National Nurses Week: RNs as Leaders

During National Nurses Week 2013, ANA is calling attention to registered nurses (RNs) and their contributions to the health care system, both in the role they play as expert clinicians in diverse care settings and as leaders who can dramatically influence the quality of care and overall performance of the system into the future.

Now more than ever, RNs are positioned to assume leadership roles in health care, provide primary care services to meet increased demand, implement strategies to improve the quality of care, and play a key role in innovative, patient-centered care delivery models. The nursing profession plays an essential role in improving patient outcomes, increasing access, coordinating care, and reducing health care costs. That is why both the Affordable Care Act and the Institute of Medicine's (IOM) Future of Nursing report place nurses at the center of health care transformation in the United States.

The public wants leaders they can trust — and nurses consistently rank at the top of a respected annual poll as the most trusted profession.

Here we outline the history of National Nurses Week and the characteristics, opportunities, and challenges of the nursing profession.

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The American Nurses Association expressed its support for President Obama’s budget, released Wednesday, for including “vital investments that strengthen the nation’s healthcare system,” according to a news release.

The ANA commended the $251 million allocated to the Title VIII Nursing Workforce Development programs. The approximately $20 million increase over Obama’s previous budget proposals is designed to allow these programs to continue recruiting new nurses into the profession, promoting career advancement within nursing and allocating nurses to critical shortage areas.

“With the proposed increase to Title VIII funding, the Obama administration continues to recognize the invaluable contribution that nurses make in the delivery of care and the need to strengthen our primary care system,” ANA President Karen A. Daley, RN, PhD, FAAN, said in the news release. “This proposed budget takes the long view and reflects tough choices by the Obama administration, while still supporting programs that are needed to transform the healthcare system and improve health for all.”

From the ANA’s perspective, other worthwhile healthcare investments in the budget include:

• $80.1 billion in discretionary funding for the Department of Health and Human Services for investments in the implementation of the Affordable Care Act, medical research and other priorities;

• $803.5 million for insurance exchange operations, part of the ACA;

• $235 million in funding for new mental health programs, including $50 million to train master’s-level mental health specialists such as nurses, psychologists and counselors who work in schools. The funding is designed to expand the mental health workforce and help schools detect early warning signs in students that can threaten the safety of classmates, teachers and the surrounding community;

• $3.8 billion for community health centers that will provide key primary care services for underserved communities.

Obama’s budget proposals drew criticism from some healthcare groups.

The budget seeks to achieve deficit reduction through a combination of revenue increases and spending cuts. Among the proposed cuts is $400 billion in federal health spending, mostly on Medicare. The decrease would affect both providers and beneficiaries.

“The solution to what ails our nation’s fiscal health is not further cuts to providers that care for millions of America’s seniors, but creative solutions to modernize the Medicare program,” Rich Umbdenstock, CEO of the American Hospital Association, said in a news release.

The Affordable Care Act includes various provisions that reduce the rate of payment growth to Medicare providers. Hospital representatives stated they could accept these decreases, figuring the influx of newly insured patients would make up for the shortfall.

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"We need to be the change we want to see," said Teri Pipe, RN, PhD. "To be healthy and active promotes health." Pipe is acting on that belief, both as a nurse and a nursing leader.

Since becoming dean of nursing and health innovation at Arizona State University College of Nursing and Health Innovation in Phoenix last year, Pipe has been putting into practice what she as a nurse espouses: getting up and moving throughout the work day improves physical and cognitive health. Her ideas include an hourly officewide Get-Up-And-Move initiative, holding walking meetings and using a standing workstation.

Health and creativity improve
Pipe introduced Get-Up-And-Move to her office-suite colleagues first. "In the lobby outside my office, about once an hour, songs play that signal the other nurse leaders and administrative staff to come out of their offices and move to the music," she said. Collectively people stretch, move or just get up from whatever they’re doing.

She encountered this idea during a meeting where the Surgeon General Vice Adm. Regina M. Benjamin spoke about first lady Michelle Obama’s efforts to get people up and moving to improve their health. Pipe said staff in her office area willingly have joined in making the change. "It’s for our productivity, our health and our minds," she said.

Elizabeth Reifsnider, RN, PhD, WHNP, PHCNS-BC, FAAN, associate dean for research at the college, is in step with Pipe on making positive health and behavioral changes.

"I do get up and dance or march during the music breaks, and I do a lot of walking around the halls if I’ve sat longer than 90 minutes," Reifsnider said. "I try to walk to talk to people as much as I can rather than emailing them if I have a quick question for them."

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In a Spanish study, nurses trained specifically to resolve acute health problems of low complexity provided care of comparable quality to that of general practitioners.

The findings, published March 21 on the website of the Journal of Advanced Nursing, suggest nurses may be able to take on some of the care generally provided by physicians, the researchers said.

Mireia Fàbregas, MD, of the Institut Català de la Salut, in Barcelona, and her colleagues randomized 1,461 adult patients who requested same-day appointments to see either nurses trained to respond to problems with low complexity or to see general practitioners. The study was conducted in 38 general practices in Catalonia, Spain, with 142 general practitioners and 155 nurses participating. The investigators measured how well patients' symptoms resolved and how satisfied patients were two weeks after the visit.

The investigators found that nurses successfully solved 86.3% of the cases. The health problem that nurses solved with greatest ease was burns, followed by injuries and acute diarrhea. Nurses were less successful at resolving low back pain, acute mild upper respiratory symptoms and urinary discomfort. “This lower resolution could be explained by the fact that these problems require more complex physical examinations that are not usual in a nurse’s daily work,” Fàbregas said.

Patients who saw nurses were as satisfied with their visit as those who saw doctors. When patients were asked about their preferences regarding which professional they would like to visit if a similar health problem arose again, more than 40% of patients in each group expressed indifference.

The study abstract is available at http://onlinelibrary.wiley.com/doi/10.1111/jan.12120/abstract.

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When hospitals hire more nurses with four-year degrees, patient deaths following common surgeries decrease, according to new research by the University of Pennsylvania School of Nursing's Center for Health Outcomes and Policy Research as reported in the March issue of the prestigious policy journal Health Affairs. Less than half the nation's nurses (45%) have baccalaureate degrees, according to the most recent data available (2008).

If all 134 Pennsylvania hospitals involved in the study had increased the percentage of their nurses with four-year degrees by 10 percentage points, the lives of about 500 patients who had undergone general, vascular, or orthopedic surgery might have been saved, the researchers found.

Specifically, a ten percentage point increase, say from 30 to 40 percent, in the overall percentage of BSN-prepared nurses in the hospitals studied between 1999 to 2006 saved about 2 lives for each 1,000 patients treated on average, according to lead author Penn Nursing professor Ann Kutney-Lee, PhD, RN, who is also a senior fellow at the Leonard Davis Institute of Health Economics. The researchers surveyed 42,000 registered nurses (RN) in Pennsylvania in 1999 and 25,000 in 2006.

Currently, RNs have obtained a four-year (baccalaureate degree), a two-year (associate's) degree, or graduated from a hospital-based diploma school. Licensed practical nurses (LPN) also practice at the bedside with a one-year degree.

"This adds to the importance of public policies to help direct a substantial shift toward the production of nurses with baccalaureates in nursing," said Kutney-Lee, noting that a recent report from the Institute of Medicine recommends that 80 percent of nurses hold at least a baccalaureate degree by 2020. "Nursing is both high-touch and high-tech requiring honed critical thinking skills in our complicated healthcare system."

While the study did not pinpoint why more patients survive surgeries, previous work in the Center found that better-prepared nurses offer higher levels of surveillance of patients, noticing subtle shifts in their patients' conditions that can lead to death from complications while there was still time to intervene. "As part of their practice, nurses are responsible for the continual assessment and monitoring of a patient's condition, identifying changes that could indicate clinical deterioration, and initiating interventions when necessary," noted Kutney-Lee.

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The resourceful F. Marie Hall SimLife Center at the Texas Tech University Health Sciences Center (TTUHSC) in Lubbock, Texas opened in September 2010. This clinical simulation center allows students in the nursing, medicine, and allied health professions to acquire and practice a full range of skills on manikins, from drawing blood and inserting urinary catheters to delivering babies.

Sharon Decker, Center Director, observes, “Learning in a simulated environment allows students to make mistakes without the need for intervention by faculty to prevent patient harm. Research has demonstrated that simulation provides an effective method of teaching while promoting learner satisfaction and self-competence.” Learners at TTUHSC can walk away from this simulated experience confident in their abilities and skills when dealing with live patients and unanticipated medical events. 

TTUHSC doesn’t plan on using the clinical simulation facility for students alone. According to Ted Mitchell, president, TTUHSC plans to use this technology for continued education for community nurses and physicians as well as faculty. “Part of our educational mission is to make sure we have as much interdisciplinary teamwork as we can,” remarks Mitchell, “and this is a great tool for doing that.”

One of the major influences that drove TTUHSC to choose Education Management Solutions (EMS) as their vendor was the ability to pull scenarios together and create a video clip of learners performing skills. This, they said, was not offered by other vendors. These clips will be important when recent graduates are searching for employment and they have visual proof of their demonstrated clinical capabilities.

Clinical simulation is the future. With many options on the horizon, TTUHSC has a plan to improve the SimLife Center by expanding the services currently offered to its customers; developing a program of educational and certification courses; and expanding the current program of research related to clinical simulation to explore transfer and sustainability of skills attainment. In this ever progressing era of technology, faculty has high hopes for goals they deem achievable. 

There is increasing recognition that nurses must be involved as leaders and decision-makers throughout healthcare, not just at the bedside or within the nursing community. Nurses are executive leaders in health systems and hospitals, of course, and also in professional associations, accrediting organizations, businesses, government, and universities. Within the nursing community, many feel that the skill set nurses need for modern-day practice also makes them valuable contributors throughout health systems, especially in leadership positions. As Maureen Bisognano points out, the best nurses are accomplished envoys among different players and interests involved in direct patient care, which is a skill needed throughout organizations and businesses, not just in hospitals or healthcare.

To develop a sense of how nurse executives view their work, Patient Safety & Quality Healthcare (PSQH) conducted a brief, informal survey of nurses who hold leadership positions in a range of organizations (see sidebar on page 34). We asked them to describe their roles; the challenges they face, especially regarding safety and quality; and accomplishments in which they take special pride. We also asked about their views of the relationship between patient safety and safety in the workplace and the usefulness of social media in their work lives.

Their responses are not presented here as “typical” or to represent a cross-section of nurse executives; in reality, they represent a “tip of the iceberg” view. In their responses, these nurses draw from deep wells of expertise, experience, and commitment to improving healthcare delivery. They deserve copious thanks for the thoughtfulness of their responses as well as for their contributions to the healthcare community. When I sent the initial surveys to a small group by email, I was thrilled to see immediate engagement—quick responses, willingness to participate, and fluid networking as my survey was shared and forwarded to colleagues. These busy executives were generous with their time and clearly interested in advancing opportunities for nurse leaders to make satisfying, lasting contributions.

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The American Medical Informatics Association estimates that employers need about 70,000 health informatics specialists to install and maintain new systems and train staff to use them.

While the increased demand for specialists is relatively new, the field is not. Nurses have been helping hospitals adopt technology  to work smarter since before the specialty even had a name.

Nancy Stockslager, who became a nurse in 1983, worked in neonatal intensive care units until she was presented with a unique job opportunity in 1995. A health care corporation was buying  products to create a clinical technology records system. When she was asked to help build the system, she accepted the challenge and never looked back.

Today, as director of clinical information at Gwinnett Medical Center, Stockslager, RN, MSN, is responsible for implementation, process analysis, training and maintaining all the health care network’s clinical technology systems. Gwinnett Medical already has adopted electronic medical records and is working toward computerized provider order entry,  in which physicians enter their own orders.

“Informatics has been a very exciting journey and I love it, but it’s a constant challenge. There is never a dull moment,” she said.
According to Stockslager,  informatics developed in two stages — an evolutionary stage and a revolutionary period.

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Nurses throughout the country give high marks to their jobs but anticipate a host of challenges within the coming years, according to a nationwide survey of nurses and their outlook on the profession.

"Vital Signs 2012: A National Nursing Attitudes and Outlook Report," highlights survey findings conducted by Jackson Healthcare, the nation’s third largest healthcare staffing company, in conjunction with Jackson Nurse Professionals.

Of 969 nurses who responded to the survey, 76% said they were satisfied or very satisfied in their jobs in caring for the sick or infirm. However, 72% reported that risks loom ahead for the nursing profession, particularly workload increases, a nursing shortage and increased liabilities and litigation involving nurses.

"Nursing is a great profession at the moment," Richard L. Jackson, chairman and CEO of Jackson Healthcare, said in a news release. "It provides good pay, rewarding work and a nice balance between personal and professional life.

"However, with so many seniors approaching retirement, a potential nursing shortage, more litigation in the medical profession and a potential explosion of newly insured patients thanks to the Affordable Care Act, nurses fear the future and changes coming to their profession."

The survey found that only 5% of nurses are very dissatisfied with their work. But those who are unhappy tend to be younger nurses (ages 25 to 34), compared with nurses ages 65 or older. Male nurses also are more likely to be unhappy compared with female nurses. The survey found a significant spike in nurses retiring in about 10 years.

"With the potential for so many nurses retiring in the near future, America’s healthcare delivery system may have a real problem if younger nurses are unhappy and leave the profession as well," said Scott L’Heureux, president of Jackson Nurse Professionals.

The survey found that in the next three to five years, 49% of nurses planned to keep their jobs and 13% said they would seek a leadership position in nursing. Meanwhile, 11% said they would return to school to earn a bachelor’s degree in nursing, 10% said they would like to teach nursing and 9% said they would like to transition to a nurse practitioner role.

To read the report data from the nurses’ survey, which will be conducted annually by Jackson Healthcare, go to: www.jacksonhealthcare.com/media-room/surveys/nurse-practice-trends-survey-2012.aspx.

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