Is the old adage, "Happy nurses equal happy patients" true?
Healthcare leaders at North Carolina–based Vidant Health have put this saying to the test. The organization committed resources to change the workplace culture for its nurses with the philosophy that engaged and motivated nurses provide better care to patients. Linda Hofler, PhD, RN, NEA‐BC, FACHE, senior vice president and nurse executive at Vidant Medical Center describes the implementation as a "holistic approach to organizational excellence" that benefits the nurses and trickles down positively to the patients.
The goal of the approach, she explains, is "to improve team member experience and rebuild joy in the workplace. [It's not just] focused on patient experience but on team member, provider, and environmental experience as well."
The Institute for Healthcare Improvement treats on the idea that creating joy in the workplace is also an antidote to burnout, which is a major issue among clinicians. In 2017, the organization released its white paper, IHI Framework for Improving Joy in Work.
Hofler became interested in a holistic approach to improving organizational outcomes when Vidant's chief experience officer Julie Kennedy Oehlert, RN, DNP, was doing doctoral research on the healthcare environment.
"[Her idea was] that if you just focus on the patient experience that you [don't] really get the engagement of your team members," Hofler says.
To test this theory, Oehlert and Hofler, along with their chief quality officer, assessed correlations among data related to employee engagement, complaints and grievances, patient experience, employee turnover data, and various nurse sensitive quality indicators.
A recent meta-analysis from Penn Nursing’sCenter for Health Outcomes and Policy Research (CHOPR) seems to support this idea. CHOPR researchers synthesized 16 years of studies to show the association between the nurse work environment (i.e., organizational elements that influence nursing care quality, such as nurse-physician collaboration, nurse manager support, and nurse involvement in decisions affecting clinical care) and four sets of outcomes: nurse job outcomes, nurse assessments of quality and safety, patient health outcomes, and patient satisfaction.
"Our quantitative synthesis of the results of many studies revealed that better work environments were associated with lower odds of negative outcomes ranging from patient and nurse job dissatisfaction to patient mortality," says the study's lead-investigator Eileen T. Lake, PhD, MSN, FAAN, the Jessie M. Scott Endowed Term Chair in Nursing and Health Policy, in a news release.
Vidant's focus on its team members' experience has been occurring for about two years, Hofler says.
"This is probably the most rewarding work I've done in a long time, but it's hard work because in the business of healthcare, people want to check a box and go on to the next thing," Hofler says. "And this is not about checking a box. It's about building networks and finding ways to create new and different ways of doing and being."
In a recent interview with HealthLeaders, Hofler shares three ways she and the leadership team at Vidant have reshaped the nurse work environment to achieve organizational excellence.
1. Nursing Salons
In the tradition of Ancient Greece and the French Enlightenment, Vidant has launched small gatherings known as salons. Historically, salons have been places where individuals increase their knowledge and share ideas and experiences through rich conversations.
During Vidant's salons, attendees—with the help of a facilitator—focus on a specific topic and engage in dialogue and learning. Hofler says the groups are limited to no more than 30 participants and meet for about an hour.
For example, the organization has a salon for leaders that focuses on the topic of empathy and is designed to be highly interactive, where participants engage in storytelling and sharing of experiences.
"During that hour, not only are you learning content, but you're learning from the experiences of the other people in the room, so it becomes very rich," Hofler says of the group. "It's kind of a recommitment to why you came into a healthcare profession. For nursing, that resonates with folks because it's so easy in the business to forget why you really wanted to do the work to begin with."
2. Games
Adding a little friendly competition among nurses when practicing problem-solving skills seems to be paying off at Vidant.
"We did a game with all of my leadership team and their direct reporting lines where they had an hour to devise a plan for how they were going to do something to focus on engagement [with] their teams," Hofler says. "They were going to get $100, so [the question was], 'How would they use that [money to engage with their employees]?"
One group created a circus theme to help connect with their employees. They designed a cart that looked like a circus tent and they dressed like circus performers and took circus-related snacks to the employees on the unit. They used that as an opportunity to start conversations "about what was the most important thing that leadership should be doing to support patient care at the front line," she says.
In the end, Hofler estimates she spent about $1,500 on that exercise.
"They all implemented their projects, took pictures, and came back, and we had a celebration at the end. We saw a change in our [employee] engagement scores. It was a small incremental change, but that's what you want … small changes over time that are sustainable," she says.
Additionally, the organization had a "Rounding Olympics."
"It was a system process and it was to determine what units could get the highest scores [regarding patient] answers to the question, 'Did a leader round on you during your hospital stay?' " she says.
The winners received $1,000 to have a party or redecorate the breakroom.
"Again, not terribly expensive, and it got a ton of people engaged, and they were excited about it and it was fun," says Hofler.
3. Support Breaks
"[Part of Vidant's philosophy] is to create a culture where team members can be resilient, where they find joy in what they do, and where they're able to show up and be their best every day," says Hofler.
One example of this culture of support is a change that occurred in the emergency department, which sees about 120,000 patients a year, says Hofler.
On a particularly busy day, she asked to see the department's breakroom.
"They asked, 'Why do you want to see the breakroom?' I said, 'Well, [the ER] is like a war zone. People are just coming and there's no stopping. Where do you go get yourself centered again?' " Hofler recounts.
The answer was typical of most nurses: "We don't do that."
And, even if the nurses did take a break, the ED space was not conducive to grounding oneself during a frenzied shift.
Holfer was able to help carve out a space that is visually appealing, and is outfitted with refrigerators, a microwave, and a serenity room painted with calming colors and inspirational quotes.
"Now [nurses] will go in there and talk to each other," she says.
Hofler says getting the physicians and the nurses committed to taking breaks and having charge nurses ensure that staff members are taking the much-needed recovery time has helped the nurses' workplace experience.
There are an estimated 167,375 providers of direct patient care in the emergency/trauma/transport nursing workforce.
43% of the workforce is under 40 years old.
78% of the workforce are women.
Compared to the overall nursing workforce, emergency/trauma/transport nurses are more likely to be male and white.
Education and Experience
On average, those surveyed have 16 years of career experience.
78% of the RNs surveyed hold a BSN or higher.
58% hold specialty board certification.
Work preparedness
69% felt prepared or well-prepared to excel at their jobs regardless of their age.
40% desire more training on specific equipment or leadership/management skills.
Work Environment
65% are satisfied or very satisfied with their jobs and the work they do
59% of their time is spent on direct patient care
28% of their time is spent on documentation
39% report the workload is too heavy or overwhelming
Nurse Well-Being
42% say their employers value their contributions and care about their well-being.
38% report some symptoms of burnout
50% report their employers provide access to counselors
36% report no resources to address burnout
Salary and career plans
$77,500 is the median salary for nurses working full-time
Nurses desire funding for professional association membership, conference attendance, and advanced certification.
47% plan to continue in their current roles.
The most common planned career changes are to obtain a specialty certification or become an advanced practice registered nurse.
According to the study, the data should help healthcare organizations understand the makeup of the current workforce and accurately project the types and amount of resources necessary to meet the demand for emergency, trauma, and transport nursing services now and in the future.
"The combination of MedEvac Foundation's highly regarded track record in managing quality research studies and the invaluable input, insight and funding support from STN, ASTNA and ENA, has yielded a treasure trove of critical information that will benefit emergency nursing and emergency care, today and in the years to come," says BCEN Executive Director Janie Schumaker, MBA, RN, CEN, in a news release. "This research will inform and enrich our emergency, transport and trauma specialty certification programs and provides valuable information to develop, support and maintain a well-prepared emergency nursing workforce."
Insufficient pay and training are driving a national pediatric home care nurse shortage.
Inadequate pay and training are major drivers of a national shortage of pediatric home care nurses, experts from Ann & Robert H. Lurie Children's Hospital of Chicago say in an article published in the June issue of Health Affairs.
Not only does the shortage affect pediatric patients' health, it can also cause social, emotional, and financial hardship for families, according to Carolyn Foster, MD, MSHS, and colleagues. Additionally, children often cannot be discharged home from the hospital safely because home care nursing support is unavailable, forcing them to remain in the hospital for weeks or even months until homecare nurses can be found.
"Families with children who need medical technologies to survive life-threatening illness are legally entitled to home care services, but frequently they cannot find a nurse to do the work for the long term," Foster, the paper's lead author and physician at Lurie Children's, and assistant professor of pediatrics at Northwestern University Feinberg School of Medicine, says in a news release. "Parents can find themselves exhausted, staying up night after night for weeks or even years, as they try to keep up with the care their children need to stay out of the hospital."
Salaries for pediatric home care nurses fall well below those in hospitals and surgical centers as less than 2% of Medicaid spending goes to children with medical complexity to support home care.
"Increasing wages for pediatric home care would likely attract more nurses to this field," Foster says. "Greater investment in home care for children would be a better use of healthcare dollars than paying for prolonged hospitalizations that can amount to millions in excess health care spending."
The authors recommend homecare nurse payment should reflect the skill level required to provide care, with nurses who take on more complex patients receiving higher wages. Additionally, the authors say, nurses working in areas of greatest shortage should receive greater pay.
Foster and colleagues also recommend:
Increased partnerships with children's hospitals to better coordinate hospital and home care services
Better training for pediatric home care nurses
Reimbursement for telemedicine services, including videoconferencing and remote home monitoring technologies, to extend and support home care of children with chronic illnesses
"Telemedicine initiatives … are especially important for the medical support of children and youth who live in remote areas or who are difficult to transport," Foster says. "Payment for these services is important, especially since telemedicine has been shown to decrease emergency department use in children with medical complexity, which reduces healthcare costs."
To advance home care for children, the authors say, it is be important for pediatric experts and advocates to be included in government efforts to expand and improve adult home care.
"As the baby boomer generation ages and increases policy attention to adult home care, we need to make sure that children who need home care and their parents also benefit from future improvements in this arena," she says.
Unhealthy worksite food purchases are associated with an unhealthy diet outside of work.
Hospital employees are what they eat … at work. A new study in the American Journal of Preventive Medicinefinds that hospital employees who purchased the least healthy food in the cafeteria were more likely to have an unhealthy diet outside of work, be overweight and/or obese, and have risk factors for diabetes and cardiovascular disease when compared to employees who made healthier purchases.
Employees' health can affect an organization's bottom line in multiple ways. Prior research shows obesity contributes to higher absenteeism, lower productivity, and higher healthcare expenses for employers.
With this in mind, healthcare leaders can help their employees and their organizations by shaping worksite wellness programs that improve long-term health outcomes and reduce costs.
"Employer-sponsored programs to promote healthy eating could reach millions of Americans and help to curb obesity, a worsening epidemic that too often leads to diabetes, cardiovascular disease, and cancer," lead investigator Anne N. Thorndike, MD, MPH, division of general internal medicine, department of medicine, Massachusetts General Hospital, and Harvard Medical School, says in a news release.
Healthy Food, Healthy Employee
Researchers studied 602 Massachusetts General Hospital employees who regularly used the hospital's cafeterias and were enrolled in a health promotion study in 2016 to 2018. They analyzed worksite food purchases from cash register data, food consumption reports from surveys, cardio-metabolic test results, diagnoses, and medication information.
After developing a Healthy Purchasing Score (HPS) to rate the dietary quality of employees' overall purchases, the investigators compared participants' HPS to the quality of their overall diet. They also assessed measures of obesity, diabetes, high blood pressure, and high cholesterol.
Employees with the lowest HPS had the lowest overall dietary quality and the highest risk for obesity, diabetes, and high blood pressure. Healthier purchases were associated with higher dietary quality and lower prevalence of obesity, hypertension, and prediabetes/diabetes.
Employers Can Support Good Health
Most Americans spend about half their waking hours at work and consume food acquired at work so there is strong potential for employers to positively influence their workers' health.
"Workplace wellness programs have the potential to promote lifestyle changes among large populations of employees, yet to date there have been challenges to developing effective programs. We hope our findings will help to inform the development of accessible, scalable, and affordable interventions," says study investigator Jessica L. McCurley, PhD, MPH, postdoctoral fellow at the department of medicine, Massachusetts General Hospital and Harvard Medical School.
For example, as part of the hospital's "Choose Well, Eat Well" program, foods and beverages in its cafeterias have "traffic light" labels to indicate their healthfulness:
Green is healthy.
Yellow is less healthy
Red is unhealthy.
To reduce unhealthy impulse purchases, healthier choices are placed in the direct line of sight on food displays while unhealthy foods are made less accessible.
"Simplified labeling strategies provide an opportunity to educate employees without restricting their freedom of choice. In the future, using purchase data to provide personalized nutritional feedback via email or text messaging is another option to explore to encourage healthy eating," Thorndike says.
May is mental health awareness month. Here is a roundup of four HealthLeaders articles to raise awareness of behavioral health issues affecting nurses.
In a given year, 43.8 million adults experience mental illness, according to the National Alliance on Mental Illness, and mental illness will affect one in five adults in their lifetime. Healthcare professionals are not immune from experiencing issues such as depression, anxiety, burnout, and suicide. In fact, they may have higher rates of behavioral health issues than the overall public.
However, that lack of data doesn't mean nurse suicide isn't an issue.
"We had nurse suicides in our own workforce and when we started talking to people, we found that many knew someone who had a nurse suicide in their organization. So, it wasn’t just us," she says. "It really brings up the concrete message that we cannot hide this. The more we talk about it the more lives we can save."
In the article, Davidson outlines three actions nurse leaders can take to prevent nurse suicide. These include offering confidential suicide screening, providing behavioral health referrals, and knowing the risk factors for suicide.
Despite all the talk about burnout in healthcare, its rates among nurses still remain high. According to a 2017 Kronos survey of RNs employed in hospitals, 63% report experiencing burnout.
To make progress in reducing burnout, healthcare leaders must delve into its many layers to find solutions that work for their specific organizations and nurses.
By analyzing engagement data to measure the key components of nurse resilience, the researchers found resilience varies according to nurse demographics such as generation, role, and shift.
Among the findings:
Millennial nurses working the night shift have an even further activation (i.e., the degree of respondents' engagement with work) disadvantage
Nurse managers have better activation than non-managers
Non-managers have a greater ability to decompress than managers
Interestingly, bullying's effects cause damage beyond the victim. A December 2018 study in the Journal of Occupational and Environmental Medicine found workplace bullying increases employees' psychological distress and intent to leave their job—even for workers who aren't personally being bullied.
When the results were adjusted for bullying on the business division and department levels, researchers found division-level bullying had a greater impact on both psychological distress and intention to leave, compared to individual exposure to bullying.
Another studyin the same journal foundthat non-bullied coworkers in work units where bullying was reported, had 15%—22% more long-term sickness absences than employees in work units without bullying.
As many nurses sadly know, bullying, incivility, and disruptive behaviors among nurses are prevalent in the healthcare work environment. In fact, the released a in 2015 calling for nurses to "create an ethical environment and culture of civility and kindness, treating colleagues, co-workers, employees, students, and others with dignity and respect."
How can this be achieved?
For starters, nurse manager visibility is key. Being present on the unit, especially at shift change, can help identify disruptive behaviors, saysKathleen Bartholomew, RN, MN, author of . Also, addressing disruptive behavior as a team helps individuals feel supported by management.
"[Managers] need to watch for the non-verbal [clues], such as raising eyebrows, making faces, etc., and make it about ALL of us as a team instead of an individual issue," she says.
For Jenny Shrapnel, BSN, PICU manager at in San Diego, a series of disruptive behaviors and low employee engagement scores on her unit indicated it was time to reevaluate how to effectively address these issues.
Shrapnel had the nursing team undergo personality testing to help them understand the strengths and weaknesses of each personality type present on the team. The goal was to help team members gauge how receptive another person would be to a difficult conversation and how to address individuals based on their personality type, Shrapnel explains.
The team members also used role-playing to practice positive communication among nurses. In addition, Shrapnel distributed handouts to help nurses brainstorm how to respond in a positive way during difficult conversations or conflicts with other nurses.
I thought about this sentiment during the AONE 2019 Plenary Session, "Innovative Research Impacting Leadership: Emerging Topics from the Perspective of the Editor-in-Chief" by Karen Hill, RN, DNP, NEA-BC, FACHE, FAAN. In addition to being chief operating officer and chief nursing officer at Baptist Health Lexington in Lexington, Kentucky, she is also the editor-in-chief for the peer reviewed Journal of Nursing Administration.
A few years ago, I spoke with Hill about the success of her patient flow nurse program at Baptist. At the time I remember her saying the reason she was able to implement so many innovative ideas at the organization was because she learned about them through her work with JONA. She reiterated that during her plenary presentation.
"I've been the chief nurse [at Baptist Health Lexington] for 28 years, and one of the things that my staff ask me is, 'How do you keep thinking of all these ideas?' " she says. "I'm honest with them. I have very few original thoughts. I learn a lot from people who take time to publish because when you do something great and you let other people know about it in writing, it lives forever. I really appreciate that."
In other words, when it comes to nursing, "Sharing is caring." By sharing their challenges and successes, nurse leaders can find solutions that improve patient care and outcomes, elevate the nursing profession, and achieve organizational goals.
Below are Hill's insights on emerging issues and trends nurse leaders grapple with today plus HealthLeaders articles on the topics.
1. Ensuring Nurse Managers Have the Right Skills and Competencies
"Nurse managers have very complex roles. Things that have been published [about nurse managers include] competencies, the engagement not only of the nurse manager, but the role of the nurse manager in engaging others," Hill said. "There's been a shift [toward] complex accountabilities and responsibilities."
Ronda J. McKay, DNP, RN, CNS, NEA-BC, vice president of patient care services and chief nursing officer at Community Hospital in Munster, Indiana, and Paula McKinney, DNP, RN, NE-BC, vice president, patient services at Woodlawn Hospital in Rochester, Indiana, recognized there was often a variation in the skills and competencies of nurse managers since nurses with strong clinical skills often find themselves in role of nurse manager without the training and skill development to thrive in the role.
In McKinney and McKay's study, "Improve Nurse Manager Competency With Experiential Learning," published in the October 2016 Nurse Management, 86% of respondents said they had no formal leadership development when they first became a nurse manager.
However, when nurse managers have the right skills and competencies, they can play key roles in improving financial, clinical, and quality outcomes, say McKay, McKinney, and Hill.
In the HealthLeaders article "Investing in Nurse Manager Development Pays Off," the pair spoke about how a targeted experiential education module gave nurse managers a better understanding of financial issues, such as the topics of expense forecasting and cost-benefit analysis.
2. Defining Nurse Manager Job Scope
"We have really burdened our nurse managers with so much today," Hill said. "They're the chief retention officers, the chief strategy officers, and they have to make sure all the patients are happy. They have to meet their budgets and they have to manage a million metrics in addition to having a life."
She encouraged CNOs to ask: "What are the supports that nurse managers need to be resilient in that role?"
For Hoying, that meant evaluating expectations placed on nurse managers. She had noticed a trend among the nursing directors at her organization. "What I was seeing was all the directors getting out of here at seven or eight o'clock at night and not being able to get home in a timely manner," she says.
To combat overworking its nursing directors, the organization implemented a one-manager-to-25-FTE ratio.
"By that [ratio] you're able to work with the staff and do all of the education with the staff that's needed and vice versa. It allows the manager to be successful and be the nurse leader that individual could be."
3. Developing Millennial Nurses
"Almost 50% of the nursing workforce right now are millennials," Hill said. "We have to learn how to work with them, how to engage them, and how to maximize that talent capability."
"In my hospital, I have five generations of nurses working for me, and I want to make sure I’m meeting the communication needs, the recruitment and retention needs, [and] the development needs of our nurses," Clements said when interviewed for the HealthLeaders article, "Why This Nurse Takes Advice from a Millennial Nurse."
When Clements meets with her millennial mentor they discuss topics like professional development, recruitment and retention, scheduling, work-life balance, and work environment.
4. Improving Nurse Retention
"I think the costs of [nurse] turnover in the United States is severely underestimated. I'm in southeast United States, and I cannot cover turnover of a nurse for $61,000. They give you a month's notice when they leave, then you have to submit the request [to fill the position] to the budget control committee, and they have to decide if they want to let you replace it or not," Hill said.
"It takes me, honestly, eight to nine months to replace a nurse. So, I think we've underestimated that [cost] in our business case for more resources. One statistic I did want to show you, because I do think this would be helpful on a business case, is a 1% decrease in turnover of nurses is worth about $337,000 a year. That's a big deal," she said.
In the recent HealthLeaders article "Want to Keep Nurses at the Bedside? Here's How," three nurse executives share how they are working to recruit and retain nurses. Their solutions include improving nursing's reputation at the organization and in the community, modernizing their clinical ladder program, recruiting nurses back to the bedside who had stepped away from practice, and implementing a holistic nursing practice model.
Nurses Week, May 6-12, is the right time to reflect on how to evolve as a leader
It's Nurses Week—a time to pause and celebrate all that nurses do. And, as the healthcare industry shares its gratitude this week for nurses, it must not forget to include nurse leaders when giving thanks. Because it's not easy being a nurse leader.
"As nurse leaders, we help create circles of care, safety, reliability, quality, and trust for the patients and communities. We are guardians at the gate of all of these things," Cole Edmonson, DNP, RN, NEA-BC, FAAN, chief clinical officer at AMN Healthcare, Inc., said during the AONE 2019 Keynote introduction.
"Leadership in healthcare is not an easy path and, in order to do it well, we have to take time to develop ourselves and those around us," Edmonson said.
While much has changed since the time of Florence Nightingale, the original nurse leader, the qualities that make a nurse leader great have not.
"We must be willing to be brave, courageous, authentic, vulnerable, and practice forgiveness to create the future," Edmonson said.
AONE 2019's opening keynote presentation, "Get Out of Line: Step Up, Stand Out & Succeed" bySarah Robb O'Hagan, founder of EXTREMEYOU and former executive at companies such as Nike, Gatorade, and Virgin Atlantic, covered how to develop some of the qualities Edmonson mentioned.
Below are five ways O'Hagan said nurse leaders can propel themselves toward personal and professional success.
1. Get Out of Line
"[Get out of line] means stepping up, standing out, kicking butt, and stepping out of the line of others around you to take risks and create new value for your organization," O'Hagan said. "Often it can be uncomfortable. Many of us choose not to do that because we don't want to take a risk and fail."
During the keynote, O'Hagan shared a personal story when she took a risk and it paid off. On her first day in a marketing position at Virgin Atlantic airlines—after moving from New Zealand to New York for the job—she was informed that the person who hired her was no longer with the company. Fortunately, she still had a job but secretly wondered if the "last in, first out" philosophy would be implemented. As she noticed the chaos that had developed in the department, she made a bold move by drafting a marketing plan and slipping it under the marketing president's door.
"That could have gone one of two ways, but what ended up happening is I got a promotion," she said.
While O'Hagan was new to the company, she had enough career and marketing knowledge to fill in the leadership gap that occurred when the hiring manager left the company.
The lesson here: Embrace your knowledge and experience and don't be afraid to share solutions with others.
"If you recognize those moments where your experiences [can fill a gap you see] in front of you and you're solving a problem for someone else, it can be incredibly, incredibly successful" she said. "I always say to everyone, scan for opportunities around you."
2. Make Failure Your Fuel
With the rare exception, nobody likes to fail. According to O'Hagan, fear of failure is increasing.
"For about the past 50 years, every generation from the boomers to Gen X to the millennials to Gen Z has statistically become more scared of failing. We do not like taking risks," she said.
But willingness to fail, and to learn from it, is necessary for personal and professional development.
"We have a generation that is scared of failure and, therefore, somewhat risk averse. [If] people are going to develop the best sides of themselves, they actually need to take risks every now and then," she said. "If you don't experience different environments, different types of work, you don't know where you are going to shine, and you want to learn where are you at your very best."
Nurse leaders should keep this in mind especially when working with younger generations of nurses."Talk to the younger people on your team because [a willingness to fail] is actually the most important thing," she said. "When we start our careers, in the world we live in today, there's this feeling that I have to look perfect on Instagram. I have to have a perfect resume on LinkedIn. And, guess what, you actually have to fail."
3. Play Your Specialist Game
O'Hagan asked the AONE attendees: Where do you excel? What excites you? She said once nurse leaders answer those questions, they should embrace their strengths because that will help build a foundation of success.
"Once you know you at your very best, if you find yourself playing in an organization that really wants that out of you, you will be more confident, and you will be more involved," O'Hagan said.
4. Bring Out the Extreme in Others
For nurse leaders, bringing out the best in others is the key to developing an outstanding and engaged nursing staff.
"If we're doing a good job of knowing who we are at our core as leaders, then the most important thing is how you bring out the best in others, so they can play to their full potential," O'Hagan said.
Leaders can encourage staff to reflect on their positive attributes and exceptional skills. Then the leaders should commit to helping the nurses develop those skills at their organization. O'Hagan said committing to diversity in age, ethnicity, gender, and skill can also contribute to an organization's success.
"Diversify those different styles and points of view and the team because that is when you will perform at your best. I do think it's important to partner with those that are least like you," she said.
5. Break Yourself to Make Yourself
"Get yourself out of your comfort zone," O'Hagan said. "It may be at work, it may be in your personal life, but take on a new adventure. Just get out of your comfort zone so that you're being exposed to new and different things."
By being uncomfortable, says O'Hagan, leaders can challenge their most stubborn beliefs.
"Often those beliefs are things that we think we're not good at and we're not giving ourselves enough of a chance," she said.
For example, O'Hagan says she labeled herself as terrible at finance. But when working at Gatorade, she realized she didn't have the option of not feeling comfortable with the subject.
"I took myself back to what I call 'remedial education' and did a finance for executives course and discovered at the age of 38 that I absolutely loved it," she said. "And, because I now had real-world experience that I could apply to what I was learning, it suddenly made sense. I'm never going to be a powerful finance person but at least I now feel confident in that fundamental."
"Sign up for an initiative or a project with other people. It might be that you are needing to transfer to a different kind of hospital or somewhere else [in your current organization]. You have to get out of the places of comfort if you're really going to allow yourself to blossom and find new areas of growth."
There's more to building a strong nursing workforce than just filling open positions, and even in organizations with top-notch nurse recruitment programs, research has found there's no guarantee that nurses will stay put.
According to the recruitment firm NSI Nursing Solutions, Inc., the average national turnover rate for bedside RNs was 16.8% in 2017.
Additionally, Press Ganey's recent analysis of 250,000 RNs who participated in the 2017 National Database of Nursing Quality Indicators RN Survey found close to 21% of nurses planned to leave their current jobs within one year, including those retiring. When asked about their job plans over the next three years, 26% said they will pursue other options ranging from new positions in an organization to retirement.
The survey also found those at highest risk for attrition were newly licensed nurses and those who have been in practice for two to four years.
"We're all feeling the pain of [nurses leaving organizations] within a few years and going to do travel nursing or to insurance companies," she says. "But some are just leaving practice altogether for reasons that we could probably address internally with some creative ideas."
The RetuRN to Practice Program at Allegheny Health is one creative initiative Zangerle is using to address some of these issues.
The program is designed to attract nurses who have stepped away from practice and want to return to bedside care, which helps reduce the workload of current staff and fill staffing gaps.
Flexible scheduling attracts RNs
The RetuRN program offers flexible scheduling opportunities in high-need clinical areas.
Participants must offer managers availability in a minimum of three-hour blocks at any time on a day, evening, or night shift, or on a weekend or holiday.
During their shift, the RetuRN nurses conduct "rover-type" duties, as Zangerle describes it. They cover other nurses' patient assignments during breaks or when staff has to do continuing education off the unit. Or they may come in to do admissions, discharges, or patient education.
"The [RetuRN nurses] know they won't know what they're going to do until they get to the unit," she says. "They're flexible, and they're there on the floor to be able to do that."
Because the RetuRN nurses have been out of practice for various amounts of time—Zangerle says one had not practiced in 20 years—there is an online nurse refresher course through the University of Delaware plus on-the-job clinical shadowing built into the program.
Additionally, there are resources dedicated to helping these nurses through the entire onboarding process, from getting their licenses verified to following up on their satisfaction levels after they've started on the unit.
"We have had a lot that have rushed in and said, ‘OK, I want to do this,' and then when they see all the things they need to do [to onboard], they get scared," Zangerle says. "So we have almost a concierge service–type support. It is worth every single nurse that we bring on board to do this program, to have that for them."
After an initial kick-off event, the organization hired 22 nurses ranging from 0.5 FTE status to 1.0 FTE status.
The retention rate of that group is 100%, Zangerle says.
Creative thinking pays off
For others interested in starting a similar program, Zangerle has suggestions on what nurse executives should consider.
First, nurse managers will have to adjust to scheduling three-hour blocks for the RetuRN nurses instead of the typical eight- or 12-hour shifts.
"We've engaged those nurse managers to say it's really a logistics exercise with scheduling," she says. "We're fortunate that we have electronic scheduling, and that's been helpful."
Once the RetuRN nurses start on a unit, the program easily wins converts among staff nurses and nurse managers.
"Once they get a couple of [the RetuRN] nurses on the unit, they hold onto them and they won't let go," she says. "If you educate the nurses on the unit about why [the RetuRNs] are there and solicit ideas from them on how we can enhance the program, it makes the program robust."
In fact, says Zangerle, current nurses can be a source of referrals to the program.
"They might have friends who left nursing to raise their children and now want to come back, or they left because the hours just weren't there," she says.
Hosting information sessions, connecting with academic partners that run refresher courses, and social media marketing are other ways to get the word out about RetuRN programs. She also recommends having one recruiter dedicated to the program to help it grow.
And, indeed, the program is growing. Between February and May 2019, three more cohorts of 10 RetuRN nurses each are slated to begin. The program has also been opened to retired nurses who have been away from the bedside for one year or less.
"A lot of nurses still want to practice but they don't want 12-hour shifts, or they don't want every other weekend," she says. "Then as time goes on, we'll certainly survey our RetuRN nurses to find out what we did right, what we did wrong, and how can we grow this program."
Reflecting its commitment to nurse leaders at all stages of their careers, the organization will become the American Organization of Nursing Leadership.
SAN DIEGO — "The times they are a changin'." For the nursing profession, these words are as true today as they were when Bob Dylan first sang them in the 1960s. Issues like value-based care, changing care models, and new reimbursement methods are challenging nurse leaders to develop new skill sets, to create new roles, and to find new solutions to deliver care across the continuum.
Just as the profession is evolving so too is the American Organization of Nurse Executives. On April 11, at its annual meeting in San Diego, the organization announced it is changing its name.
"Throughout my involvement in AONE, one of the recurring questions that I've heard is whether AONE is exclusively for nurse executives. Our name can sometimes get in the way of demonstrating that we are an organization for all of nursing leadership," 2019 AONE President Mary Beth Kingston, MSN, RN, NEA-BC, chief nursing officer at Advocate Aurora Health in Milwaukee, said during the conference's opening keynote session.
"It reflects what [the organization] is about and what nursing leadership has become," Kingston said.
The name change will better reflect that the organization serves nurse leaders at all stages of their careers and across the entire care continuum.
AONL will continue with the mission of shaping healthcare through innovative and expert nursing leadership through professional development programs, advocacy initiatives and research.
Randy Moore shares his thoughts on areas in healthcare where CEOs struggle to control costs.
Even when change is exhilarating—like buying a house or starting a new job—it can also be fear-inducing. Take, for instance, the current state of the healthcare industry.
The shift from fee-for-service to value-based reimbursement, the steady pace of mergers and acquisitions, and the movement of care out of the hospital to alternative settings, are all issues that can cause even the most seasoned healthcare executive to lose sleep.
Moore says he understands how these factors can increase healthcare leaders' need to focus on cost control and containment. Before beginning his role at AANA in 2017, Moore managed a $35 million budget and more than 100 employees as the director of perioperative and anesthesia services at Passavant Area Hospital in Jacksonville, Illinois.
"[In that role], I was acutely aware of the impact and the importance of cost control in the hospital and in the health system," he says. "One of the things that's been really interesting and fun about my [role as AANA CEO] is gaining that perspective at the hundred-thousand-foot level. I have the privilege of meeting and talking with people, whether they're CEOs or CNOs of hospitals or health systems or other organizations, and [through those conversations] one thing that is abundantly clear to me is that, without a doubt, every CEO in this country is trying to figure out how to control costs."
HealthLeaders recently spoke with Moore about various components of cost control and containment and his insights on this topic for healthcare leaders. Following is a lightly edited transcript of that conversation.
1. Care Moving to Alternative Settings
"One of the things I think is really starting to heat up is the movement of healthcare out of hospitals, which makes a lot of people nervous, whether you're a nurse that works in a hospital or you're a CEO running a hospital. If I was a [hospital] CEO seeing what's happening in terms of these companies that are trying to move surgical care out of hospitals, [it] would keep me up at night."
"If you would've told me 10 years ago that we'd be doing total knee replacements in an ambulatory surgery center, I would have said you were nuts. Now it's happening and it's happening in a big way. The reason why more and more healthcare is being moved out of the hospitals and into office-based settings and surgical centers is because it's just cheaper to do it there. The cost structure is much more favorable to do a surgical case in an ambulatory surgery center than it is to do in a hospital. That is causing significant pressure on hospitals because we know, typically, in hospitals there's two areas that serve as the economic engine—the emergency room and the operating room. When you start taking volume out of either, it causes hospitals and health systems significant financial difficulty. It is all about cost containment and trying to find the most cost-effective environment to provide that care."
2. Standardizing Care
"Expenses are essential and that has opened up opportunities for nursing and for advanced practice nursing to be a part of the solution in terms of value-based healthcare and the roles that they play. One of the things that is clear to me around expense control is [the need to] control variation in clinical care across the spectrum from a nurse who is in a critical care unit to a CRNA or [APRN] in a hospital or in an operating room."
"Variation in care typically has two major problems. One is that quality outcomes could be impacted, and two, the cost is frequently higher. So, I think more and more administrators, healthcare administrators are going to have a laser focus on variation of clinical care at the bedside and the operating room."
"One of the things we're starting to see proliferate in the anesthesia space is enhanced recovery after surgery. It's a program that is designed to layer in protocols so that a patient who's having, let's say a total knee replacement or other type of surgery, is receiving care that is consistent with established and well-known evidence-based interventions, starting preoperatively all the way through the spectrum of care. Enhanced recovery is intended to decrease the variation in clinical care and implement protocols and procedures that are demonstrated to provide better outcomes."
"It seems almost counterintuitive at first because, frequently, enhanced-recovery-after-surgery programs cost a little bit more on the front end because you're using different drugs, and sometimes those drugs are more expensive. But on the back end, patients have fewer complications, so their hospital stays are shorter and surgical-site infections and postoperative pneumonias are lower. The investment in the front end results in significant cost savings on the back end."
3. Change Management
"The most difficult part [of standardizing care] is the change management piece. I'm a CRNA, and I know what it's like when someone tells you, 'Hey, we want you to do something different.' Your knee-jerk response is that you've been [practicing] a certain way for so long and your outcomes are spectacular—at least you think they are. [Change] is the most difficult thing because we, especially anesthesia providers, get into a groove and we like to do things a certain way. It's difficult to get outside of that comfort zone unless there's a compelling reason to do so. So, we need to look at the number of hours, the outcome data, and the expense savings that could be realized or have been realized in other programs [to make a change]."
4. Mergers and Acquisitions
"One of the things that we're seeing, and not just in the anesthesia space but across the board in healthcare, is related to merger and acquisition activity. I think the predominant driving force behind that is, as a health system or even as the anesthesia company, trying to control the cost structure. They know that they're trying to gain this economy of scale and get influence over payers and supply chain management. That really is driving a significant uptick in the merger and acquisition activity, and I think that will continue."
"We're seeing hospitals closing because they're unable to navigate in this environment where reimbursement's shrinking and cost control is imperative, and you're being asked to move to a completely different model. You're moving from fee-for-service to a value-based care and quality model. There are a lot of hospitals not able to survive in that structure."
"Not all of these mergers or acquisitions result in success, and we're now starting to see some of these health systems become huge and they're starting to close some of the facilities they've acquired—[there may be] cultural issues within the facilities or business issues or they're unable to control the expenses the way they thought they would."
"One of the things that we're seeing on the anesthesia side of the equation in merger and acquisition activity is anesthesiologists and CRNAs getting caught up in it and that's not always to their benefit. For example, if you were acquired by a large anesthesia company, they may come in and have a completely different philosophy about the way anesthesia should be delivered, the way it should be reimbursed, or the way they treat their employees."
