Temple University Hospital's interdisciplinary Dermal Defense Team stopped Stage 3 and 4 pressure injuries acquired after admission at their organization to improve patient care and outcomes.
At Temple University Hospital, Stage 3 and Stage 4 pressure injuries acquired after admission have truly become never events, thanks, in part, to the work of the organization's Dermal Defense Team.
In 2018, the team set out to achieve zero Stage 3 and Stage 4 pressure injuries developed by patients after a hospital admission. Through education, risk assessment, and other prevention protocols, the goal was met in quarter three of 2018. In recognition of its work, the team received the 3M Award for Excellence in Skin Safety in June 2019.
Stage 3 and Stage 4 pressure injuries acquired after admission at healthcare facilities are some of the offenders that make up the list of 29 "serious reportable events" in healthcare, and according to the Agency for Healthcare Research and Quality, pressure injuries cost the U.S. healthcare system an estimated $9.1–$11.6 billion annually.
While the high cost of pressure injuries is motivation enough to eliminate their occurrence, finances weren't necessarily the driving force behind the Dermal Defense Team's goal.
"The community that we serve is, in a lot of ways, impoverished and [community members] lack a lot of standard medical care," says Meghan Dunleavy, BSN, RN, a nurse in the surgical ICU at Temple University Hospital, and a member of the Dermal Defense Team. "It really was that people in this community need just the absolute best-quality nursing care."
Top-quality nursing care is something all nurse leaders are eager to replicate. Here are five ways the Dermal Defense Team has achieved success tackling pressure injuries.
1. Get Support From Administration
Diane Wagner, MSN, BSN, RN, CWOCN, clinical nurse specialist and Dermal Defense Team program chair at Temple University Hospital points out to improve care at the bedside, there must be support from hospital leadership.
"[When the Dermal Defense began in 2014], we had a team from the nursing education department, and then we would ask for volunteers from the nursing floors. It could be really destitute at times, or staff would get called back [to the unit] to work. We just couldn't get any momentum under it," she says.
But much has changed under the current nursing administration. There are now over 50 staff members on the committee, and Wagner says nursing staff are rarely called back to the unit during the meetings.
Dunleavy says discussions with nurses at different organizations made her realize how necessary administration's support is to reach success.
"What I heard from a lot of nurses is that it's very difficult to maintain a group for meetings when nurses are being called out of that meeting or they're not being properly covered on the floor when they're in that meeting. They tend to worry, [about their patients], and they don't focus on the meeting that they're attending. That's something that I hadn't realized," she says.
At Temple, most of the Dermal Defense Team committee members are not scheduled to work on the unit on days the meetings occur. Instead, they are paid to come in to attend the meeting. This allows managers to ensure units have appropriate staffing that allows committee members to implement changes and participate in meetings.
2. Use Compassion as a Driver of Change
At Temple, says Dunleavy, doing the right thing for patients was the real driver of change to achieve zero cases of Stage 3 and 4 pressure injuries after admission.
"What you find is a lot of our patients come in with comorbidities that are untreated. They don't have home supports, so you have a lot of elderly in the community that aren't receiving good medical care," she says. "We recognized that we wanted to serve [the community] more. It was genuine compassion towards our patients [from which] the whole program was driven. We wanted to improve and to take away that risk [of pressure injuries] because they have so many other risks that they deal with on a daily basis."
3. Make Care a Team Effort
Members on the Dermal Defense Team include representatives from almost all the hospital's nursing units, including the operating room, and some nurses from the evening shift, Wagner says.
"Then, as time went on, the patient care assistants became part of the committee as well. We felt they were just critical to being part of this committee and getting the work done that, and they have been invaluable," she says.
Wagner says the committee continues to grow across disciplines.
"We added physical therapy. Respiratory care has expressed interest in being part of the committee, and dietary has done different things with us," she says.
4. Educate Staff Members
The beginning of each Dermal Defense Team monthly meeting begins with an educational presentation for committee members who then disseminate that information to staff on the nursing units.
"We've done education with the staff around staging," Wagner says. "The Dermal Defense Team members will huddle with the staff and talk about what we're working on and remind people about the care they need to perform," she says.
One example of this is the team's Back Off program.
"Our premise is that people spend a lot of times on their backs between eating and tests, so now instead of the usual side-back-side-back, we just turned people side to side. That's something we've implemented," she says.
Additionally, team members collect unit-specific data and create posters that are part of a larger Dermal Defense Team display.
"[The posters] will show the results of that day so [the team] can see how many patients were looked at, and whether or not anybody had a pressure injury. We also collect data on how many layers of linen patients are on and that goes on the poster as well. They also take that information and communicate that with their staff as well," she says.
5. Be Highly Visible
In addition to huddles, rounds, and posters, the Dermal Defense team members maintain a public profile by wearing bright yellow team t-shirts that say, “To Prevent, Protect and Save,” during monthly data collection rounds.
"The t-shirts have done a couple of things. They've identified and unified us as a team. They also made the staff and patients aware of what we're doing," Wagner says.
Begley, an experienced nurse leader, had spent 35 years of her career at AtlantiCare in Atlantic City, New Jersey, before taking on her role at AONL in 2018.
"I had always planned on retiring from AtlantiCare, but this was an opportunity that came out of the blue that I just couldn't pass up," she says.
She encourages other nurses to be open to and embrace change in their careers as well.
"In my career, I've had opportunities that I've taken advantage of, and I wasn't afraid to make changes. I was glad [when] an opportunity arose, and it was something that I went for. So, my life wasn't a planned progression of a career trajectory," she says.
With new payment models, changing workforce demographics, and evolving technology, openness to change seems to be a much-needed characteristic in nurse leaders today.
During a recent interview with HealthLeaders, Begley shared her perspective on the nursing profession including what's changed, what still needs to evolve, and the challenges and opportunities facing nurse leaders.
Following is a lightly edited transcript of that conversation.
HealthLeaders: How did you get started in nurse leadership?
Begley:I was the oldest of six daughters and I always just took charge. In college, a few of my professors said I just automatically started organizing things and getting people to do what needed to be done. It was just something that I think I was suited to.
My first management job was after I was only a nurse for a very short time. [I don't think it was] even a year. We had a management training program for nurses, but I really learned management and leadership from the people I worked with. They may not have [had the manager title] but they had the skills. There were a few staff nurses who were from the UK, who worked with me and they were so instrumental in my learning. They really took an interest in helping me develop and they were wonderful.
I also looked to other nursing leaders in the organization who I admired and who had management and leadership traits I wanted to emulate. So, that was sort of my immersion into nursing leadership.
HL: Did that experience shape your leadership values?
Begley: [Those staff nurses], who were probably in their 50s, really helped me on my journey despite the fact that I was a young, 22-year-old newbie. They were just wonderful. I remember doing my first set of evaluations for staff and being a nervous wreck about it, but they helped me and made it easy. People were very kind to me, and I try to pay it forward. Mentorship and helping the next generation of leaders is a core value of mine.
HL: How has the nursing profession changed over the course of your career?
Begley: The perception of the profession and the role of the nurse has changed. I think the biggest positive change is that nursing is now seen as a distinct profession. Nurses were previously seen as individuals who carried out physicians' order, and who were hospital-based. Now we are recognized as a distinct profession that not only cares for the sick and injured, but we also protect, promote, and optimize health and wellness. We advocate for the care of patients, not just individually, but also in communities and populations. I think we're at a time in our history, as it intersects with the transformation of healthcare, to fully define the role of the nurse.
HL: What do you think still needs to change for nursing to be ready for the future of healthcare?
Begley: Different technologies are crucial for us to be able to provide care across the continuum. We're just beginning to understand how those technologies can assist us, our patients, and populations. There's going to be an explosion of technology and nurses must figure out how to optimize it, use it appropriately, and embrace it. I think that's been a challenge for us. I think these new technologies are going to help us to reduce errors and to do those task-oriented things that don't necessarily use our higher skills. [Technology will] allow nurses to help improve the health status of our communities. For example, things like artificial intelligence, we're just beginning to learn how that is helpful in targeting care.
HL: What are some of the challenges nurse leaders face today?
Begley: This has been a challenge for the bulk of my career in nursing leadership—recruiting and retaining nurses. Not only are we losing numbers of nurses, but we're also losing the intuition, the expertise, and the collective wisdom of the nurses who are retiring.
There are places that are not experiencing shortages. The cities that have many academic centers and schools of nursing perhaps are not experiencing a shortage, but the rural hospitals and underserved communities, they are really having a difficult time. Recruiting is variable depending on where [a healthcare facility is]. And of course, specialty recruitment is still a challenge.
We also have the movement of the younger nurses. Younger nurses do not stay in one place for a long period time. Even if it's in the same organization, they want some flexibility and fluidity and change across settings. At my former organization, we had nurses in our urgent care centers who wanted to go work in care management or in medical home roles. That's not necessarily a bad thing, it's just a challenge.
Another challenge is around violence. Whether it's mitigating violence against nurses in the workplace, caring for victims of violence, or addressing community violence, violence is a major issue affecting healthcare.
Additionally, there are financial pressures for nursing leaders. We know that the world of healthcare is changing to value. The old way that we were reimbursed is changing and we need to look at models that will provide high-quality care and give the patient the best experience.
Finally, we need to keep an eye on our workforce to make sure they are feeling productive, that they're feeling valued, and they feel that they're able to actualize their goals.
HL: What are some of the opportunities and drivers of change in healthcare?
Begley: Technology, whether it's portable monitors, wearable devices, or telehealth, is an opportunity for us to serve more, not just from a volume perspective, but to also serve the needs of patients at a higher level because some of those things that were more task-oriented can be taken care of by machines.
The economics of healthcare is changing as we change to a value-based system. The emphasis really moves from treating illness to promoting health and wellness. We need to have a systematic approach to the core challenges facing our patient populations.
Diversity and inclusion are critical to achieving health equity and reducing disparities in healthcare. A critical part of this is recruiting and retaining a diverse and inclusive nursing workforce. That's important in order to achieve our goal of health equity.
Nurses in many health systems are in creative and innovative roles where they're screening patients for socioeconomic risk factors and needs. Everyone's talking about the social determinants of health, but this is key work as we move forward. It's important that nurses are aware of the cultural sensitivities and social inequalities that people experience within their community. So, we really need to work on diversity and inclusivity.
Another driver of change is the rise of consumerism in healthcare. In the past, patients relied on referrals and insurance coverage for their care. Now, the patient is much more involved in decision-making. They readily access healthcare information in many ways. They want care to be convenient. We always think about the nurse-patient or the physician-patient relationship as critical, and I think it still is, but I think it's [becoming] more episodic because people are very self-directed when it comes to healthcare.
After noticing black women were not well-represented in academic leadership, one researcher was prompted to study what influences can impact black women from securing leadership roles.
Does your healthcare organization's leadership team represent the diversity of your organization and surrounding community? Not likely.
"When I started [working] in higher education, I was at an institution where I was the only person of color," Bland says.
The lack of black women in leadership roles in higher education inspired Bland's doctoral research, Factors that Impact Black Nurses’ Leadership Opportunities in Higher-education, she says.
"As I went to conferences and talked with others, [I noticed] there weren't many black women in positions of leadership. I thought it would be good to look at what variables were impacting women of color to be in such roles," she says.
In 2017, Bland undertook a mixed method, explanatory correlational study "to determine any correlation between Black nurses and the influence of racism, leadership attributes, mentors, institutional support, self-efficacy and financial barriers and the participants’ achievement and success in their professional role."
Through a Likert scale survey distributed to nursing faculty from 88 nursing schools in Illinois, Bland collected data on nurse’s beliefs about "leadership roles within higher-education and the impact of racism, leadership attributes, mentoring, institutional support, self-efficacy and financial disparity" that affected attainment of leadership roles among black nurses in the state. Data from 28 participants was collected that included an open-ended qualitative question.
For purposes of the study, the variables were defined as follows:
Racism: prejudice, discrimination, or antagonism directed against someone of a different race based on such a belief.
Leadership attributes: social influence process where leaders use interpersonal behaviors to motivate followers.
Mentoring: an experienced person in a company, college, or school who trains and counsels new employees or students.
Institutional support: refers to the support received from the institution in which the participant is employed.
Self-efficacy: refers to an individual’s belief in his or her capacity to execute behaviors necessary to produce specific performance attainments
Financial disparity: relates to the difference between financial statuses among other ethnic/minority groups
Following are insights Bland shared with HealthLeaders about her research and advice about how to create a more diverse and inclusive group of nurse leaders both in academia and at healthcare organizations.
The transcript has been lightly edited for brevity and clarity.
The State of Black Women in Healthcare Leadership
"The 'a-ha' moment for me [after doing the study] was how little things have changed. We've made very little progress in the past 20 years to diversify faculty roles and leadership roles within higher education and within organizations. We haven't done much to address and change that, and I thought, 'Wow, that's kind of sad.' "
Factors Affecting Leadership
"The variables that showed the most statistical significance were self-efficacy, financial disparity, institutional support, and mentoring. One of the other variables that I listed and asked questions about was racism. However, that showed no statistical significance."
"In order to rectify the barriers, leaders of all backgrounds and ethnicities must first understand and accept that these barriers exist. It's important that healthcare providers are representing the racial or ethnic minorities that they are caring for. We need to understand the ways to overcome the barriers and increase the representation of black women in leadership within healthcare. Then [these leaders] could take that knowledge and their personal cultural insights to effectively address disparities within their own communities."
"[In the survey findings,] black women wanted to pursue higher degrees, but financially either [they] couldn't or didn't want to get into debt. When it comes to the mentoring piece, I think a good mentor can help you find funding or find something that you're passionate about and then help you overcome the obstacle of, 'I can't do this because of finances.'"
Finding a Mentor Is Critical
"I think organizations are starting to put those mentoring programs in place, but if we want more people of color or racially diverse backgrounds, we have to fund this somehow."
"Black nurses are looking for leaders that can help inspire them and achieve that higher aspiration of being in leadership roles, whether it's within academia to be an assistant dean, a dean, a president or provost, or in the healthcare setting to be a CNO. Representation of women of color within both settings could bring a different perspective to healthcare."
Institutional Support Is Essential
"One of the things that came up [during the research was], black nurses didn't necessarily feel valued as leaders, and black nurses also had fewer opportunities to participate in funded research and less opportunity to be published."
Diversity Can Affect the Future Workforce
"In my opinion, the implications of empowerment of black women into the field of education and leadership would help to extinguish stereotypes, break the minority stigma, and further diversify colleges and universities."
"One outcome [of more black nurse leaders] would be enrollment of more [black] students. What I've found in the research was that everyone wants to be represented. If institutions don't have diversity and inclusion, what they do is they inadvertently contribute to a system that marginalizes women of color, whether it's faculty or students. If we could increase inclusion and diversity and foster the role of black nursing faculty or administrators as an integral part of any institution, I think that would increase the value of the organization. I think you would also improve or increase retention and attainment of students or faculty within those settings."
"To be represented shows that, 'I could achieve that goal because this person did it.' "
"As an undergraduate, I did a dual degree. I did a bachelor's in nursing as well as a bachelor's in business administration at the same time. My mother was a nurse and she told me the only way she'd let me go into nursing is if [I also had] a business background," she says. "She really pushed me to do that. It was probably one of the best things I did. It set me on that dual track—healthcare as a business, but also taking care of patients and driving toward outcomes."
After graduating from nursing school, Rocchio used those healthcare optimization skills—which she describes as eliminating barriers in order to achieve high-quality outcomes—while starting wellness programs at a business that helped employers with healthcare needs and health promotion. She later became a certified nurse anesthetist and worked with orthopedic surgeons who eventually started an orthopedic hospital. There Rocchio helped build the anesthesia department, and eventually became chief nursing officer of that hospital. Once the hospital was sold to a health system, she became the system's perioperative director. Later, a colleague who had joined Mercy asked Rocchio to come on board to do perioperative work at the St. Louis–based organization.
"I learned to optimize the perioperative space, focusing on the lowest cost for the best outcomes for our patients," she says of the opportunity.
After Mercy's CNO left about three years ago, leaders realized they had an opportunity to reshape its nurse leader position.
"I believe our senior leaders saw that nursing was changing and becoming more operationally minded. They came up with a fantastic title: 'chief nursing optimization officer,' and that's how I got here," she says.
In addition to her current role, Rocchio continues to work a few days a month at Mercy as a CRNA.
Rocchio recently spoke with HealthLeaders about the chief nursing optimization officer role, the future of nursing leadership, and how her continued clinical work informs her leadership decisions.
Following is a lightly edited transcript of that conversation.
HealthLeaders: What is your definition of the term optimization?
Rocchio: Optimization basically means we're driving the best outcomes with the best performance of our coworkers with a minimal amount of friction in daily processes. So: an easy process for people to be able to do the right thing for patients. That's basically how I define it.
HL: What were the goals and outcomes that Mercy was hoping for when you came into this position?
Rocchio: We have been focusing on three paths: cost, quality, and service. I split my work up into those buckets on a daily basis. We hit each of those kind of pillars in Mercy and we're doing it in nursing. Now everyone is aligned underneath me from a nursing perspective. Peri-op reports up through me, cath labs, all of nursing. I have all of that structure underneath me, [and I'm] trying to make sure that we are able to stay optimized and bring all those specialties and nursing with us.
In the cost sector, we're all about delivering the best care with the least amount of resources. That is exactly where we want to be. I think the government is pushing us that way as well as the payer. We are concentrated on trying to manage our cost structure while keeping our quality the same or better.
HL: Tell me a little bit more about your role and title. How does it differ from a CNO or a CNE?
Rocchio: Changing out that chief nurse executive role for my title really signifies the operational work that needs to go on in nursing.
I would say the biggest difference is the way the work gets done. The CNE works through a strict process and nursing structure. The chief nursing optimization officer is freed up to do work through innovation. Everything we do has a creative slant to that nursing structure that most other CNOs are working on like Magnet Recognitionstatus or NDNQI. We're … becoming innovative in the ways that we're looking to accomplish the same things that they're looking to accomplish.
Part of that innovation is having a technology slant as well as an analytics slant. I like to say the technology is how we get the work done. It gives our providers that extra something they're going to need [in order] to spend more time with their patients at the bedside.
HL: Can you give me an example of innovation in action?
Rocchio: One of the technology platforms that we're working on right now is called Epic Rover. It gives the nurse the ability to have a hospital-issued smartphone to do their work. Now instead of being tied to a computer, they can do most everything through the smartphone. One of the things that makes Mercy innovative is we're tagging on to voice-activated charting through that. No longer does the nurse do their assessment and have to go back to a workstation to be able to chart it. [Instead], they're voice activating the entire assessment while they're [completing it]. Your phone is logged in for you and you'll say, 'Pull up the adult neuro assessment,' and then you start charting.
[The technology] does more than just give back time to the nurse. It allows for communication with the patient as the nurse does the assessment. …We explain to [patients]: 'We're going to be talking to the phone, but we're going to be charting while we're talking, and feel free to ask questions.' It also allows the nurse to chart in real time.
HL: Would you suggest other organizations create a similar role of chief nursing optimization officer?
Rocchio: Yes, but I would caution against having a CNO and a chief nursing optimization officer because you want to pick one structure to go with. I'm not saying your CNO can't have an innovation focus, but, if you create both [roles], it becomes redundant in your organization.
Their basic fundamental philosophy is going to be completely different. If you put two of them in there, you're going to have some head butting going on. Your CNE may be focusing on retention while your chief nursing optimization officer is focusing on new and inventive ways to get people hired quicker, oriented faster, and up on the unit taking care of patients.
What I would do if you want to stick with your typical CNO structure, is to partner them with a chief nursing informatics officer that's highly innovative and who understands analytics. I would get that analytics function in there because the way to get things done is through innovation and technology.
HL: How does your continued work as a CRNA inform your ideas and the decisions that you make as a chief nursing optimization officer?
Rocchio: I [work as a CRNA] about a couple of times a month when I can fit it in.
While I'm working, I go up to the ICU and I meet those nurses. I'm interested in what goes on at the frontline from an operational and innovation standpoint [to understand] how we can reduce friction and make things better.
HL: Any advice or insights that you have for other hospitals, health systems, or nurse leaders?
Rocchio: Really listen to what the frontline staff and patients are saying. I would say that's an aggregated voice, not just one versus the other. [Rather it's] knowing what your patients are experiencing and what your nurses are delivering and experiencing together, not separate.
When leadership supports frontline nurses in asking questions, positive changes to patient care can happen, and nursing staff start to see nursing as a profession, not a job.
As chief nursing officers work in a healthcare industry that's awash in a sea of change due to evolving reimbursement models, consumerism, and M&A activities, they understand that the nursing profession must also make changes within this environment.
"I'm very excited to see, over the next number of years, what the profession of nursing brings to the table in terms of healthcare," Scanlon says. "I'm so honored to be in this profession because we are going to see [nurses] be able to create what the next version of healthcare will look like."
To propel the nursing profession and patient care forward, Scanlon, Thomas, and Northwell's other leaders, have committed to creating a culture of inquiry at the organization.
"In a culture of inquiry, we want to remain open to multiple ways of knowing the answer [to questions about improving care delivery and patient outcomes]. Right now, we predominantly rely on evidence-based practice and research, and we have a commitment to uncover and disseminate the knowledge that is embedded in practice." Thomas says. "And we have a commitment to clinical scholarship. We don't just accept things because it's the way we've always done it."
In a recent interview with HealthLeaders, Scanlon and Thomas discuss how a culture of inquiry that values clinical research can make a difference for an organization, nurses, and patients.
The transcript has been lightly edited for brevity and clarity.
HealthLeaders: What is a culture of inquiry?
Thomas: We started this work believing that the best opportunity to build nursing practice is at the bedside. So, that's where we started with the culture of inquiry. Our vision for nursing research was to establish the spirit of inquiry as a professional value, standard, and behavior for all nurses.
So that meant, we needed a culture to support that. A culture of inquiry meant nurses would constantly be questioning things regarding practice, with the goal of improving care delivery and patient outcomes. So, it's a culture where we promote questioning.
In fact, you (the nurse) should question what you're seeing regarding the patient's response to treatment. Is it working for your patients? Or should something be different in that patient experience?
Don't accept everything just because it's a standard. That's how we grow.
HealthLeaders: What qualities do you look for among the nurses you hire, both at the bedside and in leadership, to help support the culture of inquiry?
Scanlon: Bringing in the right people is key. You really want to have those who truly understand research and understand evidence-based practice. What we're finding is many of the new graduates are already exposed to this during their education.
For example, we run a program called the Golden Ticket Event each year across Northwell Health System's 23 hospitals. What we're doing with that event is we're recruiting the top-level talent (top 10% in their nursing class) across the region.
Last year at that event, we had nurses asking, 'How do I join the research committee?' As a leader, that's what you want.
I happen to know a number of graduates we've just hired have already published in peer-reviewed journals. They've gone through the experience of formulating and doing qualitative or quantitative research.
They are coming into this profession, I believe, wanting to be involved and they are always asking the questions, 'Why am I doing this? Why am I doing that?' That's the type of nurse you want, someone that is asking those questions. So, we are looking for individuals that are not happy with the status quo [and have the attitude]: 'There's got to be a better way to do something.'
HealthLeaders: Can you give me an example of how the culture of inquiry translates to bedside nursing?
Thomas: At our flagship hospital, one of the nurses in the palliative care unit had turned a patient, and noticed changes on the skin, which was pressure injury, and [the nurse] became very upset. She went to her manager and said, 'I did everything possible for the patient and this is what I'm seeing.'
From there, Kathy Trombley, the manager at that time, and the nurse went to the literature and found mention of the Kennedy terminal ulcer. They thought maybe this [situation] is something signifying the end of life. So, they called the wound care nurse, Mary Brennan, and they called me, and I said, 'Let's start studying this systematically.'
We put a protocol together, went to IRB, and studied the skin condition and how it was similar or different from pressure injuries. And then [we studied] what was the relationship between it and the time of death. We found a correlation between appearance of these skin changes and the time of death. We named the phenomenon Trombley Brennan-Terminal Tissue Injury. It's one kind of a prognosticator of death; our studies showed that 75% of our patients with TBTTI died in 72 hours. We validated it. It's a phenomenal finding.
This is an example of what can happen when we support a spirit of inquiry.
Scanlon: Then taking this concept further, we had a patient whose son had to leave [her] to go back to work. He was really struggling with that. The nurse noticed the appearance of the Trombley Brennan-Terminal Tissue Injury and called the son. He was able to get back literally within hours before his mother's passing.
Also, my mother-in-law was here as a patient, and there's 11 siblings in my husband's family. I noticed the skin changes and immediately called the nurse who came in and noted it. I called my husband and said, 'You need to get your family together. [Her death is] going to occur in a number of hours.' And, sure enough, she passed.
HealthLeaders: What are the outcomes and benefits you have seen as a result of your culture of inquiry?
Thomas: We've had improvement in terms of patient outcomes, but also, whenever evidence-based practice is implemented, it's been documented that it improves nurse autonomy, nurse satisfaction, and nurse engagement. It's also promoting professionalism because the nurses can take action to improve practice.
Scanlon: What we've done is effectuated a model where the frontline caregivers are supported under champions. The champions have been educated and updated on evidence and they become the resources for the frontline staff. The RN engagement has climbed year over year, and 'opportunity to develop' is one of the highest-scoring items that we see across our NDNQI data. That's when you start to really move things to where people see nursing as a profession, not as a job.
Nurse executives discuss some of the nursing profession's biggest challenges. Here's a roundup of those important topics.
On the surface, the settings and locations where nurse executives work may seem vastly different—rural versus urban, safety-net hospitals versus academic facilities, large multi-state health systems versus stand-alone independent hospitals, acute care versus the ambulatory setting to name some. Yet, regardless of these differences, nurse leaders across the nation face many of the same challenges and concerns.
Here are four topics that rise to the top among nurse leaders:
From 2002 to 2013, healthcare workers were four times more likely to experience incidents of workplace violence that required days off for the injured worker to recover than workers in private industry, according to the Occupational Safety and Health Administration.
Nurses struggle with workplace violence. In 2014, the Delaware Nurses Association surveyed registered nurses to assess the perception of violence against nurses. Of the survey findings, 58.15% of the respondents say the most common type of violence in the workplace is patient-on-worker violence, which includes any type of verbal or physical assault.
As Barbara Jacobs, RN, MSN, chief nursing officer at Anne Arundel Medical Center in Annapolis, Maryland, says, nurses are dealing with many factors that contribute to workplace violence. More patients are seeking care as a result of opioid use and mental health issues, and RNs often deal with patients and family members who are upset and angry at a stressful situation. As a result of these intense emotions, patients or family members may threaten the healthcare team. And, with mass shootings regularly in the news, healthcare workers are left feeling vulnerable to violence, she says.
2. Advanced Practice Registered Nurses and Specialty Medicine
According to the National Council of State Boards of Nursing, there are about 267,000 advanced practice registered nurses in the U.S. While it does not count clinical nurse specialists in its data, the Bureau of Labor Statistics estimates overall employment of nurse anesthetists, nurse midwives, and nurse practitioners will grow 26% from 2018 to 2028.
However, much like acute care bedside nurses, it can be difficult to find APRNs to fill specialty positions.
"Where I'm at, it's not that I don't have enough [nurses], it's that we have a lack of critical care nurse practitioners," Ronda McKay, DNP, CNS, RN, chief nursing officer and vice president of patient services at Community Hospital in Munster, Indiana, says. "We're putting in a program now to have a residency for those nurse practitioners so they will sit for their critical care exam."
3. New Care Models Needed
In the past, nursing care has been acute care–centric. But, to meet the demands of the evolving healthcare environment, nurse leaders will need to use foresight and innovation to develop new models of delivering care in a variety of settings.
Technology may also play a role in developing new ways of providing nursing care.
"Virtual nursing [has the potential] to bring high-level [nurse] expertise to complement the newer nurse residents on the acute care side when you don't have enough clinical coaches," Tammy Daniel, DNP, RN, BSN, NEA-BC, MHA, senior vice president and chief nursing officer at Florida's Baptist Health, says.
4. Keeping Nurses at the Bedside
As more nurses seek to become APRNs and experienced nurses retire, nurse leaders will have to find ways to entice a new generation of nurses to stay at the bedside.
One question nurse leaders will need to ponder, LaCross says, is: "How do you have that group be as competent as possible, as fast as possible, and stay as long as possible while the patients are getting sicker and more complex?'"
Nurse executives will gather November 13–15, 2019, for the HealthLeadersCNO Exchange at theOjai Valley Inn in Ojai, California, to discuss these and other topics during roundtable sessions with their peers. The CNO Exchange is one of six healthcare thought-leadership and networking events that HealthLeaders holds annually. To inquire about the HealthLeaders Exchange program, email us at exchange@healthleadersmedia.com.
Recognizing experienced nurse retirements were inevitable, Seattle Cancer Care Alliance took a proactive approach to building specialty skills and knowledge among new graduates.
We’ve all heard the saying, "An ounce of prevention is worth a pound of cure." In other words, a little foresight and planning can fend off a crisis.
At Seattle Cancer Care Alliance, nurse leaders have taken a preventive approach to the organization's future workforce needs.
"[Combined] with what was being anticipated nationally with the [nursing] shortage, we were also looking at a large group of our very experienced nurses retiring," says Sharol Kidd, BSN, MBA-HL, RN, advanced practice registered nurse, DEU and residency program coordinator at SCCA.
Additionally, more care is taking place in settings beyond acute care.
"When you look at the environment where care takes place, 60% of nursing care occurs in a hospital [setting] and 40% occurs in other places," says Rae Niculescu, MN, RN, professional practice coordinator at SCCA.
This is particularly relevant to an organization like SCCA.
"What we're seeing is that oncology care [is a shift] to the ambulatory clinic [setting]. So that's also driving the need to have to plan for the future," Kidd says.
As a result, SCCA has become proactive in developing the next generation of nurses in the community oncology setting. Here's how its program began and evolved to develop a pipeline of nurses with much needed specialty care knowledge.
"They called for novel educational models," Kidd says. "At the Seattle Cancer Care Alliance, we were looking to introduce a dedicated educational unit that was a collaboration between the academic site with the clinical site."
With the DEU in the ambulatory clinic, students were given the opportunity to gain clinical experience in specialized oncology care.
"We partnered with an academic center in Seattle in 2012 to develop a clinical rotation for senior nursing students to learn about the ambulatory oncology center and what it is like to be an oncology nurse," Kidd says.
SCCA staff works closely with instructors from the university to ensure they met the school's requirements. The instructor and the student's preceptor, an SCCA staff nurse, meet throughout the student's rotation, but the staff nurse takes the lead in providing the student with learning experiences.
"It's the staff nurse who is teaching the students. The faculty is present and available if we need them, but the clinical expert is the staff nurse, who coordinates and provides the opportunities for the students to learn," Kidd says.
Additionally, participants attend a series of lectures by SCCA experts on a variety of topics, including how to successfully perform lab draws, bone marrow transplant issues, or cancer prevention and screening.
"That helps tie some of the knowledge together and to increase complexity a little bit as you go along," Niculescu says.
Expanding the Program
"When [the DEU] initially started, we were just going to bring in the students. We had not thought about the residency program," Kidd says.
But, once the first group of students completed their senior rotation, their interest in oncology was piqued.
"There were two students that really, really, really wanted to do their residency here. We were able to ask for that FTE for them, and they continued on the unit doing the residency," she says.
After that experience, both residents were hired by SCCA.
"After those two completed [the residency] and were hired, the [organization's] leaders really acknowledged and understood the benefit of it," Kidd says.
Today, the DEU hosts 16 students in their senior rotation and four senior practicum students annually. The senior rotation clinical experience is 128 hours, or about eight weeks long.
"We provide [nurses with the] opportunity to see what patients go through in the outpatient setting," Kidd says.
The experiences can include anything from learning about medication regimens, radiation, and chemotherapy; observing physician and social work appointments; and partaking in education from other nurses.
Students in the senior practicum spend 156 hours or about 10 weeks in their experience.
"The primary focus of the senior practicum is for [the students to have experience with] direct patient care. We usually assign [the students] to the infusion area where they're able to have hands-on bedside or chairside experience," Kidd says.
Some of the opportunities the students have include drawing blooding, starting hydration and antibiotics, and performing physical assessments.
All these experiences are guided by an SCCA staff nurse preceptor.
"The next step of the program is the residency program," Kidd explains.
Residencies are open to new graduates who have gone through the DEU or have done a clinical rotation within the organization.
The program is 16 weeks long (640 hours) and is a preceptor-based orientation program.
"It is designed to gradually introduce and develop critical thinking and experience," Kidd says.
Challenges, Opportunities, and Results
Since the residency program began, 42 nurses have gone through the program. Out of the 42, SCCA has hired 40 RNs. The group's retention rate is 95%.
Additionally, because of the program, leaders and staff nurses alike have changed their belief that new graduate nurses need one to two years of acute, inpatient care experience before moving to an ambulatory setting.
"We always thought new grads should go inpatient," Kidd says. "It took a little bit of convincing and work to embrace that new concept. I had to convince my staff that it was okay to bring students [to the outpatient setting]."
Though there is a time commitment, she points out, once the nursing staff supported and understood the idea that they're helping to develop the next generation of nurses, they can see the rewards.
"Once we hired the new grad after completing the program, the staff members were all impressed with 'their' accomplishment—that they were able to train a new grad to be so successful in the outpatient setting," Kidd says.
And contributing to others' success keeps staff engaged and benefits the nursing profession, Niculescu says.
"I think it's a part of being a witness to that journey … having [new nurses] come in the first week and they can't find their way around to when they have a first successful lab stick. Just seeing that growth is really rewarding," Niculescu says.
While some nursing workforce projections predict a balance of nurse supply and demand, nurse leaders still report challenges finding RNs to fill open positions.
Are you experiencing a nursing shortage at your organization? Are you flush with job candidates or is it a struggle to fill open nursing positions? Are new graduates beating down the door while experienced nurses become harder and harder to come by?
Yet, despite this widespread concern, some nurse workforce forecasts do not seem to support this fear.
"This has been interesting to watch because, at the same time, national federal forecasts and other local state forecasts generally suggest that the labor market is producing adequate numbers of nurses," she said. "This produces a bit of a conflict about what's going on and thus, we've been engaged in surveillance of data across a variety of different sources to try to understand what's happening, specifically in California, but [also if] what we're seeing here resonates across other states in the U.S."
During the recent webinar, Spetz and fellow panelists shared a variety of data points and insights regarding nurse supply and demand, including California chief nursing officers' perceptions of the RN labor market.
While the number of nurses needed to fill open positions seems to match up, there is more to nurse supply and demand than just numbers. Variables like geographic location, desired candidate skill sets and experience, and education requirements influence whether CNOs are able to find the right nurses for open positions.
"A consistent story that seems to be emerging is that, the overall numbers look roughly in balance, but there is an imbalance in what employers seem to be wanting and what they are finding in the workforce," David Auerbach, PhD, director, research and costs trends for the Center for Interdisciplinary Health Workforce Studies at Montana State University, said during the recent event.
"You have a lot of very experienced baby boomer RNs who are leaving the workforce. Employers [want] to replace that experience but [have] a large pool of new graduates who don't really have what they want, and sometimes, they're either keeping those vacancies open or turning to traveling nurses, and you do have a disconnect in various parts of the market."
Below are some of Spetz's insights garnered from data about California CNOs' perceptions of the RN labor market that she shared during the webcast.
CNOs See a Growing Nursing Shortage
Since the fall of 2010, USCF has conducted a survey to gauge California CNOs' perceptions of the RN labor market. In 2018, 118 hospitals responded to the survey, and CNOs were asked to rate their perception of the labor market in their region of California on a scale from "high demand: difficult to fill positions" to "demand is much less than supply available."
"In 2010 when we began these surveys, there were more hospitals reporting a surplus of nurses than a shortage. But, by the time we get to about the past four years, we have the vast majority of hospitals reporting that they perceive a shortage of nurses in their region, and very few hospitals saying they perceived any surplus of nurses in their region," Spetz said.
Supply and Demand Varies by Region
Spetz points out that there are regional differences in the overall labor market.
"What you can see in the data is some regional variation with the perception of the shortage being generally less in the San Francisco Bay area and somewhat more in Central California and the Southern Border Counties," she said.
Experienced Nurses Are Hard to Find
Additionally, nurse leaders are reporting a significant shortage of experienced nurses, particularly since 2014 and 2015. Again, this varies across regions in California.
"It's less of an issue in the San Francisco Bay area and more of an issue in most of the other regions in California," Spetz said.
This contrasts quite notably to CNO responses for the degree of shortage for newly graduated nurses.
New Graduates Are Plentiful
As reported by the survey, in 2018, as in previous years, employers in nearly every region in California perceived a surplus of new graduate RNs.
"This surplus is less of an issue in the Central California region where hospitals actually reported, on average, a balanced labor market. Then Sacramento and the Northern Counties and Southern Border Counties also indicated, perhaps, less of a surplus of new graduate RNs. But in San Francisco, Los Angeles, and the Inland Empire, the CNOs, on average, are reporting a pretty notable surplus of newly graduated nurses," Spetz said.
Urban vs. Rural Settings
"There are some differences between rural and urban regions, with rural hospitals being more likely to report a shortage than the urban areas, and this has been pretty consistent over time," Spetz said.
The Use of Travel and Temporary Nurses
In the survey, CNOs were asked about the employment of temporary and travel nurses. "Statewide, more hospitals reported lower use of traveling nurses over the past year compared to the prior year, while the use of local temporary RNs appears to have been fairly stable," Spetz said. "So, there's a little bit less use of traveling nurses, which is important in thinking about the degree of shortage hospitals might be experiencing."
International Nurses on the Rise
According to survey respondents, international recruitment has increased over the past few years.
"Last year when the data came in it was a little unclear to us whether that was because the group of hospitals that happened to respond that year were more engaged in international recruitment or if it was the beginning of a trend. Now that we have two years of data, I think it's possibly the beginning of a trend," she said.
Spetz said of the hospitals reporting international recruitment, most were in the Inland Empire area.
"This is consistent with the perception of a shortage of experienced registered nurses, but it isn't consistent with the perception that there's a surplus of new graduates," she said.
Hiring Preferences
Regarding the hiring of new graduate nurses, CNOs were asked about their hiring requirements and preferences. About 18% said they have no specific hiring preferences, which was similar to data in 2011.
"There was a notable increase in the percentage that reported that they require a bachelor's degree this year compared with prior years. In the past, that share was stable around 5% and this year it was up to 18%," Spetz said. "The hospitals that were reporting that they required a bachelor's degree for their open positions were almost all in the Los Angeles, San Francisco, and Southern Border regions. Now, these are regions in which larger hospitals seem more interested in pursuing Magnet status, and nationally this tends to happen in regional clusters as a part of hospitals competing with each other for patients and for experienced nurses."
Additionally, about half of the hospitals responding said they had a minimum experience requirement for RNs.
Future Hiring Plans
When asked about hiring expectations in the survey, more hospitals reported they planned to increase their hiring over the next year.
"We have more than half say that they expect to do more hiring they did in the last year. They were also asked about their hiring expectations for new graduates and nearly one-third expect to increase their hiring of newly graduated nurses over the next year, while only 9% expect to decrease their new grad hiring," Spetz said.
When asked why they planned to increase new graduate hiring, the most common response was "high [nurse] vacancy rates," she said.
"Other common reasons were that they are anticipating more retirements and want to do some hiring in preparation for that, that they're developing programs to mentor new graduates, and that they've improved relationships with nursing schools, including collaboration on residency and onboarding programs," Spetz said.
In light of the industry's movement toward issues such as value-based care, changing reimbursement models, and increased consumerism, today's nurse leaders must develop creative, innovative, and effective solutions that can improve healthcare delivery.
Meet five CNOs from around the country who are helping to do just that. These leaders share their experiences, ideas, and successes shifting organizational outcomes, elevating patient care, and changing the work environment.
Nurse executives like these will share their ideas and successes in healthcare at the upcoming HealthLeadersCNO Exchange being held November 13–15 in Ojai, California.
Below is a roundup of stories HealthLeaders has written about these five nursing leaders and the ways they are helping to shape the healthcare industry.
Nurses can improve quality and outcomes, enhance an organization's culture, and build relationships with patients, colleagues, and the community.
The key to moving forward is having strong nurse leaders who are willing to advocate for nursing in the C-suite.
"It is really being able to have nurse leaders that can stand with their finance person, with their CEO, and work to get proper data analytics or IT resources to better utilize and manage nursing resources. When our frontline nurses are stretched with managing volume and high acuity, nurses barely have time to perform value-added care that is meaningful versus what we see today—less critical thinking and largely computer-driven protocols, which is 'color by numbers' nursing care," says Katie Boston-Leary, RN, MBA, MHA, BSN, CNOR, NEA-BC, chief nursing officer at University of Maryland Prince George's Hospital Center in Cheverly, Maryland.
Boston-Leary shares how she empowered nurse residents to come up with evidence-based solutions to improve the work environment.
When Karen Clements, RN, BSN, MSB, FACHE, CNO at Dartmouth-Hitchcock in New Hampshire, decided to enlist a millennial nurse to be her mentor to ensure she was meeting the needs of this generation of nurses, Clements flipped the traditional mentoring model on its head.
In an effort to improve the organization's retention rates by better understanding the needs of millennial nurses, Clements sought guidance from a millennial bedside nurse.
“I think it’s important to stay on top of the issues of the nurses coming in and managing the different generations, [and] to be able to provide opportunities for growth, preceptorship, and communication methods,” she says. "I think all of us need to figure out how to communicate with these different generations [about] the work ethic and the schedules and everything that goes along with that."
Clements shares insights she's gained from her millennial mentor on how to meet the needs of this generation.
To improve nurse job outcomes, nurse leaders need to pay special attention to the work environment.
Leaders at North Carolina–based Vidant Health have committed resources to change the workplace culture for its nurses with the philosophy that engaged and motivated nurses provide better care to patients. Linda Hofler, PhD, RN, NEA‐BC, FACHE, senior vice president and nurse executive at Vidant Medical Center describes the implementation as a "holistic approach to organizational excellence" that benefits the nurses and trickles down positively to the patients.
Vidant's focus on its team members' experience has been occurring for about two years, Hofler says.
"This is probably the most rewarding work I've done in a long time, but it's hard work because in the business of healthcare, people want to check a box and go on to the next thing," Hofler says. "And this is not about checking a box. It's about building networks and finding ways to create new and different ways of doing and being."
Hofler shares how she and the leadership team at Vidant have reshaped the nurse work environment to achieve organizational excellence.
In 2001, the Institute of Medicine (now the National Academy of Medicine), issued the report, "Crossing the Quality Chasm." In it, the organization cited patient-centered care, which it defines as "care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions," as one of six aims for improving the healthcare system.
is a proponent of making personal connections with patients to facilitate a patient-centered approach.
Jacobs' interest in fostering nurse-patient connections started when she noticed the practice of interacting with the patient as a person was beginning to get lost amid hectic days and technology.
"We were getting everything into the computers and getting so technologically savvy and had volumes of information on a patient, but we were missing the human side of their care," she says. "If you look at people who went into nursing, what helps us feel good about ourselves is helping other people. We want to do that, but sometimes [because of] the distractions of busy days and all of the multitasking that people do, we lose track of the caring part that makes that patient feel cared for."
Jacobs shares how she has worked with staff to help them connect with patients without making it into another time-consuming thing on an already overflowing to-do list.
By traditional nursing standards, Erin LaCross, DNP, RN, CMSRN, CENP, CNO at Parkview Regional Medical Center and Affiliatesin Fort Wayne, Indiana, moved up the leadership ladder swiftly. She has gone from unit clerk 2003 to chief nursing officer in 2018.
As a new CNO, she has learned multiple tactics to become a strong leader.
For example, she emphasizes the importance of getting feedback from both nurses and physicians to better inform the decisions she must make to drive the organization forward.
"I think for a new CNO just out of the gate, [it's good to have] that frame of mind that you're not expected to know all the answers yourself," she says. "It's always best to ask the people who provide direct care to your patients and to your community."
Additionally, adopting a "better is better than perfect" philosophy can help nurse leaders and bedside nurses embrace a mindset of continuous improvement.
"I think where we can get hung up is, we want things to be perfect before we implement any changes," she observes. "And then, in the meantime, while we're waiting for perfection, how many patients could have had better care?"
She shares more details about her leadership strategy that focuses on empowering and inspiring other leaders and staff to improve healthcare.
The CNO Exchange is one of six healthcare thought-leadership and networking events that HealthLeaders holds annually. While the events are invitation-only, qualified healthcare executives, director-level and above, will be considered. To inquire about the HealthLeaders Exchange program, email us at exchange@healthleadersmedia.com.
A study found that a lack of interpersonal connection with patients left millennial nurses feeling unfulfilled in their careers.
Think back on your nursing career and try to pinpoint the moment you felt like a "real nurse." Did you start an IV that seemed impossible? Did you notice a patient was declining before anyone else did and take action? Did you receive a heartfelt thank-you note from someone you cared for?
You probably remember the specifics of that moment like it just happened.
However, Heather Caramanzana, PhD, RN-BC, CRRN, nurse manager, brain injury unit and rehab at Northwell Health'sGlen Cove Hospital in New York, noticed many millennial nurses couldn't identify that touchstone moment.
"I was in professional staff development as a nurse educator, and I noticed nurses who had successfully completed orientation were coming to me saying they didn't feel like a nurse. They were inquiring about different positions in nursing and some said that nursing might not be the right fit for them," she recalls.
Caramanzana wondered why this was happening, so she shadowed the nurses to shed light on the issue.
"I observed the way they spoke with patients," she says. "[Their conversations were] very brief. I didn't really feel like they connected with patients, and I even got some feedback from the patients that they felt like the nurses were just doing their job [rotely; like the nurses] weren't really connecting with them and didn't have compassion for them."
As one study finds, the quality of nurse and patient communication can affect HCAHPS scores. After implementing a customized nurse training program known as PatientSET, one hospital found that after the training, patients were 15% more likely to be "most satisfied" with communication with nurses, and patients were 33% more likely to be "satisfied" with their discharge information.
Caramanzana gave the nurses feedback about her observations and coached them on how to make connections in the short moments they had with patients. For example, she advised they look around the room and ask about patients' family pictures or come out from behind the computer screen to make eye contact with the patients.
"It was just little things like that. I worked with [the nurses] and then, all of a sudden, they felt much more fulfilled in their jobs," she says.
Caramanzana began to wonder if feeling disconnected to patients was influencing how these nurses felt about their nursing careers.
At the time, Caramanzana was enrolled in a PhD program and decided to study what connecting with patients means to millennial nurses. As a result, she was able to get their perspectives and uncover themes regarding their experiences. She also identified the needs of millennial nurses in communicating empathy and compassion with patients.
By understanding millennial nurses' experiences connecting with patients, nurse leaders can help this new generation of nurses develop skills for transpersonal, caring relationships that benefit the nurse, the patient, and the organization.
About the study
For her research, Caramanzana posed the question, "What is the experience of the millennial nurse connecting with patients in the 21st century?"
Through face-to-face interviews and field notes, she collected data from 12 millennial nurses with at least two years' hospital work experience in New York City and Long Island, New York. The nurses had to have been born between 1982 to 2000 and self-identify as a millennial.
The 8 Themes of Connection
Out of Caramanzana's data, eight themes about millennial nurses' experiences connecting with patients arose.
1: The Void: Into the Darkness
The study participants voiced an awareness of the importance of forming connections with patients, Caramanzana found.
"They described the empty experience of just completing the technical tasks of nursing," she says. And they voiced that this experience left them feeling unfulfilled.
In one anecdote relayed to Caramanzana, an orientee told her preceptor she didn't feel like she was "enough" and that nursing wasn't for her.
"The orientee said, 'I really don't feel like I am doing nursing,' " Caramanzana says. "Even though she was doing all the technical skills. She just felt an emptiness."
2. Unconnected: Unable to Find the Light
During Caramanzana's interviews, the study participants expressed feelings of failure or guilt when they failed to connect with patients.
"It weighed heavily on them. I know that's when they felt really overwhelmed in their assignments because, for them, it's like caring is a separate thing. They don't realize they can incorporate it when they are doing all their technical tasks," she says.
3. Uncomfortable: Patients as Strangers
Millennial nurses told Caramanzana they often felt uncomfortable initiating conversations with patients.
"It was a real stretch for the [nurses] to just strike up a conversation if it was something that [did not] pertain to an assessment," Caramanzana says.
Time was identified as a barrier to forming connections with patients, according to the study participants.
The nurses said that technical skills and procedures took precedence over establishing connections with patients, and when the nurses were busy, the technical tasks needed to come first.
As Caramanzana points out, the two things don't have to be separated.
"Caring is just as important as the technical skills and that is not something that, if they're feeling overwhelmed, they can just leave to the side," she says.
5. Becoming: Real RN
"In this theme, participants described experiences of what it felt like when they made their first connection with a patient and how it impacted their perception of nursing in a very positive way—how it really changed them [at their] core," Caramanza says.
6. Fulfillment: Giving Through Receiving
In this theme, survey participants described a passionate association between communication, compassion, and their own well-being, Caramanzana says.
"They said when they do connect with patients, not only did the patients benefit but they benefited. [also]. They felt much better about themselves. They felt fulfilled as a person and as a nurse," she says.
7. Enlightenment: Turning on the Light
All 12 study participants identified a need for more knowledge about the concept of transpersonal caring relationships and how to form them.
One participant remarked that while she had heard about the idea of transpersonal relationships in nursing school, some of her friends who had gone through other nursing programs had not.
"In general, it should always be something that they're educated on," Caramanzana says.
8. Guidance: Educational Needs
"Every single one of them wanted more simulation with [communication and connection skills]," Caramanzana says. "They wanted more immediate feedback on how they can improve."
What nurse leaders can do
As Caramanzana uncovered, when nurses don't make a connection with patients it can also affect nurse retention.
For example, dissatisfied nurses are more likely to leave their jobs. The 10-year RN Work Projectstudy found 17% of newly licensed RNs leave their first nursing job within the first year and 33% leave within two years.
According to the 2019 National HealthCare Retention & RN Staffing Report by NSI Nursing Solutions, Inc., the average cost of turnover for a bedside RN is $52,100 and ranges from $40,300 to $64,000 resulting in the average hospital losing $4.4 million to $6.9 million. Caramanzana advocates for increased education for nurses around communication and connection with patients.
"I think in both academia and [in] the profession, we need to evolve and change how we educate nurses. As nurse educators, [especially with] with new orientees, we need to be focused on teaching and assessing how they form connections with patients," she says.
For example, she encourages preceptors to observe orientees' interactions with patients and give them feedback on their interpersonal skills.
"Plus, with all the annual skills [reviews] we do in a hospital—like how to change a central line dressing—we should also educate on caring skills and how people can improve those because everybody can benefit," she says.
