How hospital executives can help strengthen nursing care, save patient lives and improve the bottom line
Strengthen nursing clinical practice as we have outlined on our page about improving Magnet Hospital standards
Improving hospital websites
Hospital and other clinical care executives should take steps to learn what nurses really do, then promote the facilities' nursing to the media, on facility web sites, and in other ways. Hospital nurses play a central role in patient outcomes and cost control. Long-term care institutions are essentially nursing facilities; thus the name "nursing homes." And of course, many urgent care and retail "quick" clinics rely primarily or exclusively on advanced practice nurses. Because your facility's nursing is at least as important as its medicine, nursing deserves to get at least as much attention. In January 2014, Valley Health Services of Herkimer, NY, actually issued a press release to let the community know about the clinical background and plans of the facility's new cardiac rehabilitation nurse, a recent BSN graduate! And as a result a local newspaper, The Telegram, ran a short but helpful story on the nurse's arrival.
Sadly, that kind of effort to promote nursing is rare. The Truth About Nursing's 2012 analysis of the top 17 U.S. hospitals as ranked by U.S. News & World Report also examined the hospitals' websites, and it revealed an almost complete failure to publicize the expertise of nurses. In stark contrast to the attention lavished on physicians and medical care, the sites typically offered little about nursing care or the hospitals' nursing leaders, beyond some basic information directed at recruiting nurses themselves. We searched the websites for information or links to information about nursing from the main, "about us," "patient information," "patient services," and health specialties pages. We found those pages to be devoid of any mention of nursing, except that the bottom of Duke's "about us" page included the header "Nursing," and beneath it the link, "Get information about nursing at Duke." That was almost certainly aimed at prospective nurses, and we doubt many patients would click on it, but at least it did lead to a page with short biographies of the hospital's nursing leaders. A couple hospitals mentioned their membership in the Magnet Recognition Program of the American Nurses Credentialing Center, but those pages were also aimed at prospective nurses, not the patients who might be interested if they knew that research suggested nurses are more likely to save their lives at a Magnet hospital. Typical hospital web pages that were directed at patients were like the extensive "Why Choose Mayo Clinic" page, which had 521 words about the expertise of the Clinic's physicians but not a single word about nursing. The site's discussions about a long list of medical "departments" did not include anything on nursing. Likewise, urgent care and retail clinics did not initially seem eager to acknowledge that their care was mainly provided by nurses, although that seems to have started to change somewhat recently.
Promote nursing within
Executives should also promote nursing within hospital and clinic walls, to physicians, to patients, and to the nurses themselves: some may need reminding of their own importance! Encourage physicians to follow nurses for a few days, just as physicians accompany paramedics in periodic "ride-alongs" in ambulances. Give patients information about what your nurses do and why, the qualifications of your nurses, and the hospital's efforts to strengthen nursing. Download, print and hang our "I Am Your Registered Nurse" poster, which explains a nurse's role in simple terms, so patients and visitors can see it. Adjust forms, records and software so that staff and patients are not compelled to provide the names of physicians when the relevant provider may actually be an advanced practice nurse.
Magnify nurse identifiers
Help your nurses tell everyone who they are. In today's clinical settings, many different staff wear similar uniforms, and in some cases this trend has obscured efforts to replace nurses with cheaper unlicensed personnel. Instead, facilities should encourage nurses to wear distinctive uniforms and use other identifiers, like RN patches. Some have argued persuasively that a true professional does not need a patch with big letters on it. But we think that at this point in the development of public understanding of nursing, nurses need some way to ensure that they receive the credit and blame they deserve, so that awareness of their true role in heath care grows.
Restructure nurses week events
Of course, there is one widespread exception to the general rule of nursing invisibility at hospitals: the annual Nurses Day or Nurses Week in May. However, as we suggested in chapter 7, we are ambivalent about those celebrations. Their heavy reliance on angel imagery undercuts the sense of nurses as skilled professionals, and the events arguably reflect the once-a-year "pat on the head" often given to underpowered jobs as a substitute for real respect and resources. In a June 2011 episode of Nurse Jackie, the main character dismissed the celebrations as "patronizing." If hospitals do observe Nurses Day or Week, they should focus on nursing skill, not hearts and flowers.
Invest in public relations for nursing
Every hospital should have a public relations professional to promote the facility's nurses--their stories, research, and community activities--and to direct media inquiries to nurses when their expertise is called for. Yet we know of only one hospital that has a PR officer who works solely on promoting the nursing profession. If you know of others, please tell us!
Georgia Peirce is the PR person for nursing at Massachusetts General Hospital (MGH). She is not a nurse, but she persuaded the Boston Globe to follow nurses in the hospital and to create one of the best newspaper accounts of nursing practice that we have seen in the last decade. The result was the excellent four-part October 2005 series about MGH ICU nurses, especially a formidable veteran who was training a new nurse, as described in chapters 3 and 4 of our book Saving Lives. Reporter Scott Allen and photographer Michele McDonald followed the nurses intermittently for nine months. Their series, which remains available online, educates society about the vital, skilled, and difficult work that nurses do.
To make the Globe series happen, Peirce spent time picking the right medium and the right writer. She geared her pitch around a high-autonomy area for nursing, the ICU. She focused on nurses in a mentor/apprentice role, so that it would be easier for the reporter to learn what was going on inside their heads. That might otherwise have been difficult, because nurses are still socialized to defer and mask their skills. It took Peirce many weeks to overcome the Globe's skepticism, but after she persuaded the reporter to come observe, he found plenty of interest and he agreed to pursue the story.
Publicize efforts to improve nurses' working conditions
If you're an executive at a health care institution during today's nursing crisis, you probably want to improve the morale of your nursing staff and reduce turnover. The best way to do that is to strengthen nursing. Reversing the denursification of health care can save hospitals money and save patients' lives. But if you publicize what you're doing--as some hospitals have publicized their Magnet status--through advertising and other media, you can also improve understanding of nursing. You will not only present your institution in a positive light but also explain nursing to society and encourage others to take similar steps. That was the effect when Philadelphia's Hahnemann Hospital decided to end the use of nursing assistants and adopt an all-RN staffing model, as the February 2012 coverage of that move in The Philadelphia Inquirer showed. Inquirer reporter Stacey Burling described how the all-RN staffing in a pilot program improved care by enabling better front-line surveillance, thereby reducing the number of bedside emergencies, patient falls, bedsores, and trouble with blood thinners, while at the same time improving patient satisfaction, especially with pain control. That kind of specific information is valuable to nursing because it improves public understanding--and ultimately valuable to patients, who deserve to be monitored and evaluated by nurses.
Specific ideas to consider include
- increasing RN-to-patient ratios and eliminating the use of assistants and "techs" for nursing tasks;
- helping nurses improve their education levels, including through tuition reimbursement, and providing rigorous continuing education and professional development programs;
- empowering nurses by including them in authoritative positions and roles, including on your governing board and ethics committees, as well as in morbidity and mortality conferences, patient-family meetings, and nurse-driven daily rounds;
- creating multi-year nursing residencies;
- providing nurses with more support staff, including aides and clerks;
- ensuring that each unit has 24/7 coverage by clinical nurse specialists; and
- instituting zero tolerance for abuse policies.
There are many more suggestions on the Truth About Nursing's website page about Magnet status. If you implement changes like these, tell the world: you're helping to resolve the nursing crisis.
Matthew McHugh, Lesly A. Kelly, Herbert L. Smith, Evan S. Wu, Jill M. Vanak, and Linda H. Aiken, "Lower Mortality in Magnet Hospitals," Medical Care 51, no. 5 (May 2013): 382-388, http://tinyurl.com/n2a4cer.
Jack Needleman, Peter I. Buerhaus, Maureen Stewart, Katya Zelevinsky, and Soeren Mattke, "Nurse Staffing In Hospitals: Is There A Business Case For Quality?", Health Affairs 25, no. 1 (2006): 204–211, http://tinyurl.com/m7kdm3l.
Stacey Burling, "Hahnemann Boosts Use of Registered Nurses in Bid To Improve Care," Philadelphia Inquirer (February 7, 2012), http://tinyurl.com/6sdfvsj; TAN, "America's Top RN Model?" (February 7, 2012), http://tinyurl.com/pk7kjlc.