Journal of Nursing Administration:
Departments: Spotlight on Transitions
Author Affiliation: Principal, Joan Ellis Beglinger Designing Tomorrow, Madison, Wisconsin, and Consultant, Tim Porter O’Grady Associates, Inc, Atlanta, Georgia.
The author declares no conflicts of interest.
Correspondence: Ms Beglinger, 3528 Timber Lane, Cross Plains, WI 53528 (email@example.com).
This department column is devoted to posing insights about transitions through, to and from, administrative roles in nursing. The unprecedented challenges posed by healthcare reform present new and complex challenges for nurse executives. The author discusses transitions in thinking and approach that will be needed to respond to the challenges and keep the focus on nursing practice excellence and patient outcomes.
Although most of the details have yet to emerge, nurse executives must think and act with collective urgency to meet the demands of healthcare reform and redesign. It is clear the future will be focused on outcomes, and the evidence is clear; outcomes are managed at the point of care, enabled through the leadership of the nurse executive. Ownership and engagement are required at all levels. Nurse executives are challenged to think and act in new and different ways.
The Institute of Medicine report on the Future of Nursing1 has clearly articulated that this is a time of unprecedented opportunity for nursing. There are unequivocal recommendations that nurses must be integral not only in the delivery of care, but also in the design of the healthcare system.1 Nurse executives must lead in all realms as changes are contemplated, formed, and implemented.
Evidence is mounting that this is also a time of unparalleled risk for nursing and, consequently, for patient care. The looming prospect of provider payment reforms and the accelerated pace of change and innovation have hospital and nurse executives looking for quick expense reductions. Healthcare does not have a strong history of learning from past mistakes of failed redesign. In the absence of new thinking, leaders often revert to failed methods of the past, betting that the outcomes will be different. Anxiety and fear may not yield to the evidence, unless sound alternatives are presented, thus the challenge for nurse executives.
Call to Action
These challenges pose an urgent call to all nurse leaders for action. Individually and collectively, we must be courageous and principled as we participate in system redesign. We are eager to contribute to generating solutions that will result in a healthcare system that actually improves population health. At the same time, we must insist that the growing body of evidence that links nurse staffing and practice environments to patient outcomes is not ignored.2,3 Specific areas that require our focused attention are as follows:
* Ensuring we continue to strengthen practice environments with the shared governance structures that afford direct care nurses a position of ownership of their practice and provide them with a meaningful voice in the organizations in which they practice. These structures ensure the autonomy integral to all professional disciplines and are characterized by flat management structures, collegial partnerships between managers and direct care nurses, and investment in the continuous learning and development that are the life blood of knowledge workers. There is a significant difference between investment and cost. That difference is not well understood by too many who are in a position to make decisions that can destroy the capacity to produce exceptional outcomes. Alarm bells should sound, and red flags should go up any time the word ”discretionary“ is linked to investments in knowledge acquisition and skill development and to the time clinicians must spend at decision making tables, examining the practice evidence and defining how care will be delivered and improved. Wise leaders understand that it is only through these investments that exceptional patient outcomes and exceptional patient experience can be achieved. It is our responsibility to make the case that now is the time for greater investment in those who will produce the outcomes against which we will be measured.
* Insisting that the substantial body of knowledge linking nurse staffing to patient outcomes continues to drive our resource decisions. There is perhaps no more misused word in healthcare today than ”benchmarking.“ Time and time again we see comparisons of staffing numbers among organizations referred to as benchmarking. The purpose of benchmarking is seeking to learn best practices from others as an improvement strategy. To undertake benchmarking in a meaningful way, one must understand the resource inputs of the comparable organization, as well as the outcomes being produced in every dimension of interest. If we are to compare the nursing hours of care for a given patient population, we also need to understand the clinical outcomes being produced, the level of patient satisfaction, and the level of nurse and physician satisfaction. Variables such as the patient length of stay, support structures in place, and even the geographic design of the care environment are also significant. Today’s benchmarking is often simply identifying the average hours of nursing care in any database as the desired target. We must challenge this strategy and approach as nurse leaders. Are we not, after all, embarking on healthcare reform, in part, because our outcomes are not generally exceptional? What evidence is there to support that taking staffing to the average, which is simply a function of administrative decisions that have been made by others, will lead us to an improved state? This may unwittingly end up being a race to the bottom. There promises to be tremendous pressure to reduce the hours of nursing care, despite the evidence and despite the complexity and acuity of our aging patient population. This will not occur out of malice, but rather a sense of urgency, fear, and a lack of real understanding of the impact it will have on patient care. It is our responsibility, as nurses and as leaders, to bring forward the evidence and to articulate the far greater cost of disengaged staff, high turnover, agency utilization, poor clinical outcomes, and patient dissatisfaction with the healthcare experience. If we look to the nurse shortages of the past, it becomes clear that they were created, in part, because administrative responses to declining reimbursement created unworkable practice environments.
The future of healthcare and the future of nursing are inextricably interwoven. Reduced cost will be achieved through highly skilled, engaged professionals working in partnership with patients within well-defined, effective systems of care. Access to primary care will be expanded; chronic disease will be well managed, and acute episodes of care will result in discharged patients being well prepared to manage their health as they transition to home. Reduced cost will not be achieved by asking nurses, who are already grappling with the magnitude and complexity of their patients’ care requirements, to do more with less. At the top of the list of costs to be eliminated must be the cost of bad decisions.
1. Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press; 2011.
2. Aiken LH, Cimiotti JP, Sloane DM, Smith HL, Neff DF. Effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments. Med Care. 2011; 49: 1047–1053.
3. Needleman J, Buerhaus P, Pankratz VS, Leibson CL, Stevens SR, Harris M. Nurse staffing and inpatient hospital mortality. N Engl J Med. 2011;364: 1037–1045.