The president of the American Association of Critical-Care Nurses shares what nurse leaders can do to support nurses during the pandemic.
"Unstoppable." That's the American Association of Critical-Care Nurses' 2019–2020 theme and, given the way nurses have had to battle against COVID-19, it seems that no better word has been chosen to describe nursing. While many Americans are sheltering in place due to stay-at-home orders, nurses and other healthcare professionals are heading to work each day to care for patients with and without COVID-19.
"[Nurses] are rising up and charging [toward] the problem. It just validates to me how much I'm really honored to be part of this profession," says Megan Brunson, RN, MSN, CCRN-CSC, CNL, AACN president and night shift supervisor for the cardiovascular ICU at Medical City Dallas.
During the COVID-19 crisis, Brunson has had both an up-close and personal as well as eagle-eye view of what critical care nurses are experiencing during this time.
"I work at the bedside, I work 12-hour shifts, and am president of a national organization, so I really feel I have a unique perspective," she says.
During a recent interview, Brunson shared her insights on what it's like being a critical care nurse during the coronavirus pandemic. She also shares how nurse leaders can support nurses as COVID-19 continues to ramp up during the coming weeks.
The following is a lightly edited transcript of that conversation.
HealthLeaders: Can you paint a picture of what you're seeing across the country as critical care nurses deal with the pandemic?
Megan Brunson: As a bedside ICU nurse, when you add personal protective equipment, 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.
On a national level, nurses are bravely rushing into this crisis without question of their duty. Nurses across the country are feeling it in different ways. There are nurses who don't have PPE or have severely limited PPE, and there are nurses right now that are not able to work because their hospital censuses are dropping significantly due to the cancellation of routine surgery. There are nurses that are in the preparation stage, and nurses coming out of retirement or working more than part-time. They're being introduced to critical care all over again.
The projections [of when the pandemic in the U.S. is] supposed to start hitting its peak are changing. I think that it is difficult for nurses to have this ball that's constantly rolling down that hill.
HL: Are nurses across the country seeing shortages of ventilators and PPE?
Brunson: There's no bigger way for me to say yes. Yes, yes, yes, yes. Many hospitals in the United States are at their own level of contingency planning, which is recommended by the CDC. We have to call on others in this time, like those that are not necessarily in healthcare, whether it be the community or industry partners. For example, there are a lot of research labs that don't do human experiments and have N95 masks. That's another place where we can come together as a community to see how we can mitigate these shortages.
It's completely unacceptable to not have the PPE at all levels of where you provide healthcare. Every time we have a shortage, it's nurses who are at risk. It's so, so important that from the government level down to our states and communities that nurses have PPE.
HL: What are some ways that communities can support nurses?
But the other way, that's more important than all that, is to just stay at home. Nurses are begging, in fact, imploring, the public to stay home to slow the spread of the disease because it's just making the risks posed to nurses and healthcare providers even greater. We're willing to go to work, but [the public should] please stay home.
HL: What are some of your biggest concerns for nurses over the next couple of months?
Brunson: We really need to have the discussion about making sure nurses are not going to be put in a place where [they can get sick] because of frequent exposure to the COVID-19. It's not like they're taking care of one patient and one exposure, it's multiple exposures. [We can't risk them] getting gravely ill each day without having proper protection. The other concern is not having the ventilators. We can't put nurses and providers in a place where they have to make a decision on care. Moral distress is already evident in the pandemic and it will be ramped up to another level if nurses and healthcare providers have to make decisions [about which patients receive care or not].
Nurses also have their own worries at home—loss of jobs for their spouses, perhaps kids with no childcare. They want to be taking care of patients, but they have the effects of this pandemic on them equally at home.
HL: What are your long-term concerns for nurses?
Brunson: Moral distress and burnout. The Critical Care Societies Collaborative (of which AACN is a part) has placed a priority on [addressing] burnout. This pandemic is going to elevate it even more. We have to recognize that nurses are experiencing not only more stress but also ethical dilemmas. We have nurses who are managing ethical concerns during a disaster in a crisis situation. We're confronted with our standards being altered. It's not just one time. It's constantly going back to work with those challenges. So, I do worry about the long-term effects of burnout and moral distress and the ethical challenges.
HL: How do you recommend nurse leaders support nursing staff members at this time?
Brunson: As leaders, it's important that we're in there masked up and gowned up with them and walking through their daily life. It's important that we acknowledge their ethical and moral conflicts, [and] that we take time to talk about it and make sure that they're aware of what resources are available, whether it be resources within your organization like [the Employee Assistance Program] or counseling.
We need to encourage staff to speak up when they're seeing things that are distressing them now, whether it be care situations or ethical concerns, and [to escalate those issues]. When you do that, you're asking nurses to be courageous, to speak up, and sometimes that's not easy. So being available as a leader to really encourage them to have that courage is important. Then finally, acknowledge what they're doing and their contributions.
HL: What are some positive things that could come out of this situation?
Brunson: I am just in love with the innovation now that I'm seeing. It makes me smile. As nurse leaders, we really need to support innovation by empowering others to implement solutions and discover those who are doing out-of-the-box thinking.
Sharing ideas is important because if there ever was a time to cast competition aside between hospitals, it's now.
Also, as a leader, it's important to leverage [staff] expertise and bring forward nurses who are those shining lights that have the potential to be leaders. Ask, 'How can they lead in a small way?' and give them license to do that.
HL: What's been the most difficult experience that you've ever had as a nurse? And how does it compare to the pandemic?
Brunson: By far, nothing compares to this. Every breathing minute I think about COVID-19 and the teams at risk. It's a marathon, not a sprint. The AACN community knows my story, but I was kicked out of nursing school my senior year. That is a very long story, but I had someone tell me I couldn't be a nurse. Although that part of my life is behind me, some aspects of this [are the same]. Nurses are being told that they can't be the nurses they want to be, in so many ways. Maybe not verbally, but with lack of PPE, they're not able to be the nurses that they want to be. For me, that reminds me of that feeling I had when I was told that I couldn't be a nurse.
They want to feel protected and supported. The hard part about wanting to be a nurse is that you walk into a patient's room every day and you want to provide excellent care with every interaction. When there's a barrier to that, it's crushing to your practice.
National Nurses United urges the president to order an immediate increase in PPE production.
Today, National Nurses United (NNU), the largest union of registered nurses in the country, sent a letter to President Donald J. Trump demanding he immediately and fully invoke the presidential authorities granted in the Defense Production Act to increase the supply of necessary personal protective equipment for healthcare workers during the COVID-19 pandemic. The union called on the president to order manufacturers to increase production of respirators, face shields, coveralls, gloves, gowns, testing equipment and supplies, ventilators, and extracorporeal membrane oxygenation machines.
"Across the nation, our healthcare workforce does not have the personal protective equipment it needs to safely care for patients without risking exposure to the virus," NNU states in the letter. "As a result, healthcare workers are at risk of illness and death, which puts our entire health care system at risk of collapse. Further, when health care workers are exposed to the virus, they risk transmitting the virus to their families, patients, and communities. If our country fails to immediately protect our health care workers, we will fail to contain the COVID-19 pandemic."
NNU represents more than 155,000 registered nurses across the country, many of whom are on the frontlines of the pandemic caring for COVID-19 patients. According to the union, the executive orders and presidential memorandum the White House has issued regarding the use of the Defense Production Act do not yet fully exercise the presidential authority available under the statute.
"The president has taken the first steps to exercise the authorities given to him by the Defense Production Act," NNU Executive Director Bonnie Castillo, RN, says in a news release. "We applaud him for using the statute to order ventilator production by General Motors, and we urge him to take similar actions to order manufacturers to immediately increase production of respirators, including N95s, and other personal protective equipment."
The union calls on the president to immediately take the following actions to invoke the Defense Production Act:
Invoke Title III of the Defense Production Act immediately by directing increased production of equipment and supplies from existing manufacturers, directing other industrial manufacturing facilities to transition to production of the equipment and supplies needed in the COVID-19 response, and immediately generating manufacturing purchase orders to ensure expedient production of essential equipment and supplies
Direct the Department of Health and Human Services to gather information on supplies and implement restrictions on hoarding
Ensure the immediate and continued release and distribution of personal protective equipment, testing equipment, ventilators, and ECMO machines in the strategic national stockpile.
As the pandemic continues to challenge the public and the healthcare sector, nurse executives need to be armed with knowledge to make the right decisions.
The amount of information coming at healthcare leaders during this COVID-19 pandemic is enough to cause whiplash. It seems every hour of every day there is a new development. We know that as nurse leaders, your focus is on managing response to the COVID-19, supporting nursing staff, and leading your organization during this stressful time.
In this chaotic environment, you may not have had the chance to delve into all the COVID-19–related, solutions-based topics HealthLeadershas been sharing. So, in case you missed them, here are four COVID-19 stories of interest to nurse leaders.
As learned in the past weeks and months, the coronavirus can also be transmitted through contact with some surfaces— where it can remain viable for hours to days. Therefore, it’s best practice and necessary to clean and disinfect surfaces to prevent the spread of COVID-19 and other viral respiratory illnesses in healthcare facilities and other settings.
As the COVID-19 situation ramps up, there continues to be an enormous amount of mental and physical pressure on the healthcare workforce.
According to a recent journal article in the Journal of the American Medical Association, "The pressure on the global healthcare workforce continues to intensify. This pressure takes two forms. The first is the potentially overwhelming burden of illnesses that stresses health system capacity and the second is the adverse effects on healthcare workers, including the risk of infection," the article coauthors wrote.
To protect and support healthcare workers and their families, the authors recommend six measures. Read about the measures here.
There has a been a grassroots movement encouraging the public to sew cloth face masks in the case of a disposable surgical mask shortage, and on March 10, the Centers for Disease Control and Prevention updated its recommendations and advised that facemasks for clinical providers are an acceptable alternative when there is a shortage of N95 respirators.
However, the American Nurses Association is calling the CDC to issue evidence-based PPE guidelines that focus on the transmission of COVID-19 rather than supply chain issues.
"It’s also concerning that these recommendations do not offer strategies to address the limited manufacturing and supply chain of necessary personal protective equipment," the association said in a news release. "While the interim recommendations may assist in preserving the supply of N95 respirators and other PPE, it could also confuse health care professionals considering appropriate levels of protection that may be needed when caring for a known or suspected patient."
4. Despite Federal COVID-19 Stimulus, Many Hospitals Could Face Layoffs Within Two Months
According to recent research by Strata Decision Technology, without significant action from the federal government to relieve financial pressures related to the spread of COVID-19, hospitals will be forced to undergo drastic cost-cutting measures, including laying off "large numbers" of non-clinical workers.
Based on a proposed federal stimulus package that would raise the Medicare reimbursement rate by 20% for COVID-19–related DRGs, Strata projects that hospitals will lose an average of $1,200 per case, with some providers losing between $6,000 to $8,000 on the high end.
Nearly all hospitals would lose an average of $2,800 per COVID-19 patient case if reimbursement rates aren't raised, according to Strata, with some losing between $8,000 to $10,000 per case.
The study concluded that without a 35% reimbursement rate hike, many hospitals will exhaust cash flows within 60 to 90 days.
In addition to insufficient reimbursement rates for treating COVID-19 patients, Strata noted that hospitals are financially strapped due to the loss of elective surgeries, a primary source of revenue for provider organizations.
An experienced healthcare executive recruiter shares insights on how nurse leaders can find positions that are the right match and that can move them forward in their careers.
Healthcare professionals are living in turbulent times. Even before the recent COVID-19 pandemic hit the United States, mergers and acquisitions, restructuring, and retirements were catalysts of uncertainty for many nurse executives.
Off the record, I have heard myriad concerns from the nursing field regarding job stability. They are asking, what if their hospital goes through an M&A? Will their positions change? Some are wondering, at their age, will they be able to find a new position? Will they be passed over because it is assumed they'll retire in a few years? And others may want to move into a larger C-suite role, but are not sure how to get there.
To help answer career questions for nurse leaders, I recently spoke with Donna Padilla, managing partner and practice leader, healthcare, at WittKieffer, a global executive search firm in Chicago.
The transcript has been edited for clarity and brevity.
HealthLeaders: How has the role of the "top nurse" changed over the years?
Donna Padilla: What a top nurse is depends on the environment. There are top nurses, meaning the senior leader within a hospital—the chief nursing officer in the flagship of a large system, for example.
But, when you look at systems and how they've crafted the nursing organizational charts given that there are 10 or 11 hospitals in a system, you may have 10 or 11 CNOs sitting around a table. Is there a broader system CNO who focuses only on that job or is it a combined job? Or do all those CNOs come together in a council and create strategy across the system?
HL: What are some of the qualities and attributes organizations look for in their next high-level nurse?
Padilla: I think there are some common elements [organizations] look at when they start to think about who's leading. One is the ability to advance the professional practice of nursing. I see that just about in every profile we write. [Organizations] are looking for the ability to understand what it means to elevate [nursing] and to have nurses working at the highest level of their practice.
[They are also looking for the ability to come to the table with a hat beyond nursing. So positionally do [nurse leaders] come in with, "I'm great with change as long as it doesn't affect my nurses," or is it, "I'm part of the broader team, just like finance, just like operations, just like legal, and I have a specialty but I'm not protectionist. I'm an ambassador of nursing but I think broader about what's happening."
The other piece, which probably isn't surprising, is [needing a] depth of business acumen. Early on in a career, it's very much about the clinical ladder and working your way through it and starting to gain muscles around leadership. Then it moves into [if you] can sit side by side with the finance team and talk about projections? For example, if [they're] thinking about opening five new towers, what does that mean? From your particular role, what will you need resource-wise? What does that look like strategy-wise for nursing? One of the questions we get [for job candidates] is, "Where's your nursing strategic plan? What does that look like?"
HL: Let's go back to the ability to advance professional practice for a moment. What specifically is meant by that? Because sometimes I think what that looks like in real life gets lost or it turns into a cliché like, "We want to take things to the next level."
Padilla: Some of it is around being able to answer the question around care models. So, it's getting very detailed on care model pieces, shared governance, and ability to interact with physicians. When you sit with a frontline leader, they understand how they connect to the whole. To me, the professional practice of nursing in its best expression is the fact that everyone within the nursing team—frontline manager to top-line—have an answer to, "What does nursing look like within this institution? What's our goal long term? Do we have a healthy relationship with the other clinicians and is there a care team model around that?"
[And] I think that from an attribute perspective, [it's important to have the] ability to read the room, read the environment, and to read the culture.
HL: Have you noticed any hiring trends among organizations? Do they tend to hire from within versus doing succession planning or hiring from the outside?
Padilla: This is my opinion, but I think it's easier to move into the operations role internally and from there, there's a path to CEO. Sometimes the broader CNO to CEO is sometimes harder than CNO to COO to CEO. If the question is how do you get to the CEO role, the answer is get experience and accountability for things outside of nursing. Broaden [your experience] to pharmacy and lab and other things that may still be clinical in nature but aren't necessarily just nursing. Or get accountability for some of the service line pieces as well. Start to flex some of the business development growth pieces because on the CEO report card it's always important to make sure the trains run on time, but it's also important to look at how [your organization is] growing.
The more involvement CNO candidates can have with boards, with quality committees, and externally in the community, the [more experience they gain].
Smaller organizations tend to combine the CNO and COO roles, which I think is a great opportunity for individuals that aspire to be a CEO because then they've got two-thirds of the house basically.
Also, among what I call "flagship CNOs," you would expect them to say, 'Hey, I want to be a system CNO.' I would say we see more and more folks saying they'd actually like to be a COO or CEO or something different. Their job opportunities have become much broader. I think it's fantastic especially with organizations that want clinical credibility in a CEO. Typically, we've seen nurses have a strong showing in that. In fact, a couple of systems we've worked with had a preference for someone who had been a nursing leader before.
HL: What are factors that stand out to CNOs when they're considering a job opportunity?
Padilla: They ask me when I call them, 'Is it snowing in the location you've told me about?' Joking aside, I think location is often the first question, especially if it's an individual who is already in a seated role, then reporting structure and where they would fit in. Are they at the table? Are they the equivalent to the CMO? That's a question we get all the time. They want to know what the physician-nursing relationship is.
[Also,] what's the [organization's] reputation and its quality metrics? It doesn't mean that if [the organization is] in desperate need of someone to help advance that, that it's a bad thing. Some candidates are really excited by massive turnaround and others say, "I've already done that three times and I don't have another one in me."
[They also ask,] is there a union? Some candidates are much more facile at working in those environments and others don't have that lens.
And [they also ask about the] organization's goals.
Nurse leaders from around the nation called for a focus on nurses' safety during the pandemic.
During a March 18 White House meeting with President Trump, Vice President Pence, and members of the Coronavirus Task Force, nurse leaders discussed issues pertaining to nurses during the COVID-19 pandemic.
"It is imperative we recognize that nurses are our most valuable resource in fighting this pandemic," Eileen Sullivan-Marx, PhD, RN, FAAN, The Academy's president said a news release. "They are tasked with making real-time, difficult decisions on the ground in rapidly evolving, uncertain circumstances so full-scale support of our nurses is essential."
Suzanne Miyamoto, PhD, RN, FAAN, chief executive officer of The Academy, emphasized the importance of protecting the most vulnerable populations, supporting nurses on the frontlines, and increasing access, scale, speed, and accuracy of testing, the news release stated.
"It is imperative that as a nation we come together collectively to flatten the curve by aggressively practicing and promoting social distancing. We have to help the public understand that they cannot take this lightly. Clear, consistent, and fact-based communication about this grave situation is vital," Miyamoto said in the statement.
Additionally, The Academy highlighted the importance of active monitoring and testing to prevent the spread of the virus.
"As we look at the challenge before us, it is imperative that the safety of the public, our nurses, and our nursing students, are top of mind," said Trautman in remarks prepared for the briefing. "AACN's member deans, faculty, and students are leaders in their communities who are committed to ensuring that our nation remains healthy and strong through the duration of this public health challenge. AACN looks forward to working with the administration to address the needs of the nursing workforce."
Debbie Hatmaker, PhD, RN, FAAN, chief nursing officer at the American Nurses Association, took the opportunity to urge the administration to provide a sufficient supply of appropriate personal protective equipment for nurses and to share the need for creative staffing strategies to sustain the nursing workforce so they can continue to provide care during this pandemic, reports the association's news release.
"Our number one priority is keeping frontline health care professionals, including our nurses, healthy by making sure they have the personal protective equipment they need," Hatmaker said in a news release. "If frontline professionals are put into danger and become sick, it will exacerbate the crisis in the U.S., much like we have seen happen in China and Italy. ANA stands ready to work with all stakeholders to solve this crisis, but without proper personal protective equipment our job will become immensely more difficult, leading to more deaths and even further damage to our nation."
According to the news release, Hatmaker touched on the following points during the meeting:
Support for incentives to ramp up production of N95 respirators plus easing restrictions on the export and distribution of PPE and other medical supplies.
Promoting the use of telehealth technologies to provide care, reduce exposures, and preserve PPE and other facility resources during this emergency.
Adjusting nurse staffing plans in real-time based on the number of COVID-19 cases within a facility and patient needs.
Implementing creative staffing strategies that utilize nurses who are currently not in direct patient care and senior nursing students to help meet patient demand.
Removal of barriers to testing and treatment to aid in the early identification and treatment of infected individuals.
As the number of COVID-19 cases in the United States continues to grow, the Centers for Disease Control and Preventionrecommends that for the next 8 weeks, in-person events and gatherings consisting of 50 or more people be canceled or postponed as large events can contribute to the virus' spread.
"This decision was not made lightly. It was made with the singular goal to do what is best for nurses, patients, their families, and the entirety of the healthcare system. Ensuring the health and safety of you and your patients is our highest priority," AACN said in an email. "We know you are responding, or preparing to respond, on the front lines of the COVID-19 outbreak. Canceling NTI is the right thing to do because patients need us. Healthcare organizations need our leadership, and we need each other. Together, we are unstoppable."
Other major conferences that have been canceled due to COVID-19 concerns include HIMSS,AHIP, ACHE, and AONL.
As a result, The American Nurses Association has called for a more definitive statement about the transmission of COVID-19 from the CDC. According to an ANA news release, "Nurses must feel confident in this guidance that a medical mask, along with the other required droplet personal protective equipment, is appropriate to provide patient care for known COVID-19 cases."
While, in light of recent events, the ANA acknowledges the difficulty of ensuring an adequate PPE supply, the organization is concerned that the updated CDC recommendations are based solely on supply chain and manufacturing challenges, the news release says. Instead, of focusing on supply chain demands, recommendations should be based on "evidence that reflects a better understanding of the transmission of COVID-19. "
"It’s also concerning that these recommendations do not offer strategies to address the limited manufacturing and supply chain of necessary personal protective equipment," the news release states. "While the interim recommendations may assist in preserving the supply of N95 respirators and other PPE, it could also confuse health care professionals considering appropriate levels of protection that may be needed when caring for a known or suspected patient."
The ANA is asking that the CDC consider the following actions:
Investigate and communicate on the transmission mode for coronavirus so that decisions about appropriate PPE are based on the best information available.
Identify metrics for when the interim guidance will be rescinded to ensure that clinical providers and health care facilities can prepare to continue caring for their patients and communities.
"Nurses must trust that the decisions made at all levels are focused on their protection. This is necessary for them to walk into a room every day and to safely continue providing ongoing patient care in all health care settings," the statement says. "ANA supports ongoing efforts to address and stem the spread of COVID-19. We appreciate the efforts of all nurses, members of the health care team, decision makers and the public to respond to the COVID-19 outbreak."
A workplace culture built on love and empathy improves organizational outcomes.
Today's healthcare industry is one that focuses on data, metrics, and outcomes. But to achieve success that influences profit margins, clinical outcomes, and reimbursement, healthcare leaders also need to create a healthy organizational culture and work environment.
For example, at Vidant Health in Greenville, North Carolina, leaders are using an innovative foundation for their organizational culture—working relationships structured around love and empathy.
"We embrace the definition of love used by Dr. Martin Luther King Jr. … love is 'an understanding, redeeming goodwill for all men, an overflowing love that seeks nothing in return,' "says Julie Kennedy Oehlert, DNP, RN, chief experience officer at Vidant Health.
This type of love involves creating a safe, welcoming place where team members care about each other, she says.
"We talk a lot about the importance of empathy. Empathy put into action is compassion, which is one of [Vidant's] values," says Oehlert. "We have decided that if we design educational offerings and leadership development [around] love, and stress that empathy is of key importance in relationships, that even those times that are difficult in the health system or on the unit will be easier with love and empathy."
She continues, "it is very simple: How we treat each other is how we treat our patients, and how we experience each other is how our patients will experience us. We do not look at patient experience and design a good experience for them without thinking about how the providers feel or how the team members feel. When you look at experience in this way, you can positively contribute to both patients and care providers, which helps prevent burnout and shows that the relationship between the two is valued."
Embrace love, improve outcomes
According to Oehlert, systemwide team engagement has been improving steadily since implementing love and empathy into the workplace and has risen 5.4% over the last four reporting cycles, according to the Press Ganey Engagement and Pulse Surveys that Vidant uses to measure employee engagement. From 2017 to 2019, the organization has seen the following increases in engagement:
Clinical team member: 1.5% increase
Non-clinical team member: 0.2% increase
Clinical leader: 11.2% increase
Non-clinical leader: 4.7% increase
Supervisor, non-clinical: 12.4% increase
Supervisor, clinical: 14.2% increase
Manager, non-clinical: no change
Manager, clinical: 4.7% increase
Director, non-clinical: 1.1% increase
Director, clinical: 10.8% increase
Executive/VP: 4.7% increase
From 2015 to 2019, the questions pertaining to manager effectiveness saw "problematic" ratings decrease by 4.1%, and managers rated as "excellent" increased by 6.2%.
From 2015 to 2017, physicians rated as "engaged" increased by 6.5%.
Additionally, reporting of near misses has almost doubled over the last few years, Oehlert says. In FY 2019, 19,120 patient events were reported, a 7% increase from FY18. Of these, 4,849 were safety catches, up from 2,760 safety catches in FY18.
Improvements have also been seen in the two Agency for Healthcare Research and Quality questions regarding non-punitive response to error. These questions ask whether team members feel like their mistakes will be held against them, and whether when an event is reported it feels like the person is being written up. The AHRQ question, which highlights a non-punitive approach to safety reporting, is the single most-improved question in the last reporting period of the AHRQ survey.
"If you can take the fear and blame out of your culture, what's left is all the good things about healthcare—love, compassion, empathy, shared decision-making, interprofessionality," she says.
Patient experiences continue to trend upward as team engagement improves, Oehlert says.
Also, the nurse turnover rate at Vidant Medical Center for FY19 is 16.33%, compared to the national average of 17.4%.
"We realize that our culture and our engagement impacts turnover. Right now, our RN turnover is below the national average. We had traditionally recruited and hired locally (North Carolina and Virginia), and now we are confident in our strategy and are attracting nurses from a wider demographic," Oehlert says. "Last year, we hired nurses from 10 different states. Our newest RN recruitment campaign (#carelikecrazy) ties together our intention of love and caring right in our recruitment."
Create a 'strategy around culture'
To help measure success, says Oehlert, organizations should create standard definitions of the components of their mission, values, and goals.
"If you don't know how the organization defines something, it's hard to measure it. We measure our definition of engagement on our engagement survey, and we also define culture in a specific way," she says.
For example, at Vidant:
Culture is defined as, "How relationships are structured."
Empathy is defined as, "Recognizing and appreciating the feelings, thoughts, and stories of others by connecting and being sensitive to what, how, and why people feel and think the way they do."
Engagement is defined as, "Our shared commitment and partnership in shaping a positive, motivating, and relationship-focused culture where we can all thrive."
"What that does for the organization is it [allows us to] agree so we know what we're going for. I think that is important if you're [creating] strategy around culture," she says.
Additionally, when creating developmental offerings, Vidant leaders rely heavily on design thinking, which Oehlert says includes engaging people, getting their feedback, and trialing ideas and innovations.
"A lot of the wicked problems in healthcare today can be healed when you have a strategy that includes love and empathy. You will not have good quality outcomes if you don't have love and empathy within the culture in good measure, because people will be afraid to report quality and safety issues. You will not have excellent patient experiences unless the teams that care for patients are supported and loved. You will not be successful with recruitment and retention if your team members will not recruit for you and may not choose to stay at an organization that does not care about them," she says.
The American Association of Nurse Anesthetists issues guidelines to prevent infection and provide safe patient care.
To prevent its spread and achieve the best patient outcomes, nurses need to be informed about how to best care for patients with suspected or confirmed Coronavirus Disease 2019 (COVID-19).
“CRNAs are on the frontlines of patient care. To guide them as they deliver safe and effective anesthesia care while keeping themselves healthy, the AANA has provided a series of considerations specific to the perioperative setting and summarized recommendations from top national and international healthcare organizations,” Brett Morgan, DNP, CRNA, AANA senior director of education and practice says in a news release.
“As highly trained advanced practice registered nurses, CRNAs provide anesthesia care to all patients and are called upon to help manage patients experiencing respiratory distress and failure. This often involves invasive airway management, which places CRNAs at high risk for disease exposure,” Morgan says. “COVID-19 can spread from person-to-person through respiratory droplets, therefore it is imperative for CRNAs and all healthcare providers to be prepared with the most current infection control precautions and considerations to remain safe.”
Enforce frequent, meticulous hand hygiene. Hand hygiene is essential to preventing infection and must take place before and after donning or doffing PPE.
Personal Protective Equipment must be available for all providers. N95 masks should be worn for all known or suspected cases of COVID-19 and any asymptomatic open airway cases. A powered air-purifying respirator (PAPR) may also be called for.
Wear disposable OR caps and beard covers. Disposable fluid-resistant long-sleeved gowns, goggles, and disposable full-face shields are recommended for frontline providers.
Prior to intubationdon appropriate gloves, facemask/PAPR, eye shield, and gown. Plan to limit the distance traveled with contaminated equipment. Double glove and use the outer glove to sheath the laryngoscope blade after intubating.
Select the most experienced anesthesia professional to intubate the patient. Limit the number of staff members during airway manipulation to reduce the risk of unnecessary exposure.
Allocate ORs specifically for patients with confirmed or suspected COVID-19. In addition, these patients should not be brought to preoperative holding or recovery areas.
Take steps to minimize aerosolization of the virus. Preoxygenate the patient for five minutes with 100% FiO2 and perform rapid sequence induction to avoid manual ventilation of the patient’s lungs. Use a video-laryngoscope to improve intubation success and avoid awake fiberoptic intubations, when possible. Atomized local anesthetic will aerosolize the virus.
Use a high-efficiency hydrophobic filter. Place a high-efficiency hydrophobic filter between the facemask and breathing circuit or between the facemask and reservoir bag to avoid contaminating the atmosphere.
Follow strict environmental cleaning and disinfection procedures. Dispose of all used airway equipment in a double-zip-locked plastic bag for proper decontamination and disinfection.
“We will continue to monitor the situation, particularly as CRNAs may be called upon to care for patients infected with the disease,” Morgan says. “Excellence in care, safety, and continuous improvement of care are hallmarks of the CRNA profession.”
There is a strong correlation among nursing excellence and patient loyalty, physician engagement, and clinical outcomes, finds a new Press Ganey report.
Nurses are everywhere. They're at the bedside, in patients' homes, in outpatient clinics, in schools, even in the C-suite and the board room. We know their numbers are many—just over 3.8 million registered nurses nationwide.
The report's findings showed a strong correlation among nursing excellence and patient loyalty, physician engagement, and clinical outcomes.
For example, when the Press Ganey researchers compared performance on measures of patient experience between Magnet® and non-Magnet hospitals, they saw consistently better performance in Magnet facilities. In an analysis of Press Ganey patient experience scores, "the respective percentages of mean Top Box scoresfor the global Likelihood to Recommend measure for Magnet and non-Magnet hospitals were 75.0 and 70.9. The Top Box score percentages for Overall Rating were 75.4 and 73.4, respectively," according to the report.
Additionally, the report found that a culture that supports nursing excellence positively influences patients' perceptions of physicians. The study found that compared to non-Magnet hospitals, Magnet hospitals had higher percentages of Top Box scores and higher mean scores for patients’ perceptions of:
Physicians' concern for patients' needs
How well the physician kept the patient informed
Physician skill
Physician friendliness and courtesy
Physician responsiveness to patient concerns
Inpatient admission speed
"It reinforces and affirms what I've known all along: the impact that nursing [has] on pretty much everything in healthcare and healthcare organizations," says Christy Dempsey, DNP, MSN, MBA, CNOR, CENP, FAAN, chief nursing officer at Press Ganey. "But nursing is an evidence-based profession and, certainly, we are an evidence-based company, so we really needed the data to make sure that was, in fact, the case. We found that nursing excellence impacts physician engagement, clinical quality, patient experience, and nurse experience."
In a recent interview with HealthLeaders, Dempsey reflected upon the study's findings and results. The transcript has been edited for clarity and brevity.
HealthLeaders: Beyond Magnet designation, how do you define nursing excellence?
Christy Dempsey: We did use Magnet as the marker for analysis of nursing excellence. But what we found in terms of the characteristics associated with nursing excellence were developing and advancing strong nurse leaders who advocate for patients [and] also for nurses; an organizational structure that supports shared governance; having nurses at every level making decisions; making sure that you are measuring and looking at the data and establishing those performance benchmarks; promoting autonomy for nurses within that shared governance framework; implementing care models that optimize outcomes that include [things such as] patient experience and workforce engagement in addition to clinical quality outcomes; nurturing the culture of interprofessional [teamwork]; and the ability to grow and develop in the organization and within the profession, all within a framework of high reliability.
HL: If you walked into an organization with a strong presence of nursing excellence, what would that look like on a day-to-day basis?
Dempsey: I think absolutely it boils down to culture, but I think as a patient, you know it when you see it. As a nurse, you know it when you see it. I think a culture of nursing excellence is pervasive throughout an organization and it is tangible because all of those characteristics I talked about previously are in place.
HL:How does nursing excellence influence patients' perceptions of their care?
Dempsey: [When we compared] Magnet organizations to non-Magnet organizations, what we found is that nurses are more satisfied with their work environment [within Magnet organizations]. We have found repeatedly that work environment is critical, and nurses are more likely to stay in their job at a Magnet organization. They feel like they have more opportunities for development and more autonomy to lead care and to practice at the top of their licenses. We know that those things impact the patient experience, the data bears that out.
HL: One of the interesting things from the report is that nursing excellence influenced patient assessment of physicians and physician engagement. Can you talk a little bit about that and what your assessment of this finding is?
Dempsey: Healthcare is a team sport. Clearly, none of us can do it by ourselves. We all went into this business with the goal of helping and healing. When we have a culture that supports those inherent rewards and the fact that we are in a noble profession and that we are able to help and heal, I think collaboration, teamwork, and mutual respect help those inherent rewards outweigh the stress and distress that comes with [working in healthcare].
HL: Besides Magnet designation, what are some other ways that organizations can elevate nursing excellence?
Dempsey: I think nursing excellence is a journey. It doesn't require designation. I think the attributes that we talked about before, the domains for Magnet, all of those can be a part of a journey to nursing excellence that any organization can achieve. So regardless of whether you're going for Magnet designation, every organization should be on the journey in working toward excellence.
HL: What specific actions do you recommend nurse leaders take to boost nursing excellence? Where should they focus their efforts?
Dempsey: The first thing you have to do is make sure you know the current state of the nursing culture, including the safety culture. Again, the work environment is so critical. [You must] understand where you are right now and then define what the nursing professional practice model is going to be.
You need to identify where are you, where you want to be, what the gaps are, and how you are going to address those gaps. You have to have data transparency and a communication plan around that data. It's not enough just to post the data. You have to understand what the data means, what it's telling you, and build stories around that data. It's about making sure that you understand when you're tracking the metrics, the benchmarks, and the outcomes how that translates into a return on investment.
HL: Anything else you want to highlight about the findings?
Dempsey: I think everybody understands that nursing—most certainly acute care organizations as well as across the continuum—is the biggest line item on the budget. But [it is] also the front line of care. [Nurses] spend time with patients, and not only provide clinical care, but also coordinate care and manage the transitions of care throughout the continuum. They communicate, advocate, educate, and comfort. I think that [shows in] the patient's perception of their care experience. [The patient] notices. Those organizations that invest in the journey to nursing excellence, which everybody should be on, are best able to leverage the skill, the compassion, and the true passion [of] nurses.
