way nursing homes will change their behavior is if there is value in doing so. Some of that can come through the pressure of regulators, but it also needs to come from incentives in the marketplace, notably from expectations of current and future residents and their families."
In 2019, an online survey was sent to nearly 17,000 email addresses of AONL members and nonmembers for the third edition of the study. 2,145 respondents completed or partially completed the survey for a response rate of 13%, according to the study's executive report.
The data collected gives insight into nurse leaders' salary ranges, compensation, and job satisfaction.
Below are some of the study's findings.
Where they work
39% of respondents work at acute care hospitals (long-term or short-term)
27% work in academic institutions
5% work in a system/corporate office
29% work in other settings
Job Titles
The three most common job titles among the respondents are:
67% of respondents have worked in nursing for more than 20 years
70% have been in their current position for five or fewer years.
7% are 35 years old or younger.
86% of respondents are white.
88% are female.
Salary Data
When it comes to the range of overall salaries among nurse leaders:
57% make between $90,000 and $169,999
33% make $170,000 or more
10% earn less than $90,000
Nurse leaders with senior-level titles earn higher salaries than other nurse leaders.
The majority of non-system CNOs/CNEs, system CNOs/CNEs, consultants, presidents/vice presidents, and respondents with other c-suite titles earn more than $150,000 per year.
71% of directors fall between $100,000 and $169,999 annually.
72% of managers report an annual salary of $80,000 to $129,999.
AONL has nine geographic regions and salary varies according to location.
Nurse leaders in Region 9 (Alaska, California, Hawaii, Nevada, Oregon and Washington) have the greatest percentage of respondents (69%) earning $150,000 or more.
Region 6 (Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota and South Dakota) has the lowest percentage of nurse leaders making $150,000 or more (30%).
Bonuses and Incentives
70% of respondents say they are eligible for an incentive or bonus award.
55% of respondents not eligible for a bonus award earn less than $130,000 per year.
61% of respondents received an incentive or bonus in 2018.
Bonuses were received for factors such as an organization's financial performance (75%), clinical performance measures (66%), and customer or patient satisfaction (54%).
Job satisfaction
On a five-point scale, with 5 being "very satisfied” and 4 being "somewhat satisfied":
42% of respondents rated job satisfaction as very satisfied
40% rated job satisfaction as somewhat satisfied
Respondents were less satisfied with the benefits and compensation portion of their jobs.
39% say they are very satisfied with their benefits
29% say they are very satisfied with their compensation
What's the key to successfully recruiting and retaining nurses? Here's how one nurse leader made meaningful changes to attract and retain top-notch RNs.
The nurse turnover rate was about 22%, and some departments had vacancy rates as high as 24%, she says.
According to the recruitment firm NSI Nursing Solutions, Inc., the average national turnover rate for bedside RNs was 16.8% in 2017.
With five other hospitals within five miles, there was stiff competition for nurses and patients. Nurse recruitment at Rush Oak Park Hospital was also hindered by a negative reputation because of its poor quality outcomes and a restrictive policy to hire only nurses with experience. In addition, a revolving door of chief nurse executives led to a lack of consistent leadership and vision.
"When you have bad outcomes, and leadership is beating you up and telling you how bad you are, as a staff nurse—even if you are a great nurse—you feel hopeless because nobody wants to work in an environment where they feel like they're providing bad care," Mayer says. "There were excellent, excellent nurses working here, yet the punitive environment resulted in a lack of respect [toward nurses] by physicians [and] administrators, and from nurse to nurse."
Mayer, however, was up for the challenge of changing the work environment. She dug in and through hard work, was able to change nursing's reputation at the organization and in the community. Additionally, she was able to change the culture that lead to huge leaps in recruitment and retention.
"No nurse wants to be a bad nurse," she says. "I had experienced a bad environment where I saw it get totally turned around, and so I felt that I could make a difference in changing the lives of these nurses."
Today, turnover rates are 8.3%, and the only vacant position she has is one in the operating room.
Mayer is the first to say the change didn't happen overnight. The turnaround took many years of hard work, and a combination of solutions and interventions. Still, it can be done when a CNO has a clear vision for nursing and is willing to take risks and build upon successes.
Revamp the hiring process
Mayer's first step to improvement was to focus strictly on recruitment. That meant improving nursing's reputation outside the organization and overturning Rush Oak Park Hospital's previous policy that said it wouldn't hire RNs without experience.
"They had gone for years of just not hiring anyone because no one with experience was applying," Mayer says. "So [we just focused] on recruitment. With the competition of five other [surrounding hospitals] and the poor reputation, we first had to figure out how we could even get people in the door."
Mayer says at that time there was a glut of nurses who could not find jobs after graduation since other organizations also had "you-must-have-experience" policies. Additionally, Rush University School of Nursing graduated its first cohort of clinical nurse leaders, and because Mayer was open to hiring entry-level, master's-prepared nurses, she hired about 25% of the first group of graduates.
After the policy change, she worked with human resources to ensure all nurse applicants were contacted for an interview within 24 hours of application. All applicants, even ones who would likely not make the cut, were scheduled for an interview, and Mayer interviewed each candidate.
"This was our one opportunity to sell ourselves. We wanted to get the message out that we were truly different from what was expected. We decided that the only way to do that was by having the CNO [me] meet with every single one of [the applicants] and identify what [Rush Oak Park Hospital's] vision for the future would be," she says.
"It accomplished sort of a ‘wow effect' because nowhere else did they get to actually meet the CNO. It also made them [think], ‘Whoa, I love that vision. I want to be part of that and I want to help get them there.' We wanted them all walking away saying, ‘I wish they would have offered a job to me. I would have loved to have worked there.' That's what we had for marketing—word of mouth," Mayer says.
The organization also moved to a behavioral interview process.
"We were seeking individuals who had what I call 'self-efficacy.' People who like a challenge, people who want to be part of fixing things," she says.
A Shift to Nurse Empowerment
Once the stream of applicants and new hires began to flow, it was time to focus on getting nurses to stay with the organization.
"During the first two years [of changing our recruitment strategy], we were still experiencing a lot of turnover … because so much more needed to be put into place so that once [the nurses] got in the door, they would want to stay," she says. "This meant addressing some of the cultural issues related to empowerment."
This included moving to a shared governance structure and coaching managers who weren't familiar with a collaborative leadership style. Additionally, it meant developing a clinical ladder to foster both career development and recognition, both of which are important to retention of
seasoned and newly licensed RNs.
"We were using tons of expensive agency [nurses], so that extra amount of money actually justified us developing a clinical ladder that had criteria tied to increases in salary," she says.
Adopted in 2008, the clinical ladder established three levels of nurses:
Level 1: Entry-level RN
Level 2: An RN who practices independently and can function as a charge nurse or preceptor to new RNs or students
Level 3: An RN who demonstrates high-level proficiency that is aligned with the organization's professional practice model
To achieve level 3 status, an RN must:
Have a BSN degree and professional certification if eligible
Submit a letter of recommendation
Provide an exemplar of his or her holistic nursing practice
Submit a portfolio highlighting his or her professional development and activities
The fact that promotion along the clinical ladder was based on achievement versus tenure did make some experienced nurses uncomfortable at first.
"There are definitely cultural value differences between millennials and boomers. I'm a boomer, and we're about experience," Mayer says. "But as some of the millennials would be reaching one-and-a-half years' experience, they were achieving some of the things that qualified them for level 3 [on the clinical ladder]."
Mayer addressed nurses' concerns by sharing with them that the decision was made based on research that found quality outcomes and mortality rates improved in organizations where the majority of nurses were BSN-prepared and held certifications.
When the clinical ladder structure was implemented, the BSN rate was about 12%, says Mayer. Today 84% of the organization's RNs have a BSN or higher, with 20% of those nurses holding a master's degree in nursing. When Mayer came to Rush Oak Park, only two nurses held specialty certification, whereas today 54% of all bedside nurses hold a certification.
Hard Work Yields Positive Outcomes
Because of Mayer's changes to nursing recruitment and retention, Rush Oak Park is now known for nursing quality.
For example, hospital-acquired pressure ulcer rates have dropped from 20% to none above stage 2 for the past two years, thanks to improved documentation and screening.
Still, Mayer says she has no plans to rest on these laurels.
"When it comes to recruiting and retention, it's an ongoing battle," she says. "Even when you get so good that you have almost no vacancies and you have a waiting list to get into your hospital."
When patients feel nurses are listening to them, they self-report better care outcomes and a happier healthcare experience.
Nurse leaders are quite familiar with this question from the HCAHPSsurvey: "During this hospital stay, how often did nurses listen carefully to you?"
And though the question seems straightforward, active listening in the healthcare environment is more complex than it sounds.
"Because listening is so integral to who we are as human beings, we have a sense of when somebody's listening but we can't necessarily articulate it," says Nancy Loos, PhD, RN, NE-BC, program manager, risk management at Dignity Health Northridge Hospital Medical Center in California.
Loos says active listening can influence HCAHPS scores and patient care compliance, and it can affect an organization's financial health.
"At the end of the day, you're going to get money taken away if you don't meet these scores," she says.
Loos says that nurse leaders must heed this advice: "If they're rounding on patients, ask them if they feel that the nurses were listening to them. These behaviors can be taught. Leaders can highlight that listening is a priority and acknowledge that it's important and not some soft, fluffy thing."
The Finer Points of Listening
To improve nurses' listening skills and create a better patient experience, nuances regarding listening must be understood.
Well before Loos began her doctoral study, she had an interest in the concept of listening. In a former position as director of nursing operations, she had been tasked with improving HCAHPS scores pertaining to nurse listening. She turned to the nursing literature for guidance but found little on listening from the patient's perspective.
"I thought, 'What do I tell my nurses to do? What behaviors do I tell them to work on?' " she recalls.
Now, thanks to Loos' research, nurse leaders can help nurses develop behaviors that patients say make them feel listened to and have a better patient experience.
How Patients Perceive Listening
The aim of Loos' qualitative study was to understand from the patient's perspective:
which nurse behaviors imply listening has or hasn't occurred
how inpatient experience with nurses who either listened or did not listen affected the study participants during hospitalization and after discharge
Loos interviewed 23 patients from 15 different health systems in Southern California after they were discharged from their inpatient stay.
"I did not want to have to ask them questions while they were still in the midst of their stay and there is the power differential," she says.
Some of the questions she asked the study participants were:
What comes to mind when you hear the word "listen" or "listening"?
Consider your recent hospitalization and recollect a registered nurse who you believed listened to you. Can you please describe the setting and what the nurse did that made you feel he or she was listening?
During your recent hospitalization did you encounter an RN who you believed was not listening to you? Can you please describe the setting and what the nurse did that made you feel he or she was not listening?
In what way did the nurse's listening or not listening affect your experience in and beyond the hospital?
From the answers to these questions, Loos quantified the number of times study participants mentioned both verbal and nonverbal behaviors they described as listening behaviors. For example, 13 patients (57%) identified asking questions as a verbal listening behavior, and 16 patients (70%) mentioned eye contact as a form of nonverbal listening.
These concepts were then divided into themes related to listening and non-listening behaviors. They are described as follows:
1. Positive Listening Behaviors
Three themes emerged regarding positive nurse behavior that made patients feel listened to.
Making a Connection
Loos describes this particular theme as the most "compelling" theme of all.
"It seemed like everything else that happened hung on that. How the rest of [the patient's] day went depended on whether that connection was made at the beginning of [the shift]," she explains.
"It means [the nurse] notes that [the patient] is different than the person in the next room," she says. "Once that connection was made, it's almost as if everything else the nurse did was okay. They were trusted," Loos explains.
Verbal behaviors that support making a connection include asking questions and personalizing care, prompting the patient to share, speaking to the patient directly, and talking to the patient before performing a care task, she says.
"[These behaviors] … didn't have to be for a long length of time. It was just enough time to say, 'I see you. I hear you [to the patient],' " she says.
Nonverbal behaviors that contribute to the nurse-patient connection include eye contact, body language (particularly sitting), and performing individual patient care preferences, Loos says.
Putting the Patient at Ease
Loos found verbal behaviors that help put the patient at ease include narrating care, anticipating questions, providing reassurance, including family in discussions, and not complaining about job tasks.
Nonverbal behaviors found to support putting the patient at ease include follow-through, empathy, not rushing to get out of the room, and therapeutic touch, she says.
One patient who participated in the study mentioned the reassurance she felt when nurses rubbed her hand, Loos says.
Ensuring Safe Care
"Patients have read [about] things that happen in healthcare environments, so they're concerned about their safety," Loos says.
Verbal behaviors that make patients feel they are receiving safe and effective care by nurses include answering patient questions, repeating back what the patient says, passing along information, and asking if interventions worked, she says.
Nonverbal behaviors that contribute to a sense of patient safety include nurses assisting when needed, noticing patient body language, believing what the patient says, taking notes, taking direction from the patient, and taking nothing for granted, Loos says.
2. Negative Listening Behaviors
Loos also identified themes and behaviors that make patients feel they are not being listened to.
Arrogance
In her dissertation, Loos describes arrogant actions by nurses indicating they knew better than the patient, even when it came to something subjective like the patient's experience of pain. Additionally, acting in ways that were dismissive of a patient's right to participate in his or her care were interpreted as arrogant by the patient.
Verbal behaviors that convey nurse arrogance toward patients include sarcasm, rude responses, speaking in a language the patient does not know, and blaming others for unfulfilled responsibilities. Nonverbal arrogant behaviors include not believing the patient and dismissing patient concerns, Loos says.
Abuse of Power
Patients often feel vulnerable in the healthcare setting. Perceiving that nurses are abusing their power leaves patients feeling that they are not being listened to, Loos says.
Verbal behaviors that imply an abuse of power by nurses include discounting or making light of patient concerns, arguing with the patient, rejection of patient input, refusing to clarify orders, and depending only on the chart. Nonverbal behaviors include not trying to understand the patient, "lazy" or uncaring body language, and standing at a distance from the patient, she says.
Incivility/Insensitivity
Verbal behaviors that patients say articulated nurse incivility and insensitivity include making up excuses, a gruff tone or attitude, and cutting off attempts at conversation, Loos says.
Nonverbal behaviors in this theme include lack of eye contact, eye rolling, acting put out, focusing elsewhere, and ignoring attempts at communication, she says.
Abrogation of Professional Role Responsibilities
"[These are] things that as a nurse, as determined by our Nurse Practice Act, we ought to be doing, whether it's presence or ensuring things happen," Loos says.
Patients feel like they are not listened to when basic elements of nursing care are not performed, she says.
Verbal behaviors include nurses not assessing a patient or asking about his or her status, implying he or she is too busy to help, not assessing a patient's readiness to learn, and not assessing a patient's understanding. Nonverbal detrimental behaviors include not following through, lack of presence, not finding solutions, and appearing rushed or scattered, Loos says.
Make Listening a Priority
Loos found that patients' perceptions of being listened to or not affect their perceptions of care.
Those who felt listened to reported feelings of comfort and safety, a happier experience, and better able to make themselves comfortable at home after discharge, she says.
For example, four patients (17%) reported "maintained/improved patient wellness," and three (13%) reported being more willing to collaborate with the plan of care.
Those who didn't feel listened to reported exacerbations of their conditions, loss of trust, loss of confidence in care, and feeling less safe. Three patients (13%) even reported refusing treatment.
"When they do feel that we're listening, it allows them to relax and sleep and recover while they're in the hospital. If they don't think we're listening, they're afraid to go to sleep or they feel they have to stay up and be their own advocate," Loos says.
"[Listening] improved adherence to the plan of care. The plan of care is important. If patients are more willing to [follow their plan of care] because of the connections that they've made with the nurse and because they felt better about the care, we should be embracing [the value of listening skills]," says Loos.
The components of the Resilience at Work tool help nurse managers identify how to build this important skill.
Burnout is a common experience for bedside nurses. But burnout also affects nurse managers as well.
In a 2014 study published in Nursing Economics, researchers surveyed 291 nurse managers working in hospitals, and found 72% of the study participants were planning to leave their position in the next five years. Burnout was the most common reason cited for intent to leave by the entire group.
This is concerning. At 300,000 strong, nurse managers are the largest segment of the healthcare management workforce. They have immense potential to influence clinical outcomes and strategic goals, says Heinrich M. Huerto, MSN, RN, ONC, CMSRN, nurse manager at Providence Holy Cross Medical Center in Mission Hills, California.
"We are juggling so many things. [We are responsible for] operations, quality metrics, staff engagement, and patient satisfaction," says Huerto. "[We're] the ones who guide the staff. If you have a lot of turnover of nurse managers, that doesn't benefit the company or its ministry because they have such an essential role in the organization."
In light of this enormous and important job scope, Huerto, along with a group of nurse managers and researchers at the medical center, wanted to find a way to better equip nurse managers to deal with the challenges that come their way, which can, essentially, keep managers from burnout.
"In healthcare, it's never-ending changes and adapting to the new changes," she says. "And we were thinking, 'How do we support ourselves and how do we support the other nurse managers?'"
The group chose to focus on what is often cited as the antidote to burnout—resilience (the ability to recover from or adapt to stress)—and how to cultivate it among nurse managers. To help nurse managers identify specific areas in their personal and professional lives where they could cultivate resilience skills, the researchers explored the use of a tool to measure nurse manager resilience. They also promoted professional development activities to develop resilience skills.
The R@W Scale Tool
While not specific to nurse managers, the researchers identified the Resilience at Work (R@W) scale and its subscales as an accurate way to assess resilience behaviors among that group.
"The tool, although it has never been used previously with nurse managers and was really a corporate-type of tool, actually had high reliability for this population," says Sherri Mendelson, PhD, RNC, CNS, IBCLC, director of nursing research and Magnet program at Providence Holy Cross Medical Center, and who was involved in the study.
Designed in 2011 by organizational psychologist practitioner Kathryn McEwen and psychological well-being researcher Peter Winwood, the R@W scale is a measure of individual workplace resilience that measures seven components that interrelate and contribute to overall resilience outlined in the R@W Sustain 7 model.
Those taking the R@W Scale survey complete a personal assessment and rank the components on a scale of zero to six, with zero being the weakest and six being the strongest in each area.
Knowing and holding onto personal values, deploying strengths, and having a good level of emotional awareness and regulation.
2. Finding Your Calling
Having work that offers purpose and a sense of belonging. Aligning work with personal core values and beliefs.
3. Maintaining Perspective
Staying optimistic and keeping a solution-focus when things go wrong. Reframing setbacks and minimizing the impact of any negativity around you.
4. Mastering Stress
Having work and life routines that help you manage your everyday stressors. Working to create work-life balance and ensuring time for relaxation and recovery.
5. Interacting Cooperatively
Seeking feedback, advice and support, and providing support readily to others.
6. Staying Healthy
Maintaining a good level of physical fitness, having a healthy diet, and getting adequate sleep.
7. Building Networks
Developing and maintaining the personal and professional support networks needed at home and at work to perform well in your job.
"It's asking about how you deal with resiliency, not only on the professional level, but also on a personal level," Huerto explains of the tool.
Strong Values, Strong Leadership
Huerto and her colleagues rolled out the R@W Scale survey to the Providence Holy Cross nurse managers. Forty-eight nurse managers responded to the survey. Huerto discovered that the nurse managers' three highest-ranked components about what they believed about themselves were Living Authentically (5.3), Interacting Cooperatively, (5.1), and Finding One's Calling (5.0).
"When I looked at those three: Living Authentically, which is living your personal values, that really is what nursing is all about," Mendelson says. "And, in order to be a leader and lead the nurses within your department, you have to be able to live by your own personal values."
Nurse managers in the Providence Holy Cross study ranked the subscale Maintaining Perspective (3.1) the lowest of all the subscales.
"If we look at the lowest [score], it suggested negative influences at work influenced nurse manager perspective. When problems arise at work, nurse managers tend to worry—and [they] worry about things while away from work. Maintaining perspective is hard when you are constantly on," Mendleson says.
Resiliency in Real Life
Naturally Huerto, like many other healthcare leaders, hoped to uncover the one secret ingredient to promote resiliency among all nurses through the study.
"I was hoping that it would have a standout result … [and be] the answer to the question: 'What do we need to be resilient?' and the "majority" of people would choose one. But it didn't go that way," she says.
Instead, the results reinforced that what is needed to develop resiliency varies from person to person.
"It's subjective and depends on what you were exposed to when you were young," she says. "Depending on hardships you've been through, you would answer it differently," Huerto says.
Yet that is the beauty of the R@W tool, Huerto explains. Through the self-reflection the R@W scale requires, nurses can identify areas where they need to build resiliency skills.
"[Nurse managers] can say, '[I] scored low in this [particular] subscale, so maybe I need to be more physically fit or I should do more deep breathing exercises or jogging or something to relieve that stress, which will help me be more resilient at work," she says.
Both Huerto and Mendelson say the R@W tool has value in helping organizations and nurse managers identify and cultivate the resilience skills needed to succeed as nurse leaders.
"One of the things within the workplace that will help with resilience for nurse managers, since most nurse managers come into their roles with a high sense of ethics, is if their organizations support their ethical values. Then they're going to be more resilient within their jobs," Mendelson says.
"[The R@W is] a good way to assess resiliency and open that topic to nurse managers—the challenges of the nurse managers, resiliency of nurse managers—as we are so focused with staff nurse resiliency," Huerto says.
Hospitals and healthcare systems are turning to new graduate RNs and staffing agencies to fill open positions.
Hospitals are largely relying on new graduate registered nurses to fill open nursing positions finds a new survey by Avant Healthcare Professionals, a staffing agency specializing in internationally educated RNs, physical therapists, and occupational therapists.
To assess national trends in nurse staffing, Avant surveyed 171 chief executive officers, chief nursing officers, and human resource executives from multiple healthcare settings including critical access hospitals, state facilities, and healthcare large systems and compared those responses to its 2018 survey.
50% of hospitals report having between 10 and 74 nurse job openings to fill
26% of hospitals are looking to fill between 1 and 10 nursing positions
61% of organizations have anticipated nurse retirements during 2019
78% of respondents say they will rely on new graduate RNs to fill open positions
Additional ways respondents plan to fill open positions are:
Internal recruitment efforts (78%)
External ads (66%)
Sign-on bonuses (36%)
Staffing agencies (34%)
Improving pay packages (28%)
It appears more healthcare executives are open to recruitment through staffing agencies than in the past. The survey results showed an 8% increase in hospitals that will rely on staffing agencies to recruit nurses in 2019 as compared to 2018.
The use of travel nurses also increased by 7% in 2019, and 13% of the hospitals surveyed are using more than 25 travel nurses this year to fill openings.
Respondents say the nursing specialties with the highest needs are:
The study analyzed responses of nearly 250,000 RNs to identify trends in intent to stay based on age, tenure, and unit type, as well as drivers of intent to stay.
"Dissatisfaction with the work environment was the most commonly cited reason for leaving," Christy Dempsey, RN, MSN, CNOR, CENP, FAAN, chief nursing officer at Press Ganey, says. Nurses across all age groups and experience levels cited this as a reason they planned to leave their job within the next year.
A 2018 article in the International Journal of Nursing Sciences, authors reviewed 54 studies on the nursing work environment and found not only do healthy work environments promote a stable and sufficient workforce, they also "promote hospital safety, encourage nurse performance and productivity, improve patient care quality, and support healthcare organizations' financial viability."
"The work environment, workloads, and the impact of things like technology and new innovations in healthcare—it's really challenging to keep up," says Kelly Johnson, PhD, RN, NEA-BC, vice president, patient care services and chief nursing officer at the organization. "[We need to] provide environments where nurses are supported in professional growth and development and staying abreast of new evidence-based practices [so they can] get to the top of their game regarding professional nursing practice."
Nursing Practice Model Focuses on Caring Science to Improve Environment
The organization has made a formal commitment to creating a healthy work environment and culture.
"We're looking at lots of initiatives around wellness in the workforce," Johnson says, "and how we promote professional fulfillment and prevent burnout and look at moral resilience and intentional integrity in healthcare."
This includes designing a nursing professional practice model, which addresses the holistic needs of both patients and staff, and implements concepts from Dr. Jean Watson's Caring Science Theoryand HeartMath.
According to its website, HeartMath is a "system that empowers people to self-regulate their emotions and behaviors to reduce stress, increase resilience, and unlock their natural intuitive guidance for making more effective choices."
The core concept of the Caring Science Theory, according to The Watson Caring Science Institute's website, is "a relational caring for self and others based on a moral/ethical/
philosophical foundation of love and values."
Some principles included in the theory are:
Moral commitment to protect and enhance human dignity
Respect/"love" for the person—honoring his/her needs, wishes, routines, and rituals
Heart-centered/healing caring based on practicing and honoring wholeness of mind-body-spirit in self and each other
Inner harmony (equanimity)—maintaining balance
Watson also outlines 10 Caritas processes that include "creating a healing environment at all levels, whereby wholeness, beauty, comfort, dignity, and peace are potentiated."
Johnson says these processes are threaded throughout all aspects of the work environment and include self-care activities. For example, the organization is in the process of creating "Caritas carts" filled with healthy snacks that can be delivered during leader rounding. This helps leaders make rounding intentional while supporting staff who may be busy and need a reminder to care for themselves.
"Our practice and practice environment reflects this theoretical foundation and embodies the theory in our practices. SCH is one of the first organizations to implement the integrated model with Caring Science and HeartMath," Johnson explains.
The organization has 23 Caritas coaches and several HeartMath trainers that educate the nurses on these self-care concepts.
"We do a lot of work around self-care and creating a work environment that is caring and healing, not only for the patients and families to receive care, but for our nurses to work in a place where we care about each other and we care about ourselves," Johnson says.
The Importance of Professional Development in Creating a Healthy Work Environment
For example, once a newly licensed RN joins the organization, the nurse is supported by a yearlong new-graduate residency and transition-to-practice program. The program enables the hospital to hire new grads into all specialties, including ones that are more challenging to fill, such as the neonatal ICU or cardiovascular care. The program has shown successful retention outcomes.
"We are close to 100% retention," she says.
Total nurse turnover is around 7%, notes Johnson. According to the recruitment firm NSI Nursing Solutions, Inc., the average national turnover rate for bedside RNs was 16.8% in 2017.
"That is the fact, [considering] that we have some high retirement areas, such as our neonatal intensive care unit and some of our maternity services," she points out.
Nurses are supported in their professional development through personal success plans, a succession planning development program, certification programs, and advanced degree programs.
Johnson says in fiscal year 2019, the organization formalized creation and assessment of personal success plans, which will be reviewed annually with a nurse's manager.
"It is a formal program where part of [the nurse's] evaluation process is developing a personal development plan and making sure that we document it and track progress towards it," she explains.
While all nurses at healthcare organizations are expected to help advance the organization's strategic goals, the personal success plans will help nurses hone their individual personal and professional goals. For example, this could mean working toward a master's degree or achieving specialty certification.
To celebrate nurses' various achievements throughout the year, the organization has an annual awards banquet.
The Workplace Violence Prevention for Health Care and Social Service Workers Act is voted out of committee.
From 2002 to 2013, healthcare workers were four times more likely to experience incidents of workplace violence that required days off for the injured worker to recover than workers in private industry, according to the Occupational Safety and Health Administration.
Bill supporters are calling on House leadership to quickly move it to a full House floor vote.
"Today's vote is a big step forward in passing legislation that would hold our employers accountable, through federal OSHA, for having a prevention plan in place to stop workplace violence before it occurs—literally a life or death issue, given the outrageous rates of violence in America's hospitals, clinics and social service workplaces," says Jean Ross, RN, president of National Nurses United in a news release. "We urge House leadership to schedule a vote on the floor of the House of Representatives as soon as possible, because every moment we lose puts lives in jeopardy."
Elaine Sherman, RN, says she was assaulted by a patient's family members, while helping a fellow nurse.
"Sometimes people think violence only happens in the ER or a psych unit, but I am a medical surgical nurse; it happens in all units," she says. "I was punched in the face seven or eight times. I didn't take a day off because my patients needed me, but it was very difficult."
She says her assault and similar incidents might have been prevented if her employer had more responsive security personnel in place, additional staffing on the units, and closer scrutiny of visitors. Preventive measures like these could be enfolded into violence prevention plans required in the act.
The Workplace Violence Prevention for Health Care and Social Service Workers Act:
Requires OSHA to create a federal workplace violence prevention standard mandating that employers develop comprehensive, workplace-specific plans to prevent violence.
Covers a wide variety of workplaces, including hospitals and other inpatient facilities, residential and non-residential treatment settings, medical treatment or social service settings, psychiatric and behavioral health settings, community care setting, and field work settings.
Sets a quick timeline on implementation to ensure timely protection for healthcare workers.
Sets minimum requirements for the standard and for employers' workplace violence prevention plans. These requirements include unit-specific assessments and implementation of prevention measures such as physical changes to the environment, staffing for patient care and security, employee involvement in all steps of the plan, hands on training, record keeping requirements including a violent incident log, and protections for employees to report workplace violence to their employers and law enforcement.
"We needed these protections yesterday—because violence doesn't just impact workers, it also impacts patients, visitors, family members and anyone in the vicinity," Ross says. "We all deserve to feel safe in hospitals, clinics and social service settings, which should be places of healing. We urge House leadership to take this to a full House floor vote without delay."
More vascular access specialists can help decrease patient pain and suffering from needlesticks.
For patients, needles are an often-dreaded part of the healthcare experience. But vascular access specialists can improve pain and suffering caused by needlesticks, say organizers of a movement to increase patients' access to these professionals.
"Vascular access specialists make a crucial contribution to maintaining those staffing ratios by allowing highly skilled bedside nurses to focus on patient care instead of being called away to assist with intravenous access," Connie Girgenti, RN, co-organizer of the petition drive, says in a news release. "Americans for Vascular Access Specialists in Every Hospital is a public call to action to improve health outcomes for millions of patients".
Vascular access specialists like Girgenti use specialized knowledge and skills to assess, place, maintain, and troubleshoot intravenous catheters to avoid complications.
Of hospitalized patients, 98% need a vascular access device. Most of these devices are peripheral intravenous catheters (PIVC). According to research, uncomplicated PIVC placement attempt costs between $28 to $35.
Girgenti says patients commonly experience multiple needlestick attempts during a hospital stay. In addition to pain and suffering, failed attempts can lead to complications like bloodstream infections, which affect clinical outcomes and increase costs.
"Every patient should only have to endure one stick when they arrive at the hospital and a specially trained inserter can do that more than 95% of the time," she says.
"We want to drive legislative change that will improve the hospital care received by millions of Americans every day, one stick for all patients from first time mothers to preterm infants to terminal cancer patients," says Sheri Pieroni, RN, co-organizer of the petition drive.
