Nursing's growing role

Nurse Manager Website, September 15, 2010

Rebecca Hendren, for HealthLeaders Media, July, 2010

Not so many years ago, nurses wore white uniforms and stiff white caps. They cared for patients who stayed in the hospital for days or weeks to recuperate from surgery. They received a technical education, often in a diploma program, and carried out task-based nursing duties. This picture is as antiquated now as today’s nursing model will be in 20 years.

Today’s non-cap-wearing, scrub-bedecked nurses are increasingly educated at colleges that focus on care coordination, as well as clinical skills. They care for higher-acuity patients in the course of shorter lengths of stay. They are technologically savvy critical thinkers who coordinate care across a broad spectrum of healthcare.

In 20 years, this picture will have shifted again due to changes wrought by healthcare reform, rising numbers of insured patients, an aging population, and the projected shortage of physicians.
Nurses will assume ever-greater leadership. Nurse-led primary care will be the norm, and physicians will be relieved of much of the burden of routine care coordination.

Nurse leaders at the bedside

“In nursing, we have to get away from the task-oriented focus of bedside nurses who are focused on medication administration, activities of daily living, and so on,” says Jill Fuller, RN, president and CEO of Prairie Lakes Healthcare System in Watertown, SD.

To retain nurses and encourage nurse leadership, nursing processes need to be redesigned to remove petty time wasters from nurses’ days and help them focus on what we really need them to be: leaders at the bedside.

Fuller’s organization has been working hard to figure out how to do this, and its revolutionary professional practice model is one for the future. Nurses at the 81-licensed-bed Prairie Lakes Hospital have gone from concentrating solely on what they are going to do with their patients to thinking about what the team as a whole will do.

Rather than having a model of care imposed from above, the nurses designed their own model that sets them firmly at the forefront of leading patient care in the hospital. The nurses wanted to remove bureaucracy and wanted every nurse to touch patients. “We got rid of a lot of the noise in the professional nurse’s day,” says Fuller. By taking out the busywork and broken systems, it gives nurses time to focus on patients, she says.

“We’ve worked hard on developing a rich information environment and developing our technology,” says Fuller. “Documentation is no longer a big task for nurses. It’s just a byproduct of doing your own stuff.”

Nurses practice in a team model that places RNs at the heart of care coordination and does away with much of the hierarchy of traditional nursing care. The teams are generally three people who care for around 10–12 patients. Teams may include two RNs and an LPN; an RN, an LPN, and a tech; and so on. There is always an experienced nurse who can huddle with the team to discuss patient care.
“Because acute care has a lot of variability with what a team will encounter, we want the team to decide how to take care of patients that day,” says Fuller.

Fuller admits that the new model was a bit chaotic early on, in part because it eliminated the charge nurse role. “At first doctors didn’t like it because they were used to having charge nurses round with them,” she says. Nurses now go to daily care conferences and participate in the discussion about their patients.

Fuller says the outcomes of the new care model have been outstanding. Employee satisfaction scores improved, and the redesign also improved productivity from 10.2 hours per patient day to 7.8 hours, indicating an increase in efficiency. Nurses now average 60% of their time in direct patient care, compared to a national average of around 30%.

Education of nurse leaders

“Nursing leaders are increasingly becoming pivotal at the strategic planning level—as well as at the new delivery system design level—to position us for healthcare reform,” says Deborah Zastocki, RN, DNP, FACHE, president and CEO at Chilton Memorial Hospital in Pompton Plains, NJ. “With healthcare reform, our focus is shifting toward the continuum of care, population health, and disease management. I think the nursing role is being acknowledged so significantly because of the fact that nursing education is one of holistic education. We focus on all aspects of patients’ lives.

“We have to become increasingly certified and specialized and be able to demonstrate the use of evidence-based practice as part of our nursing care models.”

 Doing so requires new graduate nurses to enter the workforce with a different set of skills. Colleges of nursing are working to prepare nurses to not only handle clinical responsibilities, but also to understand the care continuum, be technologically adept, and be ready to assume leadership roles.

Earlier this year, the National Council of State Boards of Nursing raised the passing standard on the National Council Licensure Examination for Registered Nurses. But despite the tougher standards, many feel nurses still are not sufficiently prepared to tackle the realities of practice. One solution is to raise the minimal educational preparation for nurses to baccalaureate level. “Currently, only 21% of community college graduates go on for a baccalaureate degree,” says Patricia Benner, RN, director of the Carnegie Foundation for the Advancement of Teaching.

Although the idea was applauded by nursing organizations early this year, it’s unlikely to be adopted any time soon.

“We’re one of few professions in healthcare that operates with an associate-level degree,” says Susan Hassmiller, RN, FAAN, the Robert Wood Johnson Foundation senior advisor for nursing. “How do you close the door on community colleges, especially in rural areas? How do you tell them they are not really RNs? There’s a real discrepancy between reality and what the ideal should be.”

Organizations have their work cut out in bridging the gap from school to practice. Most hospitals have preceptorships to provide extended orientations to new grads and help them learn through mentorships with more experienced RNs, but often these last for only a few weeks. One way to provide more long-term support is through residency programs.

“Every physician has a residency program before [being] deemed fit for practice. But for some reason, someone goes to nursing school and, the day they pass their boards, all of a sudden they are responsible for practicing as a full-fledged practitioner,” says Hassmiller. Residency programs can help prepare nurses for the demands of future healthcare needs, she says. “It would help with errors; it would help with the psychological and sociological transition to becoming a healthcare leader.”  

Importance of clinical leadership

Many organizations are turning to advanced practice nurses (APN) and nurses with specialty certifications to fulfill leadership needs, including Chilton Memorial Hospital. The 260-licensed-bed hospital is actively looking to grow its numbers of nurses with certification and advanced degrees. “One of the things we expect to see is the exodus of baby boomer nurses; we will need to think about different, nontraditional care delivery models,” says Zastocki. “Ensuring a well-educated workforce with a sound body of knowledge, as evidenced by certification, is one strategy that we are employing. CNLs are another potential model that could help us.”

The clinical nurse leader role is relatively new. Robert Rosseter, chief communications officer for the American Association of Colleges of Nursing, defines CNLs as advanced generalists who serve as “air traffic controllers” on nursing units. “A CNL evaluates outcomes, performs risk analysis, and implements changes in care plans, with the goal of reinforcing patient safety,” says Rosseter.

Units that employ CNLs have been shown to have shorter lengths of stay and readmission rates, decreased fall and infection rates, and lower RN turnover.

“We’re using clinical nursing leaders to focus on quality measures,” says Zastocki. “They help to examine the intricacies of a patient’s condition, help them prepare for transition to another care environment, and coordinate their care while they are here in the hospital.”


Advanced practice nurses

The explosion of APNs is a direct response to the need for nurses to play a greater role in healthcare. “We have a real shortage of primary care providers,” says Cheryl Peterson, MSN, RN, director of nursing practice and policy for the American Nurses Association. “Way too many people end up in emergency rooms with primary care needs.”

Hospital leaders should embrace APNs, says Peterson. “It’s the right thing to do to increase access to care.”

“Using practitioners such as NPs and PAs allows doctors to do even more with the education and training they received,” says Hassmiller. “My mother just had surgery and we only met the surgeon once, right before surgery, and he caught me in the hall afterward to say that the surgery went well. She was cared for [on behalf of the surgeon] by an office-based physician assistant ahead of time and then all follow-up care was provided by a nurse practitioner, with home care provided by a home healthcare nurse.

“We never thought anything was amiss with any of this. Everyone working together is what it took to get the job done,” she says. “This is called collaboration. This is how it should be.”

Harnessing the economic power of nursing

Nurses make up the single largest sector of healthcare professionals, but the actual costs of nursing care are unknown because it is billed as room and board. That may soon change.

“Nursing is invisible at the payment and policy level,” says John Welton, PhD, RN, professor and dean of the School of Nursing and Health Sciences at Florida Southern College. “We don’t put a price on it, so it has no economic value.”

Welton and his colleagues have studied the potential of a nursing intensity billing model and have been calling for a substantial change in how healthcare institutions cost, bill, and reimburse nursing care. The industry can’t answer the question about nursing value until it starts tracking how much nursing time and costs are expended for each patient, Welton says.

“We treat every patient the same in the billing system and charge it as a daily room rate. That hides the variability in nursing care hours and types of nurses caring for patients,” he says. “In the future we will be in a much more competitive environment with a much greater emphasis on value. So what is the added value that nurses bring to the bedside and what are consumers willing to pay for that care?”

More experienced nurses should be caring for the patients with the most complex problems, says Welton. “If we truly want to improve healthcare and get a better value for our dollar, we need to separate out nursing into its own cost center.”

Healthcare executives will be able to benchmark performance across healthcare settings. Payers will have better information about nursing care, which could lead to a more equitable payment system, and consumers will benefit by knowing where the best nursing care is being delivered.

“It just makes good business sense to get better information about how nurses affect each patient, identify the costs per patient, examine how individual nurses improve outcomes of care, and then align the billing and payment to reflect best nursing care value,” Welton says.

Source: HealthLeaders Media

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