caring in nursing leadership virginia organization of nurse executives and leaders june 2, 2015...
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Caring In Nursing LeadershipVirginia Organization of Nurse
Executives and LeadersJune 2, 2015
Deb Zimmermann, DNP, RN, NEA-BC, FAAN
Current Challenges in Healthcare
A Changing Tapestry in VirginiaPopulation Health Strategic Moves Strategic Alignments
National Trends that ChallengePopulation Health and Value-Based
Strategic MovesStrategic Alignments
A Range of Options along the Traditional Continuum…
Source: Sg2 publication “Health System Consolidation Navigating the New Wave of Mergers and Acquisitions”
Patient & Family Centered Care Is A National Priority in Healthcare
20022008
2010
Acceleration of Patient Experience Measures Post Affordable Care Act
Consumer Assessment of Healthcare Providers & Systems
– Hospital CAHPS (HCAHPS) 1. Pilot (Not Mandated) (2005)2. Pay for Reporting (2007)3. Pay for Performance/Value Based Purchasing (2012-present)
– Home Health CAHPS (HHCAHPS)1. Pilot (Not Mandated)2. Pay for Reporting (2011)3. Pay for Performance/Value Based Purchasing (2013)
– Clinician and Group CAHPS (CGCAHPS)1. Pilot (2014-2015)2. Pay for Reporting (2014-2015)3. Pay for Performance (c. 2015-2017)
- CHILD HCAHPS1. Pilot (2013)2. Pay for Reporting (c. 2016)
Patient Centered Care and Improved Patient Experience Part of New Value Care Model
Value = (Quality + Safety + Service) Cost
Current Medicare Value Based Purchasing Model
Value-Based Purchasing Readmissions Reduction
System Integration
Percentage of Hospital Revenue at Risk
Stronger Business Case and ROI For Our Services
1% - 1.75%
Our Role as Nurse Leaders
• Drive:– Quality– Safety – Satisfaction– Stewardship
• Charged to:– transform cultures where clinical knowledge and
caring practice are shaped and lived
Jones, Havens, Thompson (2008), Havens, Jones, Carlson (2014), Boykin Schoenhofer (2001) Cathcart (2008), Bathceller (2010), Dyess, Pestica, Smith (2015)
Model for Nursing Leaders
Leadership
Caring
Self care
Resiliency
Patient Outcomes
AccountabilityReflection
Dyess, Prestica, Smith (2015)
Resiliency QuizPART ONE:Do you have the conditions in your life that help people to be resilient?• People bounce back from tragedy, trauma, risks, and stress by having the following “protective” conditions
in their lives. The more times you answer yes, the greater the chances you can bounce back.• Answer yes or no to the following. Celebrate your “yes” answers and decide how you can change your
“no” answers to “yes.” (You can also answer “sometimes” if that is more accurate than just “yes” or “no”.)• 1. Caring and Support
______I have several people in my life who give me unconditional love, nonjudgmentallistening, and who I know are “there for me.”______I am involved in a school, work, faith, or other group where I feel cared for and valued.______I treat myself with kindness and compassion, and take time to nurture myself(including eating right and getting enough sleep and exercise).
• 2. High Expectations for Success______I have several people in my life who let me know they believe in my ability to succeed.______I get the message “You can succeed,” at my work or school.______I believe in myself most of the time, and generally give myself positivemessages about my ability to accomplish my goals–even when I encounter difficulties.
• 3. Opportunities for Meaningful Participation______My voice (opinion) and choice (what I want) is heard and valued in myclose personal relationships.______My opinions and ideas are listened to and respected at my work or school.______I volunteer to help others or a cause in my community, faith organization, or school.
4. Positive Bonds______I am involved in one or more positive after-work hobbies or activities.______I participate in one or more groups (such as a club, faith community, orsports team) outside of work or school.______I feel “close to” most people at my work or school.5. Clear and Consistent Boundaries______Most of my relationships with friends and family members have clear,healthy boundaries (which include mutual respect, personal autonomy,and each person in the relationship both giving and receiving).______I experience clear, consistent expectations and rules at my work or in my school.______I set and maintain healthy boundaries for myself by standing up for myself,not letting others take advantage of me, and saying “no” when I need to.6. Life Skills______I have (and use) good listening, honest communication, and healthy conflict resolution skills.______I have the training and skills I need to do my job well, or all the skills Ineed to do well in school.______I know how to set a goal and take the steps to achieve it.
PART TWO:The following list can be thought of as a “personal resiliency builder” menu. No one has everything on this list. When “the going gets tough” you probably have three or four of these qualities that you use most naturally and most often.
Note the top three or four resiliency builders you use most often. Ask yourself how you have used these in the past or currently use them. Think of how you can best apply these resiliency builders to current life problems, crises, or stressors.
Relationships — Sociability/ability to be a friend/ability to form positive relationshipsService – Giving of yourself to help other people; animals; organizations; and/or social causesHumor — Having and using a good sense of humorInner Direction — Basing choices/decisions on internal evaluation (internal locus of control)Perceptiveness — Insightful understanding of people and situationsIndependence — “Adaptive” distancing from unhealthy people and situations/autonomyPositive View of Personal Future – Optimism; expecting a positive futureFlexibility — Can adjust to change; can bend as necessary to positively cope with situationsLove of Learning — Capacity for and connection to learningSelf-motivation — Internal initiative and positive motivation from withinCompetence — Being “good at something”/personal competenceSelf-Worth — Feelings of self-worth and self-confidenceSpirituality — Personal faith in something greaterPerseverance — Keeping on despite difficulty; doesn’t give upCreativity — Expressing yourself through artistic endeavor, or through other means of creativity
Practices that support caring and resiliency
Tips outside of healthcare literature
You Can Best Help Yourself or Someone Else Be More Resilient by…
1. Communicating the Resiliency Attitude: “What is right with you is more powerful than anything wrong with you.”
2. Focusing on the strengths more than weaknesses, and asking “How can these strengths be used to overcome problems?”
3.Having patience…successfully bouncing back from a significant trauma or crisis takes time.
https://www.resiliency.com/free-articles-resources/the-resiliency-quiz/
Practices that Support Caring and Resiliency in Nursing
• Intentional connecting with self and others• Fostering Relationships• Establishing boundaries• Accountability for a caring culture• Advocating for Nursing• Setting Decision Making Priorities• Reflection• Accepting the past/anticipating the future• Appreciating Humanity• Finding Meaning
MacLeod, Prestica, Smith (2015)
As a Nurse Leader Do I model self care• What behaviors do I model?• How do I allow for moments of rest in the day?• Do policies reflect self-care?• Do I support a healing environment?Suggestion: Practice thankfulness or short periods of meditation
Do I prioritize connections• How do I maintain work-life balance?• How often do I set aside time for my significant other?• Do I live my personal values?Suggestion: Arrange to meet an friend for coffee
MacLeod, Prestica, Smith (2015)
Do I create a culture of caring
• How do I acknowledge each team member’s impact on quality, safety, and satisfaction
• How do I support the renewal, recharge, and refocus on important team work
• Do I articulate caring theory regularly?• How often does the interprofessional team meet with
patientsSuggestion: Daily affirmation of a team member in public
MacLeod, Prestica, Smith (2015)
Do I advocate for the profession of nursing?
• Do I consider the impact and outcomes on patients with all decisions
• How do I seek out and share wisdom from other nurses• Are lifelong learning principles supported• How does the unique contribution of nursing contribute to
patient outcomesSuggestion: Ask, is the patient in this decision?
MacLeod, Prestica, Smith (2015)
Do I reflect in action
• How can I respond best in this situation?• What is my response• Is my response caring?• What happens because of caring?Suggestion: Inhale and exhale slowly before responding or keep a journal reflecting on challenging situations
MacLeod, Prestica, Smith (2015)
Are you ready to lead and transform
Vision
• Vision must be tangible enough for everyone to understand. It must provide a picture of what practice will look like and it must be measurable in order to verify progress.– Patient satisfaction and team satisfaction– Engagement of family and patient in plan of care– Partnership of care team
A story of Resilience
A Period of TurbulenceRochester General Hospital
The Genesee Hospital
2001 Regional Study
► Aging New York State population
► Average Registered Nurse 47 years of age
► 43% of RN’s intended to leave profession within 5 years
► Widespread dissatisfaction in pay and job
► Young and AD RN’s were least satisfied
Source: Finger Lakes Nursing Workforce Collaborative, July, 2001
Genesee Hospital Acute Discharges Per Day
30
35
40
45
50
Jan
99
F eb
99
M ar
99
A pr
99
M ay
99
Jun
99
Jul
99
A ug
99
S ept
99
O c t
99
Nov
99
Dec
99
Jan
00
Feb
00
M ar
00
A pr
00
M ay
00
Jun
00
Jul
00
A ug
00
S ep
00
O c t
00
Nov
00
Dec
00
Jan
01
F eb
01
Ac
ute
Dis
ch
arg
es
Pe
r D
ay
Dis c harges P er Calander Day
L inear (D is c harges P er Ca lander Day )
$300
$320
$340
$360
$380
$400
$420
$440
$460
$480
Jan99
Feb99
Mar99
Apr99
May99
Jun99
Jul99
Aug99
Sept99
Oct99
Nov99
Dec99
Jan00
Feb00
Mar00
Apr00
May00
Jun00
Jul00
Aug00
Sep00
Oct00
Nov00
Dec00
Jan01
Feb01
Rev
enu
e P
er D
ay (i
n th
ou
san
ds)
Revenue Per Calander Day
Linear (Revenue Per Calander Day)
Genesee Operating Revenue Per Day
The Genesee Was Projected To Lose $27.8 M in 2001 and Up To $38.0 M in 2003
Statement of Revenues and Expense
(In millions)
2000 1
2001
Proj. 2 2002 3 2003 3
Net Operating Revenues 147.7$ 138.9$ 138.9$ 138.9$
Salary & Benefit Expense 89.9$ 89.1$ 91.8$ 94.5$
Other Operating Expense 76.7$ 77.7$ 80.0$ 82.4$
Operating (Loss) Before Non-Recurring Expense (18.9)$ (27.8)$ (32.8)$ (38.0)$
Newspaper Headlines
► “ViaHealth Ends Year $18 Million in the Red” Rochester Democrat and Chronicle, February 28, 2001
► “Mounting Fiscal Woes Close Genesee Hospital”Rochester Democrat and Chronicle, March 29, 2001
► “Loss of Genesee Quickly Rippling Through Region”Rochester Democrat and Chronicle, March 30, 2001
► “Hospital Reveals Crushing Debt Load”Rochester Democrat and Chronicle, April 5, 2001
► “Doctors Want Offices Still at Genesee Site”Rochester Business Journal, April 6, 2001
► “New York Balks at Genesee Schedule”Rochester Democrat and Chronicle, April 11, 2001
► “Genesee Hospital Closure Strains Area’s Emergency Medical Services”
Rochester Democrat and Chronicle, April 11, 2001
► “Genesee’s Other Griefs”Rochester Democrat and Chronicle, April 18, 2001
► “Genesee’s ER Closing Gradually”Rochester Democrat and Chronicle, April 24, 2001
► “Genesee Patients Fear the Future After Closing”Rochester Democrat and Chronicle, April 26, 2001
► “Genesee Cuts off Ambulances”Rochester Democrat and Chronicle, May 3, 2001
► “Anguish Grips Genesee Donors”Rochester Democrat and Chronicle, May 6, 2001
► “Genesee Now All but Empty”Rochester Democrat and Chronicle, May 11, 2001
► “The Closing of Genesee Hospital is a Needless Tragedy”
Rochester Democrat and Chronicle, May 18, 2001
► “Why Did Genesee Collapse” Rochester Democrat and Chronicle, May 13, 2001
► “Y2K had a Deadly Effect on Genesee Hospital”
Rochester Democrat and Chronicle, December 10, 2001
Rochester General Hospital – 2002 Nursing Demographics
►22% Staff Vacancy►25% Turnover Rate►60 Agency Nurses►1% of Nurses Certified in their Specialty►Level of Job Enjoyment in Lowest Quartile on
NDNQI►50 Employees Enrolled in College►33% Baccalaureate Prepared Staff
Rochester General Hospital – 2002Clinical Indicators
► Rate of Patient Falls 4.9 per 1000 Patient Days► Rate of Nosocomial Ulcers .38 per 100 Discharges► Ventilator Associated Pneumonia 6 per 1000 Vent Days► Urinary Tract Infections 5 per 1000 Foley Days► Line Associated Bacteremia 8 per 1000 Line Days► Length of Stay 5.1 Days► Discharges: 35,663► Medication Errors Related to Mis-Identification: 9.1%► No Consistent Evidence-Based Criterion for Pathways, Protocols,
Procedures, and Policies.
Gwen Williams, RN, MS, CEN
Gave hope to nurses during a
time of crisis
Strategic
True North
2002 2005
Total Discharges 35,663 37,467
Length of Stay 5.10 days 4.75 days
CMI Medicare 1.736 1.747
CMI Non-Medicare 1.576 1.629
Adjusted Cost per Inpatient Discharge
$4,344 $4,358
ED Visits 78,415 80,470
Days Cash on Hand 29 64
Operating Income $868,000 $19.8 million
Financial Performance
Nursing Demographics
2002► 22% Staff Vacancy► 25% Turnover Rate► 60 Agency Nurses► 1% of Nurses Certified in their Specialty► Average length of service not tracked► Level of Job Enjoyment in Lowest Quartile
on NDNQI► 50 Staff Enrolled in College► 5% of Staff Enrolled in College Non-
Caucasian► 33% Baccalaureate Prepared Staff► 80% NCLEX Passage
2005► 3.3% Staff Vacancy► 10% Turnover Rate► 8 Agency Nurses► 25% of Nurses Certified in their Specialty► Average length of service is 11.2 years► Level of Job Enjoyment at or above NDNQI
mean► 346 Staff Enrolled in College► 26.5% of Staff Enrolled in College Non-
Caucasian► 41.1% Baccalaureate Prepared Staff► 97% NCLEX Passage
Clinical Outcomes2002
• Rate of Patient Falls 4.9 per 1000 Patient Days
• Patient Falls with Major Injury 3.4%• Rate of Nosocomial Ulcers .38 per 100
discharge • Ventilator Associated Pneumonia 6 per 1000
Vent Days• Urinary Tract Infections 5 per 1000 Foley
Days• Line Associated Bacteremia 8 per 1000 Line
Days• Medication Errors Related to Mis-
Identification: 9.1%• Patient Satisfaction Below Press Ganey
National Average• No Research• No Consistent Evidence-Based Criterion for
Pathways, Protocols, Procedures, and Policies
2005• Rate of Patient Falls 3.6 per 1000 Patient
Days• Patient Falls with Major Injury 1.35%
• Rate of Nosocomial Ulcers .29 per 100 discharges
• Ventilator Associated Pneumonia 2 per 1000 Vent Days
• Urinary Tract Infections 2 per 1000 Foley Days
• Line Associated Bacteremia 1 per 1000 Line Days
• Medication Errors Related to Mis-Identification: 2.4%
• Patient Satisfaction At or Above Press Ganey National Average
• 15 Staff Nurses Conducting Research• Consistent Process for Evidence-Based
Review on all Documentation
Quality of Care
Contemporary Clinicians living the call to action in the Future of Nursing
Debra S. Holbrook, RN,BSNForensic SANE Nurse/SANE Program CoordinatorMercy Medical Center, Baltimore, MD
Debbie changed care for victims of sexual violence in the United States and around the world. Her advocacy led to a federal mandate for forensic nursing and her care delivery model defines national policy. She testified before a U.S. Senate Judicial Subcommittee on behalf of the bill that was signed into law as the DNA Justice Act. She also serves on a national review panel for the Department of Justice.
Tod Brindle, MSN, RN, CWOCNNurse Clinician, Wound Care TeamVCU Health System, Richmond, VA
• His spirit of inquiry led him to perform study on the use of a prophylactic dressing for pressure ulcer prevention. Results triggered a hospital-wide practice change, resulting in an overall reduction of hospital-acquired pressure ulcer rates from 8% to <2%. Tod’s work was published, embraced on a national level, resulting in over 1,100 health systems having duplicated, adopted, or implemented his findings. He has presented nationally, and achieved international recognition in Portugal, China, Japan, Australia, and Denmark
New Outcomes• New Knowledge, Innovations &
Improvements: Paula Kobelt, MSN, RN-BC, Columbus, OH
• Sought to improve the safety of patients in the PACU by implementing a standardized approach to prevent unwanted opioid-related sedation. The study propelled the American Society of PeriAnesthesia Nursing to adopt and publish new recommendations for assessing post-operative patient sedation. This new knowledge will affect safety and pain management for adult patients nationally and across the globe.
Patient Centered Care
American Nurses Credentialing Center. (2014)
Rationale
• A professional practice model depicts a nursing philosophy and links it an organization’s mission
• The model frames and directs nursing practice according to legal and ethical professional standards
• Nurses are accountable for safe, ethical, evidence-based care
Practices that Support Caring and Resiliency in Nursing
• Accepting the past/anticipating the future• Setting Decision Making Priorities• Advocating for Nursing• Intentional connecting with self and others• Fostering Relationships• Accountability for a caring culture• Reflection• Finding Meaning
MacLeod, Prestica, Smith (2015)
Making Wishes Come True
Jaime Scott, RN, BSN, OCN, CNII, Oncology Virginia Jones, RN, CNII, Labor and Delivery
Karen Salamon, RN-C, BS, CNIII, Neonatal ICUDawn Quinn, RN, BSN, CHPN, CNIV Palliative Care
A Mother’s Choice
Making Wishes Come True
Resiliency and Relationship Based Care
• Kyle Hannon
Advancing Nursing Practice
Future of Nursing Call to action:
• Practice to the full extent of your education
• Continue your education and embrace life long learning
• Partner with colleagues, in redesign of health care
• Participate in workforce planning and policy making
References• Batcheller J. Chief nursing officer turnover: an analysis of the literature. Nurs
Clin North Am. 2010 45(1):11-31.• Berwick, D. M., Nolan, T. W., Whittington, J. (2008). The triple aim: Care,
health, and cost. Medical Care. 27(3) 759-769.• Boykin A, Schoenhofer S. The role of nursing leadership in creating caring
environments in healthcare delivery systems. Nurs Admin Q. 2001;25(30:1-7.• Cathcart EB. The role of the chief nursing officer in leading practice: lessons
from the Benner tradition. Nurs Admin Q. 2008:32(2):87-91.• Cline, S. Nurse Leader resilience: career defining moments. Nurs Admin Q.
2015; 39(2) 117-122.• Felen J. Caring: core value, currency, can commodity…Is it time to get tough
about “soft” Nurs Admin Q. 2003;27(3):208-214.• Havens DS, Jones CB, Carlson J. Chief nursing officer retention &turnover.
2013: is the crisis still brewing? Paper presented at AONE Annual Meeting:2014; Orlando, Fl.
References• Institute of Medicine. (2001). Cross the quality chasm. Crossing the quality
chasm: A new health system for the 21st century. Washington, D.C.: National
• Institute of Medicine. (2011). The future of nursing: leading change, advancing health. Washington, D. C.: The National Academy Press.
• Jones CB, Havens DS, Thompson PA. Chief nursing officer retention and turnover a crisis brewing? Results of a national survey. J Healthc Manage. 2008;53(2):89-106.
• MacLeod Dyess S., Prestia A, Smith M C. Support for caring and resiliency among successful nurse leaders Nurs Admin Q 2015 39(2) 104-115.
• Patient Protection and Affordable Care Act, 42 U.S.C. § 18001 (2010).• Stewart I. In: Donahue P, ed. Nursing :The Finest Art . St Louise, MO:
Mosby; 1985:476. Originally published in: 1929.
Questions
