Cedars-Sinai Serenity Lounges allow nurses to return to the floor better equipped to manage stress.
Cedars-Sinai Medical Center Serenity Lounges—break rooms equipped with massage chairs, aromatherapy oils, artwork, and other soothing amenities to provide a respite from nurses’ demanding work—are proving to be effective in nurse well-being, staff engagement, and retention rates.
Since the first Serenity Lounge opened during the COVID-19 pandemic, 13 more have opened throughout the medical center, says Melanie Barone, RN, MSN, associate nursing director and co-creator of the Serenity Lounge initiative.
Nurses who used a massage chair in a quiet room for as little as 10 minutes experienced mental and emotional relief, allowing them to return to patient care better equipped to handle the stress, according to a study by Barone and Cedars-Sinai nurse Florida Pagador, RN, MSN, published in the American Journal of Nursing.
"Specifically, we found that using the massage chair for 10 to 20 minutes is the most effective," Barone tells HealthLeaders. "Being in the chair at least 10 minutes shows the most reduction, so you don't need to be in it for 40 minutes. If they use it more than 20 minutes, it didn’t have an impact, which I thought was really interesting."
Nurse retention rates also improved because of the Serenity Lounges, Barone notes.
"Specifically on my unit, prior to implementation of the lounges, our turnover rate was about 4%. After the lounges, we went about six months achieving our goal, which was less than a 2% turnover rate, and we actually went 0% for five months," she says.
Retention rates have seesawed, but not because of stress and burnout, Barone says. "I have lost some staff, but it’s usually because of life circumstances, such as moving back home to take care of family or things along those lines," she says.
Staff engagement scores also have continued to rise since implementing the lounge, she says.
"It was pretty good before—in the 70s—and now we're at 86 for staff engagement and it comes down to the culture here: 'You are supported. Your mind, body, and soul are cared for by our team. We are making it a priority for our staff.'"
A place to recharge
The first Serenity Lounge opened when Pagador expressed a need for relaxation from her demanding duties during breaks.
"I needed a place to relax and recharge, so I pitched the idea and we got to work," she says.
Pagador and Barone found an underused locker area, gave it a makeover, and established the first lounge. As the pandemic continued, more Cedars-Sinai nursing teams created their own Serenity Lounges, which have gathered attention and inquiries from nursing professionals throughout the United States.
Success in well-being, retention, and engagement is due not only to the Serenity Lounges, Barone says, but to the larger care culture at Cedars-Sinai.
"The lounges are important to the staff but also to the leadership team," she says. "It's our way of putting our money where our mouth is and it’s telling our nurses, 'We talked about wanting your wellness and we're holding true to what we have been saying and we want you to use this.'"
The program not only helps solve retention challenges, but also retains the expertise of experienced nurses to avoid knowledge gaps that can occur when nurses retire and new nurses join the care team.
Novant's nurse emeritus program began to take shape during COVID-19 as Novant nurse executives were configuring care teams to have enough critical thinking skills and knowledge, says Akers.
The program officially debuted in January 2022 and has about 15 participants.
"As we are bringing many new grads into our building, we wanted people to be available that had experience, that could work side by side, be there for questions, help with critical thinking, and utilize new equipment," Akers says. "They were not to be a preceptor, because the new grad has a preceptor, but this is in addition to that—to be part of that care team."
"These nurses have the experience, knowledge, and critical thinking skills to work side by side with new nurses," Akers says. "They also bring the ability to help nurses work through problem solving."
Most of the teaching moments are small, confidence-building lessons, she says.
"I ran into one of our emeritus nurses recently who was working with a nurse who was probably a year into her career but had not had the opportunity to start many IVs. She had asked this nurse emeritus to go in and start the IV for her, but instead of doing so, the nurse emeritus went to the bedside and walked her through the process," she says. "This [newer] nurse did a fabulous job, felt more confident, and got the experience. That nurse emeritus helped her to get to that point."
"The other thing I love is seeing the education that the emeritus nurses are providing to the team members on the floor," Akers says. "They find new creative ways to educate and bring real-life situations that could occur with the specific population that they're working with."
Such guidance furthers the program's goal of helping less-experienced nurses successfully grow into, and find satisfaction from, their job.
"The nurse emeritus program works for retention," Akers says.
The program is primarily evaluated through performance reviews and direct team member feedback. And while Novant has observed a decrease in turnover across all of the units that participate in the emeritus nurse program, the program is just one portion of the health system's retention efforts, so it's unable to assign a specific cost savings or retention rate to the presence of emeritus nurses, according to the hospital.
A solid background
All of the emeritus nurses were bedside RNs at one time, Akers says, and bring at least a required decade of nursing experience to their roles as coaches and mentors.
"Some of them have been nurse leaders," she says. "We've got a real variety of where they retired from, or where they were transitioning their career into an emeritus nurse role, so we have all types."
"All of the [emeritus nurses] are working in the specialty that they worked in for the majority of their career," Akers says, "so if they've got a strong cardiac background, they're working on our cardiac floors or if they have a strong neuro background, they're working with our neuro teams."
Emeritus nurses are typically scheduled in four-hour shifts on their chosen workdays, but they can work longer or shorter hours if they prefer, Akers says. Their compensation is based on years of experience.
Novant recruits by posting the emeritus positions to online employment sites, but most of the participants have been recruited by word of mouth, Akers says.
"This is a way for them to remain part of the care team, and to have an impact on the care we're delivering and an impact on the community they're living in," Akers says, "so it’' just as fulfilling for the nurse emeritus as it is for the team itself."
'Go-to person'
Neurosurgery nurse Elizabeth Emshwiller, who retired from Novant after about 37 years of nursing, enjoyed two years of a relaxed retirement before she felt compelled to join the emeritus program about a year ago to coach and give less-experienced nurses a guiding hand.
"I coach, inspire, and mentor, and whatever needs to be done to educate the staff," she explains. "I am not at the bedside giving medicines; I do not have a patient assignment; I am not the primary care nurse for any patient; I do not fill in when there's a call-in. I am here for the coaching, inspiring, and mentoring."
Nurses who encounter a situation where they need assistance, or simple affirmation that they're providing the correct treatment, can quickly summon Emshwiller by facility phone.
"I'm a troubleshooter, a problem solver, and the go-to person on the floor," she says.
Having that "go-to person" can make all the difference for an inexperienced nurse, Emshwiller says.
"I remember when I was in their position, just graduating from school, and how I felt I wish there was someone to bolster me up," she says. "It definitely gives them confidence, and I'm hoping because of that, we won't lose as many nurses because there is somebody who can support and help them."
The new center joins more than 40 other state nursing workforce coalitions working to increase the nursing labor pool.
Kansas healthcare has a new ally in efforts to address shortages of nurses and nursing faculty: the Kansas Nursing Workforce Center.
The center, housed at the University of Kansas (KU) School of Nursing, joins more than 40 other state nurse workforce entities engaged in increasing the nursing labor pool to resolve the critical nursing shortage.
"Statistics show how critical the situation is," said Sally L. Maliski, PhD, FAAN, dean of KU School of Nursing. "The Kansas Department of Labor’s 2022 Occupational Outlook report shows that by 2026, we will need more than 28,000 nursing assistants, 18,000 registered nurses, and 6,000 home health aides. Rural Kansas hospitals are facing nursing shortages that could mean hospital closures."
"As we saw the growing crisis of nurse and nurse educator shortages, we knew something had to be done to address this in a unified and collaborative manner. Also, Kansas was one of only 10 states that did not have a nursing workforce center to help address this critical issue for Kansans," she said.
Like other state nursing workforce centers, Kansas will collaborate with employers, schools, professional associations, government agencies, and other stakeholders to strengthen the state’s nursing workforce by examining and analyzing the supply, demand, educational pathways, and demographics of nurses, while also researching methods to develop and sustain the existing nursing workforce.
State nursing workforce centers also educate organizations and policymakers about issues and policies affecting nurses by collecting and analyzing data, publishing reports and relevant information, and recommending changes necessary to resolve the nursing shortage.
The Kansas center’s focus areas are:
Support how nurses lead in all work settings
Health and well-being of nurses individually and as part of the care team
Approaches used to build, sustain, and retain the nursing workforce
Best practices for optimal patient care experiences
Optimal ways to deliver improved or new care to patients
The center is currently forming its advisory board and developing nursing data dashboards.
Amy Garcia, DNP, RN, FAAN, associate clinical professor at KU School of Nursing, will be the newest center’s director.
"The Kansas Nursing Workforce Center will do things that matter," Garcia said. "We will help people find their pathway to becoming a nurse. We will develop programs to help nurses find joy in their work. We will study the supply of, and demand for, nurses and provide reports to help communities find and keep the nurses they need. And we will convene schools, employers, associations, and government to find better ideas to strengthen nursing and resolve the ongoing shortage of nurses."
While KU School of Nursing has provided initial financial and operational support, the center will seek additional funding, including research and program grants, to operate.
"People trust nurses to be there when they are sick, injured, or simply trying to be healthy," Garcia said. "Nurses care for us at the beginning and the end of life. Every Kansan should have access to high-quality nursing care, and nurses should have access to the education and support they need to excel in their jobs."
For example, virtual reality’s simulation systems provide nursing students with tailored, real-world situations to let them safely develop their skills in caring for patients; in management, tech is used for staffing and scheduling; and clinically, AI is used in venipuncture, where it scans the patient’s arm and identifies the best vein for an IV more than 90% of the time, Benton says.
These three stories from HealthLeaders illustrate how nurses at hospitals and health systems around the country are embracing the advancements that technology and AI can provide:
The challenge to effectively train nurses without enough preceptors led Singing River Health System to turn to technology to get the job done.
Singing River Health, a community-based, nonprofit healthcare provider for the Mississippi Gulf Coast, piloted the customized Elemeno Health workforce empowerment app at its Pascagoula hospital a little more than a year ago for nurse training and orientation and recently deployed it in numerous departments throughout its entire health system, says Susan Russell, MSN, RN CCRN-CSC, the health system’s chief nursing officer.
The platform provides nurses with a resource hub they can consult for bedside care by delivering hospital best practices in readily digestible resource formats such as interactive guides, how-to video clips, concise updates, and intuitive checklists.
"With high turnover rates, it's been an enormous challenge to get people in and get them trained because we have less people with experience to help train new nurses," Russell says. "With the app, we’re able to replicate the best preceptor you ever had and have them available as many times or anytime you need it," she says.
"Say I am that less-experienced nurse on night shift and I'm not familiar with gastric tubes. I learned virtually in school but maybe I just haven't seen it. Theoretically, you would have a preceptor," she says. "That's what we're able to get with this [technology]. Where we used to lean on human resources is now available in electronic format."
HCA Healthcare nurses are using ever-developing technology that has enhanced communication, decreased administrative burden, and provides skill development—all with the goal of improving patient care, says Sammie Mosier, DHA, MBA, BSN, NE-BC, CMSRN, senior vice president and chief nurse executive.
"One we have implemented very wide scale is our iMobile platform where smartphones are deployed to caregivers, or nurses and beyond, to improve communications. It has secure text messaging, so they can send that without worry," Mosier says.
"Obviously, they can make phone calls, but then the platform also has the ability to provide some updates from our EHR so they get those alerts directly to their phone. Any critical labs for the patient or other necessary information are right there at their fingertips," she says. "Our nurses love that technology, and it has enhanced communication among the care team."
HCA has continued to invest in that platform to improve workload for other areas, Mosier says.
"One example that we did last year was wound care imaging, so that after a nurse takes the photo, it's a seamless integration with our EHR. Prior to that, nurses had to take a photo, print it off, and scan it in, which took about 20 minutes per image," she says. "It removes time for administrative tasks so the nurse can focus on patients."
What began as an innovative way to monitor and care for COVID-19 patients at the height of the pandemic is evolving into a growing virtual nursing program at Atrium Health.
The North Carolina-based health system, now part of Advocate Health, launched its virtual nursing program in March 2021 when, like other health systems, nurses struggled to meet staffing demands.
Nurses loved it, patients loved it, and the health system noticed positive outcomes: decreased medication errors, decreased falls, increased patient satisfaction, and more, says Patricia Mook, MSN, RN, NEA-BC, CAHIMS, FAONL, vice president of nursing operations, professional development and practice.
"The virtual nurse allows for early recognition of any changes in patient status, so attempting to get up would certainly be among those things we’re watching for," she says. "It has also provided us an earlier notification of when the rapid response team needs to engage, and in instances where the patient has coded."
Atrium Health has seen a 56% reduction in the number of call bell responses, and patient experience scores have risen dramatically, Mook says.
"It’s also useful in helping avoid mistakes. If you have a novice nurse on the floor, having an experienced nurse ‘in the room’ with them via video can be a huge comfort and ensure that all elements of care are provided appropriately," she says. "It truly has proven to be an additional layer of support to enhance patient care and outcomes."
With more than 100 million Americans lacking access to primary care, employing more nurse practitioners (NPs) and allowing them to practice at the top of their license is critical to making healthcare more accessible in rural areas, NP leaders say.
NPs could ease "care deserts" created by physician shortages and rural hospital closings. Nearly 80% of rural U.S. counties are medical deserts, according to the NRHA. About 35% of all U.S. counties are "total maternity deserts"—no access to prenatal or delivery services—and another 54% are considered partial deserts, which equates to 7 million women without access to maternity care, according to the March of Dimes.
"It is definitely a need in rural health that we get providers out in every community," Kapu says.
Growing in number
The demand for NPs is growing and their role is expanding, thanks in part to an aging U.S. population, increasing infectious diseases, rising chronic diseases, and fewer physicians, the AANP says.
The percentage of rural physicians has declined—12.8% from 2008 to 2016. But the percentage of NPs increased 17.6% during that same time period, according to a 2020 study.
"We're growing at a rate of about 9% a year," Kapu says. "We are up to more than 355,000 nurse practitioners across the U.S. today, and we are estimated to grow by 46% by the year 2031."
Nearly 90% of NPs are certified in an area of primary care and 70.3% of all NPs deliver primary care, according to the AANP, with 83.2% of full-time NPs seeing Medicare patients and 82% seeing Medicaid patients. Additionally, nearly half of all rural primary care practices have at least one NP, according to the NRHA.
A well-rounded approach to healthcare
NPs' holistic, wellness-centered approach to primary healthcare—health promotion, prevention, and chronic disease management—is particularly beneficial to rural patients who must travel long distances when illness requires acute care.
"One really valuable thing they bring to rural health is the approach to healthcare, which differs a bit from the medical model," says Michele Reisinger, DNP, APRN, FNPC, a working NP and assistant professor of doctoral nursing at Washburn University in Topeka, Kansas. "Nurse practitioners are trained to look comprehensively at the individual."
NPs are well positioned for primary care roles because of their education and training, says Reisinger, who has helped obtain an advanced educational nursing workforce grant centered on educating nurse practitioners for rural practice.
"When we train them as nurse practitioners, we train them to manage chronic disease states; we train them to be experts in promoting health and wellness [as opposed] to an urban setting where they may work only in urgent care … or have a very targeted education in cardiology or neurology," Reisinger says.
Instead, rural nurses treat the spectrum of pregnant women, infants, children, adults, and geriatric patients, along with entire families, she says.
"Nurse practitioners in rural areas wear many hats," she says. "They may be seeing primary care patients; they may be tasked with extended care rounds in nursing home facilities, which requires extensive geriatric management; or they may be in a setting that requires knowledge of trauma. So, we try to prepare them in a way that is global in that manner."
Working closely with patients allows NPs to create collaborative prevention plans to help patients make lifestyle changes and health choices that can stave off chronic disease and keep them out of the emergency department, Kapu says.
"We know that timely access to care, particularly preventative care, is crucial to the early detection of health issues," Kapu says. "It has a huge impact on the mitigation of healthcare cost, and so important to health and well-being overall, and whenever that care is delayed, we know that individuals face a greater risk for complications for not following up on chronic diseases."
Such preventive care makes a difference to rural patients, Kapu says. "Many large-scale reliable studies have shown that we have a tremendous impact on the reduction of unnecessary emergency department visits," she says.
Breaking down barriers
Despite the advantages that NPs can bring to rural, underserved areas, barriers continue to limit them from working at the top of their license, Kapu says.
For example, even though more than half of U.S. states have granted NPs full practice authority (FPA)—which allows them to evaluate and diagnose patients, order and interpret diagnostic tests, and initiate and manage treatments under the exclusive licensure authority of the state board of nursing—nearly as many states make it illegal for NPs to practice their profession without a collaborative agreement with a physician.
The American Medical Association (AMA) and other physician groups accuse FPA of "scope creep" and charge that nonphysicians practicing medicine is a threat to patient safety. At its annual meeting in June, the AMA passed a policy amendment calling for advanced practice RNs (APRN) to be licensed and regulated jointly by the state medical and nursing boards. Nursing groups denounced the policy amendment.
States that have embraced FPA have increased their nursing workforce and helped ease care deserts, Kapu says. When Arizona enacted FPA in 2001, the NP workforce doubled across that state within five years and grew by 70% in rural areas, and North Dakota's adoption in 2011 saw its nursing workforce grow by 83% within six years, she says.
Some barriers are being reconsidered. The Improving Care and Access to Nurses Act (ICAN) was reintroduced in the U.S. Senate in April and would allow NPs, physician assistants, and other APRNs to provide particular services under Medicare and Medicaid. ICAN would, among other things, authorize NPs to order and supervise cardiac and pulmonary rehabilitation, certify when patients with diabetes need therapeutic shoes, and certify and recertify a patient's terminal illness for hospice eligibility.
"These are substantial barriers that, if they were removed," Kapu says, "we will be able to provide much-needed, timely care, and [for] our elderly and Medicare beneficiaries who live in these rural communities."
New initiative is expected to avert costly rehospitalizations while helping patients get and stay healthy.
Emory Saint Joseph's Hospital in Atlanta has launched a nursing-led program to help patients navigate post-discharge health needs with one-on-one lifestyle coaching to fend off future hospitalizations and the costs they incur.
More than $52.4 billion is spent annually to care for patients readmitted to the hospital within 30 days for a previously treated condition, according to a 2022 study.
At Emory St. Joseph’s, nurses not only will work with newly discharged patients for 12 weeks to ensure they properly take their medication and keep timely medical appointments, but they’ll also provide weekly lifestyle and health coaching to help them establish and maintain healthy behaviors that will keep them out of the hospital.
"In this program, our nurses will collaborate with patients to determine one lifestyle behavior that could be getting in the way of their overall health, such as smoking or blood glucose management, and then chart a course to make meaningful progress over those months," says Rebecca Heitkam, director of Emory Saint Joseph’s Congregational Health Ministries and Faith Community Nursing program.
The new initiative is part of Emory St. Joseph’s larger Faith Community Nursing program, which trains nurses on post-discharge transitional care management while connecting with the patients on a spiritual level, but it takes the original program one step further by connecting nurses with specific patients one-on-one for 12 weeks following a discharge and adds the lifestyle coaching component.
The nurses call patients once or twice a week either by phone or on Zoom for up to 90 minutes to help them determine small-step goals and actions for the next week, and help them stay motivated to accomplish the goal, she says of the program launched with the help of a two-year $60,000 grant.
"With the original program, the patients seemed to become almost co-dependent on their nurses to tell them what to do each step of the way, make calls for them to obtain resources they needed instead of doing it themselves, and be the go-between for the patient and physician provider, but few patients were really strengthening their skills on managing their own chronic conditions or better yet, making a change in the chronic condition through lifestyle behavior change, where appropriate," Heitkam tells HealthLeaders.
"I had recently taken a course and become board-certified in health and wellness coaching, and I was convinced that the nurses’ time might best be spent coaching willing patients into making lifestyle changes using SMART [Specific, Measurable, Achievable, Relevant, and Time-Bound] goals and positive coaching techniques rather than being so prescriptive for the patients’ outcomes," she says.
Some patients more readily accept post-discharge care management than others, she says.
"Once patients realize that they have a good bit of control over their health outcomes if they are willing to make some crucial behavior changes, they get very excited and are on board with being coached and supported to success," she says, "or they decide that the lifestyle changes are not worth it, and they keep doing the very same things that continue to get them readmitted to the hospital."
"We have learned to be a little more intentional with choosing patients to offer the program to, and we always leave space open for patients who didn’t appear to be receptive to change, but who surprised us and made incredible changes for their own benefit," she says.
The initiative is expected to do more good than saving rehospitalization costs, Heitkam notes.
"One of the unique aspects of this initiative is that rather than measure success only through a reduction in readmissions," she says, "we’re going to be taking into account overall outcomes for patients to demonstrate how focusing on attainable health goals can make a big difference in the lives of these patients."
Gov. Gretchen Whitmer vetoed a previous attempt in 2020.
Legislation to allow Michigan RNs and licensed practical nurses (LPNs) to hold multistate licenses through the Nurse Licensure Compact (NLC) has been reintroduced after a previous attempt nearly three years ago was vetoed by the governor.
The legislation calls for Michigan to enter into the compact allowing RNs and LPNs to practice in person or via telehealth, in both Michigan and the other 39 states and two U.S. territories—Guam, and the U.S. Virgin Islands—that have joined the compact.
Michigan Gov. Gretchen Whitmer vetoed a previous bill in 2020 because it violated the state constitution, she wrote at the time in a veto letter to the state legislature.
"While I value interstate cooperation, especially around issues that are peculiarly interstate in nature, these compacts require Michigan to cede its sovereign interest in regulating health professions to an outside body," Whitmer wrote.
State Rep. Phil Green, who introduced the new legislation, said he plans to work across the aisle during this go-round to ensure a different outcome, according to the Michigan Public Radio Network.
One of the most recent to join the compact is Pennsylvania, which allowed NLC RNs and LPNs to begin practicing in Pennsylvania September 5, 2023. Pennsylvania nurses must wait, however, to practice in NLC regions until certain preconditions are met, one of which is certifying to other compact states that Pennsylvania's State Board of Nursing has performed an FBI criminal background check on Pennsylvania applicants. That move is pending.
Rhode Island also recently enacted the compact when Gov. Daniel J. McKee signed the legislation. The state is awaiting implementation with no determined start date.
A multistate license eases cross-border practice for many types of nurses who routinely practice with patients in other states, including primary care nurses, case managers, transport nurses, school nurses, hospice nurses, and more. Military spouses who experience moves every few years also benefit from the multistate license.
The NLC also benefits facilities that might have an acute shortage in one of their units to recruit a nurse for that unit or shift around their resources if they're an interstate facility and moves nurses between different states, according to Nicole Livanos, director of state affairs at the National Council of State Boards of Nursing (NCSBN).
Each addition to the NLC helps to strengthen the nursing workforce, she said.
Front-line nurses are the clinicians most likely to encounter patients suffering from high anxiety.
Full-immersion virtual reality simulation decreased nursing students’ anxiety levels when communicating with anxious patients, says new research published in the September issue of Clinical Simulation in Nursing.
With anxiety as the most prevalent mental health disorder in the United States, nurses do not feel adequately prepared to care for anxious patients, according to the research by Tanae A. Traister, assistant dean of Nursing & Health Sciences at Pennsylvania College of Technology.
Traister researched the use of virtual reality simulation in nursing education to help lessen nursing students’ own anxiety in dealing with anxious patients.
Traister conducted the study by recruiting students in Penn College’s pre-licensure associate degree and bachelor’s degree RN majors to completed two full-immersion virtual reality simulations involving a patient suffering from anxiety.
Traister evaluated the students’ own anxiety levels before and after the first simulation and again after the second to identify and measure their anxiety knowing they would be caring for a patient experiencing acute anxiety.
"The goal for my research was to contribute to the currently small but growing body of knowledge surrounding the use of full-immersion virtual reality simulation in nursing education," Traister said.
Penn College’s nursing program, like other nursing schools, began incorporating virtual reality simulation into its nursing coursework during the COVID-19 pandemic, when nursing students were unable to do in-person clinicals in hospitals and had to rely on simulation to provide students with the education they needed. And although nursing students are returning to in-person clinical rotations, simulation labs remain an important part of their education.
As nurses spend the most time with patients, they are most likely to encounter those suffering from high anxiety, according to Traister.
"Unfortunately, many anxiety sufferers go undiagnosed or untreated because of a perceived negative societal stigma, personal embarrassment, or normalization of symptoms," Traister wrote. "Those who attempt to seek treatment for their anxiety symptoms may perceive their encounters with healthcare providers as unsupportive or dismissive; therefore, avoiding care."
However, nurses who are more comfortable treating anxiety-prone patients will have a more therapeutic nurse-patient relationship, the research notes.
4 nurse executives reveal how they are adapting to a challenging healthcare environment.
Until COVID-19 turned healthcare on its head, care models had not changed much since the early 20th century.
But now, nurse executives are finding new and more efficient care models to adapt to the current state of nursing shortages, workforce pipeline challenges, fewer physicians, increased patient acuity, and countless other challenges in today’s healthcare environment.
HealthLeaders talked with four nurse executives and asked each one, “What does practice redesign look like at your organization?”
Their replies have been lightly edited for brevity and clarity.
Associate vice president for advanced practice
Private Diagnostic Clinic at Duke University Health System
We started in 2010 in my practice of cardiology, and along with the cardiologists, we had a group of six NPs and PAs that had about 75 years of combined experience with high-quality training and yet, they were working far below scope, basically doing the work of a nurse.
We had an access issue because our next available appointment for a new patient was a month away, and that's not OK if somebody's calling because they're dizzy or because they have chest pain.
We received funding to hire nurse clinicians to form the hub of an interprofessional team consisting of four physicians, one APP, and the nurse clinician. The model that we chose for our patient population was that the APP would see return patients, acutely triaged patients, and hospital follow-up patients. This freed up the physicians to see complex patients new to our practice and establish a plan of care.
This met our aim of all members of the team working to the top of their scope of practice, while increasing access for our patients.
From there, it was so successful that it spread across our health system in all our ambulatory specialty practices. Each one looks a little bit different because each specialty practice is going to be different. For example, in dermatology, APPs might do general dermatology and the physicians might do the surgical subspecialty part of that.
As we move toward value-based care, we have to take care of lots of people, especially as Medicaid is expanded throughout our country. My mantra is everyone on the team will be working to the top of their scope and that means the top of their license, their board certification, and their training, and that aligns with how we attract and engage and retain the best talent. It’s worked. We have amazing people who come to work with our organization, and they stay.
Chief nursing officer and vice president for patient care
Brigham and Women’s Faulkner Hospital
We started with the fact that we have too many patients and they have to come up from the emergency department when we're overwhelmed and can't provide care. And we started weighing in: Can they go in many different arenas?
And we decided it would be hallway spaces, but what hallways? Can we use conference rooms? Can we use vacant office spaces? We had to look at what was there and what met potential code opportunities for necessary requirements: Can beds fit into them? Can we get suction and oxygen, etc., available to those patients?
Once we said, “No, it has to be in these hallways in these areas,” then we asked, “Will this fit for all of our units?” And the answer even at that was no. We needed to, again, be innovative and go back to redesign.
So, on one unit, we have larger rooms, so we knew we could double up rooms, and we did. We’ve also put potential hallways under certain criteria meeting certain trigger points, so we could bring up beds, put them in halls, and decide which patients are appropriate to be put there.
Executive vice president and chief nurse executive
Indiana University Health
As we are entering in this work, we want to be thoughtful about how this is going to be different. A lot of times we trial things, but then we don't always get good data for what works or what doesn't, or we try to wait for the perfect model before we would implement anything because, quite frankly, the stakes are high and there is that innate fear that you're going to make a mistake that's going to cause you not to give quality care.
So, we created a vision statement for care model redesign, and then associated guiding principles: we wanted to engage our frontline team members, we've encouraged autonomy, rapid testing, and frequent evaluation. We’re trying to get a little more agile and nimble with what works and what does not and spread that so we share the lessons learned across our system.
We have a lot of different pilots going on in the system and we have a research study that's going on with five innovation units across the state, so we're not waiting for perfection on this, but once we communicate the vision and the criteria, we developed some change management tools for our frontline leaders to help with how to go about this.
Part of the mindset shift for this has been to lead more through guiding principles that are not a one-size-fits-all. There were some who were probably waiting for me as the chief nurse executive to say, “This is the care model at IU Health; now everyone go out and implement this and everything will be fine.” I don't think that you can lead this way. I could have done that, but I think it would have failed miserably.
We’ve done some things not considered innovative now, but they were cutting edge at the beginning. We utilize LVNs [licensed vocational nurses], but not in an assistive supportive role; we use LVNs for part of our primary care model, to have them taking patient assignments, taking fuller extent of their capacity here in Texas to evaluate patients and take care of patients.
We’ve implemented and designed an LVN internship, residency, and fellowship program, recognizing that this entry to practice has not really been tapped here locally or in the region, as an opportunity to grow individuals in that space.
We put them on a path where we will pay them to get their RN through a transition program with a local community college partnership here, and that has been very successful. We had 15 individuals in our first cohort that we were able to upskill and get them onto the path to become an RN.
We are looking at our skill mix, as everyone in the country is looking at different skill mixes and how you can have unlicensed assistive personnel in the clinical environment. We redesigned some of our models where we're increasing our UAPs [unlicensed assistive personnel] and having them take on the care, feed, and activity roles where their sole focus is supplementing that aspect.
In addition, we are working further down the pipeline. We recognize that before COVID we were focusing on older adults—high school graduates, adults in the working world, or college kids trying to work toward the healthcare career. We've lowered our hiring limit to age 16. We are working with our local independent school district to create an Explorers program where not only do they get to come into the hospital and experience different areas of healthcare—different roles and disciplines—but also the ability to work as an unlicensed assistive personnel during their downtime that enables them for our employee benefits, such as tuition assistance.
We're getting these individuals plugged in earlier and getting them on a healthcare track so they're not waiting until they graduate to figure out what they want to do, and we as a hospital support them so that gives them a little bit of an edge when it comes to applying for whatever program they want to get into.
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Pennsylvania nurses, however, must wait for criminal background check authorization before receiving a multistate license.
RNs and licensed practical/vocational nurses (LPN/LVNs) from 38 states and two U.S. territories who hold multistate licenses through the Nurse Licensure Compact (NLC) will be able to practice in Pennsylvania beginning September 5, 2023.
The compact allows RNs and LPN/LVNs to have one multistate license, with the ability to practice in person or via telehealth, in both their home territory/state and other NLC states.
The move is expected to help address Pennsylvania’s severe nursing shortage and increase healthcare access—both in person and via telehealth—for patients across the commonwealth.
Pennsylvania’s General Assembly authorized its NLC participation with Act 68 of 2021, signed into law by former Gov. Tom Wolf.
"This is a critical first step in the full implementation of the Nurse Licensure Compact," said Al Schmidt, secretary of the commonwealth. "The Department of State continues to work diligently with its state and federal partners to satisfy the preconditions necessary to fully implement the NLC."
Among those preconditions is certifying to other compact states that Pennsylvania's State Board of Nursing has performed an FBI criminal background check on Pennsylvania applicants, a process that requires FBI authorization. The Department of State has sought this authorization and is awaiting a response.
Indeed, licensure requirements are aligned in NLC states, so all nurses applying for a multistate license are required to meet those same standards, including submission to a federal and state fingerprint-based criminal background check.
Once that occurs, Pennsylvania's State Board of Nursing will issue NLC multistate licenses to Pennsylvania nurses, allowing them to practice in compact member states and territories, Schmidt said.
A multistate license eases cross-border practice for many types of nurses who routinely practice with patients in other states, including primary care nurses, case managers, transport nurses, school nurses, hospice nurses, and more. Military spouses who experience moves every few years also benefit from the multistate license.
The NLC also benefits facilities that might have an acute shortage in one of their units to recruit a nurse for that unit or shift around their resources if they're an interstate facility and moves nurses between different states.
"Anything we can do to attract nursing talent to the state is a win for patients and the commonwealth," said Debra Bogen, MD, acting secretary of health. "Participating in the nursing compact overcomes a barrier to attracting that talent and building our state's healthcare workforce."