Patients' ratings of hospitals have almost no correlation to the quality of care, new research finds.
Your friend tells you she needs a knee replacement. There are two hospitals in town. One that has rooms with amazing views and delectable food. The other has a rate of zero hospital-acquired conditions. She asks which one you would choose.
Of course, you'd pick the one with better clinical outcomes. Who wouldn't?
Yet, according to new research from Cornell University, patients’ ratings of hospitals and their willingness to recommend them have almost no correlation to the quality of care.
“The No. 1 thing that ultimately matters to patients – are you going to survive your operation? Can they fix you? – does not really factor into patient satisfaction scores,” says Cristobal Young, associate professor of sociology in the College of Arts and Sciences at Cornell University in a news release.
The study found patient satisfaction scores at hospitals with the lowest death rates were only 2 percentage points higher than hospitals with the highest death rates.
A far bigger factor in patient satisfaction, with scores varying by nearly 27 percentage points, was interpersonal communication by nurses, including their responsiveness and compassion.
Additionally, the tidiness and quietness of rooms had a larger influence on patient satisfaction than death rates or medical quality.
Young says the fundamental problem is that patients generally can only see and understand a hospital’s “front stage” room-and-board presentation.
“They know when the food is cold and tasteless, when their room is loud and overcrowded, when the nurses are too busy to tend to their pains and frustrations,” the study authors write.
Patients have little insight into the “backstage” operations where critical medical care happens, and as a result, the study concludes, front stage room-and-board care creates a “halo effect” of patient goodwill while the backstage delivery of excellent care does not.
While many hospitals have invested in hotel-like amenities including atriums with waterfalls, private rooms with patios and scenic views, gourmet food, and premium TV channels, those investments, Young cautions, represent a distraction and a shifting of resources from what should be an organization's core mission – providing excellent healthcare.
“No one would object to nurses being friendly or to patients having private rooms and great food and manicured gardens,” Young says. “But none of those things are medical treatment. They won’t fix your health problem. And hospitals have limited resources and razor-thin margins.”
Forty-four percent of nurses say they often feel like quitting their jobs. Here's what nurse leaders need to know to change that.
It's not easy being a nurse. And that's not just an anecdotal observation. Recent results from The AMN 2019 Survey of Registered Nurses highlight the pressures and challenges RNs face daily. These challenges include the effects of working second jobs, the experiences of bullying and workplace violence, and concerns about how their jobs affect their health. Because of these and other stressors, 44% of the RN respondents say they often feel like quitting.
Here are some of the survey's findings from the almost 20,000 nationwide sample of RNs:
Second jobs
More than one-in-five (22%) nurses hold more than one job as a nurse
Nearly one-in-five nurses (18%) working more than one job say it negatively impacts the quality of their work
37% of nurses working more than one job say it negatively affects their quality of life
One quarter say that working more than one job negatively influences their post-shift driving ability due to drowsy driving
Exposure to workplace violence
41% of nurses say they have been victims of bullying, incivility, or other forms of workplace violence
27% of nurses say they have witnessed workplace violence
10% say their organization addressed the situation extremely well or very well
63% say their organization did not address the situation well at all
Career vs. job satisfaction
81% of nurses say they are satisfied with their career choice, with “extremely satisfied” as the largest category
65% say they are satisfied with their jobs, with “somewhat satisfied” as the largest category
75% say they are satisfied with the quality of care they are able to provide to patients
66% worry that their job is affecting their health
44% say they often feel like resigning from their jobs
Factors in job turnover
39% of nurses say flexibility and work-life balance are the most important factors that influence their intent to remain at their current organizations
31% say compensation and benefits are the biggest influences on their intent to remain at their current organizations
27% say it is unlikely they will be working at their current job in one year
Diversity and job satisfaction
60% of nurses say their organizations support diversity in the workplace extremely well or very well
Of those nurses who say their organizations support diversity extremely well, 43% are also extremely satisfied with their jobs, compared to only 5% of those whose organizations do not support diversity well at all
Of nurses who say their organizations do not support diversity well at all, 45% strongly agree that they often feel like resigning from their position, compared to 11% of those whose organizations do extremely well at supporting diversity
Of nurses who say their organizations support diversity extremely well, 59% say they are extremely likely to be working in their jobs one year from now, compared to only 18% of those whose organizations do not support diversity well at all
Support for professional development
43% of nurses say their organization does extremely well or very well in supporting professional development; 29% say their organization does slightly well or not well at all
Nurses working for organizations that do extremely well at supporting their professional development are significantly more likely to be satisfied with their career, job, and ability to provide quality care, and they are more likely to remain at their current job
Retirement
20% of nurses say they are planning to retire in the next five years
86% of baby boomer nurses say they are planning to retire in the next five years
Of baby boomers planning to retire, 39% say they will retire in one year or less
Of all nurses who say they are not planning to retire, 10% say they will leave direct patient care in the next year
These results may make it seem like there is a dire situation in nursing, but it doesn't have to be so, says Cole Edmonson, DNP, RN, FACHE, NEA-BC, FAONL, FAAN, chief clinical officer at AMN Healthcare, headquartered in San Diego.
"These are strong cautionary tales from practicing nurses that are telling us exactly what they want, what they're experiencing, and what will keep them at the bedside and in healthcare," he says of the results. "We need to be listening to what nurses have to say. We need to understand what it means, and we need to be solutioning with nurses and other providers and leadership to solve these challenges in healthcare."
In a recent interview with HealthLeaders, Edmonson discusses the survey's findings and key insights for nurse leaders. The transcript has been edited for clarity and brevity.
HealthLeaders: What are the biggest takeaways from this report for nurse leaders?
Cole Edmonson: There are several key takeaways for nurse leaders in the C- suite as well as those at the bedside. One, is that nurses are extremely satisfied with their choice of careers, but only about two- thirds are satisfied with their job. Then that drives us to start to think about how nursing jobs are structured and what's driving that dissatisfaction and what's driving satisfaction.
Second—I think this is well documented—the experiences that nurses are having with workplace violence and the opportunity for us to better address those as healthcare organizations and as leaders to make sure they're addressed effectively. This survey was also the first time we asked how important diversity and inclusion was to a nurse with intent to stay at [his or her] job. The surprising finding that [diversity and inclusion] was one of the highest correlated elements of what nurses wanted in their job with the intent to stay. This was also the first time we saw nurses say that flexibility and work-life balance are one of the top drivers [for intent to stay], even above competitive pay.
HL: Based on the survey results, where do you think nurse leaders should focus their energy?
Edmonson: There's three key areas where I would tell leaders to focus. The first one is addressing and providing for the flexibility in life-work balance. You might notice I put life before work because I think that's a shift in trend as well. The second one is making sure that you have professional development opportunities for nurses in your organization beyond the traditional tuition reimbursement and scholarships and continuing education.
The third is making sure that as leaders in healthcare, we are effectively addressing workplace violence issues, not only from the prevention and mitigation, but the event and the recovery after that event. Because we know these events change people for their entire lives.
HL: Are there specific solutions that have caught your eye as you meet with nurses across the country?
Edmonson: I'm seeing a lot of opportunities where people are literally leaning in to address some of the challenges that we uncovered in the survey. Some of those are related to particularly the graying and the greening of the nursing workforce. 86% of the baby boomers in the survey said they were going to retire in the next five years.
We don't have a solution that's going to keep up with that level of retirement unless we make some changes. So, where I see people leaning in is more academic practice models: Truly partnering between academia and practice to create different types of programs, a reemergence of dedicated education units and tighter partnerships between academic and practice where they're choosing strategic partners in academia based on their workforce needs.
With the graying of the nursing workforce, part of what I'm seeing is formal emeritus programs that are giving nurses, who are at the latter stages of their careers, more opportunity to stay engaged in mentoring and onboarding and transferring that knowledge to that next generation of nurses.
Going back to [nurses being satisfied with their jobs] … what we're seeing there is sometimes 20% or greater of the nurses' time is spent "hunting and gathering." Now we have studies that are showing that up to 50% of a nurse's time is spent on the EHR documentation. So even in a best-case scenario, 50% of a nurse's time is spent on those two activities, hunting and gathering and EHR documentation. This is a huge cognitive load for nurses in terms of how they're structuring their work, prioritizing their work, and getting time and presence with patients.
[An] interesting solution I've seen as I've traveled across the U.S. engaging with different strategic partners is nurse scribes. They are providing nurses with either virtual or actual scribes as a partner in care. I also had the opportunity to help develop a test of the first mobile nurse assistive robot in the U.S. That [solution] was about taking those lower-value, routine tasks of the nurse and having the robot [do them] on unit as part of the care team in order to provide time for the caregiver to have presence with the patient.
HL: We've talked about career versus job satisfaction and job turnover. What are the factors that
rose to the top in the survey?
Edmonson: When we did our correlation of the data, we found five top factors, the first being flexibility and life-work balance. I think the second is organizations providing professional development, the third is a diverse and inclusive organization, the fourth is having effective leaders and systems to help prevent workplace violence, and then the fifth is around staffing adequacy.
All those, to me, really point out the fact that we have to think about how people have joy at workand start leaning in to that concept of how do we make sure people are feeling great about the care they're providing, the work that they're doing, and how to help them continue to feel great about their profession. I think we don't often emphasize enough the amount of joy that people get from being caregivers and in the healthcare system.
Steep reductions to nursing workforce, education, and research are proposed.
In its Fiscal Year (FY) 2021 budget, released February 10, the Trump administration proposes steep cuts to and the elimination of essential nursing programs under the Department of Health and Human Services (HHS) and Department of Education.
Under the new budget, the majority of Title VIII Nursing Workforce Development Programswould be eliminated with the exception of the Nurse Corps program, which would receive $83.135 million. Additionally, the National Institutes of Health would face a nearly $3 billion proposed cut. This includes cutting the National Institute of Nursing Research's (NINR) budget down to $156.804 million in FY 2021. These reduced funding levels are about a 9% overall cut to HHS.
"Federal funding for Title VIII Nursing Workforce Development Programs is essential to our nursing schools, students, and the profession. Without adequate funding for these programs, the health and well-being of all Americans will suffer," Ann Cary, PhD, MPH, RN, FAAN, FNAP, dean of the School of Nursing and Health Studies at the University of Missouri-Kansas City and Chair of the American Association of Colleges of Nursing's Board of Directors, says in a news release.
The budget also proposes a 7.8% reduction in the Department of Education's budget and lowering of caps on lifetime loan limits for PLUS student loan programs, which could hinder American's ability to access higher education, including those pursing nursing degrees. The budget also eliminates the Public Service Loan Forgiveness program and the Graduate Assistance in Areas of National Need.
According to the AACN news release, the association says support for institutions of higher education must be maintained and elevated to ensure healthcare workforce, including nurses, is adequately prepared to care for patients in all communities, including those in rural and underserved areas.
"Investments in academic nursing and the workforce are necessary to ensure that the nurses educated today are ready for the challenges of tomorrow," says Deborah Trautman, PhD, RN, FAAN, President and Chief Executive Officer of AACN in a news release. "The proposed cuts would significantly hamper the nursing profession's ability to educate and retain a qualified workforce."
According to a news release, the AACN strongly opposes the budget's reductions it views them as undermining the federal government's longstanding commitment to educating the future nursing workforce to meet the healthcare needs of the nation.
Millennial and Gen Z nurses cite team dynamics, professional growth opportunities, and flexible scheduling as important factors in the work environment as part of a new study.
"What matters to you?" This is a question the Institute for Healthcare Improvement encourages clinicians to ask patients to help create customized plans of care. Healthcare leaders can also ask this question of their staff members to improve the work environment and cultivate joy at work.
In this same vein, leaders at Nashville-based HCA Healthcare, with 94,000+ registered nurses, were curious about what matters to millennial and Gen Z nurses as those two groups have started to make up a larger portion of the nursing workforce.
"We've seen a big shift in our demographics now for about the last four years. We went from the millennials and the Gen Z being the minority in our employee population, particularly our nursing group, to now they're the majority," says Jane Englebright, PhD, RN CENP, FAAN, senior vice president and chief nurse executive at HCA Healthcare. "It was a pretty rapid swing for us, so we wanted to make sure we weren't missing anything and that we were meeting the needs of this changing workforce."
Hence, HCA Healthcare, teamed up with The Center for Generational Kinetics to study what drives, engages, and motivates millennial and Gen Z nurses. The results are published in the report, Employment Vitals: Millennial and Gen Z Nurse Expectations.
Here are some of the study's findings, which surveyed approximately 1,250 millennial and Gen Z nurses nationwide:
44% of millennial and Gen Z nurses rate team and managerial relationships as the No. 1 dynamic in a positive work environment.
42% say communication and the ability to make clinical decisions are important factors impacting the working environment. 43% of respondents indicate professional growth opportunities through career advancement are crucial.
More than one-third of the nurses surveyed say career advancement training, learning a new specialty, or getting a new certification, is the most helpful type of education they could receive at work.
More than 28% of millennial and Gen Z nurses cite the importance of modern facilities and updated equipment as contributing factors in creating a positive working environment.
Offering flexible work schedules was selected by 49% of respondents as a top organizational strategy that would absolutely make them feel supported by their employer.
When nurses were asked to choose the support system that means the most to them, 57% said they feel most supported through their team.
When it comes to career development, 28% of nurses rate moving to a different floor or department as equal to being given increasing amounts of responsibility.
One-third of nurses who have been in the field five years say moving to a different floor or department is one of their top two definitions of career progress. 39% of nurses with a six-year tenure said the same thing.
64% of nurses who have been in nursing for nine years have been with their current employer four to five years.
Four to five years is how long most nurses with seven or more years of experience have been with their current employer, indicating earlier movement between employers.
In a recent interview with HealthLeaders, Englebright discusses the study's results and what nurse leaders should be aware of regarding the needs of millennial and Gen Z nurses. The transcript has been edited for clarity and brevity.
HealthLeaders: To what do you attribute this change in demographics? Is it due to retirement of baby boomer nurses?
Jane Englebright: We definitely see retirement but, I think for us, a lot of it has been hiring more nurses, between the growth that we've had in HCA and the fact that so many nurses now aren't really choosing the hospital as their preferred place to work. There are so many more options out there for nurses, so we have been hiring new graduate nurses at a much higher rate than we have in the past. We've put a lot of support programs in like residency programs and things like that to support the new nurses. It's been a pretty marked change in terms of how many new people we're bringing into the profession every year.
HL: So, tell me what were the study findings?
Englebright: A lot of things we thought we knew, we validated, and then there were some other new insights that we didn't expect. We found out [nurses] have high expectations for their own performance, and they have really high expectations from us as an employer. We were pleased to see they were focused on teamwork and that their team was as important to them as their manager. They were really focused on their own personal development.
HL: It sounds like they view personal and professional development differently than previous generations of nursing. Can you explain that?
Englebright: They want to grow and develop and learn new things, but they want to do that at a little bit faster pace than what we have seen in the past. [M]ovement [in the organization] and doing something new and different feels like progression to them, whereas traditionally we thought if you weren't getting a promotion or moving into management, it wasn't progression. They see any opportunity to learn and gain new skills and knowledge as progression, which was refreshing to see.
HL: That's interesting. So, instead of a new title, you could give them a project to do?
Englebright: Changing specialties, changing settings, moving from an inpatient setting to an outpatient setting—all of those types of movements are exciting and motivating because they're learning new things.
HL: Are you seeing a lot of new grads who are interested in becoming nurse practitioners?
Englebright: We are seeing a lot of interest in the nurse practitioner role. We have a lot of those roles inside our hospitals and our other sites of care. I did a little bit of teaching here at Belmont [University] a couple of years ago, and I had people in my program fresh out of their undergraduate program. They were just going straight through. But we're trying to embrace that and begin to look at our medical-surgical units as places where they set the culture and they set expectations and get everybody started on the right foot.
HL: And it looks like the study also found that support and professional relationships are important to this group.
Englebright: They had a broad way in which they defined support and the type of support that they're looking for. They see that as some of the traditional things that we've done in terms of benefits, but they also see support as flexibility and scheduling.
Personal relationships are very important and feeling like a part of a team is important, and the amount of training that they have. Training has been a huge focus of ours, and we've doubled our efforts in that area. They also want the ability to have a voice, so we are seeing greater participation and involvement in our professional practice councils with this younger generation.
HL:What do you plan to do with the findings you have gained from the study?
Englebright: [We plan to share] them with our leaders so they can understand this group more. We're certainly looking at a lot of things that we've been doing. For example, I mentioned clinical education and how we had started the residency programs, but we're trying to take that to the next level by putting what we're calling "clinical advancement centers" in each one of our markets so that we can provide that education, growth, and retraining opportunities throughout the [nurse's] life cycle.
We just invested in a partnership with a nursing school, and we're hoping that that further strengthens our ability to provide learning opportunities throughout the career path of a nurse. And we're exploring how we can make it easier for nurses to move around inside HCA Healthcare. They know what's available in their hospital, but they may not know what's available in the other 180 hospitals in the system. That could offer them geographic mobility and new specialty or whatever it is they're looking for in terms of the next challenge in their career.
Editor's note: This article has been updated to reflect that the study was a nationwide survery.
"Using the 2005-2016 National Violent Death Reporting System dataset from the Centers for Disease Control, we found that male and female nurses are at a higher risk for suicide, confirming our previous studies," says senior author Judy Davidson, DNP, RN, research scientist at UC San Diego in a news release. "Female nurses have been at greater risk since 2005 and males since 2011. Unexpectedly, the data does not reflect a rise in suicide, but rather that nurse suicide has been unaddressed for years."
The researchers found female nurse suicide rates from 2005 to 2016 were significantly higher (10 per 100,000) than the general female population (7 per 100,000). Similarly, male nurses (33 per 100,000) were higher than the general male population (27 per 100,000) for the same period.
"Opioids and benzodiazepines were the most commonly used method of suicide in females, indicating a need to further support nurses with pain management and mental health issues," says co-author Sidney Zisook, MD, professor of psychiatry, UC San Diego School of Medicine in a news release. "The use of firearms was most common in male nurses and [is] rising in female nurses. Given these results, suicide prevention programs are needed."
UC San Diego has successfully tested the Healer Education Assessment and Referral (HEAR) suicide prevention program. HEAR provides education about risk factors and proactive screening focused on identifying, supporting and referring clinicians for untreated depression and/or suicide risk. HEAR has been deemed a best practice in suicide prevention by the American Medical Association.
Since 2009, more than 500 HEAR referrals have been made for clinicians to mental health professionals. Approximately 40 nurses per year, many in crisis, have communicated with counselors, often anonymously through the website and always confidentially by email, phone or in person.
"It is time to take urgent action to protect our nursing workforce. The HEAR program is ready for replication at the national level to address this newly recognized risk among nurses," said Davidson, who co-chairs a task force for the American Nurses Association to address nurse suicide. "The HEAR program can be complemented with tested cognitive-based therapy resiliency skills building for maximum effect."
The World Health Organization reports that one person dies every 40 seconds by suicide. It is the 10th leading cause of death in the United States, occurring at a rate of 13 per 100,000 persons. While overall mortality rates are decreasing in the US, the suicide rate is rising.
No community is immune from disasters and emergencies. Here's how nurse leaders can do their best by planning for the worst.
The coronavirus that originated in the Chinese city of Wuhan has grabbed headlines over the past few weeks, as it sickened thousands and hundreds of people dead as of January 31. In addition to the cases in China, there have been 11 confirmed cases of the virus in United States, with one case of person-to-person transmission occurring on January 30 in the Chicago area.
While domestic numbers of the virus are still low, the situation serves as a reminder that hospitals and health systems need to be prepared for whatever virus, outbreak, disaster, or emergency event comes their way.
Here are four HealthLeaders articles that highlight how nurse executives can prepare for and lead when these types of situations occur.
1. Technology Can Zap Fear of the Unknown
Before coronavirus, there was Ebola, SARS, and middle eastern respiratory syndrome. In 2014, Community Hospital in Munster, Indiana, earned the distinction of caring for the first person in the U.S with a confirmed case of MERS. There have been only two confirmed cases of MERS in the U.S. The other one was in Florida.
"I don't think anyone can ever realize the kind of stress an organization is under when this type of event occurs," says Ronda McKay, DNP, RN, CNS, chief nursing officer and vice president of patient care at Community Hospital.
The fact that they were heading into unknown territory hit home when, during a conference call, McKay asked Indiana State Department of Health officials what would happen if the patient tested positive for the MERS virus.
"There was a pause on the phone call and [the] exact words were, 'Life as you know it will change,'" McKay says.
Read on to get McKay's pointers on how Community Hospital thwarted any further transmission of MERS and prevented widespread panic by creatively using existing technology to gather data and then carefully communicating it to public health authorities, staff members, and the public.
2. Ready for a Disaster? If Not, It Will Cost You.
Emergencies and disasters follow a Forrest Gump philosophy, "You never know what you're gonna get."
"This stuff's happening all over the place in different venues and at different times," says Eric Alberts, corporate manager, emergency preparedness at Orlando Health. "A fertilizer plant explosion or a train derailment with chemicals or a vehicle that crashes into a building or a shooting. These things are happening everywhere, and you can't predict it."
Alberts speaks from experience. Orlando Health Medical Center is just a few blocks from Pulse nightclub where 50 people were killed and more than 50 were injured during a mass shooting in 2016.
But hospitals and health systems can, and should, prepare for the unexpected, and administrative leaders should lead the charge, he says. In this article, Alberts shares insights he gained from the incident.
3. 3 Ways Health Systems Can Prepare for Natural Disasters
There's no stopping Mother Nature. Hurricanes, earthquakes, and wildfires are all bound to happen, and when they do, hospitals and health systems will be affected. However, there are tangible things leaders can do to make sure their organization is prepared when disaster strikes.
One way to ensure patients can still receive care even if roads are closed or transportation is difficult, is to make sure patients and the community are aware of an organization's telehealth options.
Electronic health records have become a necessity in providing patient care. But what happens if patients are displaced during a disaster? Patient records can remain available through Health Information Exchanges. However, leaders must be proactive and make sure electronic connections are set up in advance of a disaster.
Take a look at the article for details on how to ready your organization for disaster.
4. Nurses Not Immune to Stress from Disaster
When a community begins the path to recovery after a disaster, it's important to remember the experience may also leave marks on victims' psyches. And that includes nurses.
For example, two reports centered on nurses working at NYU Langone Health's main hospital during Superstorm Sandy in 2012, found that RNs are personally and professionally affected by natural disasters. Key themes that emerged were the need for communication—both improving channels and its importance in connecting nurses with others during a crisis—and social support.
Insights on emergency preparedness, recovery, and resilience can be found here.
When nurses reported less frequent use of palliative care for their patients, they tended to experience higher levels of moral distress, a study finds.
Minimally invasive surgery, telemedicine, electronic medical records. These, and other healthcare innovations, have changed the way patient care has been provided over the past few decades. Yet, even in modern healthcare, care delivery for certain patients can sometimes be lagging.
For example, when researchers analyzed 167 questionnaires completed by critical care nurses in seven critical care units at the University of Virginia Medical Center in Charlottesville, Virginia, they found that less than 40% of the respondents reported being highly competent in any of the palliative care domains such as pain control, symptom management, legal and ethical considerations, cultural humility, and spiritual and psychological approaches to care. They also reported palliative care education to be lacking, with 38% reporting that they had no palliative care training the past two years.
The use or non-use of palliative care obviously affects patients, but lack of its use also affects nurses. During the study period, most respondents reported experiencing moral distress, and "moral distress levels differed significantly on the basis of perceived use of palliative care," the study's authors write. Nurses who perceived less frequent use of palliative care for patients tended to experience higher levels of moral distress.
So, how can nurses' rates of moral distress be decreased and patients' palliative care needs be met?
One of the study's coauthors Ken White, PhD, AGACNP-BC, ACHPN, FACHE, FAAN, University of Virginia Medical Center Professor of Nursing and Associate Dean for Strategic Partnerships & Innovation at the UVA School of Nursing, and palliative care nurse practitioner at UVA Health, recently shared his perspective on palliative care as well as the study's implications with HealthLeaders. This transcript has been lightly edited for brevity and clarity.
HealthLeaders: Since you are a palliative care expert, can you give me a little background on the history and evolution of palliative care?
Ken White: It's a relatively new [specialty]. I'm a big fan of nursing and healthcare history and nurses got [their] start as palliative care providers. By that, I mean there weren't all these treatments available and nursing's original goal was to care for and comfort and provide compassion to people who are suffering.
But gradually, over time, with more technology and more advances and people living longer, there is this sort of erosion of dealing with total suffering, which is much more than physical. In America, we find it so difficult in our culture to talk about death and dying.
There was a grassroots consumer movement, it started in about the '80s, and people began to say, 'We should be able to decide what we want for our lives.' In 1990, the Patient Self-Determination Act was [signed into law]. It says people have a right to refuse treatment, and they should have an advanced directive. It's been slow to be adopted because you know, because the medical establishment and nursing to some degree, hasn't really kept up with the requirements for what it takes to sit down and have a conversation with a patient's family at the time of a diagnosis of a life-limiting disease or condition.
HL: What was the intent of the study?
White: The purpose of this paper was to say there are lots of consequences, not only to the patient and the family of not having those discussions, but also to the care providers, especially nurses.
HL: The study mentions moral distress as a consequence nurses might experience from the lack of palliative care for patients. Can you talk about the specifics of moral distress among nurses?
White: When an individual knows the morally correct action to take but is prevented [from] doing so because of internal or external restraints, that's moral distress. Specific to critical care patients and this study, when a nurse does not believe that delivering treatments will help or decrease suffering, it may lead to moral distress.
I think a lot of people confuse or conflate moral stress or just plain stress. There's going to be stress when you're taking care of patients because they're all different and they all have different situations. But moral distress, and Beth Epstein, [one of the coauthor's of this study], has done research that says that if a nurse faces moral distress and nothing is done about it, it will [eventually] come to an end because the patient will die or be transferred. But, if the nurse doesn't come to some sort of resolution about it, then the next time [a similar situation] happens, it activates what Beth calls "moral residue." It becomes additive [with each patient]. It has to be dealt with or people burn out or they become emotionally numb and don't care anymore or they leave the profession, or they leave the job.
HL: What are the study findings?
White: The results are robust and stable across the [critical care] units that [the respondents] don't get enough [palliative care] education. [They] believe that all the palliative care competencies are important, but they don't rate themselves as competent in those areas. And the nurses that had the least amount of competency in those areas say that their moral distress higher.
HL: Has palliative care education changed over the years?
White: [Many years ago] I started working with Pat Coyne, who is a nationally known pain management specialist nurse. He and I developed a survey that went out to all the members of the oncology nursing society. Our results were from 1999. The paper that was published was called Are Nurses Adequately Prepared for End-of-Life Care?
The conclusion was no. The top thing that they felt like they lacked was communication techniques with people about death and dying. We repeated the study 10 years later with oncology nursing society members. There was no change, but the most appalling thing was the low amount of education that our nurses had had on the topic.
HL: What are some of the barriers nurses face regarding palliative care?
White: They seem to know that all [palliative care] domains are important, but the low amount of palliative care education they receive is a barrier. I would also say that interprofessional education is a barrier. We know from work that has been published that sometimes when nurses get education on palliative care their moral distress goes up rather than down because they know what to do, so they're even more frustrated when they can't get their physician colleagues to do it.
Often the response from the physician is, 'I don't think they're ready for hospice yet.' That's a misunderstanding on the part of other care providers of what palliative is. They equate palliative with end-of-life care when palliative care can be a layer of support and expertise at any time during the trajectory of a life-limiting illness. We use an interdisciplinary approach to decrease suffering, lessen uncomfortable symptoms, and define what is most important in a person’s life and defining goals of care.
HL: What are some ways to address barriers to palliative care?
White: I would say interprofessional collaboration and giving the nurse a voice on the team, so they can say, 'I think it's time to call in palliative care,' or 'I think it's time for us to have a discussion with the patient.' If they get the education, they should be allowed to use it.
I also think nurses need a supportive framework wherever they work. For example, at UVA, we have something called a moral distress consult service. If a nurse feels like they're experiencing distress over a situation, they can call someone who has training 24/7 and be able to work with that person to help them resolve that. This is in addition to an ethics consult service.
Another thing is regular training on resilience. We have retreats for ICU nurses on resilience. We take them out of the workplace to do it. We have regular yoga classes. We have a palliative care champions program so that any nurse who wants to learn more about palliative care can do so. There's a lot of things that management leadership can do.
HL: Can you talk about the importance of interprofessional collaboration in palliative care?
White: [I think issues around] interprofessional collaboration are probably a symptom of a systemic lack of training in team science. I think that points to a missing element. If we look at high-reliability organizations in other industries like the airlines, they devote a much larger percent of their education budget to team science training. With a physician colleague, I've developed a portable training program called advanced disease life support (ADLS), which is modeled on ACLS. It's a primary palliative care program that has to be completed interprofessionally between a physician and nurse. More programs like that need to be developed.
2020 will be a big year for nursing. It's the goalpost date that was set for the recommendations to come to fruition in the National Academy of Medicine's landmark report, "The Future of Nursing: Leading Change, Advancing Health," and 2020 has also been designated as the Year of the Nurse and Midwife by the World Health Organization.
So, what issues will rise to the top this year for nurse leaders? To understand where nurse executives should focus during 2020, HealthLeaders spoke with Shela Kaneshiro, MBA, RN, BSN, NEA-BC, CPHQ, vice president, patient care services and CNO at MemorialCare Orange Coast Medical Center in Fountain Valley, California and an attendee of HealthLeaders CNO 2019 Exchange event.
According to Kaneshiro, there are five issues that CNOs should have in their line of sight during 2020, ranging from succession planning to the work environment to workplace violence.
Succession planning
The upcoming retirements of baby boomer nurses are causing concern among many. One particular fear is that when this generation departs the profession they will take their years of knowledge and skills with them and a gap will be left. However, if CNOs plan for the future through succession planning they'll be able to utilize the talents of Generation X and millennial nurses to continue to deliver quality patient care.
"Sometimes there is this picture that it's all just new grads [to replace the baby boomers]. But if you look at the ages of millennials, some of them can be as old as their mid-thirties, and some have been practicing since their mid-twenties. I think sometimes we don't give them enough credit. Some of our new grads are second- career nurses and that gives them a competitive advantage because they've been in the workplace and already have time management and coping skills.
"And don't forget about the Gen Xers who've been practicing for 20-plus years. Even though we may have this mass exodus of our boomers, we have a good couple of generations in the workforce that's available to take on these new challenges. I think we need to look at more similarities and not so just the generational differences. And I hear this from all of the generations, they want to be valued for the work that they do," Kaneshiro says.
There's no doubt that stress is inherent in the nursing field. Nurses are on the frontlines during life-and-death situations, for example. But that doesn't mean they should bear stress alone. Nurse executives should commit to creating environments that help nurses process stressful events in a healthy manner.
"One of the things that we did because it's becoming more stressful for staff, whether it's a traumatic event or compassion fatigue or moral distress, is we worked with Johns Hopkins to develop a confidential peer-to-peer support program. We just launched it in August [2019] and did a modified version because we're building our program. We had [representatives from] John Hopkins come out to our hospital and train our peer responders. They're nurses, they're volunteers, some of them are managers, respiratory therapists, and occupational therapists. They are available from 8 a.m. to 4:30 p.m., Monday through Friday.
"Those who wanted to be peer responders went through training. We have our employee assistance program, but this peer-to-peer support program is something that [nurses] can tap into during the day when [they] are having a difficult shift; for example, they had a traumatic event or they had a death of a patient they had been caring for for a while, or they've had issues with physicians or coworkers. They can call [the peer responder] confidentially and … the peer responder can meet with them or just be on the phone so that they can talk and unload. We just take very minimal information to keep it confidential. We just [note] the date and the time and the unit that you're calling from, just because we want to identify any trends. For example, ED is having a rash amount of calls or oncology because they have a lot of end-of-life issues. We want to capture that data but nothing very specific because we want to stress that [the conversation] is confidential," Kaneshiro says.
As violence seems to become more prevalent in society, nurse leaders cannot ignore that it is occurring at their organizations. Nurse executives must support staff who are victims of workplace violence and find effective ways to decrease its occurrence.
"Workplace violence is a big thing. I don't think you can escape it. It doesn't matter where you work. [It's important to check in] with those who've had some kind of [violent] interaction. It means a lot to the staff to know the organization puts it at a high priority. We have signs [around the building that] basically state that there is no tolerance for specific types of behavior.
"I don't think we've emphasized enough that you have patients who are not necessarily violent in terms of their aggressive behavior, but, for example, you may have patients with dementia or patients waking up from withdrawal, and they may kick staff and it doesn't hurt any less. So, it's just circling back with them when there's some kind of incident and checking in. It's not always easy because sometimes [nurses are] reluctant to report it.
"Through our town halls, staff have asked for active shooter drills, so we did another set of active shooter drills. It's important that if they want information or education that we at do that," Kaneshiro says.
It's becoming increasingly common for nurse managers to have a large amount of direct reports. But is this a best practice? This is something nurse executives need to contemplate.
"We need to make sure that we give them the tools [to be successful] and that we give them support by making sure the span of control is manageable to some degree," she says.
With so many new opportunities for RNs, retaining nurses with excellent clinical skills and knowledge at the bedside is a challenge. By being creative with positions and learning opportunities, nurse leaders may entice those with expertise to stay at the bedside.
"I think sometimes we need to step out of our traditional models of nursing positions. There are some nurses who are nurse practitioners but still want to provide bedside care. We're looking at how we can still keep them at the bedside for those who want to stay and looking at succession planning for some of our special expert NPs, like those in palliative care and cardiac care. We have a telemetry nurse who just earned her nurse practitioner degree and we have a palliative care nurse practitioner who is willing to train her because she'll eventually be retiring. Before we even get to that (retirement), there is some time to have her shadow and learn," Kaneshiro says.
Editor's note: This article has been updated for quote clarification.
For 18 consecutive years, the public has ranked nursing as the most honest and ethical profession.
Once again, Americans have ranked nurses as the most honest and ethical professionals in Gallup's annual survey of U.S. adults. This is the 18th year in a row that nurses have earned this honor.
Healthcare professionals in general rate highly in Americans' assessments of honesty and ethics with at least six in 10 U.S. adults saying physicians, pharmacists, and dentists have high levels of these qualities. Yet, nurses are consistently rated higher in honesty and ethics than all other professions that Gallup asks about.
Interestingly, a non-healthcare profession nabbed second place in the poll with 66% of respondents saying engineers have very high or high levels of honesty and ethics.
The top five professions on the list are:
Nurses
Engineers
Physicians
Pharmacists
Dentists
Americans' do not look so favorably upon stockbrokers, advertising professionals, insurance salespeople, senators, members of Congress, and car salespeople, all of which garner less than 20% of U.S. adults saying they have high levels of honesty and ethics.
Honesty, Ethics Results Remain Stable
Americans' assessment of the honesty and ethics of most professions on Gallup's list has been consistent over time. However, there have been a few notable changes in the past year, including:
Americans' assessment of the honesty and ethics of journalists fell by five percentage points to 28%, returning journalists to levels seen in 2015.
The ongoing decline in views of the honesty and ethics of clergy seems to have paused. From 2012 to 2018, the percentage of Americans saying clergy had high levels of honesty and ethics dipped from 52% to 37%. Currently, 40% of respondents now regard clergy as having high honesty and ethical standards.
Trust in the honesty and ethical standards of members of Congress rose to 12%, up from 8% in 2018. The percentages saying legislators have high honesty and ethics rose slightly among both Republicans (from 7% to 9%) and Democrats (from 6% to 12%).
Car salespeople rounded out the bottom of the list with only 9% of respondents saying individuals in this field have high levels of ethics and honesty.
To be effective in today's healthcare industry, nurse leaders' knowledge must extend beyond traditional nursing issues.
The amount of information that nurse executives must synthesize to be effective leaders can be overwhelming. They must not only have a handle on traditional nursing issues like staffing, recruitment and retention, and nursing practice issues, they also must be keenly aware of big-picture organizational goals and healthcare industry trends.
To help an organization achieve its strategic goals, nurse leaders must be well-versed in the overall business of healthcare. Here are five stories from HealthLeaders editors on business topics that will help nurse leaders keep abreast of need-to-know industry developments.
Twenty years ago, the landmark reportTo Err Is Human: Building a Safer Health System was released, thrusting the need to improve patient safety into the spotlight. Unfortunately, since its publication, estimates of deaths from medical errors have increased.
A recent study in the journal, Diagnosis, reports that diagnostic errors contribute to significant cases of preventable harm. Misdiagnoses of three conditions—cardiovascular events, cancers, and infections—make up 74% of all serious harms from diagnostic errors and were linked to death or permanent disability.
"Our findings suggest that the most serious harms can be attributed to a surprisingly small number of conditions. It still won’t be an easy or quick fix, but that gives us both a place to start and real hope that the problem is fixable," says study lead author David Newman-Toker, MD, director of the Johns Hopkins Armstrong Institute Center for Diagnostic Excellence, in remarks accompanying the report.
The top three challenges for healthcare executives in performing analytics over the next three years is timely analysis, insufficient skills, and lack of funding, finds a recent HealthLeaders Intelligence Report: Investing for the Future: Analytics, AI, and ROI.
Additionally, 62% of healthcare leaders say clinical best practices are the most promising area of analytics development. Real-time delivery of actionable information (54%) and population health data (44%) complete the list of the top three most promising areas.
"The other part to this challenge is the delivery of the actual insight," says Todd Stewart, MD, vice president of clinical integrated solutions and clinical informatics at Mercy Technology Services, the IT division of St. Louis–based Mercy. "If somebody has to go outside of their typical workflow to get it, there is potential for it to be overlooked. As an example, you could have a really great sepsis algorithm that is predicting things perfectly, but if you deliver it out of context or out of the workflow, it's going to be tough to get the impact you need."
Want to improve HCAHPS scores, reduce falls, or improve disease management? There could be an app for that.
HealthLeaders highlights five healthcare technologies that have potential to appeal to patient-consumers, while simultaneously creating value for healthcare organizations. The featured devices and apps have been found to improve many of the outcomes organizations are striving to achieve.
At Allina Health's New Ulm Medical Center in New Ulm, Minnesota, patients who visit the emergency department at least three times within four months are added to a high-utilization list.
A social worker follows up with each patient directly to try to solve underlying problems that may be contributing to frequent ED use, such as mental health needs or housing instability.
This is not an unusual intervention. Many hospitals and health systems have similar programs, but when it came to the cost of employing a full-time ED social worker, New Ulm Medical Center did something different. The hospital partnered with local insurer South Country Health Alliance to split the personnel expense 50/50, beginning in 2012.
That partnership has paid off. By the end of the third year, the cohort's overall ED utilization was cut in half, and its inpatient admissions fell 89%.
"I don't think the driver was necessarily just cost but appropriate care at the right place, at the right time, with the right kind of provider," says South Country Health Alliance Chief Medical Officer Brad Johnson, MD.
When organizations talk of mergers and acquisitions, there's hope there will be a match made in heaven. But sometimes it turns into a love 'em and leave 'em situation.
When one potential partner decides the relationship is not to be, the other party needs to move forward. David Jarrard, CEO of healthcare strategic communications consultancy Jarrard Phillips Cate & Hancock Inc., offers some tips on how leaders can keep strategic communications on point when a potential partnership falls through.
For example, he says, if a partnership breaks apart, leaders should share tangible next steps that will be taken in moving forward and explain why the deal failed with their stakeholders.
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