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  1. Starting a new thread to encourage RN's to post helpful hints in caring for COVID-19 patients, With permission of Spotangel MSN, DNP, RN, APRN, NP, re-posting her advice from Texas Governors thread, Karen
  2. The nursing profession has evolved over the years which includes working conditions, duties, skills, educational and practice standards, technology, regulations and policies. Many of these changes occurred as the result of research and evidence-based practice. There has always been a focus on patient safety and decreasing and preventing medication errors. Research has shown working 12 hour shifts often effect nurses’ critical thinking, productivity and job satisfaction which impacts patient care and patient safety. This Article will discuss how the Lewin change model can be used to implement changes to the current practice of hospital staff nurses working 12 hour shifts. The primary people effected are hospital staff nurses, patients, nurse managers and nursing supervisors. What are Goals of the Change? Decrease nurse fatigue Optimize the nurse’s critical thinking Increase productivity Increase job satisfaction which will result in reduced rate of medication errors Improve quality of patient care According to Kearney-Nunnery (2016) Kurt Lewin’s change model consisted of three main components: unfreezing, moving, and refreezing. “To achieve change, the restraining forces must be weakened and the driving forces strengthened” (Kearney-Nunnery, 2016, p.183). Restraining forces are forces that resist change. Pertaining to the 12 hour shifts, restraining forces for nurses include ability to “work less hours and days, and potentially have an improved work/life balance” (Rollins, 2015, p.162), (Ball, Dall’Ora & Griffiths, 2015). Restraining forces for hospitals include paying less overtime, less dependency on agency nurses and scheduling coverage for only 2 shifts. Patients and families tend to like having the same nurse for the longer part of the day and “having fewer names and faces to remember” (Rollins, 2015, p. 162). Driving forces promote change and includes “desire for more novel, effective, efficient or merely different activities” (Kearney-Nunnery, 2016, p.183). There are several driving forces indicating the need for change. Nurses often work longer than the 12 hour shift (Scott, Rogers, Hwang & Zhang, 2006). A greater number of nurses working 12 hour shifts report burnout and plans to leave their job compared to nurses working 8 hour shifts (Rollins, 2015) and often work 2 or more 12 hour shifts in a roll. Nurses, especially older nurses-who are more experienced, report physical and emotional exhaustion after working 12 hour shifts, “aches and pains, sleep deprivation” (Rollins, 2015, p. 162). Overtime and working consecutive 12 hour shifts further increases the rate of fatigue and burnout which decreases patient satisfaction with the quality of care received (Stimpfel, 2012). Nurses also report poor quality of care provided, decreased patient safety and more duties left undone when working 12 hours or more (Ball et. al., 2015). According to Stimpfel, Sloane and Aiken (2012) when a greater number of “nurses working more than thirteen hours on their last shift, higher percentages of patients reported that they would not recommend the hospital to friends and family” (p. 2506). Also studies have shown working more than 12 hours increases the risk for medication errors (Scott, 2006), nurse burnout, job dissatisfaction and intention to leave the job (Stimpfel et. al. 2012, page 2504). How to Bring about Change Nurses and hospital administrators must review both research and their hospital’s collected data from patient surveys, circumstances surrounding medication error reports and patient safety and nurse/employee incident reports and complaints related to quality of care filed. Executive administrators must be willing to review the financial impact of the driving forces verses the financial benefits from the restraining forces over the past several years and be open to seeing future trends. This is the unfreezing stage of the Lewin change model. During the moving stage, “change objectives must be selected with consideration of activities for progressive change” (Kearney-Nunnery, 2016, p.185). “Organizations such as the Institute of Medicine and the American Nurses Association have made or supported recommendation to minimize fatigue and improve patient safety” (Rollins, 2015, p. 164). Nurses need food, hydration and proper rest in order to maintain optimal productivity (critical thinking, alertness, and providing quality nursing care and ensuring patient safety) on the job. As people advance in age, energy level and stamina decreases. Viable options for change include limiting overtime requirements, ensuring nurses receive uninterrupted breaks, making meal options available at all times, providing eight hour shifts as well as split shifts for nurses who want to work part-time (Geiger-Brown & Trinkoff, 2010). Nurses can work within organizations, such as the American Nurses Association to lobby for legislation to promote change. Nurses and nursing supervisors can work with hospital administrators in implementing and maintaining the changes. Over a period of time, staff and administrators will adjust to, get in the habit of and maintain (refreezing) the change. This will lead to improvements in nurses’ job performance and patient satisfaction. In summary, nursing has evolved over the years including the scheduling of work hours for the nurse. Twelve hour shifts has become popular with both nurses and hospital administrators but research has shown working 12 or more hours has adverse effects on the quality of nursing care provided, patient safety and patient satisfaction largely as well as nurse fatigue and burnout. The Lewin change model can be used to bring about changes to nurse schedules which positively impacts the nurse’s job performance and job satisfaction which increases patient safety and patient satisfaction. Effect of the 12 hour shift on patient care and the nurse.docx
  3. Nurse Beth

    CEO Says More Nurses Won't Improve Care

    The fight for safe patient staffing is being waged right now in Illinois. The Safe Patient Limits Act, HB 2604, which calls for safe nurse-patient ratios, will be voted on this week in Springfield, Illinois in the House of Representatives. The bill requires: One nurse for every four patients in Med Surg One nurse for every three patients in Stepdown, ED, or intermediate care units One nurse for every two patients in ICU If it passes, Illinois will be on its way to joining California as the only state with mandated safe staffing (nurse-patient ratios). It won’t pass if the American Hospital Association (AHA), hospital CEOs, and even the American Nurses Association (ANA) have their way. Doris Carroll, Vice President of the Illinois Nurses Association, flatly states that “Not one CEO (in Illinois) is in favor of the safe staffing legislation”. It has a good chance of passing if Illinois nurses call their legislators (see below) today. Mark Gridley, CEO of FHN Memorial Hospital, raised the ire of Illinois nurses in a public statement opposing the bill. He used predictable arguments and unsubstantiated claims that are intended to mislead nurses and the public. More Nurses Won’t Improve Patient Care The CEO, who says that he worked as an LPN prior to becoming a CEO, declared that “increasing the number of nurses won’t improve care”. Does Mr. Gridley really believe that fewer nurses result in improved care? At what ratio does he determine that "more nurses won't improve care"? One nurse to six patients? One nurse to eight patients? It has been proven over and over in the literature that lower ratios are associated with significantly lower mortality. It is concerning that evidence can be ignored in lieu of sweeping statements. Especially when rhetoric is valued over evidence by a hospital CEO. There are Not Enough Nurses According to the Illinois Center for Nursing Workforce Survey, there were 176,974 registered nurses in Illinois in 2016. According to the federal Health Services and Resources Administration (HRSA), an agency of the US Department of Health and Human Services, 139, 400 registered nurses will be needed in Illinois by 2030. HRSA projects an overage of registered nurses in Illinois, yet the CEO of Fairhaven hospital claims that Illinois has an “anticipated shortage of 21,000 nurses in 2020”. While different numbers and predictive models can be used to support different arguments, mandated safe staffing ratios in California not only improved staffing, it alleviated the severe nursing shortage at the time (Aiken,2010). There’s Not Enough Money Mark Gridley then states that staff would have to be cut in other areas. This is intended to frighten nurses, and perhaps to serve as a veiled warning, but it is unfounded. HB 2604 specifically prohibits cutting staff. Dall and colleagues (2009) determined that ” hospitals with greater nurse staffing levels resulted in cost savings due to reductions in hospital-acquired infections, shorter lengths of stay and improved productivity”. Hospitals with a higher nurse-patient ratio that focus on retaining nurses have a competitive edge. Nurses report less burnout and job dissatisfaction when the quality of care is higher, as in hospitals with safe staffing ratios (Everhart, et al., 2013). Staffing Committees Are All We Need “Illinois already has laws...to ensure safe, optimum nurse staffing levels”, Mark Gridley. Illinois nurses strongly disagree. Seven states, including Illinois, have legislation in place that requires hospitals to have staffing committees. Staffing committees are to include bedside nurses as well as management to create staffing plans specific to each unit. Staffing plans are to take into consideration: Intensity of patient care Admissions, discharges and transfers Level of experience of staff Physical layout of the unit Availability of resources (ancillary staff, technology) It sounds good in theory, and theory is where it remains. According to the ANA-Illinois, over 70% of nurses say the staffing plans are not being used. Nurses say that staffing committee meetings lack accountability, are hijacked by management, are not taken seriously, and serve as lip service only. Hospitals with staffing committees are free to staff 1 RN for every 6-7 Med Surg patients, or 8, or however many they see fit. Ratios Are Inflexible Ratios are not inflexible. On the contrary, nothing in the Safe Patient Limits Act precludes the use of patient acuity systems and nothing precludes a facility from assigning fewer patients that the Act requires. As an example of how flexible ratios are, a Med Surg nurse in a mid-sized CA hospital who is assigned a patient with continuous bladder irrigation will only have 3 patients, even though ratios call for 5 patients. Ratios are not inflexible unless hospital administrators want them to be. It would be interesting to know the staffing assignments at FHN Memorial, and for Mark Gridley to give examples of the staffing flexibility in his facility. Hospitals Will Close or Reduce Services Critics say hospitals will close or reduce services. Acquisitions, takeovers, mergers and closures are taking place in all of the 49 states that do not have mandated nurse-patient ratios. Hospitals all over the country have merged or closed due to decreased reimbursement and low patient volume, for example, a 25-bed hospital in Celine, TN, that recently closed on March 1, 2019. According to Linda Aiken “There is no evidence that hospitals closed as a result of the legislation (in California). Indeed, there is very good scientific evidence that staffing improved even in safety-net hospitals that long had poor staffing.” Consider this- if the surgery department had surgeries scheduled but didn’t have adequate nursing staff, should they cancel cases? The answer is yes. Only safe services should be provided. Illinois nurses, the time to speak up is today. If you are reading this, call your legislator now. Leave a voicemail. You are a constituent, and your opinion matters. Call to Action The Illinois Who is your State Rep? Follow this link and enter your address information into this link: https://bit.ly/2FtE2A3. Here is a script (thanks to Doris Carroll): Hello Representative _________, My name is ___________, I have been a constituent in your district for ___ years. I’ve been a nurse for ___ years. I am calling today to ask that you please vote Yes on the Safe Patient Limits act, House Bill 2604, which ensures that there is a maximum number of patients any one nurse can be assigned depending on her unit. Unsafe staffing costs patients their lives. Please put patients over profits. Please Vote Yes on HB 2604! References Aiken, L. H., Sloane, D. M., Cimiotti, J. P., Clarke, S. P., Flynn, L., Seago, J. A., ... & Smith, H. L. (2010). Implications of the California nurse staffing mandate for other states. Health services research, 45(4), 904-921. Dall T, Chen Y, Seifert R, Maddox P, Hagan P. The economic value of professional nursing. Medical Care. 2009;47(1):97–104. [PubMed] [Google Scholar] Everhart, D., Neff, D., Al-Amin, M., Nogle, J., & Weech-Maldonado, R. (2013). The effects of nurse staffing on hospital financial performance: Competitive versus less competitive markets. Health care management review, 38(2), 146. U. S. Department of Health and Human Services, Health Resources and Services Administration (201) Supply and Demand Projections of the Nursing Workforce:2014-2030.
  4. Advocating for our patients is what we do. However, how do we learn to do this effectively amid the barriers? Alene Nitzky, PhD, RN, OCN states it simply, "Many nurses think of advocacy as the most important role we play in patient care. We need to remember that to best serve patients, we must have our own house in order. That house includes the other healthcare professionals with whom we and our patients interact, as well as the organizations providing those services and the policies and legislation that influence them." So, communication is the first step - how do we effectively communicate our concerns to members of the healthcare team? Here are some tips: Decide on a goal. Do you know what you want before you start the conversation? If not, do you have all the facts necessary to assist with decision-making? Start your conversation with patient-centered language; "in the patient's best interest, I think we should ........." Or, "Mrs Smith and I were talking earlier today and she said she would not want a feeding tube." Learn your facility's policies on communication. How are you to contact another care team member? A phone call, paging system or something else? SBAR is another tool to facilitate communication: S = Situation (a concise statement of the problem) B = Background (pertinent and brief information related to the situation) A = Assessment (analysis and considerations of options — what you found/think) R = Recommendation (action requested/recommended — what you want) You try to communicate but.... What if the other care team member disagrees with you or just doesn't respond in an appropriate manner? Again, reference your policy manual. Also, be aware of cultural differences. Our healthcare team is very diverse; we come from all parts of the world and while we work in the US, we all have deeply ingrained thoughts and cultural norms that might differ from others on the team. Consider this when communicating. Try repeating your request in a different manner, use different words. Be precise as to what you want for the outcome. "For example, in some cultures, individuals refrain from being assertive or challenging opinions openly. As a result, it is very difficult for nurses from such cultures to speak up if they see something wrong. In cultures such as these, nurses may communicate their concern in very indirect ways. Culture barriers can also hinder nonverbal communication. For example, some cultures ascribe specific meaning to eye contact, certain facial expressions, touch, tone of voice, and nods of the head." Above all, mutual respect is the key to successful communication. So, what happens if you can't resolve an issue? Several nurses recently have suffered dire consequences when they have advocated for their patients. Julie Stephens was a 20 year employee of a hospital and she was fired when she reported unsafe conditions at her facility. And nurse Julie Griffin was fired when she refused to accept a third ICU patient as she felt this wasn't safe care due to not having enough monitors to monitor all patients. Some tips when advocating at work: Utilize solid communication skills and be clear in your expectations Document your interactions whether they be with another member of the healthcare team or management Know your chain of command Utilize your legislature and national organizations too Advocating for our patients is always our first priority. However, it's equally important that we advocate in a way that produces results. What tips do you use to advocate for your patients? References: From Our Readers, Practical Approaches to Patient Advocacy Barriers
  5. J.Adderton

    Is Concierge Medicine Elusive for Most?

    Concierge medicine, also referred to as retainer, boutique, platinum and membership medicine, has gained momentum over the last 5-10 years. There are different models with the same basic concept…. patients pay an additional fee for physician care with added benefits. Concierge physicians are typically in primary or internal medicine but may include some specialties. The cost depends on the age and health of the patient and the services that are provided Limited Statistic According to the Specialty Concierge Medicine Polling Data (2018), there are 5,000 to 6,000 practicing private medicine physicians. However, these numbers lack accuracy since there is no federal registry or national database to document physicians practicing under this care model. Statistically, concierge physicians: See an average of 6 to 8 patients a day Earn a salary range of $150.000 to $300,000 and more Typically maintain a patient roster of fewer than 500 patients Usually accept health insurance and charge an additional fee Keep in mind, statistics on concierge services are limited, widely varied and lack reliability. What is the Patient Draw? It’s easy to understand the lure of concierge services, especially for those with chronic illnesses. Imagine having access to your doctor 24/7 with guaranteed same day appointments. Your physician may even give you a personal email or cell phone number. Common perks include: Priority and longer appointments House calls and hospital visits Preventative and wellness care No crowded waiting room and long wait times Highly coordinated care with specialists Assistance with insurance claims Some concierge services offer premium or “executive” services. These may include unlimited appointments, all office services covered, transportation, covered diagnostic services and even spa type amenities (i.e. bathrobe, slippers). Surrounding Ethical Issue Concierge services have been controversial and often considered elitist. Let’s take a closer look at these ethical issues: The Haves and the Have-Nots: Does concierge medicine promote a two-tiered health system that favors those who can afford extra services? One concern is further limiting the number of available physicians to care for those unable to afford premier services. According to a recent survey, Americans wait about 24 days to see a new doctor. This is a 30% wait time increase since 2014. Abandonment: Consider a primary care physician with a patient load of 2,500 patients transitioning to concierge practice with only 500 clients. Patient downsizing raises 2 ethical issues of abandonment. Patients can’t pay the retainer will no longer have access to their doctor. Due to a national shortage of primary care physicians, finding a new one may be a challenge. The American Medical Association (AMA) offers specific guidelines for ethical practices in retainer services. This includes ethical standards for the transferring of patients for continuity and the obligation to uphold access to care regardless of ability to pay. Minorities and Cherry Picking: Critics argue minorities are poorly represented in concierge medicine. According to the CMT (2017) practice demographics are reported as 64% suburban clinics, 29% metropolitan and 7% rural practices. There is also concern physicians are “cherry picking” the healthiest patients and leaving sicker patients to be absorbed into traditional primary practices. Ethical Obligation: The Graduate Medical Education Program (GME) financially supports training of physicians in hospital settings. Some argue use of taxpayer dollars in the GME program ethically obligates physicians to care for more patients than in concierge practices. Ethical concerns are also raised regarding physicians using concierge services to “cash out” early in their career. One viewpoint is individuals take spots from medical school applicants who may have practiced in areas benefiting more people. Consumer Drawbacks Patients need to consider the financial drawbacks before using a concierge service. Fees paid to these physicians are not tax deductible. The less expensive services may not use electronic records or other advanced technology. Therefore, patients may need to go elsewhere for some labs and diagnostic tests. Conclusion There are always going to be controversial ethical issues surrounding health insurance and healthcare. As physician and consumer frustration continues to build around the nation’s current health system, the use of concierge services will continue to rise. Share your insight. What experience or ethical concerns do you have with concierge medicine? What is the likelihood you would someday move to this personalized model of care? References: The Future of Healthcare Could be in Concierge Medicine Question: Is Concierge Medicine Ethical? Retainer Practices- American Medical Association Code of Ethics
  6. Shortly after 4pm on Monday, May 6th, nurses, physical therapists, and paramedics at Mercy Health St. Vincent Medical Center in Toledo, Ohio went on strike. The group of workers, represented by the United Auto Workers Union was unable to reach an agreement with hospital management concerning health care costs, on-call regulations, and overtime policies. WCPO in Cincinnati reported that president of the health center, Jeff Dempsey, declined to discuss the plan to replace those on strike. He did, however, report that the facility was prepared to handle the walkout. The hospital said last week that they felt the contract they presented to the workers was generous and included increases to staff’s wages. A Family-Member's Perspective Have you ever wondered what happens to patient care during a strike? Shirley Parrott- Copus, a family member of a Mercy Health St. Vincent Medical Center patient, was interviewed by 13abc about the changes in the care she observed. Shirley said that services had dropped since the strike began. She went on to describe the nurses before the strike as “wonderful.” She stated that the morning after the strike started, she was woken by a nurse who asked her where her dad was because she didn’t know. Shirley was alarmed by this event and worried that they had lost her father. Of course, there are many different reasons for the possible missing patient, but to a family member, a statement like that can impact their ability to trust employees. Parrott-Copus is a nurse herself and stated, Who Cares for the Patients? When facility administrators can see a strike on the horizon, they prepare by calling in non-union travel and agency nurses to fill in for staff. The nurses who step up to work don’t have any connection to the hospital, but probably understand the issues at hand. They usually won’t cross the picket line and try to keep a low profile on the job. Travel agencies warn their nurses that tempers can flare at any time during a strike. They advise staff to travel in pairs, remove their name badge and scrubs in public, and to avoid engaging in conversations about the strike with patients, family members, or hospital staff. During a strike, the work is hard and the hours are long. Many nurses work up to six 12-hour shifts each week. Many agencies require staff to sign a contract agreeing to work up to 72 hours a week if needed. Because the hospital is desperate, they need all hands on deck, but what do these long hours do to patient care? The Impact to Quality Care One study conducted in the state of New York found that patient care suffers during nursing strikes. The effects of strikes between 1984 and 2004 revealed that in-hospital mortality increased nearly twenty percent and readmissions went up by 6.5 percent for those patients who came to the hospital during the strike. The study also estimated that 138 more people died because of the strikes. While patient care continues and nurses from agencies fill in, it’s just not the same as having nurses who are comfortable with the inner workings of the hospital, unit, and even politics of the facility. Other issues such as a sense of ownership might be at play for those who are just there to “fill in” until an agreement is made. What’s the Answer? You might be wondering if there is a better solution. Is it better for nurses to continue working in unsafe and conditions, so that patient care remains at a higher level or should they strike and potentially place their patients at an increased risk for adverse outcomes? We’re not sure if there is a right or wrong answer in this situation. What do you think?
  7. tnbutterfly - Mary

    Celebrate Certified Nurses Day - March 19

    The American Association of Critical-Care Nurses and the AACN Certification Corporation are teaming up with healthcare organizations and hospitals across the country to recognize and celebrate certified nurses for their professionalism, leadership, and commitment to excellence in patient care. To honor and celebrate Certified Nurses Day, several critical care and progressive care nurse were asked by AACN to describe the extensive and diverse benefits of certification. Read a few of the stated benefits below. Validation “What I value most about my certification is the opportunities it’s opened up for me – the respect that I receive from my nursing and non-nursing peers, and the changes I’ve been able to make to the nursing practice at my current and previous organizations. I am a better practitioner because of my certifications,” said Sam Merchant, MBA, BSN, RN, CCRN, PCCN, NE-BC, RN-BC, Progressive Care Unit, University Health System, San Antonio. Excellence “Besides personal satisfaction and a sense of accomplishment, certification validated all of the knowledge and experience I’ve gained working in the ICU for almost 10 years. My certification has made me a more confident nurse, knowing what I’ve been doing for my patients is aligned with national guidelines and standards for excellence in patient care,” said Erica McCartney, BSN, RN, CCRN-CMC, ICU/IMCU resource RN, Swedish Medical Center, Edmonds, Washington. Career Advancement “Certification opened doors for me by allowing my supervisors to trust me enough to teach competencies and mentor new nurses. My supervisors trusted my nursing and clinical judgment enough for me to become a valued resource on our cardiac unit. Certification allowed me the opportunity to climb our clinical nurse ladder, which also provided an additional monetary component,” said Kendra Armstrong, MSN, RN, ACNPC-AG, PCCN, acute care nurse practitioner, Phoebe Putney Memorial Hospital, Albany, Georgia. Pride “Being certified is a validation of my commitment, experience and clinical expertise. I am proud to work along with my fellow certified nurses every day. It is a constant reminder and reassurance to our patients and family members that they are receiving the highest quality care. Certified nurses are determined professionals who invest in their professional and personal growth – they inspire me to be the best,” said Sherley John, MSN, RN, CCRN, clinical nurse, Neurosurgical ICU, North Shore University Hospital, Manhasset, New York. Congratulations and a big thank you to all certified nurses. You deserve to feel very proud! To read more about Certified Nurses Day, please see the complete AACN Press Release. Also view the video below of an interview with Karen Kesten, DNP, APRN.

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