Professional Empowerment and Success in the Nursing Field

Nurses have always been held to a very high standard when it comes to their role in the healthcare system. They are expected to put their patients’ needs before their own, aim for the highest quality of care imaginable, and ensure the most efficient and safe environment possible. The hectic environment of any healthcare setting, combined with the heavy workload, long hours and high stress rates can sometimes lead to burnout, especially in the nurse who hasn’t yet found her place or is not completely satisfied in her position. Evidence has shown that work environments that provide access to resources, support between colleagues, and the opportunity to continue education and personal development will ultimately increase feelings of professional empowerment in their staff, enabling employees to feel more satisfied and be more effective at their job (Oliver et al., 2014).

Image courtesy of http://angelabrook.com/nurse-burnout-what-is-next

 

Advancing our own careers as nurses:

In the field of nursing, personal and professional empowerment is crucial to job satisfaction. The empowered nurse will feel inspired and motivated to contribute to their cause, and will have a greater feeling of respect and trust among colleagues, knowing that their contributions are recognized and valued by the other members of the healthcare team (Larkin et al., 2008). The organizational structure of the environment in which the nurse works can greatly impact professional empowerment of the nurse, and with a moving trend towards “inter-disciplinary practice”, the integration of nurses into positions of power within these structures can have an immensely positive impact on the quality of care provided throughout the healthcare setting.

Professional empowerment and career advancement are highly attainable goals, especially for young nurses in this day and age. Although our first few years are spent “paying our dues” by working hard on night shifts, getting last choice of vacation days, and picking up extra shifts to show our dedication, the hard work will eventually pay off for some when we are finally offered the position of “nurse manager”. These positions are currently held by men and women from the “baby boomer” generation who are now nearing the age of retirement, and will need young, ambitious and determined nurses to fill their spots when they leave (Keys, 2014). The role of the nurse manager is a critical part of the health care organization, and is essentially a link between administration and the actual floor workers. It is also the responsibility of the nurse manager to create an environment where the staff nurses feel supported and encouraged to continue their growth and development as future nurse leaders in their workplace. Studies have shown that both job satisfaction and commitment to the organization are both greatly influenced by a feeling of trust in management, the perception that management act fairly in their practices, and respect the staff working below them (Oliver et al., 2014). By incorporating nurses into these management roles, feelings of trust and comradery will increase amongst the nursing staff and provide for a more positive and rewarding work environment.

iStockphoto | Thinkstock + Scrubs

Image courtesy of http://scrubsmag.com/18-inspirational-quotes-for-burned-out-nurses/

 

Finding our voice in healthcare:

Another area where nurses can achieve great success in professional empowerment and standing within their organization is in participation on the board of directors, the highest level of organizational leadership in healthcare. Surprisingly, nurses very rarely strive to (or are sought out to) occupy this prestigious position, and are often overlooked in the recruitment for board members (Hassmiller et al., 2012). According to the AHA, a recent survey of over 100,000 hospital boards found that nurses only occupied about 6 percent of board positions. There are numerous (speculated) reasons for this lack of nurse representation on the boards, but are generally related to biases and misconceptions regarding the nursing profession. Some of these reasons include gender bias, the perception that nurses do not have adequate leadership skills, and the lack of understanding of the nurse’s role in determining quality care for their patients. There is also a belief that nurses would be more suitable as representatives for their fellow nurses, rather than as representatives for the institution as a whole (Hassmiller et al., 2012). These reasons are entirely based on bias and false perceptions surrounding the nursing profession, and contribute to the distorted belief that nurses do not have the skill or experience to serve in a role where they can help to make important decisions in healthcare.

In order to squash these fictitious convictions, nurses need to step up and prove that we are worthy and fully capable of holding these high-powered positions, and that we can bring great value to the organization as a whole. Many traits exhibited by nurses are inherent in the profession, including an intimate knowledge of patient care and how to best improve healthcare quality and safety. Nurses also have received education in healthcare administration, including time and money management, methods of quality improvement and knowledge about the newest technologies in the field (Hassmiller et al., 2012). These multi-faceted attributes qualify members of the nursing profession to hold positions on the board, where their educational background, willingness to learn, and desire to participate in decision-making processes will undoubtedly bring value and respect back to a profession that has been discounted and slandered by others who had previously held power in these positions.

 

Nursing leadership and voice:

One of the most important factors influencing career satisfaction in nursing is being able to voice your opinion and feel that it is being accepted and respected by the other members of the healthcare team. Since the nurse is generally expected to be the greatest advocate for the patient, it is important that they step up and work to advance their positions within that multi-disciplinary team. Aiming to advance their career as a nurse manager is a great way to make their voices heard, as nurse managers are generally present during multi-disciplinary round and act as the voice of the patient, to give their pertinent background as well as any significant changes in the plan of care for each individual case. Although the advancement to nurse manager can have a great impact on their feelings of professional empowerment through respect from other members outside of the nursing field, it also helps the staff nurses to feel that they can step up as leaders and have their voices heard as well. By creating an environment where all of the nursing staff feel empowered in their work, the nurse manager creates a healthier workspace, with decreased turnover rate, as well as increased staff and patient satisfaction overall (Oliver et al., 2014).

 

Systems Theory:

The healthcare system as a whole is trending towards an increase in interdisciplinary and team based structures, and as such, power is being shifted from just a few individuals to everyone involved in the organization. One example of this type of a healthcare system model is the Collaborative Governance (or shared governance) theory. This model has already been implemented in many different healthcare settings, and emphasizes an increase in participation and communication within and across all medical disciplines in order to facilitate and improve the decision-making process. These types of models aim to support professional development, empowerment and commitment to the overall mission of the organization (Larkin et al., 2008). Nurses have the opportunity to play an incredibly important role in these types of healthcare systems by joining one of the many committees that are contained within the model. One example of a healthcare organization that has implemented the Collaborative Governance model of systems organization is Massachusetts General Hospital. This particular hospital has seven different committees that comprise their Collaborative Governance structure: Nursing Practice, Ethics in Clinical Practice, Diversity Steering, Patient Education, Quality, Staff Nurse Advisory, and Nursing Research (Larkin et al., 2008). As you can see, each of these committees focuses on building empowerment within their nursing staff. By joining these committees and taking on roles as committee leaders, the nurses in this environment are able to develop both personally and professionally. With Collaborative Governance, the nurse is able to exhibit greater feelings of professional empowerment by improving the nursing conditions in her workplace, as well as communicating more efficiently with the other members of the healthcare team in order to provide an environment where important decisions regarding patient care and safety are made based on the input of all of the individuals involved.

 

Professional and Interprofessional Practice:

When it comes to success in interprofessional practice, the nurse must first find empowerment and satisfaction in his or her own personal professional practice. When nurses are unsatisfied in their position, whether it be due to fatigue, burnout, lack of feelings of empowerment, or feelings of underappreciation, the rest of the team (as well as the patients) suffer. Creating an environment where nurses feel empowered and valued as members of the healthcare team with create better relationships between colleagues, thus resulting in an increase in collaboration between disciplines. By advancing their own education, as well as stepping up as members of committees and boards, the nurse will be able to improve drastically when it comes to interdisciplinary communication and coordination. The leadership skills that he or she will gain from these experiences will in turn improve their communication within their own nursing setting as well, fostering a workplace where staff nurses also feel empowered and satisfied in their positions.

 

Value – The Quality of Nursing Care and Outcomes:

Building empowerment in the nursing field will have a direct impact on the care provided to our patients. By increasing the number of nurses on hospitals’ board of directors, we can bring the voice of the patient to the forefront of some of the biggest decisions made in the healthcare setting. The experience obtained from working directly with our patients allows us as nurses to share valuable input about ways to improve quality and safety in our patient care, as well as the ways that these changes can be implemented while still saving the organization money. The quality of care and patient outcomes can also be greatly improved by providing environments where there are low levels of nurse burnout. When nurses are overworked and overstressed with few support resources, burnout rates increase greatly (Vahey et al., 2010). These rates are also affected by organizational stressors and the negative characteristics associated with the workplace. Research shows that healthcare organizations where nurses have a greater level of autonomy, greater support from their administration, and better relationships between nurses, physicians and other members of the healthcare team generally result in lower rates of nurse burnout as well as a much higher rate of patient satisfaction (Vahey et al., 2010). This research proves that increasing empowerment and satisfaction in nursing practice has a direct effect on the quality of the care provided to our patients, as well as improved outcomes overall.

Image courtesy of http://www.netce.com/coursecontent.php?courseid=827

 

Emerging Theory – Evidence-based Tool for Professional Growth:

The concept and creation of a “Clinical Ladder” program has gained a lot of momentum in the past twenty years. These programs were implemented as a mechanism to enhance recruitment and retention of competent, experienced staff, to foster professional development, to establish a reward system for improved clinical performance of staff, to strengthen the quality of nursing practice, and to recognize staff nurses for excellence in patient care (Pierson et al., 2010). This type of program enhanced nurse empowerment by focusing on six major characteristics of the exemplar nurse: education, experience, professional and leader, provider, teacher, and advocate (Pierson et al., 2010). These six characteristics provided the areas in which the staff nurse could potentially earn points required to advance to the next level of the “ladder”. Advancement to the next level could only occur if the staff nurse reached a minimum number of points for each category, putting greater emphasis on the fact that nursing is a multi-faceted profession, and in order to succeed and develop further as a nurse, he or she must progress in all of these different areas. By stepping up to the next level of the ladder, staff nurses are rewarded with a salary increase each year at their annual review. This encourages the nurses to continue participating in the ladder program, and consequently improves their value as a member of the healthcare team.

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These types of clinical ladder incentive programs have been studied as evidence-based programs proven to increase nurse empowerment and encourage career growth in many areas including educational advancement, increases in committee involvement or project work, as well as a variety of other activities that contribute to a better work environment for staff nurses. This program is also essential to providing a workplace environment that promotes recruitment and retention of staff nurses, professional advancement within the nursing practice, as well as increasing staff satisfaction and empowerment (Pierson et al., 2010). By adapting this form of Clinical Ladder program, healthcare organizations across the world can provide the incentive for staff nurses to branch out and develop themselves both personally and professionally in order to advance their careers as nursing leaders.

 

Additional Resources:

Alexander et al article/course – This mini-course focused on the causes, symptoms, measurement and effects of nursing burnout. By examining the most common factors causing this dilemma, suggestions were made in order to help reduce this common occurrence, create a healthier work environment, and promote better quality care and safety for our patients.  

Dent article – This article came from Scrubs Magazine and was an inspirational segment that aimed to lift the spirits of nurses who have had a tough shift, or are beginning to really feel the effects of nursing burnout.

Oliver et al article – This article looked at how advancement to a Clinical Nurse Manager position can affect levels of empowerment in nursing staff. It provided information regarding how structural empowerment in these nurses can have a great impact on quality care for the patient as well as increased career satisfaction in the staff nurses.

Pierson et al article – This article looked at one evidence-based practice program that has been proven to improve professional growth, increase leadership potential, and improve overall job satisfaction in staff nurses. The implementation of this program in a variety of settings has proven effective in increasing employee retention and creating a greater feel of professional empowerment in its staff.

Vahey et al article – This article also focused on the impact of nursing burnout and its negative effects on patient satisfaction. The study focused on interviews of patients about their satisfaction with the nursing care they received using the La Monica-Oberst Patient Satisfaction Scale. The results showed that the overall level of nurse burnout was associated with the amount of staffing, administrative support, and the relationship between the nurses and the other members of the healthcare team. These factors, in turn, affected patient satisfaction.

 

References:

Alexander, L., Cannon, S. (2012). Burnout: Impact on Nursing. Continuing Medical Education Resource. Retrieved from http://www.netce.com/coursecontent.php?courseid=827

Dent, S. (2013). 18 inspirational quotes for burned-out nurses. Scrubs Magazine. Retrieved from http://scrubsmag.com/18-inspirational-quotes-for-burned-out-nurses/

Hassmiller, S. & Combes, J. (2012) Nurse leaders in the boardroom: a fitting choice. Journal of Healthcare Mangement 57(1). 8-11. Retrieved from http://thefutureofnursing.org/resource/detail/JHM-NurseLeadersintheBoardroom

Keys, Y. (2014) Looking ahead to our next generation of leaders: Generation X nurse managers. Journal of Nursing Management 22(1). 97-106. Retrieved from http://onlinelibrary.wiley.com.ezproxy.library.wisc.edu/doi/10.1111/jonm.12198/full

Larkin, M., Cierpial, C., Stack, J., Morrison, V., Griffith, C. (March 31, 2008) Empowerment Theory in Action: The Wisdom of Collaborative Governance. OJIN: The Online Journal of Issues in Nursing. 13(2). Retrieved from http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN?TableofContents/vol132008/No2May08/AQrticlePreviousTopic/EmpowermentTheory.html.

Oliver, B., Gallo, K., Griffin, M.Q., White, M., Fitzpatrick, J. (2014). Structural Empowerment of Clinical Nurse Managers. JONA: The Journal of Nursing Administration 44(4). 226-231. Retrieved from http://ovidsp.tx.ovid.com.ezproxy.library.wisc.edu/sp-3.12.0b/ovidweb.cgi?QS2=434f4e1a73d37e8cc34210a22d1e597c5d56473a6f129cfdd4f510c5766664c7dc0809bc792e2e754d5f5af434b28633a6c50e6041615e64c2e022df2bdcf5749144b33da131de913e10ba1329a85cf64f469e2e5c99e9b13c41479c0c2ad4e660719acdfb799030ff96dcaf235443570515f1b508408e741c61a1af38ce8f373a6a1b8020493eb2847132f4554d022d1b331c1ec7d373c43bb101486628cca70a805f6bd1b3ebf580a27fc9663207259abba01e8bdd6869bd5fcc53fdd11f277cee5add643f9a2f50a356b1587947dde97e1f44abbabbe0f9675a3091ff09649822fcc29bb469ac696ed2fdc6a2f19c2479a3b1b6bc0daf597cd56892cef2a3d2222c086089a3cd6b248583a2d9a6f7b135dd08fb56966ad9d5659ce6f3be4753bbb276321046165b20dd87c46478243978ebcd2352194b06284122de0073e5f8d3b1580ecbaf6a9c6927617a7a54b4

Pierson, M.A., Liggett, C., Moore, S. (2010). Twenty Years of Experience With a Clinical Ladder: A Tool for Professional Growth, Evidence-Based practice, Recruitment, and Retention. The Journal of Continuing Education in Nursing 41(1). 33-40. Retrieved from http://web.b.ebscohost.com.ezproxy.library.wisc.edu/ehost/pdfviewer/pdfviewer?sid=498a866f-3468-4375-9137-ecb3608fcbe8%40sessionmgr110&vid=2&hid=125

Vahey, D.C., Aiken, L.H., Sloane, D.M., Clarke, S.P., Vargas, D. 2010. Nurse Burnout and Patient Satisfaction. PubMedCare 42(2). 1157-1166. Retrieved from http://web.b.ebscohost.com.ezproxy.library.wisc.edu/ehost/pdfviewer/pdfviewer?sid=498a866f-3468-4375-9137-ecb3608fcbe8%40sessionmgr110&vid=2&hid=125

 

 

The Nurse’s Role in Care Coordination

As we all know, our healthcare system is currently in the process of going through significant changes. One such change is an emphasis on care coordination. Care coordination involves intentionally arranging patient care activities so that information is shared between all people who are concerned with a given patient’s care.1 This allows us to provide care which is safer and more effective.1

care coordination

Image courtesy of http://www.improvingchroniccare.org/index.php?p=Care_Coordination_Model&s=353

 

Both the American Nurses Association (ANA) as well as the Institute of Medicine (IOM) have recognized the importance of the nurse’s role in care coordination. Truly, nurses have always been key contributors to coordination of care.2, 3 However, according to the ANA, with the growing interest in coordination of care it is essential for nurses to “step up” and draw attention to their role in this extremely important aspect of patient care.2 This involves nurses, along with other healthcare professionals, assuming reconceptualized roles as care coordinators.3 In their Future of Nursing report, the IOM identifies nurses as “key workers” in the coordination of care.3 They state that nurses are the ideal providers for continuity of care because they “are experts in coordinating both the physical and psychosocial care” (Institute of Medicine, 2011, p. 394).3

 

Current Policy

There have been a handful of policy initiatives that focus on care coordination as well as transitional care. Probably the most notable of such policy initiatives would be parts of the Affordable Care Act. This act included several initiatives which aimed to advance care coordination and transitional care.4 A few specific policies include the HHS Partnership for Patients, a Medicare Community-based Care Transitions Program, as well as a Medicare Hospital Readmission Reduction Program.4

This issue is of interest because by improving care coordination and transitional care, nurses are able to ensure that their patients get the correct care at the correct time. Nurses can directly impact quality of care, cost, and patient outcomes by (for example) reducing the number of medical errors and also by eliminating unnecessary duplication of services through quality care coordination.5 We can also reflect on the importance of this issue by looking at the ANA’s model of professional nursing practice.6 This model shows us that our nursing care should be safe, be of good quality, and also be evidence-based.6 Performing good care coordination really helps nurses achieve all three of these objectives. By again looking at the example of reducing medical errors5, we can see that care coordination truly results in safer care. Also, by sharing information between everyone concerned about a given patient, we increase our ability to deliver quality care because everyone is working together cohesively as one team. There is even evidence which backs up care coordination as being a best practice for continuity of care7, so as a whole it is clearly very applicable to our model of practice.

nursing model

ANA’s Model of Professional Nursing Practice. Image courtesy of http://www.nursingworld.org/modelofpracticeregulation

 

As stated earlier, nurses are the ideal providers to perform care coordination. Not only is it something we have always done anyway, but simply putting a nurse in this role (rather than a physician) saves money itself. One study we found concluded that a principle cost driver of care coordination appeared to be the percentage of activities which were performed by physicians.8 This means that the more physicians perform the care coordination, the more costs go up, so let’s stick to having nurses do it!

 

Nursing Leadership and Voice

These emerging nursing roles are really a great opportunity to increase both nursing leadership and voice within the healthcare setting. Coordinating care involves a higher level of overall involvement.  This does, however, come with added responsibility as well. In order to provide good care coordination, nurses must be good team members.1 This involves maintaining compassion (especially amongst co-workers), having good communication skills, and also knowing yourself (being aware of your feelings, personality type, etc.).1 It has always been the nurse’s responsibility to maintain competency in any role, and care coordination is not exempt from this. Diane Huber sums this up nicely by writing, “The turbulent swirl of change in this country’s health care industry… has provided both challenges and opportunities for nursing” (Huber, 2013, p. xi).9

 

Systems Theory

Having nurses as the leaders of care coordination will definitely change the system as a whole. Coordination of care is a relatively new focus in the healthcare system and will directly impact how the system operates. The IOM states that nurses must become “health coaches”.3 This role encompasses many things, such as communicating with other providers, communicating with family and friends, and also ensuring the patient understands things such as what the physician told them, why they are taking a certain medication, etc.3 Also, the American College of Physicians argues that, “real improvement in outcomes will occur only when clinical systems reconfigure themselves” (American College of Physicians, 2014, no page number).10 We believe that nurse-led care coordination could be the “system reconfiguration” they are searching for.

 

Professional and Interprofessional Practice

Professional and interprofessional practice are truly the heart of care coordination. Without collaboration with other team members, care coordination would be almost impossible. The goal of any healthcare team should be to work together to achieve a common goal of increasing a patient’s health. It is clear that care coordination is a vital aspect to this common goal, and as we already stated interprofessional practice is vital to care coordination, so they are extremely related in this way.

 

Quality of Nursing Care and Outcomes

Quality of nursing care boils down to patient outcomes more often than not. We have already established that care coordination is positively correlated with improved patient outcomes.5, 8 This makes sense too, because it is simply logical to know that care is improved when everyone involved is “on the same page”. By improving patient outcomes, we are improving the healthcare system as a whole, which we believe also adds more value to the nursing profession itself. Any nurse should take great pride in having a direct impact on improving a given patient’s outcome. By conducting care coordination, nurses may experience more of these positive outcomes with their patients which will make them value their work to a greater degree.

 

It is largely accepted that care coordination is most beneficial for patients with chronic illnesses.3, 10, 11 This is because people who are chronically ill are most likely to have acute care episodes, or have their disease progress. Both acute care episodes and disease progression reduce the quality of life for the patient and increase costs for the healthcare system. By helping patients manage their chronic illnesses through good care coordination, nurses can reduce these acute care episodes or slow disease progression.3 Also, patients who are chronically ill can often see as many as five specialists every year.11 Since these patients often receive the “most” care, it makes sense to us that they then also need the most coordinating of that care because there are more players involved.

Studies have shown that coordination of care is toughest for patients with chronic conditions, especially if they have multiple chronic conditions.11 This “theory” is just now coming to the surface because 50 years ago there simply were not as many patients who had multiple chronic illnesses. However, due to modern medicine, people are able to survive longer despite having multiple health problems. Consequently, more care is needed which results in more coordination being needed too as we have recently discovered. For example, to get the patient’s perspective on coordination of care, one study surveyed almost 10,000 adults with at least one chronic condition.11 Twenty-seven percent of the patients surveyed considered their care coordination to be a major or minor problem.11 The study went on to conclude that “health care providers should place special emphasis on coordinating care for those patients who have multiple chronic conditions” (Kahn, 2012, no page number).11

 

Additional Resources

Antonelli, Stille & Antonelli article8 – discusses the costs and benefits of care coordination.

Furure of Nursing Report3 – extremely comprehensive report that focuses on many issues surrounding the changing healthcare environment, including care coordination.

Lind Public Policy article4 – much more in-depth information about recent policy attempts to enhance coordination of care.

This YouTube Video12 – is advocating for a specific organization, but it does a nice job of explaining the problems of our current health system, and why care coordination is needed.

This website13 – has several short videos showing inspirational success stories resulting from good coordinated care.

 

References

1)      Glover, C. (2014). Emerging nursing roles [PowerPoint]. Retrieved from https://uwmad.courses.wisconsin.edu/d2l/.

 

2)      American Nurses Association (2014). Care coordination and the essential role of nurses. Retrieved April 24, 2014, from http://www.nursingworld.org/care-coordination.

 

3)      Institute of Medicine (2011). The future of nursing; leading change, advancing health. Retrieved April 24, 2014, from http://thefutureofnursing.org/IOM-Report.

 

4)      Lind, K. (2013). Recent medicare initiatives to improve care coordination and transitionalcare for chronic conditions. Retrieved April 24, 2014, from http://www.aarp.org/content/dam/aarp/research/public_policy_institute/health/2013/recent-medicare-initiatives-improve-coordination-transitional-chronic-AARP-ppi-health.pdf.

 

5)      Official U.S. Government Site for Medicare. (2014). Coordinating your care.Retrieved April 24, 2014, from http://www.medicare.gov/manage-your-health/coordinating-your-care/coordinating-your-care.html.

 

6)      American Nurses Association. (2014). Model of professional nursing practice regulation.Retrieved April 24, 2014, from http://www.nursingworld.org/modelofpracticeregulation.

 

7)      Christakis, D. A., Wright, J. A., Zimmerman, F. J., Bassett, A. L., & Connell, F. A. (2003). Continuity of care is associated with well-coordinated care. Ambulatory Pediatrics, 3(2), 82-86. Retrieved April 25, 2014, from PubMed.

 

8)      Antonelli, R. C., Stille, C. J., & Antonelli, D. M. (2008). Care coordination for children and youth with special health needs: a descriptive, multisite study of activities, personnel costs, and outcomes. Retrieved April 25, 2014, from http://pediatrics.aappublications.org/content/122/1/e209.full.

 

9)      Huber, D. L., (2013). Leadership and nursing care management. Retrieved April 25, 2014, from http://books.google.com/books?id=zVFPAQAAQBAJ&dq=nursing+leadership+care+coordination&lr.

 

10)  American College of Physicians. (2014). Chronic disease management. Retrieved April 25, 2014, from http://www.acponline.org/clinical_information/journals_publications/ecp/augsep98/cdm.htm.

 

11)  Kahn, K. (2012). People with multiple chronic illnesses have trouble coordinating care. Retrieved April 25, 2014 from http://www.cfah.org/hbns/2012/people-with-multiple-chronic-illnesses-have-trouble-coordinating-care.

 

12)  Bittman, B. (2012). The future of us healthcare part II: care coordination. Retrieved April 25, 2014, from http://www.youtube.com/watch?v=C82E075VeIE.

 

13)  Unity Point Health. (2014). Care coordination stories. Retrieved April 25, 2014, from https://www.unitypoint.org/patient-stories.aspx.

 

 

 

 

 

Improving Patient Care: Collaboration is Imperative

Image

Image courtesy of http://www.wrha.mb.ca/professionals/collaborativecare/

Who are Nurses?

Nurses do everything under the sun in the health care field. We advocate, collaborate, provide care, give emotional support, translate information given from providers, document everything we do during a shift, and so much more. The general public probably does not realize how much goes into a nursing job, and we are not sure the nursing profession would be done justice with a one minute speech describing our role in healthcare.

Interviews

To gain more information on the interdisciplinary team we interviewed a physical therapist, two social workers, and dietician. There was an overwhelming consensus that none of us really understood the others scope of practice or practice model. Much of the interviews were spent educating each other on their individual practices. It was a great learning experience and without this assignment we may have never been enlightened to this information or had this connection with these members of the interdisciplinary team.

There were many aspects of the interviews that surprised us. It seemed that no one really understood the duties or scope of practice from other disciplines. There were many opinions and opportunities to help each other, but these were never voiced to the other health care workers because “I didn’t want to tell someone else how to do their job” as stated by one of the social workers. This was shocking because, in this facility, all four of these health care professionals have interdisciplinary meetings on each of their patients weekly. For the physical therapist especially, she stated that the nurses write notes on all of the medical issues with patients, but there is not much emphasis on their functionality. This becomes problematic because she cannot fully comprehend what this patient is able to do on the unit. This is a serious patient safety issue when a patient is discharged, because a patient could perform well in therapy and their abilities could wane throughout the day. When this patient is sent home they could fall and end up right back into the hospital, and with the new regulations the hospital might not be reimbursed for the readmission.

Issues with Collaboration

Another aspect that was focused on in the interviews was how the electronic medical record (EMR) has affected collaboration. Our group figured there would be at least one person that would have stated this has limited the ability for interdisciplinary team to collaborate, but everyone thought this helped so much. Despite the raving reviews of the EMR each interviewee talked about how difficult it has been to talk face to face to other professions for help. They focused mainly nursing profession because, in the words of the dietician, “nurses have the most patient interaction and usually the most knowledgeable about the patient.” A social worker explained how annoying it can be when they have to re-interview patients, directly after a nurse has done their admission interview. This causes frustration with patients and our group has seen how much of the information is not repeated exactly the same to both professionals. This causes a gap in knowledge and conflicting ideas on how to best care for patients. One specific example was a patient that was interviewed by multiple professionals but the patient only told the nurse that there were steps in his house. This was then overlooked by the nurse because they assumed that this was explained to physical therapy and social work. This patient never tried steps in therapy and never received adaptive equipment for this and when the patient was discharged home he fell and was back in the hospital the next day. If the nurses had better collaborated or all of the interdisciplinary team would have interviewed the patient upon admission everyone would have known this information. Through interviews we found that collaboration could greatly increase moral for the team, because it seemed that everyone that re-interviews patients receives a frustrated attitude that is less cooperative, and this makes the professionals’ job much more difficult. If collaboration was done more effectively the patient rapport could be much improved and patient care can be more cohesive.

Nursing Leadership and Voice

Nurses are supposed to be the voice and advocate for the patient, so we should be the leaders of the interdisciplinary team. We are knowledgeable with the medical aspect and patients trust us to disclose personal feelings about what they want done. As new nurses we all have to deal with a lack of experience and this can restrict our ability to be a leader or have an appropriate voice in the team (Phaff et al. 2013). This was also a theme in the interviews, and we further explored the conversation to ask if there is anything we could do to be able to better communicate with other professionals in hopes that interviewees would express opinions about teaching this vital skill in school. Everyone besides the dietician stated something about working with other professions in school and how useful that would be. Each interviewee talked at length about different exercises that they were provided during school to learn how to work with other professions. This year the UW School of Nursing students were offered a limited number of opportunities to work with other health care providers, but these were not formal or mandatory classes. One of these classes attended by a couple group members proved useful and an underlying theme that emerged was how both medical and nursing students wanted more exposure to working with each other. Needless to say experience can play a huge role in the allowing the nurse to be a leader and this should be implemented throughout our schooling.

Systems Theory

Communication is critical in any system, and the health care system is no different. The health care system n is becoming increasingly electronic, and this poses problems with collaboration between professions (Steege, 2014b). The increase in technology is revered by many, but the face-to-face interactions are becoming less common and that makes the patient input necessary for interdisciplinary practice much more difficult to achieve (Steege, 2014b). The hospital system is starting to look more like a technology centered design, where we should at least with respect to collaboration be more of a Sociotechnical System Theory. This states that we would become more interactive with each other and have technology assist us instead of relying on technology (Steege, 2014a).

Professional and Interprofessional Practice

Collaboration is necessary for any team to work well towards a common goal and it is part of our ANA Code of Ethics (ANA). We are expected to be able work as one cohesive unit to provide the best care possible to each and every single of our patients. With technology becoming ever more present in the health care field, our ability to collaborate and communicate with others is changing, as nurses we need to do everything possible to keep the focus on the patient and not rely on all of the technology that can make us overlook what is most important to that patient.

Quality of Nursing Care and Outcomes

Effective interdisciplinary collaboration is imperative to positive patient outcomes (Williams, 2013). With better communication between professions we as nurses will be more knowledgeable about our patients and be able to provide more holistic care. We potentially will be able to reduce errors and provide optimal care enough to have patients discharged sooner and with lower readmission rates. This will benefit patients and the health care system as a whole. We are much worse than other developed nations in health care costs and outcomes, and with better communication maybe we could close this gap (Health Costs: How the U.S. Compares to Other Countries).

Article

In Williams’article it shows the benefits of interdisciplinary practice very close to home at the Aurora Health Care System. It describes its acute care for elderly (ACE) system and how the health care outcomes have improved without readmission rates increasing. They have also found this model has reduced their hospital costs.

In our groups experience most quality improvement in hospitals have been based on refining nursing skills or technology. We would like to see more emphasis on collaboration between teams. This will require buy-in from all disciplines, but if our common goal is to heal patients this should be well received. Our group would also like to see a push for the education system to implement more classes for us to interact more with the other health care professionals. The logistics in scheduling can be problematic, but if we want to provide better health care outcomes as seen in the Williams’ article it would be well worth it.

Additional Resources:

American Association of Colleges of Nursing website: describes educational suggestions

Robert Wood Johnson Foundation website: numerous articles explaining interdisciplinary practice and how to increase safety

Newhouse and Spring article: becoming less individualistic and working more as a team

Klipfel et al. article: Quality Improvement study increasing collaboration by simulations

Sibbald, Wathen, Kothari, and Day article: gives insight on flow of knowledge in the hospital setting

References:

Code of Ethics. (2011). Retrieved April 10, 2014, from American Nurses Association website: http://www.nursingworld.org/mobile/code-of-ethics.

In Indiana, physicians and nurses work together to transform nursing: Nurses, doctors, and other health professionals team up in the Heartland to improve health and health care. (2013 March 28). Retrieved April 12, 2014, from Robert Wood Johnson Foundation website: http://www.rwjf.org/en/about-rwjf/newsroom/newsroom-content/2013/03/in-indiana–physicians-and-nurses-work-together-to-transform-nur.html.

Interdisciplinary Education and Practice. (n.d.) Retrieved April 12, 2014, from American Association of Colleges of Nursing website: http://www.aacn.nche.edu/publications/position/interdisciplinary-education-and-practice.

Kane, J. (2012, October 22). Health costs: How the U.S. compares with other countries. Retrieved April 10, 2014, from PBS NEWSHOUR website: http://www.pbs.org/newshour/rundown/health-costs-how-the-us-compares-with-other-countries/.

Klipfel J. M., Carolan B. J., Brytowski N., Mitchell C. A., Gettman M. T., & Jacobson, T. M. (2014). Patient safety improvement through in situ simulation interdisciplinary team training. Urologic Nursing 34(1), 39-46.

Newhouse, R. P., & Spring, B. (2010). Interdisciplinary evidence-based practice: Moving from silos to synergy. Nursing Outlook 58(6), 309-317.

Pfaff, K., Baxter, P., Jack, S., & Ploeg, J. (2013). An integrative review of the factors influencing new graduate nurse engagement in interprofessional collaboration. Journal of Advanced Nursing 70(1). 4-20.

Sibbald, S. L., Wathen, C. N., Kothari, A., & Day, A. M. B. (2013). Knowledge flow and exchange in interdisciplinary primary health care teams (PHCTs): an exploratory study. Journal of Medical Library Association 101(2), 128-137.

Steege, L. (2014a). Systems Approach [PowerPoint]. Retrieved from: https://uwmad.courses.wisconsin.edu/d2l/.

Steege, L. (2014b). Interdisciplinary Practice [PowerPoint]. Retrieved from: https://uwmad.courses.wisconsin.edu/d2l/.

Williams, S. (2013, December 11). Modeling interdisciplinary healthcare: NICHE principles and ACE Model support collaboration between nursing and other disciplines. ADVANCE. Retrieved from: http://nursing.advanceweb.com/Features/Articles/Modeling-Interdisciplinary-Healthcare.aspx.

 

 

Emerging Technology and Nursing Care: SEDASYS

Background

SEDASYS Computer Assisted Personal Sedation System is a technology designed to provide sedation for minor medical and surgical procedures without an anesthesiologist present. Traditionally, an anesthesiologist/nurse team delivers a combination of benzodiazepine–usually midazolam–and opioid analgesic–most often fentanyl or meperidine–to provide sedation for patients undergoing procedures such as endoscopies or colonoscopies (Sahai, 2013). With this technology, a clinician, either nurse or doctor, is qualified to operate the machine without an anesthesiologist present (Sahai, 2013). The SEDASYS system has been proven to be effective when delivering Propofol, a sedative that is generally also used for deep sedation during these procedures (Pambianco, 2011). While administering these medications, the SEDASYS unit also monitors the patient for oxygen saturation, heart rate, respiration rate, blood pressure and responsiveness (FDA, 2013).

[image courtesy of Sedasys.com]

The system is intended to help health care systems be more efficient while delivering sedation by allowing general medicine doctors and nurse teams–those that normally perform the procedures–to administer the anesthesia. Anesthesiologists are then primarily present at other surgical procedures with sedation practices that are not always so straightforward.

 

Some outcomes of using this machine in low risk patients so far have been (Pambianco, 2011):

  • quicker patient recovery
  • fewer adverse medical events
  • fewer instances of hypoxemia in patients (a pulse oximetry reading of less than 92%)

 

These findings point to better patient outcomes overall with the use of the SEDASYS system. It should be noted that the physicians and nurse teams that were using this machine were thoroughly trained in propofol administration and how to use the machines.

 

System Challenges: Development & Implementation

Screening measures, such as colonoscopies, have become very successful in the past decade and have saved countless lives by detecting early signs of deadly colon cancer. This is in part due to the growing popularity of a drug called Propofol, which provides sedation to patients with a minimal recovery time (Goudra, 2014).

This machine was primarily developed to reduce costs and improve efficiency surrounding screening procedures at which anesthesiologists have traditionally been present. For health care organizations, anesthesiologists present a large cost. All patients undergoing sedation for a procedure must be seen by one. Not only that, but they must be present for a preprocedure consult, during the procedure, and after to make sure the effects of anesthesia are waning. Anesthesiologists are one of the highest paid professions, making this time very costly to the organization. Moreover, insurance companies do not reimburse based on salaries of the specialists, but rather for the procedure itself, often at a certain fixed rate. For instance, Medicare or Medicaid will only cover a certain cost of the procedure, regardless of whether an automated sedation machine, like SEDASYS, or traditional anesthesia was used (Cote, 2011). By cutting costs of labor, the health care provider can increase profitability and be able to perhaps provide more/different services that may not be so profitable as a result.

At the system level, the SEDASYS machines would improve not only the cost of having these specialists present, but also the efficiency within the establishment. Creating greater availability for anesthesiologists to work with more complicated cases means greater numbers of procedures, and thus more profit for the company.

 

Effectiveness

SEDASYS has been FDA approved, which means significant research has been done on the reliability and effectiveness of the product. Pambianco, et al. (2011) have done a widely recognized study that says the system is effective for administration of sedation medication for low risk patients. They found that in a 1000 patient randomized sample, patients recovered faster, patients and clinicians rated satisfaction higher, and no adverse events were reported with use of the SEDASYS system (Pambianco, 2011).

 

Material Implementation Costs

Four part SEDASYS machines cost upwards of one million dollars (Cote, 2011). In the long term, however, this is potentially cost saving, especially when considering that anesthesiologists no longer need to be present at procedures. Rockoff (2013) discusses that anesthesiologists’ presence at endoscopies or colonoscopies can add $600 to $2,000 per procedure, whereas this machine would cost approximately $150 per procedure. Machines do require properly trained staff, but any licensed doctor/nurse team already has the qualifications to complete the specialized training (Cote, 2011). Patient education will be very similar to what it is now with traditional doctor/nurse teams administering anesthesia, with an informed consent form explaining the procedure.

 

Ethical Dilemmas

When the machine sedates a patient too deeply or malfunctions, there is not a trained anesthesiologist at the procedure to correct the problem. The same trained anesthesiologist also has gone through extensive training to recognize signs and symptoms of over or under sedation and how to correct it, while a clinician with a one day training program on how to use a machine most likely does not share these qualifications. If the machine were to malfunction and the clinician not catch it, who would be at fault? It is a systems level problem, as the clinician running the machine may feel trained and able to handle the normal spectrum of operation, but feel uncomfortable in specialized situations. Does the health care organization have a duty to have an anesthesiologist on call at that facility? Or provide more in depth training than that required to simply run the machine? Luckily there have been no such cases reported yet (Cote, 2011).

 

Nursing Leadership and Voice

Nurses must communicate their likes and dislikes about the system. With any new healthcare technology, it is important to be sure those who are using it feel safe. As an integral part of the healthcare team, they must also adapt to their new role in this procedure. In the past, nurses have been responsible for administering medications ordered by the anesthesiologist. With the new machine and without an anesthesiologist present, it becomes even more pertinent that they recognize signs and symptoms of under/oversedation and be able to act quickly in concert with the doctors. As Cope et al. note, it is important for nurses to remain critical of technology rather than just incorporating it into nursing practice without questions being asked (Cope, 2008).  SEDASYS should be evaluated by nurses and other clinicians about how it is helping or hindering their practice, yet also reevaluated in terms of long term patient outcomes (Cope, 2008).

 

Systems Theory

Looking at how this technology will influence the overall system is an important aspect of systems theory. Technology plays a large roll in a smooth functioning system, whether it be electronic charting, new devices or procedures, security, or machines. Technology can interact with other players in the health care system, such as doctors, nurses, the economy or work environment to reduce errors and make healthcare safer.

At the Macrolevel, this technology is by nature being introduced into a healthcare organization by a corporation (Johnson & Johnson, in the case of SEDASYS). The interaction between these two entities is a great example of how technology relates to the Macrosystem (Steege, 2014).

When the machine is in the company, it is in the mesosystem and is functioning in direct patient care (the microsystem). SEDASYS can influence not only patient satisfaction and safety, but also provider satisfaction and other preexisting technology in the work place (Steege, 2014). These complex interactions leave room for error and must be taken seriously and analyzed completely throughout the whole system.

Professional and Interprofessional Practice

A machine such as the SEDASYS can make an impact in a particular health care system by reducing the probability of human error, but one should also consider that it could increase the chance for mechanical error, or a decrease in monitoring in patients by clinicians who trust the technology (Cope, 2008). In evolving world of healthcare technology, it becomes more and more important for nurses to communicate with other members of the healthcare team. As new practices become practice norms, professional practice in health care will change, as well as how professionals interact with other members of the team.

 

Value: the Quality of Nursing Care and Outcomes

As mentioned earlier and as Cope focuses on in Patient Safety and Quality: An Evidence-Based Handbook for Nurses, it is important for nurses to pay attention and develop a critical evaluation process for new technology (Cope, 2008). Nursing care is fundamentally about critical assessments, not just of patients but also of situations in his or her workplace. To uphold the strong tradition of thorough nursing practice and critical assessment, it is important for nurses to judge how new technologies fit into their practice and evaluate effectiveness, efficiency, safety and other outcomes constantly (Cope, 2008).

 

How has SEDASYS been working so far?

In an article published by Goudra, et al. late last year (2013), the focus is on patient selection. In the first six months after FDA approval, Goudra’s group has found the device to be largely successful in the right patient population. Potential problems arise when patients have one or more risk factors such as obesity, a history of smoking, egg or latex allergies, or have undetected sleep apnea (Goudra, 2013). To troubleshoot issues such as decreasing oxygen saturation, properly trained clinicians or nurses should be present and able to use different techniques to open obstructed airways.

 

Additional Resources:

Pambianco’s often cited article provides a good overview of safety

 

Sahai’s article about endoscopist satisfaction and effectiveness of SEDASYS

 

Goudra’s article about anticipating challenges during these procedures

 

The Wall Street Journal : Robots vs. Anesthesiologists

 

The SEDASYS Website : Watch the promotional video and read the white paper statement from the company

References:

Cope, G., Nelson, A., & Patterson, E. (2008). Patient Care Technology and Safety. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. (Volume 3). Rockville, MD: Agency for Heathcare Research and Quality (US); Chapter 50. Retrieved from: http://www.ncbi.nlm.nih.gov/books/NBK2686

 

Cote, G. (2011). The debate for nonanesthesiologist-administered propofol sedation in endoscopy rages on: who will be the “King of Prop?” Gastrointestinal Endoscopy, 73(4), 773-776.

 

Goudra, B., Singh, P., & Chandrasekhara, V. (2014). SEDASYS, Airway, Oxygenation, and Ventilation: Anticipating and Managing the Challenges. Digestive Diseases and Sciences. doi: 10.1007/s10620-013-2996-z

 

“Introducing the SEDASYS® System.” The SEDASYS® System: SEDASYS.com. Johnson & Johnson, n.d. Web. 30 Mar. 2014.

 

Pambianco, D., Vargo, J., Pruitt, R., Hardi, R., Martin, J. (2011). Computer-assisted personalized sedation for upper endoscopy and colonoscopy: a comparative, multicenter randomized study. Gastrointestinal Endoscopy, 73(4), 765-772.

 

Rockoff, J. (2013, October 9). Robots vs. Anesthesiologists. The Wall Street Journal. Retrieved from: http://online.wsj.com/news/articles/SB10001424052702303983904579093252573814132

 

Sahai, A., Wong, J., Gould, M., Byrne, M. (2013). Tu1380 Multicenter Preliminary Experience With the SEDASYS Propofol Infusion Pump for Colonoscopy in Routine Clinical Practice: Safety and Endoscopist Satisfaction. Gastrointestinal Endoscopy, 77(5), AB520.

 

Steege, L. (2014). Technology Enhanced Healthcare [PowerPoint slides]. Retrieved from: http://uwmad.courses.wisconsin.edu/d2l/

 

US Food and Drug Administration. (2013). PMA P080009: Summary of Safety and Effectiveness Data. Retrieved from: http://www.accessdata.fda.gov/cdrh_docs/pdf8/P080009b.pdf

System’s Thinking Regarding Safety, Value, and Nursing Outcomes

“Hospital A” is a 500-bed facility that ranks among the top academic medical centers in the United States and receives patients from all over the country.  The hospital includes six ICU floors and is a Level One adult and pediatric trauma center.  “Hospital A” prides itself on innovation and academic excellence and advancements.

We chose to look more in depth at a theoretical unit in an innovative hospital such as “Hospital A” when assessing systems safety and nursing outcomes.  This is a unit that is piloting a new staffing matrix for nurses allowing a smaller nurse to patient ratio in the hopes of increasing patient safety and improving nursing outcomes on their unit.  Nurses on high acuity units run the risk of getting burnt out from the demand of patients, errors can be made, and nursing turnover increases because they feel they can’t safely handle the patient load given and patients are being put at risk.  These new staffing matrices are designed to decrease patient load per nurse to facilitate a safer environment for both the nurses and patients.

 

As a group we decided to take a closer look at the safety issue of understaffing nurses on a unit with high acuity and a heavy patient burden.

 

Application to Systems Theory

It is important to take a look at safety with a system’s approach because safety research has revealed that disastrous errors are almost never due to a single mistake by one individual.  Human error will occur regardless but it is the system that fails by not setting in place the appropriate channels to minimize the risk of errors happening (Steege, 2014).

 

We took a look at the safety issue of poor nurse-to-ratios using The Swiss Cheese model of system’s safety.

Image

Image: Courtesy of J Reason, 2000

 

The first level of the Swiss Cheese model is funding and resources.  Money is always an issue when it comes to staffing.  The more nurses that are needed the more expensive it is to keep them on a shift.  Resources are also an important issue.  You can’t add more nurses to a shift if there aren’t enough available.  It has to be a feasible option to add more staff before a unit can even look to changing policies (Steege, 2014).

 

The next level is the organizational aspect of the system.  The culture on the unit must be one that accepts change and is willing to work for what is best for not only their patients but also for the nurses.  This starts at the bottom with the nurses themselves, but the nurse manager must also be willing to advocate for their nurses and patients.  Lastly, the hospital committees and boards must be accepting of change for the better.  New policies must be implemented so the appropriate parties need to begin the research and policy-making process to enact a change allowing for safer nurse-to-patient ratios (Steege, 2014)

 

The third level is the technical elements of the system.  If a nurse has a heavy patient load and becomes fatigued and frazzled they may overlook a broken piece of equipment, or they may notice that certain equipment needs fixing but may be too busy to remember to get maintenance to take a look at it (Steege, 2014).

 

The next level is the team as a whole.  This includes shift handovers and giving sufficient report.  When a nurse has a busy patient load they may miss important details in the shift report and these missing details can lead to patient harm anytime in the future.  It also takes a shifting of responsibilities.  This includes making sure that patients are distributed as evenly as possible and nurses are helping each other whenever possible to get tasks completed (Steege, 2014).

 

The final level is the providers themselves.  This is the most individual of all the levels.  This level includes the training of each nurse.  The training must be sufficient for the patient population.  The unit we took a look at has gained a much higher acuity level over the years so it would be important that all the nurses on the unit have received the appropriate amount of training for the patient population they care for.  This level also includes nurse fatigue and distractions.  The higher acuity and more patients a nurse takes care of the more fatigued and distracted they become.  Both of these characteristics do not contribute to a safe culture for patients to be taken care of.  Being fatigued and distracted can lead to many mistakes including medication errors, leaving a patient room in an unsafe condition causing a patient fall, or failing to find and report important signs and symptoms to providers (Steege, 2014).

 

If at any of these levels there is a “hole” in the system then the system fails and there is an increased risk that there will be harm to the patient.  This is why it makes it increasingly important to take a look at the entire system and how efficient it is.

 

MACRO LEVEL FACTORS: Policies, funding, resources, staffing matrix

MICRO LEVEL FACTORS: Unit acuity, training of the nurses, staffing availability

SITUATIONAL VARIABLES:  Each unit has different patient populations and acuity,

UPSTREAM POLICIES:  The previous nursing staff matrix to determine nurse-to-patient ratio, budget concerns

 

Themes of the Course

Nursing Leadership and Voice:

An important part to enacting a change is that nurses advocate for themselves and their patients when they believe there is an unsafe policy in place.  The nurses on units such as our theoretical unit must be very active in making sure that they receive safer nurse-to-patient ratios.  The nurses on these floors can form committees and the nurse managers may also get involved in these committees.  They must research other hospitals with similar patient populations and determine what ratios they work with and how nurses on those unit feel about the safety of the nurses and the patients with the ratios the follow.

 

Systems theory:

As discussed previously in the safety system’s model, it is extremely important to use a system’s model when addressing potential safety issues in healthcare.  First of all research shows that very rarely is an error the fault of an individual.  Although human error contributes to safety concerns the failing of a system is at the root of catastrophic events (Steege, 2014).  For example, on the unit we theorized about it could be possible that the nurses did everything in their power to keep patients safe but until the policy was changed upstream to give safer nurse-to-patient ratios their hands were tied.

 

Professional and Interprofessional Practice:

As with everything in healthcare, changes affect every profession involved in the care of the patients.  If nurses are overworked and mistakes are made the entire team must pick up the pieces.  If it is a medication error, physicians are notified as well as pharmacy and the team must work together to fix the mistake if possible.  Also it is everyone’s responsibility to keep their colleagues in check.  If an error begins at the top with an order from a physician, makes it past pharmacy, and finally makes it to the nurse but the nurse is too distracted and exhausted to realize the mistake then an error will occur that could have been prevented.  It is important to work as a team to make sure these never make it to the patient.

 

Value: The Quality of Nursing Care and Outcomes:

Appropriate staffing affects the quality of nursing care and patient outcomes in many ways.  First of all, it directly affects the safety of patients.  There are fewer errors made when the nurses can take their time and are not distracted by everything else going on.  There are less medication errors, patients are left in rooms that are safer (cords are out of the way, call lights are in reach, side rails are up, beds are in the lowest position, etc), and nurses make appropriate assessments of patients.  It also affects the nursing staff when they are appropriately staffed.  Nurses experience less fatigue, there are less work-related injuries, nursing turnover decreases, and nurses are healthier overall.  All of these characteristics make the patients safer as well.

 

Research on a Possible Solution to the Safety Issue

Twigg et. al (2011), offers one solution to the safety issue of nursing understaffing, fatigue, and increased patient burden.  They studied the impact of a staffing method called Nursing Hours Per Patient Day (NHPPD).  This is a staffing matrix that takes into account patient complexity, patient dependency on staff, and patient turnover as well as other factors and applies it to an equation that includes the number of hours a nurse spends with patients and this determines how many nurses are needed to work on a shift as well as which and how many patients each nurse will receive.  To read more click the link NHPPD.

 

Suggested Additional Information

The article by Everhart et. al (2014) discusses one negative patient outcome when there is not sufficient nursing staff for the patient population on certain units.  The aim of this study was to determine if adding extra staff would decrease the amount of falls seen across hospitals.

 

The article by Serratt (2013) was the follow-up of a previous study that was put into place.  The study began eight years previously and this article summarizes what they have learned about patient level outcomes with certain nurse-to-patient ratios in the state of California.

 

The article by Yoder et. al (2013) takes a look at a specific hemodialysis unit and the staffing levels as well as the characteristics of the facility.  They determined that higher number of registered nurses per patient have been associated with improved patient outcomes in acute care facilities.

 

The American Nurse’s Association has a website that discusses their recommendations for staffing plans and ratios.  If you’d like to read up more on their recommendations click the link ANA Staffing Ratios.

 

This article was interesting because it shows the Senate’s involvement in nurse staffing policy to make hospitals safer for patients.  We encourage you to read more about the act that they tried to pass in the Senate, Senate Bill.

 

References

Everhart, D., Schumacher, J.R., Duncan, R. P., Hall, A.G., Neff, D.F., Shorr, R. I.  (2014).  Determinants of hospital fall rate trajectory groups: a longitudinal assessment of nurse staffing and organizational characteristics.  Health Care Manage Rev. Unprinted.  Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/24566249.

New bill in senate calls for national nurse-patient ratios, staffing solutions.  (2013).  Retrieved March 5, 2014, from Healthcare Network website, http://nursing.advanceweb.com/News/National-News/New-Bill-in-Senate-Calls-for-National-Nurse-Patient-Ratios-Staffing-Solutions.aspx.

Nurse staffing plans & ratios.  (2014)  Retrieved March 5, 2014, from American Nurse’s Association website, http://www.nursingworld.org/MainMenuCategories/Policy-Advocacy/State/Legislative-Agenda-Reports/State-StaffingPlansRatios.

Serratt, T.  (2013).  California’s nurse-to-patient ratios, part 3: eight years later, what do we know about patient level outcomes?.  Journal of Nursing Administration.  43(11), 581-585.  Doi: 10.1097/01.NNA.0000434505.69428.eb.

Steege, L.  (2014).  Systems safety [Powerpoint].  Retrieved on February 26, 2014, from Learn@UW website, www.learnuw.wisc.edu

Twigg, D., Duffield, C., Bremner, A., Rapley, P., Finn, J.  (2011).  The impact of the nursing hours per patient day (NHPPD) staffing method on patient outcomes: a retrospective analysis of patient and staffing data.  Int J Nurs Stud.  48(5),  540-548.  Doi: 10.1016/j.ijnurstu.2010.07.013.

Yoder, L.A., Xin, W., Norris, K.C., Yan, G.  (2013).  Patient care staffing levels and facility characteristics in U.S. hemodialysis facilities.  62(6), 1130-1140.  Doi: 10.1053/j.ajkd.2013.05.007.

 

St. Mary’s Hospital: Organizational Structural Analysis

Nestled between Lake Wingra and Lake Monona, one can find St. Mary’s Hospital of Madison, WI.

St. Mary’s Hospital, Madison, WI

St. Mary’s Hospital, founded in 1912 by the currently known Franciscan Sisters of Mary, is a member of the SSM Health Care system based in St. Louis, Missouri.12 In 2013, St. Mary’s Hospital extended their network when they merged with Dean Health Systems Inc.22 This Christian based organization’s mission is, “Through our exceptional health care services, we reveal the healing presence of God.”19 St. Mary’s Hospital stresses its faith-based mission with the goal of providing holistic and competent health care services within the standards of modern day medical knowledge and practice.19 St. Mary’s 440-bed “tertiary referral hospital” provides care to those covered by Dean Health Insurance and other insurance types in Dane County and 17 other counties located in South Central WI.24 Along with providing care to those with insurance coverage, St. Mary’s Hospital provided traditional charity care to 8,200 people in 2012.8 (Click the link to learn more about hospital charity care in WI.9)

Now, the question we must consider, since this is a nursing blog, where does nursing fit into the established organization? St. Mary’s Hospital provides a model to represent the nursing organization, better known as “The Nursing Wheel.” It is pictured below.20

St. Mary's Nursing Wheel

St. Mary’s Nursing Wheel

Unfortunately, we were unable to procure information about the entire hospital organizational structure. Consequently, we do not know exactly how nursing fits in with the broader hospital organization.

Discussion of the Nursing Layers

Patients and Family: The center and primary level. This relays the idea that the patient is the center of care.

Unit Based Councils: The forefront nursing staff, such as, Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants, and Unit Managers are represented in this layer. These are the people directly involved with patient care in one form or another. Some of these employees will join councils, such as the Education Council.

Nursing Organization Service Areas: Nursing service areas/units are grouped at this layer. For example, all surgical floors would be categorized into one group. While the model does not specify, the unit managers and Clinical Nurse Specialist would most likely be collaborating at this level. By working closely with similar floors, the units are able to provide standardized care, based on what has been shown to work or not work.

Coordinating Councils: More of the leadership roles, such as council chairs, are represented on this layer. The council chairs most likely express the ideas and concerns of the council to the administrative team. As a result, the following decisions or changes could affect the lower layers.

Hospital: While specific information on this layer is not available, we would like to assume there is a Chief Nurse Officer or Vice President of Nursing in charge of the nursing department. She/he would work with the rest of the administrative team and consult with the CEO. This assumption is based on a review of other WI affiliated SSM Health Care hospitals and the SSM Health Care leadership team, which is discussed below.

Other SSM Health care affiliated groups in Wisconsin – Stoughton Hospital, Upland Hills Health, Columbus Community Hospital, and Dean Health Systems – publicize information about their administrative leadership.2, 4, 3, 18 While the listed information is limited, Upland Hills Health was the only hospital to recognize a Vice President of Nursing.4 Looking at the highest level, the SSM Health Care system administrative team, there is a Nursing leader.22 The Chief Nursing Officer position was recently created in 2011.6 It is an appointed, two-year term.6 There is evidence of nursing leadership at the administrative and decision-making levels of the corporate layer. Most likely St. Mary’s Hospital of Madison follows a similar structure at the hospital administrative level. However, the question still remains: Is there a Chief Nursing Officer on the same level as the other hospital administrative leaders?

Corporate: SSM Health Care system is represented at this layer.

Community: Represents the community/ social dynamics impacting the hospital structure. An example would be the implications of Medicare regulations set forth as a result of the Affordable Care Act.

Organizational Impact

Within the nursing department the structure could be classified as functional with a relatively “flat” design.10 We can assume the other departments are functional as well, but cannot confirm. With functional structure, departments are grouped based on specialty area.21 Nursing, physicians, environmental services, and human resources would be considered separate departments and act as their own entity. Comparison to a silo is a commonly used analogy. Each silo (department) follows their specified chain of command to the executive level.

Silo Structure Image courtesy of http://lahiriarnab.wordpress.com/

Silo Structure
Image courtesy of http://lahiriarnab.wordpress.com/

While there is still a hierarchical structure to the nursing wheel it is relatively “flat”.  Meaning theoretically, there are fewer levels between employees and the chief-decision makers.10  As depicted by the Nursing Wheel, RNs are considered to be on the same level as Clinical Nurse Specialist and their unit manager. We do not know the hospital administrative organization, so we cannot determine the exact number of layers between a staff RN and the chief-decision maker.

The Structure’s Pros and Cons on Nursing Voice and Interprofessional Practice

In 2001 the Institute of Medicine (IOM) published the report, “Crossing the quality chasm: A new health system for the 21st century.” The report suggests the patient-centered care model as a crucial component for a successful health care system. One way to achieve this is through improved clinical cooperation.15 (The entire report can be accessed here). Cowen, et al., argue the IOM did not provide sufficient detail on how to accomplish such a task. They recommend that successful organizational models include fewer layers separating the patient and executives, a webbed design to facilitate communication, and an interdisciplinary practice council in addition to specialty practice councils.10

St. Mary’s Hospital’s organizational structure does include some of the recommendations. First and foremost, the nursing wheel depicts the patient as being the center of the nursing structure. Their structure has fewer layers, which facilitates communication within the department. A disadvantage of the functional structure is poor communication between departments.21 The administrative leadership team, consisting of leaders from each department, controls the decision-making of the entire organization. Departments may have trouble understanding each other and fail to recognize how each contributes to the organization’s mission as whole.21 This could lead to delays or to decisions the forefront employees do not understand.

Loss of autonomy by forefront employees, due to the decision-making power held by the executives, is another potential problem with the functional structure.13 St. Mary’s has tried to give back some power and autonomy to the nurses by following the philosophy of Shared governance.20 According to a recent literature review, shared governance has been shown effective in empowering nurses and maintaining a positive nursing practice environment.7 The practice environment can affect the nurse and patient outcomes.

While St. Mary’s Hospital does utilize nursing councils, there is no public evidence that St. Mary’s has an interdisciplinary council, which was a recommended strategy by Cowen, et al.10 With the limited information we cannot determine the relationship or communication between other professionals like physicians, therapist, or social workers. As mentioned previously, with a functional structure communication between different professionals can be difficult.

Impact on quality and outcomes

St. Mary’s Hospital is a recognized Magnet facility, which is a stamp of approval for nursing excellence and quality.17 Please check out the provided link to learn more about magnet status.5 In terms of patient outcomes, the current nursing structure should provide positive results.  The nursing wheel depicts patients as the center of care, and they should be the ultimate focus. According to the IOM, patient-centered care is the key component for successful health care.15 What happens at each level can directly or indirectly affect the patient and determines the quality of outcomes. However, the model focuses on nursing’s role of patient care and excludes other disciplines’ philosophies. If nurses are not communicating with other disciplines or other disciplines do not follow the theory of patient-centered care, patient outcomes could be negatively impacted.

Systems Approach

The nursing wheel portrays the system within nursing, depicting a system of layers that ultimately affects patient outcomes. We do not have access to an entire hospital model so we cannot confirm how nursing’s system fits in with the hospital as a whole. Lack of an administrative leadership model is especially disappointing. This is the level where many decisions are made. If nursing is not represented, there is concern about how well their voices are being heard, even with the use of shared governance and unit councils. It would be beneficial to have information on the structure and specific employee role descriptions to better understand the intricacy of the system. Evidence of the paper model being applied in practice would also aid in determining the model’s effectiveness.

Suggested Additional Information

The article by Kramer, et al., discusses essential strategies for creating a healthy nursing work environment.16 St. Mary’s Hospital already practices some of these, but others may be beneficial to implement. The strategies could also be implemented in other nursing work environments.

The article, “Structural empowerment and the nursing practice environment in magnet organizations,” was referenced previously.7 It discusses the important role shared governance can play for nursing empowerment.

This YouTube video exemplifies the excitement of nursing staff at a hospital about to implement Shared governance.23

The IOM report, “Future of nursing: Leading change, advancing health,” Chapter 5, Transforming Leadership suggests the need for improved nursing leadership and collaboration among disciplines.14 St. Mary’s Hospital did not publicize nursing leadership but, according to the IOM, this needs to change. When analyzing other organizational structures, nurses should look at what nursing leaderships roles exist and the relationship between disciplines.

Additional information on the three main types of organizational structures is clearly presented in “Operations, Process, and Decisions: A Management Blog.”11

References

1.     About us.  (2014). Retrieved February 12, 2014, from St. Mary’s Hospital website, http://www.stmarysmadison.com/AboutUs/Pages/default.aspx

2.     About us. (2014). Retrieved February 13, 2014, from Stoughton Hospital website, http://www.stoughtonhospital.com/AboutUs/Pages/default.aspx

3.     About us:: Board of Directors. (n.d.) Retrieved February 13, 2014, from Columbus Community Hospital website, http://www.cch-inc.com/AboutUs/Pages/BoardofDirectors.aspx

4.     About upland hills health. (n.d.) Retrieved February 13, 2014, from Upland Hills Health website,

http://www.uplandhillshealth.org/index.php?module=cms&page=87

5.     ANCC magnet recognition program. (2014). Retrieved February 13, 2014, from American Nurses Credentialing Center website, http://www.nursecredentialing.org/Magnet.aspx

6.     Biography: Maggie fowler, chief nursing officer representative, system management. (n.d.). Retrieved on February 13, 2014, from SSM Health Care website, http://www.ssmhc.com/internet/home/ssmcorp.nsf/31060168df94973f86256a0e0058c993/40b6cc60da7cf27786257b4b0076a2f9?OpenDocument

7.     Clavell, J. T., O`Grady, T. P. &, Drenkard, K. (2013). Structural empowerment and the nursing practice environment in magnet organizations. The Journal of Nursing Administration, 43(11), 566-573. Doi: 10.1097/01.NNA.0000434512.81997.3f

8.     Community Involvement. (2014). Retrieved February 12, 2014, from St. Mary’s Hospital website, http://www.stmarysmadison.com/communityconnection/Pages/Community.aspx

9.     Consumer guide to health care: Charity care in Wisconsin hospitals. (2012). Retrieved February 15, 2014, from http://www.dhs.wisconsin.gov/guide/spec/freehosp.htm

10. Cowen, M., Halasyamani, L. K., McMurtrie, D., Hoffman, D., Polley, T., & Alexander, J. A. (2008). Organizational structure for addressing the attributes of the ideal healthcare delivery system. Journal of Healthcare Management, 53(6), 407-418.

11. Fahmi, S. M. (2006). Organizational Structure. Retrieved February 12, 2014, from http://sameh.wordpress.com/2006/05/13/a7/

12. General information. (2014). Retrieved February 12, 2014, from St. Mary’s Hospital website, http://www.stmarysmadison.com/AboutUs/Pages/GeneralInformation.aspx

13. Glickman, S. W., Baggett, K. A., Krubert, C. G., Peterson, E. D.,& Schulman, K. A. (2007). Promoting quality: The health-care organization from a management perspective. International Journal of Quality in Health Care, 19(6), 341-348. Doi: 10.1093/intqhc/mzm047

14. Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Transforming leadership (pp. 5-1: 5-27). National Academics Press. Retrieved from http://thefutureofnursing.org/sites/default/files/5%20Transforming%20Leadership%20%28185-212%29.pdf

15. Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.

16. Kramer, M., Schmalenberg, C., & Maguire, P. (2010). Nine structures and leadership practices essential for a magnetic (healthy) work environment. Nursing Administration Quarterly, 34(1), 4-17. Doi: 10.1097/NAZ.0b013e3181c95ef4

17. Magnet recognition. (2014). Retrieved February 13, 2014, from St. Mary’s Hospital website, http://www.stmarysmadison.com/AboutUs/Pages/MagnetRecognition.aspx

18. Our Leadership. (2014). Retrieved February 13, 2014, from Dean website http://www.deancare.com/about-dean/our-leadership/

19. Ours story. (2014). Retrieved February 12, 2014, from St. Mary’s Hospital website, http://www.stmarysmadison.com/AboutUs/Pages/OurStory.aspx

20. Shared governance philosophy. (2014). Retrieved on February 13, 2014, from St. Mary’s Hospital website, http://www.stmarysmadison.com/AboutUs/Pages/SharedGovernancePhilosophy.aspx

 21. Steege, L. (2014). Organizational structures [PowerPoint]. Retrieved on February 13, 2014, from Learn@UW website, http://www.learnuw.wisc.edu

22. System Management. (n.d.). Retrieved on February 13, 2014, from SSM Health Care website, http://www.ssmhc.com/internet/home/ssmcorp.nsf/c0ac5bba5b3a327c86256adb006da296/2ff1ca39596f7ba58625771a004a541e/$FILE/orgchart.html

23. Troycrmc. (2009, March 29). CRMC shared governance promo . Retrieved from http://www.youtube.com/watch?v=HuVZtFGiw_U

24. Where we are. (n.d.). Retrieved February 12, 2014, from SSM Health Care website, http://www.ssmhc.com/internet/home/ssmcorp.nsf/documents/wisconsin

Why is this blog here?

This blog is one of student group blogs in Nursing 415, a course taught at the University of Wisconsin-Madison School of Nursing during the Spring semester of 2014.

For more information about the course, the blog assignment, and to access other group blogs in this course, and to see a list of online resources, including video tutorials, and mobile apps that may be useful in helping you get familiar with WordPress.com, visit http://n415son.wordpress.com/, the main “hub” blog for this project.