Virtual Discharge Assistant Cuts Readmissions, Costs

Rebecca Hendren, March 8, 2011

Now that patient satisfaction and patient experience are set to be tied to reimbursement, nurse leaders are looking for innovative solutions to improve these scores without adding tasks to already overworked staff.

One technological innovation that may become more common is the virtual discharge assistant. (Yes, companies may term these robots "discharge nurses," but as I wrote last week, using the term to refer to anything other than a member of the profession of nursing does a disservice to the profession.)

A virtual discharge advocate, named Louise has proven so successful in a pilot program at Boston Medical Center that 74% of patients in the study preferred to receive information from Louise rather than from a nurse or a physician.

The program is funded by the Agency for Healthcare Research and Quality to improve the patient discharge process. The Project Re-Engineered Hospital Discharge (Project RED) found that a thorough and well-implemented discharge plan can reduce readmissions by 30% and decrease costs per patient by $412.

Boston University Medical Center researchers identified the most common problems with discharge and made improving the problem areas the focus of Project RED. The researchers then identified 750 patients at Boston Medical Center and split them into two groups. One group received standard care. The other group received care based on the Project RED principles.

Project RED patients used a discharge advocate who collated all their information and entered it into a software program that produced an After Hospital Care Plan (AHCP) for each patient.

AHCP is a thorough discharge summary. Along with information about medications and follow-up appointments, it contains images of pills and detailed instructions on when and how to take them. It also has color coded calendar information for follow up appointments, including directions to the medical facilities.

The discharge advocate reviews the AHCP with each patient to ensure thorough education and understanding. This is where the virtual component comes in. While vital that nurses talk with patients before discharge, much of patient education can be routine passing of information that is time-consuming and detracts nurses from other areas of patient care. The Project RED team brought in Louise to educate.

Louise is an animated face on a computer screen, complete with a touchscreen to allow patients to ask and answer questions, who simulates conversations with patients. She was modeled on actual human interactions between nurses and patients.

Louise reviews the AHCP with patients and her virtual face expresses emotions and even empathy with patients. She has endless patience and can cover information as many times as is necessary for patients to feel that they understand their discharge instructions. As she goes along, Louise asks patients questions to ensure they are actively participating and will present a list of options from which patients must select the right answer.

Louise proved extremely popular in the study, with patients noting that they like being able to sit as long as they want to with Louise and not feel rushed that a busy nurse or physician has to move on to other patients. In addition, many patients find it easier to answer some questions truthfully—for example, about whether they smoke—than with a live person.

Participants in the Project RED program reported feeling much more prepared for discharge and the study had excellent outcomes, preventing one ED readmission for every 7.3 patients in the study. The AHRQ is supplying funding to implement Project RED initiatives elsewhere in the country to expand the research project. Meaning it may not be long before a virtual discharge assistant is helping out with patients at your organization.

Read about Project RED and meet Louise.

Nurses vs. Robots: No Contest

Rebecca Hendren, March 1, 2011

An article about robotic technology caused a minor controversy last week when it appeared to imply that "nurse" robots could replace scrub nurses. The flurry of emails and discussion it generated illustrates the nursing profession's perception problems.

The seemingly innocuous piece discussed fascinating hand gesture recognition technology developed by Juan Pablo Wachs, assistant professor of industrial engineering, and others at Purdue University.

Visual recognition technology has previously been the purview of science fiction. With Wachs’ prototype, it's potentially a few short years away from implementation in operating rooms around the country.

The creators say the robot can recognize surgeons’ visual cues to pass instruments or recognize commands to display data during surgeries. The hope is that robots may reduce length of surgeries and potential for infection.

Robots may eventually perform some tasks now performed by scrub nurses, such as handing surgeons instruments. That’s where the debate begins. The article describes the high-tech machines as “robotic scrub nurses” and Wachs discusses the advantages the machines have over human scrub nurses when working with unfamiliar surgeons, for example.

It didn’t take long for nurses to complain to me about the use of the term “nurse” and the implications that robots could replace humans.

First, let’s look at the use of the term.

“There’s a lot of power in a name,” says Kathleen Bartholomew, speaker, author, consultant, and nurse. “The real problem is that the casual use of the word in this way validates what we already know—which is that the general public doesn’t know what we do.”

Bartholomew believes misrepresentation undervalues and damages the profession. That leads to the second point that nurses may be replaced by a machine. At first glance, this is laughable. Outside of science fiction, no one believes machines can replace humans.

“Robots cannot detect subtle changes in patients before they crash and intervene to save their lives,” says Sandy Summers, RN, MSN, MPH, founder and executive director of The Truth About Nursing, an advocacy group that works to counter misrepresentations of nursing in the media. “Robots cannot advocate for patients and correct the surgeon who is removing a gallbladder instead of removing a pancreatic tumor, because he forgot which patient this was. Robots cannot eject drunk surgeons from the operating room.”

The nurses I spoke with cite the discussion of the robot scrub “nurse” as evidence of the commonly-held belief that nursing is merely a collection of tasks that can be completed by anybody. According to TV programs like ER and Grey’s Anatomy, nurses are invisible minions who carry out low-skilled tasks such as emptying bed pans and bringing food trays. While everyone who works in healthcare knows these portrayals are inaccurate, even within healthcare the role of nursing is frequently misunderstood and undervalued.

Furthermore, the public doesn’t understand the value that nurses provide to patients and healthcare teams. They do not see the role of nurses as critical to safety because there are no true-to-life examples in the media.

If the public doesn’t understand what nurses do, then nursing priorities do not get resources allocated. Bartholomew cited the proposed reductions of the nursing workforce development programs and health professions funding by 29% over fiscal year 2010, which are before Congress. These resources are desperately needed to ease the chronic faculty shortage in nursing schools and to open more spaces to educate students so that we have enough nurses to meet the looming nurse shortfall created by the inevitable aging baby boomers.

“Clearly the general public doesn’t know what nurses do,” says Bartholomew. “It’s easy to understand why for two reasons. One, we don’t tell them. Nurses don’t sit around bragging about how they saved someone’s life or intercepted a potential physician error or broke the news to a mother that her baby was not going to live. We don’t talk about these things amongst ourselves, let alone the general public. And the second reason is because of the obvious mis-portrayal of nurses in the media.”

When a profession is misunderstood and undervalued, it does not reach its potential. In the era of healthcare reform, we need nurses—fully-engaged, well-educated, skilled professionals with vigilant observational and critical thinking skills—to meet the needs of our patients.

Nurse Patrols Frontlines of Preventive Care

Rebecca Hendren, February 22, 2011

Kay Renny, RN,is on the frontlines of the preventive care battlefield. As manager of corporate health services and immunization for the Visiting Nurse Association of Southeast Michigan, she has spent the last 13 years touting the importance of immunizations as the first line in defensive care.

Renny has developed a vaccination program that has delivered more than 325,000 immunizations, including influenza, pneumonia, and meningitis, at community and corporate sites. She has formed a travel immunization service to provide consultations and vaccines for international travelers, and even provides vaccinations in the home for patients who cannot get out easily.

For her efforts, Renny was presented with the Immunity Award by the American Nurses Association in January, as part of ANA's Bringing Immunity to Every Community project. ANA has partnered with the Centers for Disease Control & Prevention to maximize nurses' roles in boosting vaccination rates and reducing vaccine-preventable diseases. The project positions nurses as the leading advocates for immunization in the general population and among healthcare peers. It also encourages all nurses to be vaccinated.

To promote vaccination, Renny has gotten creative. Young people heading to college are notoriously ambivalent about their healthcare and it can be tricky to ensure they receive the CDC's recommended meningitis vaccine before their new life in their dorms.

So Renny initiated "shot parties" to immunize college-bound kids in their homes. A parent gets a group of friends together and Renny organizes a clinic in the parent's house to vaccinate all the students at the same time.

Renny has taken vaccination clinics to movie theatres, the Detroit Zoo, and major league baseball stadiums. She spends time taking health screening and vaccination clinics to worksites. She also offers screenings for cholesterol, blood pressure, body fat, etc.

"It's all about getting people to start thinking about where they are and what their numbers are and what they can do to either improve their numbers so that they are within normal range, or what they can do to keep themselves in those ranges," she says. "It's about educating about behaviors that can prevent future problems."

Renny has to educate people every day, particularly to counter fear and distrust about vaccinations. She says that Americans no longer see the diseases such as polio that used to scare people. "But it's a global world and every disease is one plane trip away," she says. "As nurses, we get to educate people and help them see the value of that prevention. Vaccinations are one of the best things we've done for ourselves as a preventative measure."

Like 79% of her nursing peers, Renny has a positive view of the growing role of mid-level providers in primary care.

"When I decided to become a nurse, people said to me, 'why don't you go to medical school?'" she says. "I said because as a nurse I get to care for you, I get to help you care for yourself. Physicians do that as well, but they have to focus on taking care of the immediate need. As nurses, we have that opportunity to help people care for themselves and that's not just with the issue at hand, but helping them take care of themselves so they don't have issues in the future."

Nurse Leaders' Top Concerns: Patient Experience, Quality Care

Rebecca Hendren, February 15, 2011

Patient satisfaction scores will soon be tied to reimbursement and the change has shifted everyone's attention to patient experience. Nurse executives have placed the issue at the top of their priorities list for 2011, according to the just-released HealthLeaders Media 2011 Annual Survey.

The survey asked healthcare leaders across the board to rank their top three priorities for the year. Nurse executives placed patient experience/patient satisfaction at the top, followed by quality/patient safety, and cost reduction.

The result differs from CEOs, who placed cost reduction at the top of the priorities list, followed by quality/patient safety second, and reimbursement third. Patient experience and satisfaction came in at number four on the list.

This indicates that it is nursing leaders who bear much of the responsibility for ensuring the organization provides a positive patient experience and for keeping tabs on quality and patient safety issues.

Patient experience is an interesting topic that's guaranteed to engender strong emotions. Cheryl Clark explored this topic for HealthLeaders last month in a piece titled "How Grumpy Patients Can Cost Hospitals Big Bucks." She said hospitals in some areas of the country are concerned they may be unfairly penalized for their region's collective personality. While it may be a sit-com stereotype to think that everyone in New York loves to complain, loudly, while people in the South are polite and easily pleased, some argue that regional characteristics will affect scores.

Others believe excellent patient care is reflected in good scores, no matter where in the country the organization is located, while poor experiences will be reflected whether the regional character is "suffer in silence" or "I deserve better."

It won't make a bit of difference where you're located, however, if hospital executives don't find a way to communicate the organization's commitment to improving experience to the people who really make the difference, from the nursing staff to the janitors.

All staff should receive training in communicating with patients and visitors so they know what acceptable and unacceptable interactions look like. How many poor-scoring surveys feature comments about just one staff member? An interaction with someone who is perceived to be rude, unhelpful, or just uncaring can ruin a patient's perception of what was flawless care.

I'm not saying that everyone has to subscribe to Disney-levels of plastered on smiles and "the sun always shines" fake sincerity. Rather that delivering a meal tray without a word and not making eye contact with the patient in the bed should be a thing of the past. As should not introducing oneself to patients with name and job title. There are basic levels of customer service that shouldn't have to be taught, but that may need teaching.

Above all, people need to understand how the commitment to patient experience ties into the organization's overarching goals for safe, quality patient care for all. And how every person's job contributes to the same goals.

Nurse Practitioner Elected Medical Staff President

Rebecca Hendren, February 8, 2011

Bob Donaldson is clinical director of emergency medicine and president of the medical staff at Ellenville Regional Hospital in New York. His current projects sound much like any medical staff president's goals.

What might surprise you is that Donaldson is not a physician but a nurse practitioner. He was elected to this influential position by his physician colleagues and enjoys great support from the hospital's medical staff.

I interviewed Donaldson to find out how a nurse practitioner broke down physician hierarchy and found an innovative hospital that could be a model for provider collegiality and meeting a community's healthcare needs.

Donaldson has a long background in emergency nursing and came to Ellenville Regional in 2004 when he was approached by the owners of an emergency medicine group that staffed providers for the ER, which at the time was staffed by all physicians, and asked to be the first non-physician provider for the ER.

He interviewed with the new CEO, with whom he immediately hit it off. The CEO convinced him that despite the hospital's financial difficulties those things would change, so Donaldson came on board.

"I passed muster, if you will, as the first non-physician, full-time, sole provider here as an NP working in the ER alongside the docs," he says. "It was so successful that we ultimately eliminated all the docs here and replaced them all with nurse practitioners or physician assistants."

In 2004, the ER saw 8,000 visits per year. Now, it sees 12,500 per year, a number it has maintained for the last two years. Donaldson notes that the non-physicians provider arrangement is unusual but explains that his CEO conducted extensive research on nurse practitioners and their practice as part of his graduate work.

"We have been saying in nurse practitioner circles for years that nurse practitioners can do most of the things that docs have been doing," says Donaldson. "[The CEO] felt we could do a comparable job. So we've been doing it—and people like it."

As an admitting provider in the ER, the hospital's medical staff got to know Donaldson well and in 2008 he was invited to be on the team to review and revise the medical staff bylaws.

"The medical staff, all physicians, voted to give equal rights to nurse practitioners on the medical staff," says Donaldson. "Which means if you have a practice here and you are involved in admissions to this hospital, that you are equal to a doctor as far as privileges at the facility and within the medical staff."

In another unusual move, Donaldson's work in the ER means he admits patients to the hospital and its various providers every day, so the hospital decided to give him attending status.

Donaldson says that in 2009 the hospital needed to fill the position of medical staff president and was having difficulty attracting volunteers. So he put his name in the hat. 

"I look at that as like anything else nurse practitioners have done," he says. "There's a void and we step in and we do the job. So that's what I did."

Donaldson notes with a laugh that once a nurse practitioner's name was in the running, other physicians stepped up to add their names. After three rounds of voting, he was elected with more than 50% of the all-physician vote. Since his election, he has enjoyed success and support from his colleagues

Donaldson now holds the quarterly medical staff meetings away from the hospital in a local restaurant and enjoys excellent attendance. Unlike most medical staff meetings, the event includes any member of the medical staff, whether physicians, nurse practitioner, or physician assistant.

"For a long time, we looked a lot at other hospitals to see what happened," says Donaldson. "When I look at other hospitals, I find that very few places have it that non-physicians can be members of the medical staff hierarchy."

Donaldson recommends other hospitals follow Ellenville Regional's lead. Anyone who has the capability or qualifications to run should be allowed to run if they are a member of the medical staff and meet the appropriate criteria. "Folks are doing such a large part of the job," he says. "Why wouldn't you want to get their input into what's going on?"

Donaldson doesn't spend much time worrying about hierarchy or turf wars. He's too busy getting on with patient care and helping the hospital experience a financial turnaround that's seen the ER expanded by 50% in the last five years.

Donaldson quotes his first physician collaborator, who once noted turf wars are for politicians.

"The people who are actually in the field doing the work are happy to have a colleague alongside them doing the same work in the same manner," he says. "It's not the people in the field who are making these comments and fighting over turf. They're trying to get their patients taken care of. It's the people in the medical societies who makes those battles."

Look at what happened at Ellenville, he says. Turf wars don't have to be a distraction. Clearly, this hospital has collaborative practice figured out.

Hospitals With Outstanding Nursing Quality Share 4 Key Traits

Rebecca Hendren, February 1, 2011

“Think globally, act locally” is a familiar idiom from the green movement, and it’s appropriate to apply when considering quality improvement initiatives at your healthcare organization.

Quality indicator dashboards for organizations are valuable benchmarking tools, but the interesting data analysis happens when you drill down to the unit level. You might discover that one unit has had fewer catheter-associated urinary tract infections than another unit with a similar patient population. Then it becomes a question of replicating success. 

The American Nurses Association’s National Database of Nursing Quality Indicators (NDNQI) collects nursing-related performance data from more than 1,700 hospitals at the unit-level. The data allow organizations to compare themselves to other nursing units either in their region or on the other side of the country. They can use the results to set benchmarks on various aspects of nursing care, patient outcomes, patient safety, and nurse satisfaction.

Last month, nurses and quality improvement professionals met in Miami for the fifth annual NDNQI conference to discuss best practices for improvement.

“It’s a step forward for healthcare and good for our patients whenever we can bring so many nursing experts together to share how they have used data to improve their performance,” said American Nurses Association President Karen Daley. “Transforming healthcare requires making evidence-based decisions that promote delivery of quality care and put the patient at its center. That’s what NDNQI and this conference are all about.”

Five organizations were recognized at the conference for extraordinary nursing quality:

  • University of Kansas Hospital, Kansas City, KS – academic medical Center
  • Medical Center of the Rockies, Loveland, CO – community hospital
  • Poudre Valley Hospital, Fort Collins, CO – teaching hospital
  • Children’s Hospital & Medical Center, Omaha, NE – pediatric hospital
  • Craig Hospital, Englewood, CO – rehabilitation hospital

“The NDNQI Award recognizes a hospital’s ability to identify areas for improvement in its nursing performance and to design and implement effective strategies to achieve better patient outcomes,” said Daley. “The common traits of the award-winning hospitals are strong leadership, teamwork, commitment to ongoing improvement in patient care quality, continuous staff education, and efficient use of resources.”

Hospitals that have demonstrated excellent outcomes in nursing-sensitive quality measures—such as pressure ulcers, falls, and catheter-associated urinary tract infections—share similar traits. They have identified systematic processes for quality improvement that involve staff in the identification and measurement.

1. Nurses must be actively involved. Each unit has different patient populations and different quality challenges and the most effective performance improvement arises organically from that culture. Nurses on each unit must be actively involved in collecting data, completing chart reviews, benchmarking results, and sharing results.

2. Quality outcomes should be visible. Top performing organizations communicate openly and frequently about quality data.

Many display unit-specific data right on the unit so that staff nurses can clearly see how their unit is doing and how it compares to others. This keeps staff engaged and allows for swift reaction. For example, if data shows a sudden increase in patient falls, the unit can immediately identify the problem and start a course correction.

Plus, don’t underestimate the value of unit pride. Having a “better than national benchmark” score on various quality indicators is a source of great satisfaction and can be a powerful motivator if those scores change.

3. Support evidence-based practice. Organizations with excellent nursing quality benchmarks actively ensure the latest research is implemented into practice. Many organizations employ clinical nurse leaders or doctorally prepared nurse researchers to help staff identify clinical issues and utilize research.

4. Promote autonomy and accountability. Nursing-sensitive quality indicators are so called because they are to do with the structure, process, and outcomes of nursing care. Top organizations expect nurses to be responsible for these indicators and hold them accountable to the measures. They empower them with the autonomy to decide how nursing care is provided and how improvements should be conducted.

Nurse Advocate Exhibits Nursing Images at U.S. Capitol

Rebecca Hendren, January 25, 2011

An exhibition of nursing photographs is on display this week at the Russell Senate Office Building in Washington, DC. The exhibit, Faces of Caring: Nurses at Work, is a collection by the American Journal of Nursing, which held an international contest in 2007 to find photographs that capture the important work nurses do.

The collection was first shown at New York University College of Nursing in New York City in 2007, with support from the Johnson & Johnson Campaign for Nursing’s Future, the Beatrice Renfield Foundation, and the Jonas Center for Nursing Excellence. The collection has since moved around the country—you can request the exhibition for your organization—to increase awareness of the vital role of nursing.

The photos are in the nation’s Capitol this week due to the hard work of Kathleen Bartholomew, RN, MN, author, consultant, and tireless nursing advocate. Bartholomew sponsored the exhibition and will spend this week in the Rotunda with the photos, speaking to anyone and everyone about nursing.

Bartholomew was able to display the exhibition in the Senate building through the help of her home state U.S. Rep. Rick Larsen, D-WA, and Sen. Patty Murray, D-WA.

I hope people take the time to view the photos, question Bartholomew, and learn more about the role of nurses in healthcare delivery, particularly as discussions about healthcare reform reheat.

 For the most part, the public doesn’t have an accurate view of what nursing involves. In the media, nurses are usually depicted as angels of mercy, or as mute handmaidens to physicians, rather than as well-educated partners in patient care and healthcare delivery.

As more emphasis is placed on patient experience and ensuring these patients report high customer satisfaction scores, it becomes ever more important that patients understand the role of the nursing professionals who care for them. This responsibility will fall largely on your nurses and nurse managers, who will be asked to explain the important role of nursing in your organization.

On each nursing unit, showcase nursing research projects, advanced degree completion, or specialty certifications earned. On a patient-by-patient basis, nurses and all caregivers must explain their role. When lying in a hospital bed, after all, it’s hard to differentiate providers’ roles when everyone wears scrubs.

We may not all have as visible a platform as the rotunda of the Senate Office Building to explain the value of nursing, but we all have our spheres of influence in our daily lives. We can all do our part to educate others about the real nature of nursing work and the importance of devoting time and resources to ensure nurses can focus on providing the high-quality patient care they want to provide to each and every patient.

Nursing Employment Market Looking Up

Rebecca Hendren, January 18, 2011

The stagnant nursing job market is set to pick up in 2011, according to recent reports. After suffering through layoffs, hiring freezes, and new grad unemployment, the news about nursing jobs is about to become more "normal." In nursing, that means a return to plentiful job openings, new graduate nurses in high demand (especially those with baccalaureate degrees), and renewed concern about the nursing shortage.

Healthcare has been one of the few areas of the economy that has seen steady job creation in the last few months, although nursing has continued to feel the pinch. Many nurses delayed retirement due to decimated retirement funds and concern over spouse' incomes. Despite the official end of the recession, high unemployment rates for the country continued in 2010, leading many nurses to pick up extra shifts or even return to the profession due to spouses' job losses or poor job prospects.

As the economy improves, these nurses will be able to plan their retirement, decrease shifts, or leave the profession entirely. In addition, healthcare growth and expansion will see new RN positions added. New graduate nurses should see an end to the difficulties they have faced in finding employment, particularly in California and the Northeast.

More nurses are set to enter the profession this year and the latest data from the American Association of Colleges of Nursing reveals that more of them will have baccalaureate degrees. There was a 6.1% increase in enrollment in baccalaureate programs in 2010 compared to 2009, which is the tenth year of such an increase. Despite this increase, more than 50,000 qualified applicants were turned away from nursing schools in 2010 due to a shortage of faculty and clinical placement sites.

Hospitals can prepare for the increase in demand and potential loss of experienced nurses by focusing on ensuring the organization has a healthy workplace environment and stays attractive to existing staff and future job seekers.

Take a look at your workplace demographics and get an idea of what proportion of your RN workforce is likely to be considering retirement as the economy picks up.

If you're not already paying attention to succession planning, it's time to start doing so. The looming retirement of baby boomers means a whole generation of seasoned managers will soon be leaving the workforce. Make sure the next generation is being prepared with leadership training classes and management experience now.

It's also a good time to look at your latest nurse satisfaction survey and find out what your nurses' priorities are. Haven't done a satisfaction survey lately? What are you waiting for? Even in a down economy, don't neglect this crucial area through fears your staff will eviscerate you for stagnant wages and budget cuts. What keeps nurses satisfied are not annual raises and shift differentials. Most surveys reveal that nurses rank positive working environments, good relationships with managers, being recognized and thanked for their hard work and opportunities for professional development far more highly than money.

See also:

Has the Nursing Shortage Disappeared?

Talk to Nurses About Facebook Before They Talk About You

Rebecca Hendren, January 11, 2011

Yesterday, my mother joined Facebook. When she told me she wanted to sign up, I was perplexed. Who would she be friends with on Facebook, other than my brother and me? Turns out, a lot of her friends are on Facebook and she wants to stay in touch. Plus she wants to stay up-to-date with this exciting development of the modern world.

So my brother helped her set up an account and now she's off and running. Last night, in her first status update, I learned she was excited to watch a new TV series premiering that night.

And with that harmless post, I realized that everyone I know is on Facebook. Short of my 92-year-old grandmother—who takes her TV remote control into a repair shop to get the batteries replaced, so I'm pretty sure Facebook isn't on her radar—I can keep up with everyone I know, to a greater or lesser extent, via this one medium.

Facebook's ubiquity makes people not think about it very much. It's just part of life. But when your profession involves interacting in other people's lives, the lines can be blurred.

Last month, four nursing students were thrown out of school after they posted photos of themselves with a placenta on Facebook. The students from Johnson County Community College, in Overland Park, KS, were taking part in a lab experience at Olathe Medical Center. After posting the photos on their Facebook accounts, the students got the boot.

One of the students, Doyle Byrnes, took the college to court to seek an injunction that would allow her to resume classes. According to the suit, the students asked their instructor whether they could take photos.

The placenta had no identification that could have linked it to a particular patient. Byrnes included a letter in the court case that she sent to the school after her dismissal. In it, she wrote:

"In my excitement to be able to share with my loved ones the phenomenal learning experience in which I had been blessed enough to take part, I did not consider that others might view this photograph as unprofessional, offensive to the school I was representing, and more importantly the sanctity of human life," Byrnes wrote. "For my actions I am truly sorry."

And herein lies the problem for employers. We are so accustomed to sharing our lives with our friends and families on Facebook, and it is so quick and easy to do so, that many of us do not take the time to think through the implications. What seemed a personal account of an interesting learning experience to Byrnes, through such a public medium became a potential patient privacy violation, with many considering it disrespectful and embarrassing.

Interestingly, the court sided with Byrnes and ordered she be reinstated. In court, all four students testified they had asked for  and received permission to take the photo. The lawyer argued that no patient privacy violation occurred because there was nothing identifiable in the photos. The judge found the school did not give Byrnes a fair hearing, and she and her Byrnes and her classmates are slated to resume their studies.

This case is simply the latest in a string of stories about nurses getting into trouble over Facebook and other social media sites. A story last week involved a nurse suing her former employer after she was fired for complaining about staff, including physicians, posting photos of sedated patients on Facebook. There is a case before the National Labor Relations Board about a nurse fired for posting that she had come "face-to-face" with a "cop killer" and what she hoped would happen to said person.

These cases illustrate that not only should organizations have policies in place regarding social media, but that organizations should engage in discussion with staff about their use. It's all very well to have a policy about not divulging patient details on staff's Facebook pages, but it's the smaller details and the grey areas that have got most people in trouble.

As part of HIPAA training, as well as general discussions about behavior, administration should encourage educators and managers to talk about these issues on a personal level. Most people understand that using patient identifiers on social media is a no-no. Talking about one's day, however, is a different matter and all too easy for employees to get themselves into hot water.

It's important to discuss not only patients but coworkers and the organization as well. Gossip and malicious talk about coworkers in a public setting can cause hostile work environments. The line between harmless teasing and damaging harassment is all too thin.

Talk about the grey areas, giving specific examples, and bring the issue down to a personal level. Only then will nurses understand the care they must take.

To Boost Patient Satisfaction Scores, Engage Nurses

Rebecca Hendren, January 4, 2011

Patient satisfaction is on everyone’s minds in 2011 as we face the prospect that these scores will start to affect reimbursement. Senior leadership is paying more attention than ever before and will turn to the nursing department to ask, “What are we doing about patient satisfaction?”

Trouble is, mention patient satisfaction to a group of nurses and you’re likely to be greeted by groans and eye rolling. Nursing staff already have so many tasks to complete they don’t want new ones added to their already overstretched days. When administrators say to put patient satisfaction high on the priority list, nurses counter that delivering care and keeping their patients safe is far more important. A hospital is not a luxury hotel after all, and many unpleasant things happen to patients while in the hospital. By definition, no one should enjoy their stay.

What these conversations often miss, however, is that nurses are already doing the things that make the difference in patient satisfaction. When they hold the hand of a frightened, hurting patient in the middle of the night; when they explain a complex treatment regimen in a way the patient understands; when they change a dressing with care and tenderness; when they crack a joke that makes a patient laugh.

I was reminded of this when reading Dana Jennings post on The New York Times’ Well blog last week called “In Praise of Nurses.” Jennings writes that throughout his lengthy hospitalizations, it was nurses who he liked most.

“To generalize: Nurses are warm, whereas doctors are cool. Nurses act like real people; doctors often act like aristocrats. Nurses look you in the eye; doctors stare slightly above and to the right of your shoulder.”

Nurses find whatever time they can spare so they can interact with their patients and the organization should recognize the value of these interactions. Too often, hospitals haven’t been talking about patient satisfaction with their staff in the right way.

There needs to be a shift in the conversation:

  • Try focusing on the innate nursing qualities that mean so much to patients and that make the difference between a good stay and a bad one.
  • Help nurses understand that patient satisfaction scores are not dependent on whether the TV shows HBO or the nursing staff act as waitresses.
  • Convey to nurses the idea that asking them to focus on patient satisfaction is not about adding tasks to their day; rather, it is valuing what nurses already do and helping them find ways to do more of the good stuff.

Changing the nature of the conversation and involving nursing in the solutions may make more difference to patients emotional and physical care—and thus the patient satisfaction scores—than any gourmet food tray ever could.

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