Nursing won't be the same again because of the coronavirus. Here's how nurses responded to the never-seen-before crisis to care for patients and make the profession stronger.
Mary McGinn, BSN, RN, senior administrative director, patient logistics at Northwell Health's Lenox Hill Hospital on Manhattan's Upper East Side, has been through her fair share of catastrophes. In 2001, the veteran nurse was a month into a brand-new position managing patient throughput at St. Vincent's Hospital, the closest trauma center to the World Trade Center, when the 9/11 terrorist attacks occurred.
A decade later at Lenox Hill, she was part of the LHH emergency management team in its implementation of the hospital's response to Hurricane Sandy. There, she played a key role in the ED during the triaging and immediate placement of nearly a hundred patients from New York University Langone Medical Center after its backup generator failed and the hospital had to be evacuated.
But the COVID-19 pandemic is like nothing McGinn has experienced in her 45-year nursing career.
"I remember walking down the hall with someone, and he turned to me and said, 'You've probably seen it all.' I said, 'No, I don't think that I can say that after this,' " she recalls. "This is like what you see on a TV show, or you read in a book, and then you're living it. For me, this is probably the closest we have ever been to a war in what it's done to us and to our psyche."
The pandemic has put extreme strain on the United States and its people, particularly those in healthcare. COVID-19 has especially challenged the nursing profession to its limit, as some hospitals and health systems have had to endure a lack of personal protective equipment (PPE), an influx of patients, and sudden reassignment to different nursing units and roles.
But nurses are working through these challenges with support and innovation so they can continue to care for patients. In these pages, nurse leaders from around the country, including McGinn, discuss the integral roles nurses are playing as the profession is reshaped by the pandemic.
McGinn notes how multiple physicians have commented to her that nurses always responded to patient needs, even during the height of COVID-19. "When the call bell went off, they went in [patient rooms]. They ran to it. They didn't run away from it," McGinn says. "There's no replacing the bedside nurse. There's no replacing what they did during this time and the value of what they did. The education and training it requires to be a nurse today equals the skill set required of other members of the clinical team."
Though nurse leaders express concern about nurses' mental health and emotional trauma related to the crisis, they also have a sense of pride in the innovation and creativity RNs have shown.
Below are four areas where the pandemic has changed the nursing profession, and what nurse leaders are doing about them within this new environment.
1. Nurses' mental health
Nursing burnout, compassion fatigue, and moral distress have been perpetual issues in nursing for at least the past decade. But nurse leaders like Tari Dilks, RN, DNP, APRN, PMHNP-BC, FAANP, president of the American Psychiatric Nurses Association and professor at McNeese State University in Lake Charles, Louisiana, are concerned that the scale, intensity, and pervasiveness of the COVID-19 pandemic will intensify these issues.
In addition to workplace stress, nurses are dealing with pandemic-induced stressors at home, including school closures, spousal job losses, and the fear of COVID-19 infecting their families, Dilks points out. Thus, nurses' well-being and mental health can no longer be overlooked.
"It's going to be incumbent upon their employers to make sure that mental health needs are being met," she says. "If we can figure out those things that help nurses be resilient … we're going to be in a much better place emotionally."
Peer support is one of many strategies that Penn Medicine Princeton Health in Plainsboro, New Jersey, has implemented to care for nurses' mental health, says Sheila Kempf, PhD, RN, NEA-BC, the organization's chief nursing officer.
For example, staff were trained to recognize the signs of being at high risk for emotional distress, such as verbalizing specific thoughts or emotions, and when peers should be referred to the Employee Assistance Program (EAP). The hospital also contracted a trauma clinical psychologist to talk with staff and run support groups with the EAP and the Ministries department.
"In the very beginning, when no one really knew what the [COVID-19] treatments were, it was overwhelming. But you didn't have time to stop and think about it," Kempf says about the nurses' experience. "By about June, it all started to sink in: what they went through, what they witnessed."
During the spring surge in COVID-19 cases, the 231-bed hospital had over 30 patients on ventilators with a census of around 80 COVID-19 patients a day. Typically, the hospital operates a 12-bed ICU.
To offer additional support during the crisis, the hospital's nurse advisory council formed a wellness committee. The group put together "code lavender" kits to promote self-care among the entire hospital staff. The kits included stress balls, chocolates, tea bags, cards with motivational sayings, and lavender essential oil. The team assembled about 3,000 kits and distributed them to all hospital employees.
"They went department by department and gave them out, which I thought was phenomenal," Kempf says.
The organization also began holding "clap outs," where staff gathered to clap and cheer for patients with COVID-19 who had been on a ventilator and were being discharged. In addition, for all COVID-19 patients being discharged, they played the song "Here Comes the Sun" over the loudspeaker. The intent was to celebrate patients' recovery and to show staff that their hard work was paying off, Kempf says. She estimates that song has been played about 500 times.
Yet, despite these recent efforts, Kempf says healthcare leaders should view nurses' mental health and well-being as a long-term issue.
"Even now, I'll say something to a staff nurse, and they'll start crying. It still happens," she says. "[Nurses] witnessed private conversations between husband and wife, sons and daughters, where they were saying goodbye [to loved ones]. I think that's where the crux of the emotional distress and PTSD is coming from because they witnessed things they should not." In addition, the staff was worried about bringing the coronavirus home to their own families. One of the local hotels provided free rooms to staff who either had to quarantine or could not go home due to a high-risk family member.
2. Patient throughput
As the senior administrative director, patient logistics, Lenox Hill's McGinn is responsible for the overall patient flow strategy, including the internal movements of all admitted patients from numerous portals of entry, the transitions of care within the hospital, and the facilitation and timely acceptance of external patient transfer requests.
McGinn says she believes patient safety, outcomes, and experience are all driven by the patient being in the right place at the right time. She also says nursing experience is extremely valuable in the role that she holds. Patient throughput, while operational in nature, really is a bridge between the clinical and ancillary departments of a hospital.
McGinn says she needed to utilize her previous experience, current skills, and numerous tools from her toolbox, including the enterprise TeleTracking system, when Lenox Hill's surge plan was developed with senior leadership and its ICU capacity grew from 48 beds to 123 beds. The expansion was accomplished by converting all the step-down units to ICU units, and physically moving the outpatient infusion center to Lenox Hill's ambulatory Manhattan Eye/Ear/Throat (MEETH) location, which added another 24-bed flexible-acuity unit.
"We knew we were going to need a lot of vacant beds to handle the surge volume. There are only two ways of getting beds that I know of: discharging patients, and by reclaiming and standing up closed units that were repurposed over the years. However, at some point, you finally run out of real estate, and you have to figure out what else from your surge plan you can implement," she says.
Having the support and resources of the Northwell Health system, McGinn says Lenox Hill was able to create and open a 35-bed nursing unit in the same building as the stand-alone Lenox Hill Greenwich Village ED. This was accomplished by utilizing the ambulatory PACU space of a closed surgical site. The unit's population was composed of patients who were clinically ready for discharge, but for various nonclinical reasons—such as needing a required number of negative COVID-19 tests—were screened and selected by a transition-in-care team who clinically approved the patients for lateral transfer after patient and family consent.
The unit was staffed with redeployed advanced practice clinicians, Greenwich Village team members, and a Northwell Health physician who volunteered to be the physician in charge. The transfer process was facilitated by the patient throughput team in collaboration with both the sending and receiving clinical teams to an off-main-campus nursing unit site. The Northwell Health IT team built the unit during surge planning, and the movement of these patients from one location to another was possible because of the technology platform that was in place.
In addition to discharging and relocating patients, McGinn says she was very concerned for the "load-balanced transfers" Lenox Hill admitted from several of their sister hospitals that were at the center of the epidemic.
"The last thing I wanted was for the nurses and the physicians who were already working their tails off to be running from rapid response to rapid response because we were transferring patients that were too acute to be at their level of care," she says.
McGinn called a meeting with the Lenox Hill ED leadership and advocated for triaging incoming patients through the ED, similar to what had been done during Hurricane Sandy, and the group agreed.
"I believe by transferring patients in this way, we prevented numerous rapid responses from occurring on the units," McGinn says.
One of the accomplishments Lenox Hill Hospital achieved throughout the COVID-19 surge was the timely movement of all patients to their beds, including ICU patients. There were "no boarding" issues in the ED, "which was a testament to everyone who worked tirelessly throughout this period," according to McGinn.
"We were able to get people out of the ED and up into a bed quickly. We had the ability to get them up to where the appropriate care was," she says.
The fact that McGinn is part of the emergency management team highlights the value of patient logistics.
"I go to those meetings and I participate, and I think, 'It really shows the level that people believe that throughput is valuable, and they need to have us at the table with them,' " she says.
Going forward, says McGinn, the patient throughput group will continue some of the duties it took on during the crisis.
For example, after consulting with teammates in epidemiology, the patient logistics team updated information to indicate when patients are being tested for COVID-19, whether a patient tests positive for COVID-19, and whether the patient was intubated.
"We are now taking that on permanently for all indicators," McGinn says. "That's a change in process. The throughput coordinators are utilizing Microsoft Teams®, having partnered with the epidemiology team, so they're constantly chatting with each other about who's a rule-out COVID low suspicion, high suspicion precautions, or who has a 'banner' from a previous admission. They have a clinical conversation, the outcome of the conversation is relayed, the banners are changed, and attributes in the system are removed if needed. This ensures that patients are going to the correct location the first time, thus reducing nursing handoffs."
This work will continue as McGinn's team continues to partner with the clinical teams, patient care management, and the ancillary department testing teams to identify, prioritize, and transport anticipated discharge-ready patients who require one last test before leaving.
"Those are things that we're doing to help facilitate earlier discharges," McGinn says.
3. Teamwork
In recent years, many in the healthcare industry have called for an increase in interprofessional education and teamwork and a breakdown of traditional professional siloes. Nurses, and other healthcare workers, dealing with the COVID-19 crisis helped break down those siloes through necessity.
Natalia Cineas, DNP, RN, NEA-BC, senior vice president and system chief nurse executive at NYC Health + Hospitals in New York, says tackling the pandemic calls for teamwork both inside and outside the nursing profession.
"It's changed the whole notion of what 'type' of nurse you are. The whole specialty aspect went out the door," she says. "During COVID, if you were an ambulatory nurse, you would help [with] inpatient care. If you were with the Department of Defense—Army, Navy, Air Force—they came to help inpatient. If you were a Department of Education nurse, like a school nurse, you came, and you helped. I think it changed the whole notion of, 'That's that type of nurse, or they work over there.' I think it's solidified the fact that we're all one profession. Although you have to socially distance, we've become closer than we've ever been."
Sophia L. Thomas, DNP, APRN, FNP-BC, PPCNP-BC, FNAP, FAANP, president of the American Association of Nurse Practitioners, and a family and pediatric nurse practitioner (NP) at the Daughters of Charity Health System in Kenner, Louisiana, echoes this sentiment.
"One commonality I've found in all my conversations is an unprecedented sense of comradery and unity among all healthcare providers, which has been nice to see," she says. "Another one that's been welcomed is the increased level of incredible innovation and cooperation among the providers throughout the COVID response."
For example, NPs went to help in New York when Governor Andrew Cuomo signed an executive order that allowed them to practice without a collaborative practice agreement.
"We immediately had 4,000 nurse practitioners go for temporary assignments in New York, and as they care for patients, they share critical information about the virus. The information sharing has allowed NPs in all the types of care settings to better respond to COVID cases, whether they experienced an uptick or not," Thomas says.
4. Care delivery
The COVID-19 pandemic has created an environment that calls for new ways of delivering care. This has led to a great deal of innovation from both bedside nurses and nursing leadership. At Penn Medicine Princeton Health, in an effort to preserve PPE and provide good patient care, nurses created new care models in record time, Kempf says.
"In the beginning, the nurse performed all patient-related tasks because it was about preserving PPE and providing good care. For every patient on the med-surg floors who needed respiratory treatments, the nurses completed the treatments. They provided all the dietary and environmental services tasks," she says.
But following COVID-19's initial appearance, the nurses at Penn Medicine Princeton Health redesigned the nursing model to include an "inside" nurse within the patient room and an "outside" nurse or "runner" outside the patient room.
"We had runners in the hallways that did two functions. One was to make sure PPE was correctly donned. And, if an inside nurse needed something, [he or she] could communicate with the outside nurses and get what [was] needed. We could put medications, supplies, food in the [nurse] server from the outside so that [the inside nurse] could pick it up on the inside [of the room]," Kempf explains. "We designed this inside-outside model of care with staff within the first three days on our COVID unit. We went up there, we talked to staff and the educators and the leaders, and they just designed this entirely different model of care."
Additionally, in the ICU, IV pumps were placed outside of patient rooms for the outside nurses to manage.
"The nurses created a system where they had dual bar coding. The patient had the bracelet ID on, and a duplicate label with the patient's name was placed on each pump. The inside nurse could barcode the patient, and the nurse outside barcoded the med and then hooked it up," she says.
The organization also invested in headsets that could be worn under PPE, allowing inside and outside nurses to safely communicate with each other.
Kempf's nursing directors also took on new roles, each becoming an expert in a specific area.
"One was the PPE expert. She researched any PPE that had been donated to confirm that the CDC guidelines were met. She took face shields to Princeton University, and they printed them for us on the 3D printer when we couldn't get them from the company," Kempf says. "Another person became the labor deployment expert, checking credentials and education required for their new role. Someone else was the statistical person because we had to report everything to the state."
Kempf hopes this spirit of innovation continues in nursing long term.
"I think we will all look at things differently in terms of innovation and thinking out of the box. Crisis breeds creativity, and working under these kinds of conditions, I think a lot of nurses were surprised at what they could come up with. We have to give them the methodology for innovation and allow them to do it. We need to reward and recognize the staff who think outside of the box. I think it will have a good positive effect for the future," she says.
Nursing won't be the same again because of the coronavirus. Here's how nurses responded to the never-seen-before crisis to care for patients and make the profession stronger.
Mary McGinn, BSN, RN, senior administrative director, patient logistics at Northwell Health's Lenox Hill Hospital on Manhattan's Upper East Side, has been through her fair share of catastrophes. In 2001, the veteran nurse was a month into a brand-new position managing patient throughput at St. Vincent's Hospital, the closest trauma center to the World Trade Center, when the 9/11 terrorist attacks occurred.
A decade later at Lenox Hill, she was part of the LHH emergency management team in its implementation of the hospital's response to Hurricane Sandy. There, she played a key role in the ED during the triaging and immediate placement of nearly a hundred patients from New York University Langone Medical Center after its backup generator failed and the hospital had to be evacuated.
But the COVID-19 pandemic is like nothing McGinn has experienced in her 45-year nursing career.
"I remember walking down the hall with someone, and he turned to me and said, 'You've probably seen it all.' I said, 'No, I don't think that I can say that after this,' " she recalls. "This is like what you see on a TV show, or you read in a book, and then you're living it. For me, this is probably the closest we have ever been to a war in what it's done to us and to our psyche."
The pandemic has put extreme strain on the United States and its people, particularly those in healthcare. COVID-19 has especially challenged the nursing profession to its limit, as some hospitals and health systems have had to endure a lack of personal protective equipment (PPE), an influx of patients, and sudden reassignment to different nursing units and roles.
But nurses are working through these challenges with support and innovation so they can continue to care for patients. In these pages, nurse leaders from around the country, including McGinn, discuss the integral roles nurses are playing as the profession is reshaped by the pandemic.
McGinn notes how multiple physicians have commented to her that nurses always responded to patient needs, even during the height of COVID-19. "When the call bell went off, they went in [patient rooms]. They ran to it. They didn't run away from it," McGinn says. "There's no replacing the bedside nurse. There's no replacing what they did during this time and the value of what they did. The education and training it requires to be a nurse today equals the skill set required of other members of the clinical team."
Though nurse leaders express concern about nurses' mental health and emotional trauma related to the crisis, they also have a sense of pride in the innovation and creativity RNs have shown.
Below are four areas where the pandemic has changed the nursing profession, and what nurse leaders are doing about them within this new environment.
1. Nurses' mental health
Nursing burnout, compassion fatigue, and moral distress have been perpetual issues in nursing for at least the past decade. But nurse leaders like Tari Dilks, RN, DNP, APRN, PMHNP-BC, FAANP, president of the American Psychiatric Nurses Association and professor at McNeese State University in Lake Charles, Louisiana, are concerned that the scale, intensity, and pervasiveness of the COVID-19 pandemic will intensify these issues.
In addition to workplace stress, nurses are dealing with pandemic-induced stressors at home, including school closures, spousal job losses, and the fear of COVID-19 infecting their families, Dilks points out. Thus, nurses' well-being and mental health can no longer be overlooked.
"It's going to be incumbent upon their employers to make sure that mental health needs are being met," she says. "If we can figure out those things that help nurses be resilient … we're going to be in a much better place emotionally."
Peer support is one of many strategies that Penn Medicine Princeton Health in Plainsboro, New Jersey, has implemented to care for nurses' mental health, says Sheila Kempf, PhD, RN, NEA-BC, the organization's chief nursing officer.
For example, staff were trained to recognize the signs of being at high risk for emotional distress, such as verbalizing specific thoughts or emotions, and when peers should be referred to the Employee Assistance Program (EAP). The hospital also contracted a trauma clinical psychologist to talk with staff and run support groups with the EAP and the Ministries department.
"In the very beginning, when no one really knew what the [COVID-19] treatments were, it was overwhelming. But you didn't have time to stop and think about it," Kempf says about the nurses' experience. "By about June, it all started to sink in: what they went through, what they witnessed."
During the spring surge in COVID-19 cases, the 231-bed hospital had over 30 patients on ventilators with a census of around 80 COVID-19 patients a day. Typically, the hospital operates a 12-bed ICU.
To offer additional support during the crisis, the hospital's nurse advisory council formed a wellness committee. The group put together "code lavender" kits to promote self-care among the entire hospital staff. The kits included stress balls, chocolates, tea bags, cards with motivational sayings, and lavender essential oil. The team assembled about 3,000 kits and distributed them to all hospital employees.
"They went department by department and gave them out, which I thought was phenomenal," Kempf says.
The organization also began holding "clap outs," where staff gathered to clap and cheer for patients with COVID-19 who had been on a ventilator and were being discharged. In addition, for all COVID-19 patients being discharged, they played the song "Here Comes the Sun" over the loudspeaker. The intent was to celebrate patients' recovery and to show staff that their hard work was paying off, Kempf says. She estimates that song has been played about 500 times.
Yet, despite these recent efforts, Kempf says healthcare leaders should view nurses' mental health and well-being as a long-term issue.
"Even now, I'll say something to a staff nurse, and they'll start crying. It still happens," she says. "[Nurses] witnessed private conversations between husband and wife, sons and daughters, where they were saying goodbye [to loved ones]. I think that's where the crux of the emotional distress and PTSD is coming from because they witnessed things they should not." In addition, the staff was worried about bringing the coronavirus home to their own families. One of the local hotels provided free rooms to staff who either had to quarantine or could not go home due to a high-risk family member.
2. Patient throughput
As the senior administrative director, patient logistics, Lenox Hill's McGinn is responsible for the overall patient flow strategy, including the internal movements of all admitted patients from numerous portals of entry, the transitions of care within the hospital, and the facilitation and timely acceptance of external patient transfer requests.
McGinn says she believes patient safety, outcomes, and experience are all driven by the patient being in the right place at the right time. She also says nursing experience is extremely valuable in the role that she holds. Patient throughput, while operational in nature, really is a bridge between the clinical and ancillary departments of a hospital.
McGinn says she needed to utilize her previous experience, current skills, and numerous tools from her toolbox, including the enterprise TeleTracking system, when Lenox Hill's surge plan was developed with senior leadership and its ICU capacity grew from 48 beds to 123 beds. The expansion was accomplished by converting all the step-down units to ICU units, and physically moving the outpatient infusion center to Lenox Hill's ambulatory Manhattan Eye/Ear/Throat (MEETH) location, which added another 24-bed flexible-acuity unit.
"We knew we were going to need a lot of vacant beds to handle the surge volume. There are only two ways of getting beds that I know of: discharging patients, and by reclaiming and standing up closed units that were repurposed over the years. However, at some point, you finally run out of real estate, and you have to figure out what else from your surge plan you can implement," she says.
Having the support and resources of the Northwell Health system, McGinn says Lenox Hill was able to create and open a 35-bed nursing unit in the same building as the stand-alone Lenox Hill Greenwich Village ED. This was accomplished by utilizing the ambulatory PACU space of a closed surgical site. The unit's population was composed of patients who were clinically ready for discharge, but for various nonclinical reasons—such as needing a required number of negative COVID-19 tests—were screened and selected by a transition-in-care team who clinically approved the patients for lateral transfer after patient and family consent.
The unit was staffed with redeployed advanced practice clinicians, Greenwich Village team members, and a Northwell Health physician who volunteered to be the physician in charge. The transfer process was facilitated by the patient throughput team in collaboration with both the sending and receiving clinical teams to an off-main-campus nursing unit site. The Northwell Health IT team built the unit during surge planning, and the movement of these patients from one location to another was possible because of the technology platform that was in place.
In addition to discharging and relocating patients, McGinn says she was very concerned for the "load-balanced transfers" Lenox Hill admitted from several of their sister hospitals that were at the center of the epidemic.
"The last thing I wanted was for the nurses and the physicians who were already working their tails off to be running from rapid response to rapid response because we were transferring patients that were too acute to be at their level of care," she says.
McGinn called a meeting with the Lenox Hill ED leadership and advocated for triaging incoming patients through the ED, similar to what had been done during Hurricane Sandy, and the group agreed.
"I believe by transferring patients in this way, we prevented numerous rapid responses from occurring on the units," McGinn says.
One of the accomplishments Lenox Hill Hospital achieved throughout the COVID-19 surge was the timely movement of all patients to their beds, including ICU patients. There were "no boarding" issues in the ED, "which was a testament to everyone who worked tirelessly throughout this period," according to McGinn.
"We were able to get people out of the ED and up into a bed quickly. We had the ability to get them up to where the appropriate care was," she says.
The fact that McGinn is part of the emergency management team highlights the value of patient logistics.
"I go to those meetings and I participate, and I think, 'It really shows the level that people believe that throughput is valuable, and they need to have us at the table with them,' " she says.
Going forward, says McGinn, the patient throughput group will continue some of the duties it took on during the crisis.
For example, after consulting with teammates in epidemiology, the patient logistics team updated information to indicate when patients are being tested for COVID-19, whether a patient tests positive for COVID-19, and whether the patient was intubated.
"We are now taking that on permanently for all indicators," McGinn says. "That's a change in process. The throughput coordinators are utilizing Microsoft Teams®, having partnered with the epidemiology team, so they're constantly chatting with each other about who's a rule-out COVID low suspicion, high suspicion precautions, or who has a 'banner' from a previous admission. They have a clinical conversation, the outcome of the conversation is relayed, the banners are changed, and attributes in the system are removed if needed. This ensures that patients are going to the correct location the first time, thus reducing nursing handoffs."
This work will continue as McGinn's team continues to partner with the clinical teams, patient care management, and the ancillary department testing teams to identify, prioritize, and transport anticipated discharge-ready patients who require one last test before leaving.
"Those are things that we're doing to help facilitate earlier discharges," McGinn says.
3. Teamwork
In recent years, many in the healthcare industry have called for an increase in interprofessional education and teamwork and a breakdown of traditional professional siloes. Nurses, and other healthcare workers, dealing with the COVID-19 crisis helped break down those siloes through necessity.
Natalia Cineas, DNP, RN, NEA-BC, senior vice president and system chief nurse executive at NYC Health + Hospitals in New York, says tackling the pandemic calls for teamwork both inside and outside the nursing profession.
"It's changed the whole notion of what 'type' of nurse you are. The whole specialty aspect went out the door," she says. "During COVID, if you were an ambulatory nurse, you would help [with] inpatient care. If you were with the Department of Defense—Army, Navy, Air Force—they came to help inpatient. If you were a Department of Education nurse, like a school nurse, you came, and you helped. I think it changed the whole notion of, 'That's that type of nurse, or they work over there.' I think it's solidified the fact that we're all one profession. Although you have to socially distance, we've become closer than we've ever been."
Sophia L. Thomas, DNP, APRN, FNP-BC, PPCNP-BC, FNAP, FAANP, president of the American Association of Nurse Practitioners, and a family and pediatric nurse practitioner (NP) at the Daughters of Charity Health System in Kenner, Louisiana, echoes this sentiment.
"One commonality I've found in all my conversations is an unprecedented sense of comradery and unity among all healthcare providers, which has been nice to see," she says. "Another one that's been welcomed is the increased level of incredible innovation and cooperation among the providers throughout the COVID response."
For example, NPs went to help in New York when Governor Andrew Cuomo signed an executive order that allowed them to practice without a collaborative practice agreement.
"We immediately had 4,000 nurse practitioners go for temporary assignments in New York, and as they care for patients, they share critical information about the virus. The information sharing has allowed NPs in all the types of care settings to better respond to COVID cases, whether they experienced an uptick or not," Thomas says.
4. Care delivery
The COVID-19 pandemic has created an environment that calls for new ways of delivering care. This has led to a great deal of innovation from both bedside nurses and nursing leadership. At Penn Medicine Princeton Health, in an effort to preserve PPE and provide good patient care, nurses created new care models in record time, Kempf says.
"In the beginning, the nurse performed all patient-related tasks because it was about preserving PPE and providing good care. For every patient on the med-surg floors who needed respiratory treatments, the nurses completed the treatments. They provided all the dietary and environmental services tasks," she says.
But following COVID-19's initial appearance, the nurses at Penn Medicine Princeton Health redesigned the nursing model to include an "inside" nurse within the patient room and an "outside" nurse or "runner" outside the patient room.
"We had runners in the hallways that did two functions. One was to make sure PPE was correctly donned. And, if an inside nurse needed something, [he or she] could communicate with the outside nurses and get what [was] needed. We could put medications, supplies, food in the [nurse] server from the outside so that [the inside nurse] could pick it up on the inside [of the room]," Kempf explains. "We designed this inside-outside model of care with staff within the first three days on our COVID unit. We went up there, we talked to staff and the educators and the leaders, and they just designed this entirely different model of care."
Additionally, in the ICU, IV pumps were placed outside of patient rooms for the outside nurses to manage.
"The nurses created a system where they had dual bar coding. The patient had the bracelet ID on, and a duplicate label with the patient's name was placed on each pump. The inside nurse could barcode the patient, and the nurse outside barcoded the med and then hooked it up," she says.
The organization also invested in headsets that could be worn under PPE, allowing inside and outside nurses to safely communicate with each other.
Kempf's nursing directors also took on new roles, each becoming an expert in a specific area.
"One was the PPE expert. She researched any PPE that had been donated to confirm that the CDC guidelines were met. She took face shields to Princeton University, and they printed them for us on the 3D printer when we couldn't get them from the company," Kempf says. "Another person became the labor deployment expert, checking credentials and education required for their new role. Someone else was the statistical person because we had to report everything to the state."
Kempf hopes this spirit of innovation continues in nursing long term.
"I think we will all look at things differently in terms of innovation and thinking out of the box. Crisis breeds creativity, and working under these kinds of conditions, I think a lot of nurses were surprised at what they could come up with. We have to give them the methodology for innovation and allow them to do it. We need to reward and recognize the staff who think outside of the box. I think it will have a good positive effect for the future," she says.
Ellen Fink-Samnick, discusses how the pandemic is creating trauma among healthcare professionals and what can be done about it.
Editor's note: On July 23, Ellen Fink-Samnick MSW, ACSW, LCSW, CCM, CRP, DBH(s), will present the 60-minute webinar, "Vicarious Trauma: Tackling Occupational Hazards of the Pandemic." Follow this linkto register.
In a pandemic that has gripped the United States since January, there have been over 3 million confirmed COVID-19 cases to date. With symptoms ranging from mild to death, the virus has left its mark on the nation, and, in particular, on healthcare systems and healthcare professionals as they care for patients with the disease.
As COVID-19 has spread across the country, it has also left the effects of vicarious trauma in its wake.
Vicarious traumatization, also called secondary traumatic stress, is a term coined by Laurie A. Pearlman and Karen W. Saakvitne in 1995. It describes a significant shift in a helping professional's world view when they work with individuals who have experienced trauma. Helping professionals who experience vicarious trauma report that their fundamental beliefs about the world are changed and possibly damaged by repeatedly being exposed to "traumatic material."
"We have a whole interprofessional workforce that is on not only the frontlines, but also in other areas that are not getting as much attention, like primary care clinics and outpatient programming and outpatient clinics where nurses, nurse practitioners, social workers, and different types of case managers and rehabilitation professionals are," says Ellen Fink-Samnick, MSW, ACSW, LCSW, CCM, CRP, DBH(s), of EFS Supervision Strategies, LLC, a company that provides professional speaking, training, and consultation to empower the interprofessional workforce. "You've got the whole workforce impacted directly by having to work amid so many unknowns."
In a recent interview with HealthLeaders, Fink-Samnick discusses the concept of vicarious trauma, how it affects healthcare professionals, and how to improve the mental health of the workforce.
The following transcript has been edited for brevity and clarity.
HealthLeaders: Can you explain what vicarious trauma is?
Ellen Fink-Samnick: Vicarious trauma is all the emotional "stuff" that comes up when professionals have to deal with the realities of their patients. So, [the patients'] real-life experiences impact us because, at the core of it, we're all human.
For example, I've been a clinical social worker for 37 years and a professional case manager for almost 30. I'm a person first, but I have professional training that helps me keep boundaries and helps me manage normal stress, normal tension, normal anxiety. And then even, I have had to deal with trauma that my clients or patients bring to the party.
But now you've got a pandemic and, every day, we get a different story. Healthcare professionals and behavioral health professionals [are getting] different renderings of when it's safe to start seeing people in person. This not only has a community-based impact; it's global. It impacts us on a profound, personal level. So, we've got this whole element of—what I call and a lot of other experts are calling—shared trauma. You've got the patient, the professional, and the overall population experiencing all of this 24/7. Every practitioner, nurse, social worker, physician—they are worried for their own health. They're worried they're going to bring this home to family members. They're worried they can't see their family members. They are feeling exhausted from it. They're petrified. They're dealing with human emotions because this has gone now beyond just stress; this is full-fledged trauma.
HL: How does vicarious trauma differ from stress and burnout?
Fink-Samnick: When you look at stress, there's all of those factors that we deal with that we feel something about and there's usually some sort of physical, chemical, or emotional factor that causes some sort of physical or mental tension. We worry about job stability normally, right? Perhaps you take a new position. You hope it's going to work out. You hope you're going to pay your next bill. You have a fight with your partner, and it causes some stress the next day. There's normal stress. There's even good stress. For example, you get married or you buy a house.
Trauma then is those experiences that are amped up a notch. They are more intense physical and psychological reactions. They might see a single episode, or it could be multiple circumstances like when we're talking about repeated abuse, neglect, domestic violence, sexual assault, or verbal abuse. People that live in communities that are greatly impacted by crime, poverty, constant unemployment, intergenerational violence, as a result, have this physical, emotional, harmful, long-lasting response to these events.
That's trauma. When you go to vicarious trauma, that's the shared experience.
The standard definition of burnout … the outcome can look the same—poor quality, poor response, total team disintegration.
The other part of it is, healthcare professionals, we have a habit of processing and rolling. We don't take care of ourselves. We barely address stress. We certainly barely address trauma, which is what creates that vicarious trauma response. But now we've got this whole shared trauma dynamic because we're all going through the same fear, the same worry, the same vulnerability together, the same losses together, and people are petrified. And if someone's traumatized, they're going to be burned out.
But this [COVID-19 pandemic] is a collective trauma. It's trauma that's gone viral. Vicarious trauma is trauma on steroids.
HL: What are some strategies to manage vicarious trauma in the healthcare workplace?
Fink-Samnick: First of all, [healthcare professionals] have to give themselves permission to stop. They need to do things like debrief. They need to be able to accept support from each other. It doesn't imply that they're being weak.
One thing they have to do is limit social media. [Try to] engage in more energy-fulfilling activities, which are things like virtual get-togethers, virtual dinners, and virtual happy hours. Don't talk about COVID stuff.
Another example is, someone who I know works in an emergency department of a fairly large hospital, and they had "bring a picture of your pet" day. It's not going to change the reality, but it can help shift the narrative [to something positive] because if we don't shift it, no one's going to do it for us.
Eat well—protein and healthy carbs—and hydrate. Sleep hygiene is a biggie. One of the biggest issues that's happening is people are working multiple shifts and then they are not sleeping. The Sleep Foundation website has tools specific to sleep hygiene. For example, when you're off, you just want to sleep all day. I get that but that's the worst thing you can do. You want to limit those naps and be in a normal routine. You want to keep up with your exercise and avoid things that stimulate you at bedtime; no scrolling through Facebook and getting upset about what's fact and what's fiction.
The one thing that is not working is bringing in crisis counselors. [Healthcare workers are] not wanting to utilize those resources in the moment. You can refer folks and remind them that they're there, but they need a break. What they don't want to do is sit and talk about it even though it's healthy and cathartic.
HL: What do you think the long-term effects of COVID are going to be on our healthcare workforce?
Fink-Samnick: I think we're going to have a generation with PTSD to deal with amongst our own. I've been worried about it with the uptick of mass violence we were seeing. We're going to have to make sure that there is more acceptance and understanding and less stigma for seeking behavioral health.
It's not a bad thing. This is why there are so many wonderful resources out there being built on virtual platforms strictly for professionals. If we can't attend to our own human condition, we are useless to care for the human condition of others. Mental health is not a dirty word. There's no weakness in acknowledging we need help. We have to use the resources. We have to seek therapy and not rationalize that just because you're in the "business," you know what to do. That doesn't give you the objectivity or certainly the skills and expertise to do it. There are wonderful short-term interventions.
Daihnia Dunkley, RN, interviewed black women about their experiences as CNOs. Here's what healthcare organizations need to do to support these executives.
It's no secret that healthcare executive teams often do not reflect the communities they serve.
However, that same representation is lacking in healthcare leadership. The same report found "minorities comprise only 14% of hospital board members, 11% of executive leadership positions, and 19% of first- and mid-level managers."
As Daihnia Dunkley, PhD, RN, professor at Farmingdale State College in Farmingdale, New York, points out, data specific to the number of black women in chief nursing officer roles is lacking, but their representation is likely even lower than the aforementioned numbers.
"I have been fortunate to work with several black nurse leaders, but then as I started to climb the [career] ladder, I realized how rare it was to actually work with a black CNO," she says.
This rarity of black CNOs was the inspiration for Dunkley's PhD dissertation, "The Lived Experience of Being Black and Female When Becoming a Nurse Executive."
"I thought [becoming a CNO] is something that's along my career aspirations. Why don't I study who I'm aspiring to become?" she says.
Rather than strictly studying the obstacles black women faced in becoming CNOs, Dunkley interviewed 10 black women who were working or had worked as CNOs in New York, New Jersey, and Connecticut, about their experiences becoming and leading as CNOs.
"I wanted the 'cheat codes,' " she says.
She recalls what she said to the woman she interviewed: " 'How did you do this? I already know that there are so few of you and I'm pretty sure you had challenges thrown at you, but you still did it.' I wanted to know what that process looks like."
Dunkley recently spoke with me about her study findings, common themes among the CNOs' experiences, and how healthcare organizations can support this group of leaders.
The following is a lightly edited transcript of our conversation.
HealthLeaders: What were the findings of your research? I know you were able to identify many themes and subthemes regarding your participants' experiences.
Daihnia Dunkley: I came up with three essential themes: Living in a Constant State of Readiness, Embracing the Responsibility Beyond the Job Description, and Overcoming, and several subthemes. The first theme, Living in a Constant State of Readiness, stood out to me and really captured a lot of what these nurses went through. That embodied all the different things that the participants felt they needed so they could be prepared at all times. So, whether that was educationally or in their actual role, they [felt] the need to be a step ahead by having several certifications, even though their counterparts weren't required to have the same.
For example, one study participant mentioned she'd had all these years of experience and she applied to a leadership role that she saw. The person who interviewed her was somewhat dismissive, and [it became clear] that they already knew who they wanted to hire. It was somebody with much less experience than [the participant] and no certifications, but one of the differences was that person was white.
That feeling of needing to be prepared was a pattern that came up over and over in their stories and was a subtheme [I categorized it as 'I want to be ready"].
Another thing that stood out was this whole notion of armoring. Armoring was the term used to describe the things I just mentioned—getting all these advanced degrees and certifications and always being ready. It's putting on the heavy suit or layer of protection because being black and female put them at a disadvantage.
HL:Can you tell me about the second theme you identified?
Dunkley: The second major theme was embracing the responsibility beyond the job description. Yes, being a nurse executive comes with its own specific job description and performance requirements but many of the participants mentioned that because they were the first of their race to achieve this honor, they felt like they had this weight of their community on their shoulders and felt that they couldn't mess up or make a mistake.
It was described to me as a blessing and a burden to be in their position. They didn't have that same space to fail because everybody was looking at them as a representative for success. Even though that is sort of a burden, it was also a blessing because they were the first in the position and they thought it was an opportunity to open doors and then pull others along who had the same aspirations. They also felt it necessary to do a lot of community outreach to mentor others inside and outside of the organization.
Another subtheme—the names of all my subthemes are the titles or lyrics from Negro spirituals—was "The whole world in her hands." This is how the participants felt because they were juggling the job description and the tremendous burden of being the first or only black woman who accomplished this level of achievement.
HL: And last, but not least, your third theme?
Dunkley: So, the last theme was overcoming. This was [about] the challenges that they faced and the different ways in which they overcame obstacles to attain their success and progress in their careers. One of the subthemes that fit here was "The trouble I've seen."
Basically, this is where the participants expressed the challenges they had and some of the things that they went through, like discrimination, oppression in terms of dealing with censorship, or being sabotaged or experiencing mistrust from their counterparts. For example, when you're at the same level as your colleagues, you're kind of all in the same struggle. Then suddenly you get a promotion and they did not. That can cause a little bit of friction.
There were challenges inflicted by their white or male counterparts, including sexism. That was an interesting piece because nursing is a majority female profession, so once they got to the C-suite, they saw more gender discrimination since the other executive titles were mostly male.
There was mention of the boys' club, but then it was also mentioned that even the title of nurse executive wasn't respected. My analysis of that and trying to capture what they were feeling was, "Is it because I'm a nurse that I'm not suited to be an executive, or is it because nurses are mostly women and women are not suited to be executives?"
HL: You mentioned that your last subtheme focused on how the CNOs dealt with these obstacles. Can you tell me about that?
Dunkley: My last subtheme was "How I got over," which is how the participants overcame these struggles. I categorized this with internal and external motivation. Internally, these nurses were extremely resilient. What helped them overcome internally was their own fortitude, their own sense of self. Many of them mentioned they didn't wake up thinking, "I'm a black woman. This is what I have to do today." They were people in careers, trying to do their best. They pulled from their faith. They were very spiritually driven women. They use their families as their support system to pull through.
As for the external motivation, the majority of the participants said they definitely would recommend having a mentor.
One internal motivation that was not healthy was code switching or not being able to show up to work as their authentic self. A lot of them admitted that depending on who was in the room, "I became that person." They felt like sometimes they had to look the part or speak the part or dress the part because they wouldn't be accepted otherwise.
HL:What are the implications of your findings based on knowing all this information?
Dunkley: At the end of the study, I realized that now we've got lots of data. We know about the underrepresentation. We know there are racial and gender disparities. We know about the discrimination and the obstacles that black nurses face, whether they're at the bedside or trying to pursue leadership position. The implications for nursing is there isn't sufficient career or leadership development for black nurses going beyond the bedside. The nurse executives had to take it into their own hands. You have to take the horse by the reins and spirit it in the way that you'd like it to go. However, if healthcare organizations truly want a diverse workforce, a lot of the onus is on them to support and invest in the growth and development of their employees. We know there's going to be difficulties, so why not get ahead of that and provide the resources that these nurses will need so it's not another story about how those within my organization weren't supportive or there's no diversity within your executive leadership team. Slogans and statements [about diversity and inclusion] are great, but what does your organization look like?
Ernest J. Grant, president of the American Nurses Association, discusses how racism is a 'public health crisis' and affects nurses and patients.
Protests calling upon Americans to address racism and its effects have taken place in multiple cities across the country in recent weeks. The most recent catalyst for these events was the death of George Floyd, a 46-year-old black man, who died while a Minneapolis police officer knelt on his neck for over 8 minutes. The four Minneapolis police officers involved in the incident have been arrested and charged in connection to his death.
"As a nation, we have witnessed yet again an act of incomprehensible racism and police brutality, leading to the death of an unarmed black man, George Floyd. This follows other recent unjustified killings of black men and women, such as Ahmaud Arbery and Breonna Taylor to name a few," said Ernest J. Grant, PhD, RN, FAAN, president of the ANA in the association's statement. "As a black man and registered nurse, I am appalled by senseless acts of violence, injustice, and systemic racism and discrimination. Even I have not been exempt from negative experiences with racism and discrimination. The Code of Ethics for Nurses obligates nurses to be allies and to advocate and speak up against racism, discrimination and injustice. This is non-negotiable."
I recently spoke with Grant about racism, its effects, and how nurses can work for change.
The following is a lightly edited transcript of our conversation.
HealthLeaders: I think, in today's society, there's a misconception about what racism means. People think, "I'm not racist. I'm not mean to other people. I don't discriminate against them." What they're not realizing is that racism can come from unintentional bias and that it is also systemic. Could you explain what forms racism takes?
Ernest J. Grant: Off the top of my head, I can think of three examples. The first one is in education. For the black community, there are perhaps less opportunities for an even playing field, if you will. There are stumbling blocks in the way and [black men and women] may feel they have to work a little harder to achieve the same things that their white counterparts do.
Second, there's an unconscious bias that happens in the healthcare setting as well. For example, two people come to the emergency room with identical chest pain and symptoms, but one may be given a stronger medication or receive a more extensive workup than the person of color receives.
And the third one is stereotypes. Sometimes just because of a person's skin color or their culture or religious belief, [people] automatically [assume] things.
HL: How does racism in the healthcare work environment affect patients and nurses?
Grant: [In the work] environment, obviously if left unchecked, [racism] is allowed to perpetuate so it just becomes deep rooted and ingrained. Pretty soon, you've got a culture of, "Well, we've always done it this way." Or if someone is from a certain part of the community or town they may not be treated in the same fashion as someone who's from another part of town.
Nurses need to speak up whenever they see racism going on. [It doesn't] matter if it's a physician or another nurse or another member of the healthcare team, we need to call it out.
The other thing along those lines is that, from a nursing perspective, if you've got a patient from a different culture, they should be able to receive [care] from someone who is familiar with that culture, or who at least understands that culture and their healthcare beliefs.
Grant: I do. One of the things that I've always said is I think management should be reflective of the people we care for. So, [as a healthcare system] if you look at your management team and they are all white, then there's something wrong, especially if most of the patients that you care for are from the black and brown communities.
HL: You touched on it a little bit with your example about two people getting a different workup for the same symptoms, but could you explain the role racism plays in the health of minority communities and populations?
Grant: Sure. One, its effect on access to care. We are well familiar with healthcare deserts, [which is] when someone from the black community has to travel, maybe to the other side of town, to get healthcare. That could mean they miss a whole day's worth of work in order to have that 15- or 20-minute visit with the physician or the nurse practitioner. Also, when the healthcare system doesn't address social determinants of health, that perpetuates poor health in certain communities. For example, when you have poor drinking water or air pollution or other conditions that can perpetuate illnesses.
Another example is food deserts. If a person has to go to the corner store or the dollar store to buy canned goods, which tend to be much higher in sodium, but they have a heart condition, high blood pressure or kidney problems, that doesn't help them [manage their disease].
Those are some of the examples that racism may play in the health of a community. If the resources are not there to create a better community, then it perpetuates the cycle of the community remaining unhealthy.
HL: In the ANA news release, you mentioned you personally have had "negative experiences with racism and discrimination." I know those experiences can be difficult to recount but do you have any examples you are willing to share?
Grant: One example is applying for a position or for a promotion, and even though [I] was just as qualified or even more qualified than the person who got the promotion, when I asked, "What are some ways I can improve myself?" you're given the usual evasive talk.
Another [experience is] taking care of a patient and then having the nurse manager be approached and asked, "Is there someone else who can care for my family member?" That happens all the time. I've taken care of patients who were white supremacists and they made it very blatant that they did not want any black person taking care of them. It's something that we experience in healthcare all the time.
HL: What can nurses do to adhere to the ANA's Code of Ethics to be allies and advocates against racism?
Grant: The Code of Ethics obligates us to speak up when we see [racism]. As I mentioned before, if we see [it], then we need to call it out, and make sure there is a system in place that allows for it to be addressed. The only way we're going to see change is if people don't become complacent and they speak up and be the voice of change.
Racism is a public health crisis, and I think as nurses, the most important thing that we can do is to educate ourselves and use the fact that we do have the trust of the [public] to influence and educate others and to realize the systemic injustice that is going on. And, of course, [nurses can] encourage people to educate themselves and to vote for political candidates who have a proven track record of working against racism and injustice. What's going to help to promote change is to realize the power of the vote that you have and the power of the voting box to help bring about change and reform.
In recognition of National Nurses Week, four nurse leaders reflect on what has influenced them as nurses.
2020 is designated as the Year of the Nurse and of the Midwife by the World Health Organization. Unfortunately, it's also been the year of the coronavirus pandemic. And so, as it came time for me to write my annual article to commemorate National Nurses Week, I felt a little strange. I admit, I have always been a bit of a Nurses Week curmudgeon. The 'I Heart Nurses' coffee mugs and trinkets always seemed a little superficial and too light and fluffy to celebrate the truly spectacular things nurses do each and every day. This year, with nurses on the frontlines of the battle against COVID-19, it seems inappropriate to casually salute nurses with a Happy Nurses Week!
However, as I thought about it, though the Year of the Nurse and of the Midwife and Nurses Week 2020 are taking place during a more somber than expected time, this year really has shown the public nurses' capabilities.
For the past 18 years, the public has ranked nurses as the No. 1 profession when it comes to honesty and ethics in Gallup's annual poll, so nurses have held the public's respect for almost two decades. But this year, nurses have gone above and beyond what the public imagines they do. They have had to change the way they function on a daily basis.
"As a bedside ICU nurse, when you add personal protective equipment [PPE], your whole routine changes. It's hot. It's hard to talk. Your glasses fog up when you have a mask on. You're motioning to others outside the room in a kind of horrible game of charades [to get] what you need. You have to cluster your care. You worry about every step you take and everything you touch inside and outside the room, and you wash your hands till they're raw," Megan Brunson, RN, MSN, CCRN-CSC, CNL, American Association of Critical-Care Nurses' president and night shift supervisor for the cardiovascular ICU at Medical City Dallas, told me during a recent interview.
In some cases, nurses have found themselves at risk of infection as they faced shortages of necessary PPE. Some have even lost their lives as a result of COVID-19.
Yet, nurses have consistently cared for frightened and severely ill patients. Each day they go into work, they go in with the intent of giving patients the best care they can in order for them to recover from the virus (and other illness and diseases). When patients pass away despite nurses' best efforts, they must process a tsunami of emotions, including sadness and grief.
The COVID-19 pandemic is something no one imagined going through. Even though it is exhausting and leaving nurses raw as they go through it, I hope that someday they will be able to look back and find a way this experience changed them as nurses, and that it will be positive.
With that in mind, this Nurses Week, I chose to share stories from four nurses who reflect on the experiences that have shaped them during their nursing careers.
And by the way, I am not going to say, "Happy Nurses Week." Instead, I am telling nurses:
You are strong.
You are amazing.
You are indispensable.
You are role models.
Thank you!
Compassionate care for patients with HIV
The pivotal career moment for Adele A. Webb, PhD, RN, FNAP, FAAN, Executive Dean of Healthcare Initiatives at Strategic Education, Inc., with main hubs located in Herndon, Virginia; and Minneapolis, was when she was a pediatric nurse. A young child with HIV was admitted to the pediatric emergency department where she worked. The child's mother was HIV positive as well. It was around 1990, so healthcare workers were aware of how HIV was transmitted. Still, what Webb witnessed was shocking—the majority of her colleagues refused to care for the patient or touch them when they went in the room.
"One other colleague and I provided all their care. The child didn't live for long and it was at that point that I thought, 'There is really something wrong with the fact that we have this amount of fear in our profession," she recalls. "I don't know if it was because we were in middle class suburbia and they thought this could never happen around there. But the reactions were stunning to me because we had taken care of plenty of patients with [diseases] that were contagious and put us at risk. But I think it was the fact that to people with HIV/AIDS, it was a death sentence and people became afraid for their lives. To have such a visceral reaction and actually say, 'I'll quit before I'll provide care.' I'd never seen anything like that before."
It was at that point Webb's entire career changed. She began learning everything she could about HIV, and she changed jobs in order to work in an area where there were a high number of HIV patients.
"I became involved with the World Health Organization by reaching out and saying, 'I'm willing to go.' I was actually deployed, and I've worked in over 50 countries educating nurses and other kinds of providers, like health workers, about how to care for people with HIV," she says. "And it became my life's mission. I wanted to make sure that people that needed the care could get it."
Webb says she felt a responsibility to HIV patients.
"… [P]eople need help and that's why I'm in nursing. I want to help people," she says.
Webb's international work also gave her a new perspective.
"What you learn about when you work internationally, is that there are some problems that are insurmountable and how lucky we are [here]. That's a message I continue to carry back to my colleagues," she says.
She says it also helped her to develop "stamina."
"I'm a stick-to-the-[finish type of person]. I started this, I'm going to do it because it needs to be done, in spite of the fact that a lot of people didn't want me to do it," she says.
In addition, she says her work with HIV patients gave her a high level of compassion.
"These aren't just people that you see for an hour and a half in the emergency room. You see how families are being devastated and so it gives you a higher level of compassion and understanding," she says.
'Nursing is not a profession. It's a way of life.'
"This job is tough. It's physically and emotionally demanding [at times] but it also can be so rewarding. If you live by those three tenets, you will make it rewarding. I wouldn't change my career path for anything," he says.
One experience that helped him develop this three-pronged philosophy took place in his hometown in Michigan. In addition to working as a nurse, he was also a volunteer firefighter. During his volunteer shift, there was a house fire where one child died, and another was burned and taken to a hospital.
Fast forward to Andrews' 11 a.m. nursing shift in the emergency room the next day.
"My first patient of the day was the child who was burned in a house fire. He had received some second-degree burns to his hand and needed some [debridement]. His parents had taken him to another hospital immediately after the situation, but they weren't happy there, so they came to our hospital," he says. "By God's grace, I was given the opportunity to take care of this little one. Just knowing the story, having been at the fire the night before and working hard to try to save his brother, just allowed me to really connect and bond with the family."
That experience helped Andrews develop his perspective about the nursing profession.
"It taught me that nursing is not a profession. It's a way of life. Being a nurse is really at your core. Nursing doesn't just happen within the walls of a hospital or a facility. I've been blessed throughout my career to work on an ambulance. I've worked on a helicopter, I've been in the military, and [I] worked in hospice going into other people's homes to help in end-of-life situations. It really just opened my eyes to the fact that, again, nursing is a way of life. We can't just compartmentalize it. It's who you are," he says.
Andrews says he advocates for preparing patients and families for whatever the next step may be.
"I've had an opportunity to take care of a lot of sick people from trauma situations, medical situations. One of the things I always say to folks, especially newer nurses, is that there comes a time when you stop taking care of the patient and start focusing on the family to prepare them more for what's coming next. So, when there's not much more we can do for the patients, let's take care of the family because they're the ones that will be left behind. Preparation and education are a few of the things I try to stress to newer folks that I'm able to mentor along the way."
In addition to a nurse being changed by their experiences, they also have the opportunity to change the lives of their patients and families.
"I think I was able to see that some of the things that we do, in fact, change people. Although she never said it, I feel like because I was honest and sincere and could share some of my feelings with the mom (of the boy who was burned), she was able to heal a little bit by knowing that even though she had suffered a loss, she felt that we truly cared for her child who was still alive. He could have been just another patient, but because of the connection we had [our interaction] was really a lot more sincere," Andrews says. "The golden rule is still be nice to others and treat them how you want to be treated. That makes all the difference in a bad situation."
Caring for and assessing patients' well-being
Before Iain Holmes, DNP, RN, NEA-BC, Associate Chief Nurse at Albany Stratton VA Medical Center in Albany, New York, became a nurse in 2011, he worked in horse racing, which interestingly, may have helped him develop attributes that transferred nicely to his new career as an RN.
"I think taking care of racehorses was a great steppingstone to being able to take care of the people of my community," he says. "[When you are running] a premier racing stable … you check legs every day, you want your whole group to feel well, and now I analyze and assess well-being."
Holmes transition from racing to nursing took place after he began volunteering at a hospital.
"I was working with racehorses and started volunteering at the hospital because while racing is a lot of fun … you go from race meet to race meet. Upon volunteering, I realized that I really enjoyed interacting with patients and making patients feel better and the pathophysiology of disease and the pharmacology of medicine," he says.
Holmes recalls how an interaction with a patient helped him develop a core value of his nursing career.
As a novice nurse in the ED, he took care of a college student whose parents were out of town.
"I remember how we couldn't quite tell what was wrong with her and she was feeling quite unwell," Holmes says. "I left my shift and I kind of went on my way."
Three years later, he needed a rental car while his car was in the shop.
"The person who was renting me the car realized that I was the nurse that took care of her. She told me that she was incredibly scared, and the care I provided to her was wonderful, and I was the shining light in a scary moment, so to speak. What stuck with me is that as a nurse, and as a person, I have a profound ability to determine how people feel in all sorts of situations. That is something that I work on every day. I want people to know that I truly care," he says.
In addition to taking pride in the care they provide, nurses can cultivate caring through active listening and addressing people's needs, he says.
"In every interaction I'm doing, I am trying to ensure those goals are being met. Are we making this person feel better by knowing that they're cared for and addressing their needs? Do they feel scared? Do they feel that they don't have answers to questions because they feel that people aren't listening to them? And then you go with what you've uncovered," he says.
Holmes says he advocates for developing emotional intelligence as a strength and putting others first.
"It comes back to being more than just someone who delivers medicines and treatments. [You want to be] someone who really cares for the well-being of that community and make others feel like an appreciated member of the community, whether they're a patient or an associate."
Being a patient advocate
Terry McDonnell, ARNP, MSN, DNP, Chief Nurse Executive and Vice President of Clinical Operations and Facilities at Seattle Cancer Care Alliance was influenced by both her experiences as a family member and as a nurse. Nursing is her second career and she came to it after a series of family illnesses.
First, when her son was eight, he was diagnosed with a severe form of group A strep bacterial pneumonia. He spent 25 days at the hospital, was in and out of the ICU, had multiple major surgeries, and chest tubes. McDonnell was dedicated to advocating for her son and spent as much time at the bedside as possible, picking up medical lingo and concepts along the way.
McDonnell got to know her son's primary nurse quite well, and over the course of his ICU stay, the nurse asked McDonnell, " 'Have you ever thought about going into nursing?' And I looked at her like she had 15 heads and I said, no, I never have. She said, 'You should really think about it."
Then, McDonnell's father experienced interstitial pneumonitis and was admitted to the ICU at Massachusetts General Hospital for a prolonged hospital stay before he succumbed to the disease.
Once again, McDonnell took on the role of bedside patient advocate for her father. Impressed by her healthcare knowledge, her father's primary nurse in the medical ICU suggested she considering going into nursing.
"My father passed away on his 57th birthday, and I said to my husband, 'You know, I only need to be hit in the head so many times until I get it.' That was the end of October. By January, I was back in school doing prerequisites and, by September, I'd fully matriculated into the Mass General direct entry program," she says.
Just as nurses influenced her life, McDonnell would go on to influence her patients as well.
"I had gotten to know this wonderful, wonderful patient. Just a dear, darling elderly gentleman, newly diagnosed lung cancer. And my first day off orientation he threw a massive PE and literally died in my arms. The thing is that will shake you to your core, but also you are struck, as a nurse, by the honor and the privilege that we have of being with our patients through the good, the bad, the scary, and sometimes when they leave this earth. I will never forget the look of trust on his face as he left this world. His family wasn't there. It was myself and my colleagues that were there with him," she recounts. "That's one of those moments that really formed who you become. I don't think I've ever forgotten the respect and the privilege that we all carry as nurses being on this journey with our patients."
McDonnell says she's learned there is a story behind everything.
"There's always a story. Nothing is ever as it seems. One of my instructors early on in nursing school counseled us to always look for the story. And [by doing that] you learn to pause," she says. "You're always observing. You're always learning. There's always new information."
"The one thing I've learned that I've carried forward and how I've shaped my leadership is no matter who you're with, whether it's a patient, whether it's a colleague, whether it's a student, whether it's an observer, you always have something to learn. And you always want to treat someone the way you want your family treated."
We've all heard the phrase, "Great leaders are born, not made." Yet it takes more than talent to be a great leader. It also takes time, cultivation of skills, and learning leadership competencies.
This is why AdventHealth, based in Altamonte Springs, Florida, is expanding its commitment to growing future chief nursing officers through its CNO executive leadership development program.
While the program has been in place for about four years, it is now going through a retooling process to meet the needs of a greater number of potential nurse executives in a more structured format, says Trish Celano, MSN, RN, senior vice president, associate chief clinical officer, and chief nursing executive at AdventHealth. The goal is to increase the preparedness and number of nurses ready for CNO roles in the AdventHealth system.
"[The original CNO fellowship program] started because we had a need to have a pathway specifically for development of nurse leaders. The role of the CNO in acute care is really dynamic. They need a broad background in a number of things. We [wanted a strong] structure so that we could develop our own nurse leaders from within," says Celano of the need for CNOs. "We are in nine states, and we have 50 acute care facilities."
HealthLeaders recently spoke with Celano, who discussed the importance of succession planning, shared how the CNO executive leadership development program is getting revamped, and talked about what CNOs need to learn.
More Nurse Executives Needed
"At the end of the day, we needed a lot more [nurses going through the program]. It used to be that the CNO fellowship was just a couple nurses at a time. That's not meeting the need of the organization, so one change [we're making] is we're expanding it so that we have an aggressive approach to succession planning," Celano says.
Celano is currently identifying additional nursing directors and nursing leaders who should be part of the program. She says she hopes to go from having four nurse leaders per year in the program to around 30.
"There should be a director at every facility … acute care facilities, community facilities, and postacute facilities, who is in succession planning, and who you have identified as having high potential and is interested in nursing leadership development," Celano says.
The Program's Focus
"The focus is to develop CNOs. That's what I expect 90% of [the program participants] to be doing," Celano says.
In the first iteration of the program, she estimates about 70% of the nurses who went through the CNO fellowship program ended up becoming CNOs. These nurses have also helped to identify the program's strengths, weaknesses, and opportunities for change.
As AdventHealth continues to grow, acquire facilities, and expand its services, the need for well-prepared CNOs has also grown.
"We have leaders who are solid chief nursing officers," Celano says. "But now we're ready for the next challenge. We just launched a regional nursing advisory council. In that role, we have one regional nursing lead who is a CNO at one of our facilities in Texas and provides regional support for a number of CNOs. [B]eing experienced and being able to take under her wing a couple of novice CNOs creates an opportunity."
The program is also not just about boosting the number of CNOs at AdventHealth, it's also about increasing their readiness to step into the role, she says.
Traditionally in the nursing profession, nurse leaders were left to learn on their own without much structure.
"[To] have a well-prepared CNO who could walk in and not have to learn on the job [that was rare]," Celano explains. "Learning on the job is not good for the CNO. The literature on turnover for CNOs is significant. It's high just like turnover for directors and frontline nurses."
Additionally, CNOs often have responsibility for quality outcomes, infection prevention, and case management.
"There are a number of areas beyond bedside nursing that the CNO has responsibility, so adequately preparing for that just makes sense," Celano says. "You're not going to send your kid to college without sending him to high school first, yet, we've done [something like this] forever [in nursing].
Filling in the Blanks
The CNO executive leadership development program consists of one-year didactic leadership classes where the future CNOs will go to AdventHealth's corporate offices six times. During those six visits, they'll have specific content to learn, Celano says.
"To start the development program, we needed to identify the competencies that we knew CNOs needed to develop—here's everything they should know and here's everything they [already] know. Then we reached out to new CNOs who had joined our company in the last two years and without a well-developed program. [We wanted to know,] what did they struggle with? 'When you went into the job, what didn't you know that you wish you had known?' " she explains.
"The bedside is where we have some of the greatest challenges—how to communicate effectively with direct care nurses, how to develop them, how to make sure that they understand what their challenges are, and that they feel free to speak up," Celano says.
We know that the experience of direct care nurses right now is probably at the most challenging it has ever been just because of well-being, work-life balance, nursing fatigue, and working with the general public. There are issues in workplace violence you see popping up. A nurse leader has a responsibility to make sure that they're aware of these issues and that their frontline nurses feel heard," she says.
Celano points out that newly licensed RNs may not feel comfortable "looking someone in the eye and saying, 'I'm not happy with this thing today.'"
"It requires, nursing managers and directors who learned from the CNO how to have those conversations and how to set them up in a way that people feel like they can speak up and they are comfortable and they're willing to talk," she says.
Another area for development was operations.
"It sounds so basic, but it can get away from you very easily when you're looking at the tactical elements of: do I have the schedule, do we have the supplies, am I on budget? Am I meeting all of the quality outcomes? Are all the rooms clean? Is the food hot? How are the people who are doing all of that for you?" Celano says
Dyad Development
Dyad leadership partnerships have become a trend in recent years, which is why a portion of learning in the program is done with physician colleagues who are in a CMO executive leadership development program.
"The beginning part of the day when they come in to corporate, we'll have CMOs and CNOs together going over general leadership content. That clinical dyad is so important in our hospital world. They will be in class together, going over content, [learning] how to deal with performance issues, safety and service, managing leadership conflicts," she says.
In the afternoon, they will split into their respective groups to cover separate curriculum specific to CNOs and CMOs.
Celano says she is enthusiastic about the potential the program has to set nurses up to be successful members of the C-suite.
"The CNO in the C-suite is such a pivotal role. They have responsibility for the largest portion of the workforce in any hospital. One of the most important things that health systems can do is to make sure that their nurse leaders are positioned to be able to have [an impact], that they have a seat at the table, and they are in a position to be able to give input and feedback to help guide the decision-making of healthcare system. Their feedback is crucial."
Editor's note: This story was updated on April 28, 2020.
Do you have a desire to move into an executive role that falls outside the pillar of nursing? While there's no one way to do it, here are some tips from nurses who have done just that.
Joyce Markiewicz, RN, BSN, MBA, CHCE, executive vice president and chief business development officer at Catholic Health in Buffalo, New York
1. Be open to opportunities at smaller organizations.
These opportunities can allow you to grow your skills and take on projects to help develop business acumen.
"I enjoyed my time working at the inner-city hospital. I learned a lot of life lessons. I was very young and a suburban girl and I learned how other people lived. It was very eye-opening for me and a wonderful experience. It also afforded me the opportunity to do things that I wouldn't do in a bigger hospital," Markiewicz says.
2. Volunteer to develop new skills and experience different environments.
Markiewicz's volunteer work at Meals on Wheels inspired her to work in the home healthcare environment.
Work in a variety of positions at different healthcare organizations to build perspective.
"Each organization offered me something that afforded me greater responsibility and greater opportunity to learn more about the industry," she says.
3. Pursue formal education pathways.
Markiewicz says she realized to continue to grow in the field, she needed to return to school. She earned an MBA while working at a company that supplied respiratory, pharmacy, and durable medical equipment services.
Flo Spyrow, RN, MSN, MPA, MHA, JD, FACHE, president and CEO at Northern Arizona Healthcare, Flagstaff, Arizona
1. Expand your repertoire to positions beyond nursing.
Spyrow went to law school with the intention of doing defense work for healthcare organizations.
"The CNO was a very traditional role and, at that point in time, nurses were being kind of pigeonholed into 'this is your role.' I wanted to do and experience other things and learn more about healthcare and the delivery of healthcare," she says.
2. Show off your talents, and develop new ones, through interim positions.
During her career, Spyrow has filled a few different administration positions including VP of operations and even CMO, on an interim basis.
3. Take on special projects to show others what you are capable of.
"I also had the opportunity to work on several significant projects, such as purchasing a hospital and affiliating with what is now UnityPoint Health. In that work, I built trust and respect throughout the organization," Spyrow says.
4. Build strong relationships across the organization.
5. Take opportunities when they present themselves.
"[The advice I would give] to nurses is, don't have a defined career path. Take advantage of opportunities that open up for you and have the courage to try them if you think it is work that you could contribute to and that you would be passionate about," Spyrow says.
Karen Testman, RN, CFO at MemorialCare in Fountain Valley, California
1. Pursue your interests even if they are atypical.
When Testman went back to school to pursue a business degree, she became hooked on accounting.
"I took my first accounting class and loved it, and decided I wanted to focus on accounting," she says.
2. Use your experience to connect with clinical leadership and staff.
No longer are nurses limited in the senior leadership positions to which they can aspire. Nurses have the skills and knowledge for success in a variety of C-suite roles to make healthcare better.
The annual rate of CEO turnover is significant. According to a report by the American College of Healthcare Executives, it has hovered around 18% for the past five years. And considering the reality of retirements, new professional opportunities, and mergers and acquisitions, turnover in the C-suite is not going away anytime soon.
Thus, it might be wise to reflect upon your organization's succession plan. Does it have one?
The odds are about even that your answer could go either way. In fact, almost half of the respondents to the American Hospital Association's 2019 National Health Care Governance Survey Report said their organization did not have a formal CEO succession plan. Knowing that leadership transitions are bound to occur, it makes sense to actively identify individuals who show strong leadership potential and to nurture and develop their skills, so they are ready when those transitions take place.
With healthcare being such a complex industry, it may seem daunting to find leaders who can run a successful business and make decisions that contribute to the health and well-being of individuals and communities. Healthcare literally has lives on the line. Yet, there is a group of professionals whose members are ready to rise to the challenge of steering the ship toward new horizons—nurses.
If you are now thinking about all the excellent chief nursing officers you know (and there are many), that's a step in the right direction. But don't stop there. Don't pigeonhole nurses into one executive track. Their leadership skills, industry know-how, and dedication to patients transcend professional silos. In other words, nurses can do any job the C-suite has to offer.
In fact, nurses have broken through healthcare's glass ceiling and have come out on the other side as CEOs, CFOs, and chief business development officers. They've grown organizations, managed large portfolios, and fixed flawed systems that were preventing patients from getting optimal care. Not only do they know what it takes to get the job done—because they've been at the bedside—they also know how to make it better.
"I think you're absolutely seeing that more nurses are moving into what I would refer to as nontraditional roles," says Joyce Markiewicz, RN, BSN, MBA, CHCE, executive vice president and chief business development officer at Catholic Health in Buffalo, New York. "[In healthcare], we're asking people to look at new and innovative ways of providing care, and I think many of those answers come from people who have worked at the bedside. They know what can work and what can't work. It's giving nurses an opportunity to say, 'I can get a degree in business … or I can make a bigger difference if I can be the one at the top of the organization that's actually driving care.' "
The Chief Business Development Officer: Growing Business Opportunities for Hospitals and Health Systems
Before giving a recent commencement speech at her nursing school alma mater, Markiewicz says she was asked about the biggest surprise in her career.
"I never thought that when I graduated from nursing school that the sky would be the limit," she says, recalling her answer. "Having that degree has opened up so many doors that I never even imagined could be opened."
After graduating, Markiewicz began working as a nurse in an inner-city hospital down the street from the school she had attended.
"I enjoyed my time working at the inner-city hospital. I learned a lot of life lessons. I was very young and a suburban girl and I learned how other people lived. It was very eye-opening for me and a wonderful experience. It also afforded me the opportunity to do things that I wouldn't do in a bigger hospital," she recalls.
That desire to help the underserved is what eventually launched Markiewicz's healthcare business development career, she says. After volunteering for Meals on Wheels, she says she decided to work in the home healthcare environment. Then, after applying to a few homecare agencies, she was offered a position as director of nursing.
"They said, 'We realize you don't have the experience, but you've done Meals on Wheels. You know what it's like for patients in their homes, and we really think that you could do a good job leading our nursing staff.' So, I said, 'What the heck? I'll give it a try,' " she says.
As the director of nursing, Markiewicz says she realized she had a knack for business development.
"I discovered that I enjoyed growing the business using my clinical hat. We did a lot of pediatric care. I would go to the local children's hospital and talk to families about the care their child needed and how we would set up that care. Then the families would choose our agency," she says.
She eventually became a branch manager for the home healthcare agency. Additionally, she worked for a few other homecare organizations.
"Each organization offered me something that afforded me greater responsibility and greater opportunity to learn more about the industry," Markiewicz says.
However, she says she realized that to continue to grow in the field, she needed to return to school. She earned her MBA while working at a company that supplied respiratory, pharmacy, and durable medical equipment services.
Markiewicz was eventually recruited by Catholic Health as vice president of operations for McAuley-Seton Home Care. At the time, the home healthcare agency was struggling.
"It needed a turnaround. It was interesting for me because this was my first stint in a not-for-profit. I took a lot of for-profit principles and applied them to the expectations for McAuley-Seton," she says. "A lot of it was around productivity and managing the day-to-day operational components, and then growing the business."
She says some of those growth opportunities included purchasing the pharmacy component from her previous employer and getting a liaison to connect with a large cancer institute to help generate outside business and grow the home healthcare division.
Grow your way to success
"I don't believe you cut your way to success. I believe you have to grow," Markiewicz says.
Having a nursing background has helped her understand what makes or breaks a good business development opportunity, she says.
"Because I've been at the bedside, I look at things through a different lens. When I'm looking at a potential business opportunity, I don't always just look at what does it do to the bottom line," she says. "Of course, that's an important component of it, but I also try to look at how it aligns with the mission of Catholic Health and what it's going to do for the patient. Does it improve access to care? Is it going to provide a better service? Is it something that people need? Is it what they want?"
Markiewicz says she also looks at how business decisions impact staff members.
"[Often decision-makers will say] the nurses can do this or add that to their day-to-day routine. I try to take a look at [decisions] and ask, 'Are we asking people to just keep doing more and more? Is it really going to bring value?' " she says.
Her clinical knowledge also enables her to connect with a broad group of stakeholders when making business decisions.
"Having that clinical knowledge [allows me] to be able to sit with a variety of different people, whether it's nurses, business people, or a group of doctors. I certainly understand the language that they speak. I think being a nurse lends itself to a credibility when I talk about something that is clinical in nature. I do think that I'm respected more for that clinical knowledge," she says.
Hiring leaders with this pairing of clinical knowledge and business sense can benefit organizations.
"When … you bring those two things together, it really can create some magic," she says.
The CEO: Strong Leaders Build Strong Teams That Get Results
Spyrow began her career as a nurse in a neonatal ICU in Portland, Oregon, which she affectionately refers to as a "MASH unit" because of the intensity of the experience.
"We transferred babies from all over Oregon and Southern Washington. It was all hands on deck every single night," she says of her time there. "But I loved the opportunity to care for patients and to make a difference. I had no intention of going into leadership."
But a relocation to California's Central Valley and a strong opinion about a dress code changed all that.
"We moved to a small town and there were two hospitals. I interviewed at the private, Catholic hospital and the nun said, 'We'd love to have you, but you have to wear a nurse's hat, a skirt down below your knees, and white stockings,' " Spyrow recounts. "Then I went to the community hospital and the only position they had open was a management position. I always laugh that I went into leadership not because I had a passion about leading, but because I didn't want to wear a nurse's hat, skirt down below my knees, and white stockings."
However, once she took that first nurse manager position, Spyrow says she became hooked on leadership.
"I loved leadership because it was an opportunity to make a difference for physicians and staff and impact more patients than just one very ill neonate," she says.
Spyrow's career eventually pointed to her becoming a CNO. However, she says, the CNO role didn't fit her ambitions.
"The CNO was a very traditional role and, at that point in time, nurses were being kind of pigeonholed into 'this is your role.' I wanted to do and experience other things and learn more about healthcare and the delivery of healthcare," she says.
So instead, Spyrow went to law school with the intention of doing defense work, working with providers on how to safely care for patients, and avoiding lawsuits. She worked as in-house counsel at Trinity Regional Health System, part of what is now UnityPoint Health, for about eight years. While there, her career path took another turn, and she was asked to fill a few administration positions, including VP of operations and even interim CMO.
"As in-house counsel, I had the opportunity to build relationships with the board of directors, physicians, multiple levels of leadership, and staff. I also had the opportunity to work on several significant projects, such as purchasing a hospital in an adjoining community in another state," she says.
"This purchase allowed us to become a bistate health system, providing integrated care for people who lived in one state but worked in another and improving access to healthcare in that community. We also affiliated with what is now UnityPoint Health, providing expertise across the continuum of care and more effective contracting strength. In that work, I built trust and respect throughout the organization," says Spyrow.
She continues, "The CEO that I worked for at the time taught me that leadership was about building strong relationships and then leveraging those relationships to get things done—who else would choose an attorney to be the interim CMO? He chose me for these roles … because of my success in leading the organization through several major initiatives and because of the strong relationships I had built throughout the organization.
"I loved administration and working with clinicians, physicians, and the people who were taking care of patients. So, when I had an opportunity to stay in administration, I gave up my law career," she says.
Spyrow eventually came to NAH as the chief administrator officer of Flagstaff Medical Center, and when the CEO there left, she stepped in as interim CEO. In October 2018, she became president and CEO of NAH.
Varied experiences matter
It's fair to say that Spyrow's career has been all over the map, but having a variety of career experiences is beneficial for nurses, she says.
"The career path for a nurse leader has traditionally led up to the CNO. Nurses can add value in many different roles in healthcare because they bring a passion for our patients. Providing experiences for them in ambulatory care, service line leadership, or physician practice management will broaden their understanding of the complexities of healthcare, enabling them to gain a broader perspective and be better leaders," Spyrow says.
That's why she encourages nurses to be open to new opportunities.
"[The advice I would give] to nurses is, don't have a defined career path. Take advantage of opportunities that open up for you and have the courage to try them if you think it is work that you could contribute to and that you would be passionate about," she says.
Spyrow says that nurses can use their passion for patient care to inform their work in leadership roles. Because they have served at the bedside, nurses understand both the needs of the patient and the complexities of delivering care.
"At the heart of all we do, we are entrusted by the communities that we serve to deliver high-quality, safe care to every patient, at every location, with every encounter. That is now my passion as a leader, and that passion came from my experiences as a nurse," Spyrow says.
"Nurses have a broader view of the patient," she notes. "They intuitively understand systems based on their skill sets and their training." Plus, nurses often have a strong desire to fix flawed systems that interfere with patient care, she says.
"[As a nurse], I left work being really frustrated because lots of stuff got in the way of taking great care of patients. Now, I have the passion for patient care and for creating great work environments so our staff can learn to love their jobs again," Spyrow says.
For example, at NAH they have implanted technology such as Smart Rooms, to more effectively engage patients and worked to decrease documentation in the EHR so nurses can spend more time at the bedside. Smart Rooms bring information on a patient's health condition directly to their room and better prepare them for adherence to care plans after discharge. In this way, says Spyrow, NAH is transforming patients' experience and expectations.
"In our journey to high reliability, we have implemented many standardized practices to make it easy to 'do the right thing.' And we insist on 'consistent and effective leadership in every nook and cranny' of NAH, as individual leaders significantly impact each department's work environment," she says.
In addition to annual nursing and employee engagement surveys, the organization also sets measures for individual initiatives, such as nursing admission documentation time.
Teamwork leads to success
Additionally, nurses bring a sense of collaboration that's needed among healthcare leaders.
"Nurses are trained to be team players. I think that is what healthcare needs now—strong teams and people who are willing to reach across the aisle and work together and with multiple stakeholders in order to transform the way we deliver care," Spyrow says.
These are qualities she says she looks for when hiring for her leadership teams.
"I look for people who can build relationships, work well with multiple different people, who will care deeply about the people who work for them, and who will be great team players. In healthcare organizations today, strong teams get strong results and determine whether an organization is successful," she says.
Spyrow has advice for nurses who wish to take on leadership roles.
"[Those nurses should b]roaden their skill set throughout the organization and get into a nontraditional nursing role, whether that be strategy, business analyst, etc.," she says. "Leadership is about building relationships and then being able to leverage those relationships to do the hard work."
The CFO: Bridging the Financial and Clinical Realms
Karen Testman, RN, CFO at MemorialCare in Fountain Valley, California—a Southern California health system—grew up in a family of healthcare providers. She says when she announced her intention to follow that tradition and become a nurse, her father suggested she pursue a career in business.
"Sometimes your parents know you better than you know yourself," she says. "While I [thought it] was interesting to hear his perspective, I was still going to pursue nursing as my career."
However, she says her father's inkling that she would do well in business proved correct. During nursing school, Testman says she became interested in learning more about how hospitals operate.
"It started piquing my interest about the business side of healthcare," she says. "While I was working as a nurse, I worked in a medical-surgical unit. I enjoyed it but felt like I wanted to utilize my experience and passion for the nursing profession in a role that could combine nursing with the operations side of healthcare; therefore, bringing experiences and sensitivities of the nursing profession into the business side of healthcare."
She says she went back to school to pursue a business degree, and from there it was love at first spreadsheet.
"I took my first accounting class and loved it, and decided I wanted to focus on accounting," she recalls.
After finishing college, Testman worked for a public accounting firm as an auditor in Arthur Andersen's healthcare practice. She then took those skills to Catholic Healthcare West (now CommonSpirit Health) where she worked as the controller at St. Bernadine Medical Center. From there, she became the regional director of finance for the Southern California region.
She joined MemorialCare in 1998 as CFO at Orange Coast Medical Center, and then spent time as CFO for both the Orange Coast facility and the organization's Saddleback Medical Center.
After five years in those positions, she took on the systemwide role of senior vice president of financial operations. Then in 2013, she took on the role of MemorialCare's system CFO where she is responsible for overseeing the $2.5 billion organization's financial operations.
"It's a big job, but it's a great job," she says. "I've also been pretty involved over the past five to six years in our ambulatory strategy. We have four major hospitals and more than 200 ambulatory care locations. I assist with strategic initiatives and acquisition and facility transactions. Most recently, I'm heavily involved in the development of our joint venture strategy."
Problem solving is common ground
Testman says her nursing background has greatly informed her finance career.
"I have a real understanding of hospital [operations] and, to some extent, medical office operations. I have an appreciation and understanding for what the frontline caregivers are facing and what their challenges are. I believe it helps me relate better, and I'm genuinely curious and interested in what they have to say about both the challenges and opportunities they experience," she says.
She also says her experience as a nurse helps her to connect with clinical leadership and staff.
Testman says that one example of working with clinicians includes the organization's "strong and close collaboration on information technology to make it easier for nurse leaders and bedside nurses to simplify some of their administrative tasks and improve processes so they can maximize their time with patients." These include areas such as how nurses address supply chain activities, patient education, and managing and simplifying shifts worked and payroll processes.
These activities help to "improve productivity and workflow and identify and initiate cost savings. While this work may be perceived as time-consuming, it generally results in initiatives that are time saving. As nurses, we have a shared understanding of what it takes to deliver care to patients," she says. "Having similar backgrounds adds credibility to my role. They know I have an appreciation of what it's like to care for patients at the bedside."
One example is a recently approved project to replace the supply cabinets on the patient care units that contain various patient supplies needed by the clinical care team with an easier-to-access storage unit. "This new unit allows us to continually monitor electronically the volume and level of supplies to ensure that supplies are quickly and easily replenished when needed," says Testman.
Another example is the revamping of MemorialCare's case management and utilization review functions to improve patient flow through standardized processes across the healthcare enterprise and move utilization management to the revenue cycle function to help further address the denial challenges.
And though their education is different—accounting courses versus science courses—Testman says nurses and finance professionals share quite a few positive qualities.
"From my perspective, what's similar about nursing and finance is that analytical skills are fundamental to both professions. Nurses are analyzing constantly, and they're trained to continually assess the patient. Assessment and analysis are also a key component of what CFOs do every day. Both [groups] look at data and information, talk with people, and assess situations, continually looking for opportunities to improve. I believe there are many similarities in how a CFO thinks and how a nurse thinks, and in both cases, you tend to find people that want to solve problems and make healthcare better for our patients."
She notes that the educational path to financial leadership isn't necessarily set in stone, either.
"There isn't one way to gain the skills and background to be a finance leader. I think there are many paths to that. I would tell a nurse that it is important to have a core basic understanding of accounting and finance, and there is more than one way to achieve that," Testman says.
The Academy of Medical-Surgical Nurses' free online assessment program assists in placing new hires and contingent healthcare providers in roles that match their skills.
To meet the critical need for nurses during the COVID-19 pandemic, many hospitals and health systems are seeking new hires and contingent staff members to supplement their workforce.
One challenge during this time is placing employees in roles that match their skills. To better facilitate the matching process, the Academy of Medical-Surgical Nurses (AMSN) has launched a self-assessment tool, currently free to all facilities, to help match new hires and contingent workers with the most needed roles.
The goal of the tool is to help administrators evaluate the competence of this new workforce and assign healthcare professionals to the appropriate patient assignments or tasks that are based on their individual level of practice, according to an AMSN news release.
"Within the health care industry, this is an unprecedented time for hospital administrators and human resources," Terri Hinkley, EdD, MBA, BScN, RN, CAE, AMSN CEO, says in a news release. "To help fill in their frontlines, they are looking to retired RNs, nurses from other specialties, and even students to support. Oftentimes these staff will be assigned to medical-surgical units. This self-assessment tool will help those making these staffing additions much easier, as administrators will find out where their contingent staffers' strengths lie and what knowledge they have in med-surg, so they can assign them accordingly."
The tool asks individual contingent nurses to complete a 20-minute online self-assessment survey, which they are asked to print or email and submit to the appropriate manager. According to Hinkley, institutions should make decisions that align with their own internal policies and procedures.
The competencies used in the self-evaluation survey are based on an extensive literature review, evaluation of current medical-surgical nursing role descriptions, and the practice of medical-surgical nurses from a variety of geographic, institution and practice settings, says AMSN.
The organization worked with a national task force of medical-surgical nurses and consultants on measurable competencies for nurses at all experience levels to develop the tool.
While the self-evaluation survey tool is free of charge during the pandemic, AMSN is asking those who use it to provide feedback on how the tool worked so it can be further refined and developed for future use.
