And, it appears NP salaries are growing as well, according to a new survey by PracticeMatch, which provides healthcare employers and jobseekers with career- and employment-related resources.
Most NPs Satisfied with Income Level
The survey of nearly 1,100 NPs and physician assistants was conducted in March of 2018. Among its findings:
NPs reported an average salary of $113,900, an increase of 6.6% over last year's average reported salary of $106,000.
5% of NPs reported earning more than $150,000 in 2017.
12% of respondents reported receiving a sign-on bonus for their current role, up from 11% in the previous year's survey.
15% PAs and NPs with less than 10 years of experience were paid a sign-on bonus, compared to 8% of PAs and NPs with more than 20 years of experience.
The average sign-on bonus was $7,200
86% of PAs and NPs reported being satisfied, to some degree, with their income level.
In addition to salary and income information, the survey also found that:
7% percent of all respondents had a doctoral degree.
Survey respondents have worked as an NP or PA for an average of 13 years.
On average, survey respondents had been in their current role for seven years.
Just 5% of respondents described themselves as unsatisfied in their careers as PAs and NPs, compared to 6% in last year's survey.
Primary care physicians earned $223,000 in 2018 compared to $217,000 in 2017.
Physician specialists earned $329,000 in 2018 compared to $316,000 in 2017.
Plastic surgeons were the top earning specialty at $501,000.
Public Health & Preventive Medicine was the lowest earning specialty at $199,000.
Salary is just one piece of the healthcare provider hiring puzzle, however. Healthcare executives need to consider which type of practitioner, or practitioner mix, will best meet patient needs, clinical and financial outcomes, and strategic goals.
Then they set about coaching, mentoring, and educating them so they're prepared to step into those roles when the need arises.
Succession planning geared toward direct care nurses is much less common says, Suni Elgar, MPH, BSN, RN, OCN, associate director, clinical operations, blood and marrow transplant and immunotherapy at Seattle Cancer Care Alliance, but is equally as important.
"I feel like we as a nursing community talk a lot about leadership succession planning, which is extremely important, but I also feel that we need to really focus on how we’re going to do succession planning for our bedside nurses," she says.
So, what does bedside succession planning look like? Similar to leadership succession planning, it enables nurses to build their skills and knowledge so they are ready to step into new clinical opportunities when they arise.
Here, Elgar talks about the benefits of bedside succession planning as well as ways to apply the practice.
While this new generation of nurses is eager to jump at new opportunities, baby boomer nurses are starting to retire.
In 2016 and 2017, SCCA's outpatient blood and marrow transplant clinic, which has 65 nurses, had five nurses retire. During that same time, four nurses left the clinic to either stay home with family or for other employment opportunities.
"Nurses transition to new roles throughout their careers, but there are ways we can do better [at keeping] them in their careers and keeping that wealth of knowledge," Elgar says. "With succession planning the idea is you’re retaining your nurses longer, so you’re keeping that value of experienced nurses."
Knowledge Transfer
Losing decades of knowledge and experience as seasoned nurses leave the workforce is a legitimate concern for nurse leaders.
Succession planning tackles this issue head on by making the transfer of knowledge from expert nurses to more novice nurses a priority.
It recognizes that, while retirement is inevitable, if an organization constantly prepares its next generation of nurses to step in where needed, it's effects can be mitigated.
"It’s really focused on [asking], 'Who are those amazingly well seasoned nurses with a wealth of knowledge, and how can they impart that to the next generation of nurses?'" Elgar says. "And, helping those nurses understand why it’s so important to pass on that information."
When experienced nurses understand their value, they become enthusiastic about sharing their knowledge with others.
"When we have students from our local universities come here, [the experienced nurses] are really excited to see them. They enjoy the process of learning from them as well as helping them further their education," she says. "They’re engaged in being mentors for our new nurses coming to the clinic."
An example of preparing for smooth transitions happened recently in the BMT clinic.
Elgar knew one of her seasoned nurses was going to be retiring and another one of her staff members would be filling his position. She was able to have both nurses work side-by-side for a few months until he retired.
"The nurse that replaced him has been here for five or six years, but for her to be able to spend real quality time with him before he left, was so important," Elgar says. "They have certainly had interactions and discussed patients before, but to spend that dedicated time together before he left was huge."
Hire one nurse ahead
Elgar was able to give her staff that time to share knowledge because of the organization's commitment to hire "one nurse ahead."
"By creating an internal float pool, when a nurse retires, or they leave and move somewhere else, we are able to quickly fill with one of our nurses who’s already trained, who’s already skilled, who can take on the work and make sure that patient safety is first and foremost," she explains.
Educate in place
In addition to peer-to-peer knowledge transfer, successful succession planning also includes an organizational commitment to continued education for nurses of all experience levels.
"We make sure that all of our nurses have dedicated time for education," Elgar says. "For our group, we have four 8-hour education days per year and all of the nurses go to those. Then we have additional funds and time where they can pursue education outside of our institution."
There is also a course for nurses who are mentors and preceptors.
Additionally, the organization started a nurse residency program in 2012. About twenty nurse residents have gone through the program and the organization has retained all but one of those nurses.
Staff engagement
Elgar says succession planning contributes to the BMT clinic's above-average NDNQI scores,
"We ranked in the 75th– 90th percentile in most professional practice environment subscales, consistently outperforming the NDNQI mean on all nine subscales," she says.
Here's how the BMT clinic compares in some areas to other academic medical centers:
Staffing and resource adequacy: 3.11 to 2.76
RN-to-RN interaction: 5.60 to 5.15
Professional development opportunity: 4.69 to 4.36
Professional development access: 5.11 to 4.40
"If we have nurses that are well ingrained and who are engaged in the work that they do, we know that they are going to be better performers than those who are not. If we have that ability to have someone mentor the next group of nurses, we’ve just created such a better experience for our patients and our staff," Elgar says.
With a decibel meter, the neurosurgical ICU staff measured noise levels on the left and right sides of the nurses' station—the unit's central hub shared by many providers.
Concerned that noise was negatively affecting family satisfaction, patient sleep, staff stress levels and concentration, nursing staff at North Shore University Hospital in Manhasset, New York, launched an initiative to reduce noise levels in the 16-bed neurosurgical intensive care unit.
The unit reduced noise levels and maintained quiet times with reductions in peak noise events six months after education and implementation.
With a decibel meter, the neurosurgical ICU staff measured noise levels on the left and right sides of the nurses' station—the unit's central hub shared by many providers. They also measured noise in front of two patient rooms near the nurses’ station, one of which is near the primary entrance to the unit. Data was collected for eight days prior to staff education and again six months after quiet time was instituted.
After collecting the initial data, baseline results were shared with staff through a variety of ways, including:
Unit-based in-services
Staff meetings
Journal club sessions
Neurosurgical ICU team as well as members of other departments, received education on the benefits of quiet time. All department directors were notified about the initiative.
The unit then implemented quiet time periods twice a day, from 3 a.m. to 5 a.m. and from 3 p.m. to 5 p.m. During quiet times, lights were dimmed, whispering was encouraged, and environmental noise was eliminated as much as possible.
"A darkened unit provided a strong visual cue to be quiet, but reducing noise required a comprehensive team effort," Kerri Scanlon, MSN, chief nursing officer, says in a news release. "Together, we were successful in changing unit practice and enhancing awareness about excessive unit noise."
The Strategies
Specific changes contributing to lower noise levels during quiet time, include:
Unit secretaries reminding visitors of quiet time, dimming lights, and eliminating overhead paging on the unit.
Neurosurgical ICU physicians and physician assistants shifting the start of daily teaching rounds to complete them before afternoon quiet time.
Physical and occupational therapists adjusting their schedules to see patients before 3 p.m.
Environmental services personnel did not buff floors during quiet time.
Creating a checklist that itemized tasks to be performed prior to quiet times, such as administering routine medications, taking vital signs, turning off televisions, and putting mobile phones and pagers to vibrate
Creating a unit-specific brochure explaining quiet times
Placing signage on each patient door and at unit entrances
Distributing hospitality bags with items such as sleep masks and earplugs
Upgrading smart-monitors for each patient room and the central stations to reduce nuisance alarms
Revisiting alarm parameters and adjusting monitor default settings
The results
After six months, peak noise levels decreased by 10 to 15 decibels lower than baseline data during quiet times.
The difference was statistically significant in two of the four locations, while the two busiest locations experienced quieter but not statistically significant noise reductions.
Opportunities for improvement include:
Installing push-plate automatic opening functions at the rear entrance to the unit for easier access by emergency department and operating room teams
Identifying a different time and space for physicians and PAs to conduct teaching sessions
Nurse practitioner support after hospital discharge improves outcomes among heart failure patients.
Studies have shown that heart failure care—which cost an estimated $31.7 billion in 2012 and is projected to more than double by 2030—is a leading driver of healthcare costs in the United States.
The program, which is available to all HF patients living within 90 miles of the UVA Medical Center, provides patients with follow-up care for 30 days after hospital discharge. Participants can receive follow-up visits and other support from two NPs specializing in HF.
The study compared patients enrolled in H2H to those who did not participate in the program between January 2011 and December 2014.
In the first 30 days after discharge, program participants had:
A 41% percent lower mortality rate than non-participants
A 24% reduction in the number of days where they were readmitted to the hospital
These improvements in outcomes occurred even though H2H participants were sicker than non-participants, the study found.
The cost savings from the program were estimated to be about twice as much as the program’s staffing costs.
NP Support
Within a week of being released from the hospital, patients typically have an in-person visit with one of the program’s NPs. Working with UVA physicians, pharmacists and other team members, the NPs assess patients’ heart failure symptoms and lab results, adjust their medications as needed and suggest lifestyle adjustments such as dietary changes.
“It’s important to have a program that follows patients closely and especially during their most vulnerable period following a discharge from the hospital. In this regard, a discharge from the hospital is not really a final goodbye, but rather just another phase of their care,” Sula Mazimba, MD, MPH, a study co-author and a heart failure specialist at UVA, says in a news release.
By video recording nurse-physician interactions, researchers uncover common causes of poor communication.
It was a miscommunication. When something goes wrong, a communication breakdown is often cited as a contributing factor. In healthcare, poor communication threatens patient safety and can cause anything from medication errors to sub-optimal care transitions.
Now, a small pilot study by University of Michigan researchers, sheds some light on where nurse-physician interactions can go wrong, and provides insight about the potential causes of communication failures.
Nurses: Be Direct
After video-recording interactions among nurses and physicians, the researchers had the study participants watch and critique the footage together.
Several themes emerged to help explain the poor communication.
One barrier to good communication is that the hospital hierarchy puts nurses at a power disadvantage, and many are afraid to speak the truth to physicians, Milisa Manojlovich, PhD, RN, CCRN, U-M professor of nursing, says in a news release.
The recordings showed nurses didn't directly request what they wanted or express their needs. The indirect communication confused physicians, who often ignored the nurses' requests and moved on to the next agenda item rather than ask for clarification.
The study also found that because physicians and nurses approach patient care from vastly different angles, achieving understanding isn't easy. Manojlovich defines communication as reaching a shared understanding.
One example of this was when a patient with mouth pain caused by the fungal infection thrush, couldn't swallow the pills needed to get better. The physician wanted to prescribe more medication to treat the thrush, but the nurse wanted to treat the patient with strong pain medication, as well.
"The physician realized that the pain was inhibiting the treatment, and treating the pain, as well as the condition, would solve the problem," Manojlovich says.
Additionally, the recordings showed that in good communication, the body language of both parties mimicked the other. In strained relationships, body language wasn't in sync.
Self-awareness Key to Improvement
For the study, Manojlovich and her team followed physicians and nurses at the U-M Health System. The nurses and physicians watched and commented on the video clips separately, and those comments were incorporated into the video. Finally, both groups watched the clip together.
"The only way you can become aware of your habits is by watching yourself," Manojlovich says. "One physician said, 'I didn't give the nurse a chance to answer,' and this physician had a habit of doing that and recognized it. She was one of the champions of the study."
In the future, Manojlovich hopes to record a larger group and use the videos as training tools to improve communication.
One VP of nursing gives her take on the impact New York's law will have on the nursing profession.
Earlier this year, New York became the first state to pass legislation requiring nurses to obtain a baccalaureate degree or higher within 10 years of licensure.
There has been a push to pass what's commonly known as the "BSN in 10," for years, and with it much discussion about the law's strengths and weaknesses.
While the new requirement does not affect nurses already in practice, many have wondered about its future impact on the supply of nurses, schools of nursing, and hospitals and healthcare organizations.
The following are highlights of Scanlan's recent interview with HLM. The transcript has been lightly edited.
On the law's potential to improve patient outcomes:
"We've been watching this unfold for years, and at Montefiore, we've been supporters of continued education for our nurses long before this law was enacted. [Our] value on a higher level of education for our staff nurses has been [in place] for years. So, we're very pleased, and we're in favor of this legislation."
"There's extensive research [that ties a] BSN-prepared nursing workforce to better patient outcomes and there's no better reason than that to support this legislation. Providing quality care is our priority. This bill passing fits naturally into our strategic plan to develop our workforce with that higher level of education, to ultimately improve the quality that we provide."
On leadership support for nurse education:
"At Montefiore, we have full leadership support for our staff nurses to pursue their BSNs or higher levels of education. As an example, we have a robust tuition reimbursement program. It's 100% for our staff nurses who are looking to advance their careers. Our nurse managers work directly with the staff to adjust their schedules to ensure that both work and school schedules are met appropriately. The one thing I've experienced at Montefiore is the nurses who join our nursing team without their BSN already have that pursuit of a higher education as their professional and personal goal, and we're proud to support them through their journey."
On who bears responsibility for ensuring BSN-preparedness:
"I think the responsibility is shared. There's the professional responsibility and accountability on the individual nurse to pursue and achieve this, while at the same time, professional organizations and healthcare systems [need to] support the individual."
On whether the BSN requirement could create a nursing shortage:
"I don't see it affecting the nursing shortage. There are experts that are following trends of nurse retirement rates. While there is a large number of nurses who are members of the baby boom generation who will be retiring, there's also [data] tracking the growth rate of the RN workforce and it's expected to increase within the next 10 years."
"Shortages are geographical and vary nationally. There may be some concerns in certain regions depending on their own statistics, but for us in the Bronx, I don't see the bill having any negative impact."
On nursing school capacity:
"[As part of this law], there has been the creation of a temporary commission to evaluate and report what the barriers are regarding entry into the nursing profession. They're going to make recommendations on increasing availability and accessibility of nursing programs. They've been given 12 months, so we should know more at the end of the year. I'm eager to hear the findings from that committee because I think it will help frame what the plan is to address some of the obstacles that are identified."
"I think we'll certainly alleviate some of the concern since technology has expanded access to education programs. The growth of online learning programs has increased drastically, and I believe they will continue in years to come. In that sense, it can make this process simpler."
On how the law could affect hospitals and health systems financially:
"There's an obvious financial commitment and it will vary across organizations and across the country. At Montefiore, we've made a financial commitment, [which] predates the law by many years, because of the value we place on higher education. Again, that goes back to research linking better clinical outcomes and higher job satisfaction. It really is a win-win for the professional nurse and for the organization."
On advice for fellow nurse leaders about "BSN in 10":
"I think this is already a national topic. The famous Future of Nursing report from the Institute of Medicine (now the National Academies of Science, Engineering, and Medicine) advocated for higher education [for nurses]. That was a national goal for the profession of nursing. I think my colleagues outside of New York and across the country have come together in a collaborative way and have already identified the benefits of this [law]. I know that concerns exist regarding the [nursing] shortage and the financial commitment, but from a nurse leader's perspective the value of this [law] outweighs the challenges that it will bring."
Last reauthorized in 2010, the act would reauthorize the nursing workforce development programs through fiscal year 2022.
"Speaking on behalf of the nation's 52,000 certified registered nurse anesthetists, the action taken today by the House of Representatives to ensure the continuation of nursing workforce development programs and patient access to the essential care of nurses across all specialties is of paramount importance," Bruce Weiner, DNP, MSNA, CRNA, president of the American Association of Nurse Anesthetists, says in a news release.
What's in the Bill?
The legislation will:
Amend Title VIII of the Public Health Service Act to reauthorize nursing workforce development programs, which support the recruitment, retention, and advanced education of skilled nursing professionals.
Extend advanced education nursing grants to support clinical nurse specialists and clinical nurse leaders.
Define nurse-managed health clinics.
Add clinical nurse specialists to the National Advisory Council on Nurse Education.
Reauthorize loan repayments, scholarships, and grants for education, practice, quality, and retention.
The National Association of Clinical Nurse Specialists is also pleased by the bill.
"The House of Representatives took a major step to improve the nation's health by reauthorizing the Title VIII Nursing Workforce Development Act of 2017 and by affirmatively including clinical nurse specialists – expert clinicians with advanced education and training in a specialized area of nursing practice – in the bill," says NACNS board president Anne Hysong, MSN, APRN, CCNS, ACNS-BC, in a statement.
Serving the Underserved
According to theBureau of Labor Statistics, employment of registered nurses is projected to grow 15% from 2016 to 2026.
"With our healthcare system in transition, and healthcare needs growing due to our aging population, the fact that people are living longer but with more chronic health problems, and the shortage of primary care providers, we need to do all we can to support nurse education," Hysong says.
Programs under Title VII can help attract nurses to rural and underserved areas, says Weiner.
"Title VIII provides funding to a number of very important nursing workforce development programs including Advanced Nursing Education, which contains the Nurse Anesthesia Traineeship funding as well as the National Nurse Service Corps. These programs incentivize nurses to practice in underserved areas," he says. "In many rural and underserved counties across America, CRNAs are the only anesthesia providers. Maintaining the availability of these services and ensuring a continuing flow of new CRNAs and nurses to our most vulnerable and underserved communities is critically important."
A recent study by researchers at the University of Michigan, found that of nurse practitioners tended to gravitate towards areas of high-need.
When the researchers examined where NPs work, they found the availability of NPs was about 50% higher in the least-healthy counties compared to the healthiest.
Additionally, more NPs practiced in lower-income areas with low life expectancy.
"That was nice to see," says Matthew Davis, PhD, assistant professor at the U-M School of Nursing, one of the study's authors. "The nurse practitioner workforce appears to be having some positive effects. Our work shows that nurse practitioners are more likely to set up shop in areas of higher need and other studies have shown that they provide a substantial amount of care for individuals with chronic illness."
A hospital's internal coach worked with nurse leaders to develop their emotional intelligence, raising NDNQI practice scores.
Just three years ago, the nursing unit that nurse manager Lincy M. Philip, MSN, RN-BC, oversees at Cohen Children's Medical Center in New Hyde Park, New York, was in dire straits.
Among the challenges was a move to a newly designed unit, resulting in challenges that disrupted workflows and teamwork. Along with the move came higher-acuity patients, but not the additional staff to care for them.
"We were a unit that was typically staffed with one charge nurse and four nurses, and now we needed at least one charge person and anywhere from six to seven nurses. We didn't have that coming into the new building," she says.
In addition, the staff members were dealing with an extremely confrontational parent of a patient with a months-long hospital stay while Philip was on maternity leave.
Despite various interventions with the parent such as interdisciplinary team meetings that included a chaplain and social worker, the parent continued to be suspicious, verbally abusive, and intimidating to the staff.
"Apparently, this patient had bucked all the systems and the staff felt so broken that trust from all angles was just completely severed," she says. "[They felt] there was no doctor that they could rely on, no nursing administrator they could rely on. Perceived or real, this is how they felt."
During the discord, the unit's NDNQI mean practice environment score dropped to 2.58 in 2015 down from 2.80 in 2013.
Today, however, the unit has recovered from its most difficult days with the help of the organization's internal coach, a position created in response to the unit's work environment situation.
Internal Coaching Results
From 2015 to 2017, Cohen's NDNQI scores have improved, supporting the effectiveness of internal coaching:
Nurse manager ability, leadership, and support of nurses went from 2.27 to 2.92
Staffing resource adequacy went from 1.96 to 2.74
Feeling that one is treated with dignity and respect went from 3.79 to 4.32
Feeling recognized and thanked increased from 2.71 to 3.41
The mean practice score went from 2.58 to 3.04
"I can honestly say nobody expected [these] outcomes," Philip says.
An Innovative Role Is Born
Traditional interventions didn't seem to help the unit. Even though the patient had left the unit and Philip had returned from maternity leave, the mean practice environment score drop in 2015 indicated the staff members were still carrying scars from the series of chaotic events.
"I got the phone call, and essentially the request was, 'We're having a communication issue here. Do you coach groups? Do you think you can come over and give us a hand?' " says Quinlan, who is now Cohen's manager for clinical transformation/internal coach.
Quinlan met with the staff multiple times and arrived at an assessment similar to Philip's.
"They didn't have a communication issue. They had a trust issue, which, of course, can be much more difficult to remedy," Quinlan says. "That was very difficult for [Quinn] to hear. That's the last thing any CNO wants to hear, 'My staff doesn't trust leadership. ' "
As a result of her initial work with the unit, Quinn soon hired Quinlan to become the organization's manager for clinical transformation/internal coach.
"We literally invented this role from the ground up," Quinlan says.
What Internal Coaching Is
To explain her role at the organization, Quinlan starting rounding and speaking about emotional intelligence at the monthly nurse leadership meetings, which included the senior director of operations for nursing all the way down to the assistant head nurses.
"Coaching is a process of supporting personal growth so that [the person] can become more emotionally competent and, therefore, [more] effective," Quinlan explains.
Quinlan began working with nurse leaders to develop their emotional intelligence so they would have the skills to address issues with their staff. Philip was Quinlan's first client.
The two began meeting for 30- to 60-minute sessions to work on Philip's self-awareness and identifying Philip's strengths.
During a coaching session, Quinlan may ask questions such as:
What are your strengths?
How would you use those strengths?
Are you overusing or underusing those strengths?
What happens in the unit that triggers you?
What frustrates you?
How do you react to frustrations?
"The coach's role is to create [an] accepting environment where there is no judgment; there is just insight by trying to shed some light on individual blind spots," Quinlan explains about the process.
'Chewing on Glass'
In the sessions, Philip says Quinlan would help her break down a situation and see what she did right but also what she could do differently, a process they refer to as "chewing on glass."
"[Phyllis is] able to hone in on the things that you don't necessarily want to talk about and pull it out of you in a way [so that you can] reflect," Philip says.
In addition to insight, Quinlan also provided Philip with tools and strategies to make changes.
"One of the things I did with Lincy was to help her have a pause," Quinlan says. "She didn't realize that every now and then you would be talking to her and she was wearing her frustration about something that happened 20 minutes ago, not necessarily something that happened in this conversation, but she was still upset about a previous conversation."
For her part, Philip says coaching helped her become a better listener.
"One of the concrete things that Phyllis would say was try to stay quiet more," she says. "And so, when I would go and check in with the staff, I would first ask them about their family. I would name their kids and their husband, or ask what they did that weekend. Then from there, we'd talk about nursing stuff."
Philip says that helped the staff feel cared about and, as a result, they would share issues or concerns with her in a more genuine way.
"The communication went from being this muddied, turbulent cacophony to now we can
finish each other's sentences and still disagree about something," she says.
Philip encourages other nurse executives to make coaching available to their nurse managers.
"To the CNOs, I would say be daring and take a chance. Carve out the time and the resources to give [coaching] to your No. 1 influencer of healthcare and morale on your [units]." Your nurse manager is your most useful resource, but also your most overworked, underutilized resource."
Erin LaCross is five months into her role as chief nursing officer. She shares five insights and advice for her fellow nurse leaders.
For Erin LaCross, DNP, RN, CMSRN, CENP, nursing was not her first career path.
"I have a bachelor's degree in psychology and criminal justice and worked briefly for a mental health organization before deciding to become a nurse," she says.
Inspired both by her sister, who is a nurse, and the experience of being a patient after a "health scare" in her early 20s, LaCross took a position as a unit clerk at Parkview Health in Fort Wayne, Indiana, with the intention of going to nursing school.
"Between watching my sister and being a patient, I knew I wanted to be a Parkview nurse," LaCross says.
"Not just a nurse, but a Parkview nurse."
That was in 2003. Today, she is the chief nursing officer at Parkview Regional Medical Center and Affiliates at Parkview Health.
By traditional nursing standards, LaCross moved up the leadership ladder swiftly. In 2006, she became a registered nurse on the same inpatient surgical unit where she had been a clerk.
Then two years later she became the unit's nurse manager. After five years as a manager, she took on a newly created role of vice president of nursing services at Parkview Hospital Randallia, where she was tasked with overseeing the nursing and clinical teams' contributions to the facility's $55 million renovation.
In February 2018, she became CNO at Parkview Regional Medical Center and Affiliates.
HealthLeaders Media recently spoke with LaCross, who shared insights she has gained as a new CNO.
1. Ask for your nurses' feedback
As a CNO, LaCross emphasizes always seeking nurse feedback. "The key concept is about empowerment."
LaCross says, as a CNO it's important ask yourself if you have the right people informing the decisions you make.
"I think for a new CNO just out of the gate, [it's good to have] that frame of mind that you're not expected to know all the answers yourself," she says. "It's always best to ask the people who provide direct care to your patients and to your community."
What's not going well that we need to be innovative around?
Additionally, clinical nurses are involved in an annual SWOT analysis.
"That really informs our plan for the year and everything we need to undertake," she says. "It's our 'true north' of things we need to focus on because it's come from our clinical nurses."
2. Don't forget to ask for physicians' feedback
LaCross also advises that CNOs should always ask physicians for feedback. "The overarching concept here is alignment," she says. "It's important for nurses and physicians to be aligned and making decisions."
Just as with nurses, CNOs should ask whether the appropriate stakeholders have been sought out.
"It's powerful when you have that partnership between nursing and providers," LaCross says. "We can get things right, or close to right, the first time around if we have physician leadership and we've asked our nurses what the right thing to do is."
Physician leaders are present throughout the organization's various service lines and institutes.
"We have many different projects, priorities, and initiatives," she says. "And, in general, the best traction we get and the best engagement we have is when we pull physicians in and have them champion different things."
For example, Parkview Health is currently working on care transitions, which are no longer about simply discharging patients from the hospital.
"Now, it's about how we hand them off to the next level of care within our own organization—whether it's home with home health or inpatient rehab, to our skilled nursing facility, or to our primary care clinic," she says. "As we look at how to undertake this work, having the physicians there to speak to the different vantage points has been very helpful, and it's helped us make sure that the workflows are correct."
3. Round, round, round
LaCross says the way to take care of people is to be among them, listen to them, and support them.
"This is really about servant leadership," LaCross says. "Our role as leaders is to take care of our people. And as a leader of leaders that means I'm here to take care of other leaders and to take care of coworkers. If we do that well, they will take care of our community in the way that we need."
LaCross dedicates time on her calendar for rounding. She acknowledges that this time can easily get swallowed up by meetings if she is not diligent.
"I have rounding appointments with every department and the coworkers know I'm coming," she says.
Each week she has an hour of rounding with a different department.
"Sometimes the coworkers are there in a meeting room waiting to talk to me and sometimes we just talk as I'm going through the unit," she says.
Additionally, she follows up each rounding visit with an email thanking coworkers for their hospitality and ideas, and sharing accomplishments they talked about. LaCross says through rounding and follow up she wants the staff members to know they are important and that she will listen and be their advocate.
She says she has collected many notes and items on which to follow up on through the rounding process.
"I've taken these last couple months' worth of rounding and distilled it into some common themes that I'm hearing," she says, "[and] I take that to our nursing operations team."
4. Adopt the philosophy of 'better is better than perfect'
LaCross uses a saying, "Better is better than perfect" with nurses, leaders, and nursing students.
"It's about having a mindset of continuous improvement," she says.
She recommends that CNOs take time to reflect each day on what went well and what can be done differently tomorrow.
"It just puts you in the frame of mind of always looking at being better than you are today, … and always learning and always forgiving yourself," she says. "If you did something today that you don't want to do again, then don't do it again. But you've reconciled that with yourself, and you don't have to be stressed about it."
This philosophy can help everyone from bedside nurses to CNOs learn and move forward.
"I think where we can get hung up is we want things to be perfect before we implement any changes," she observes. "And then, in the meantime, while we're waiting for perfection, how many patients could have had better care?"
5. Know that you are needed
Remembering that you are needed can help CNOs foster resilience in a challenging role.
"Nurses in this role are in this role because they have [the] skill set to put patients at the center of what we do, challenge the status quo, and bring all of the right people together to do the right thing every day," she says. "And that's not easy. That's not something everybody can do."
When things get overwhelming, especially as a new CNO, LaCross encourages others to remind themselves of their value and contributions.
"You are that voice that is speaking on behalf of the nurses, on behalf of the patients, and bringing the physicians to the table. You're bringing everybody to the table who needs to be there and seeing the big picture. You're asking the tough questions and ensuring accountability," she says.
With opioid addiction and overdose on the rise, one nurse leader developed a program to support nurses caring for that patient population.
About three-and-a-half years ago, Jennifer David, BSN, RN, MHA, associate vice president of client relations at Avant Healthcare Professionals, a Florida-based recruitment and staffing firm specializing in international healthcare employment, saw something that unnerved her.
She had visited a hospital client where three of the agency's international nurses would be working on long-term contracts.
There were 70 infants in the neonatal intensive care unit, and 28 of them had been born to mothers addicted to opioids. The infants were experiencing symptoms of withdrawal known as neonatal abstinence syndrome.
"If you've never seen that before, which I had not, it took me back. I had tears in my eyes," she recalls. "These babies never stopped crying. They just scream and they shake and they're in pain and they're going through withdrawal."
This was before the opioid crisis had made national headlines, and David was certain that the international nurses had seen nothing like what she witnessed.
"When I got back [from the hospital visit] and met with my instructors, I said, 'We're going to have to prepare these nurses. I'd rather them go through the shock here where they have the support."
David met with the three nurses who were headed to the NICU, and her hunch about their familiarity with opioid addiction and NAS was confirmed.
"I wanted to find out if they knew anything about neonatal abstinence syndrome and if they knew anything about the opioid issue in the United States, and they did not," she says.
As a result, Avant put in place a program to train and support all its nurses in caring for patients with opioid addiction.
Here are the three elements of the program to support nurses.
1. Education
David first began the support program with the nurses working in the NICU. They discussed how the opioid crisis began in the U.S., and shared statistics on deaths related to opioid overdoses. The group also learned about NAS.
"We had them watch videos because that shows what an NAS baby is going through," she says.
They also learned how to care for and support the infants clinically.
"My nurses' reactions [to the education]? They were in tears, and some of us were as well," she says. "But we realized we had to get them ready for where they were going."
A few months later, while on a site visit at a different hospital, David realized the program needed to be delivered to more of Avant's nurses.
"I was in the ER, and at this hospital, in any given shift, they would have two to four overdoses," she says. "I was there at 11am and they already had three."
Because patients with opioid addiction could end up on any unit in a hospital, the program has become part of the core training given to all of Avant's nurses, no matter where they are going on contract.
During the training, they cover topics such as categories of opioids, withdrawal symptoms, and management and treatment of withdrawal.
Recently, Avant did a survey to gage the effectiveness of the opioid training and support program. They surveyed 48 nurses who were on assignment and found:
81% said they knew nothing about opioid addiction before coming through the program
67% said the program improved how they viewed and cared for their opioid-addicted patients
79% indicated they felt comfortable managing the pain opioid-addicted patients experience
David recommends hospitals and nurse leaders be proactive in developing programs that provide training and emotional support to nurses caring for opioid-addicted and overdose patients.
"If you do have a unit that has a large amount of this [patient population], talk about it with your team and absolutely debrief," she says. "Circle back to do pulse checks, and if they need more support, then get them to somebody."
If a nurse manager notices a high number of call-ins, that should raise a red flag that nurses may be struggling.
"I think the awareness is what needs to happen," she says. "We're so busy taking care of the patients, I think the next wave is we've got to take care of the healthcare providers."
2. Pulse Checks
The program goes beyond educating the nurses and sending them off to their assignments.
"In the last three or four years, we've been taking care of a [larger volume] of these patients, but we've kind of forgotten about the nurses," David says. "So, the other piece of our program, besides just giving them all this knowledge, is doing 'pulse checks.' "
During the nurses' orientation at the facility, which is between two to four months, David and her team have weekly calls with the international nurses.
In addition to checking to see how the nurses are doing with their clinical skills, they are also asked if they have had patients who have overdosed or if they've cared for an infant with NAS.
"We ask them because many times they don't know how to handle it the first time," David says.
David also talks with the nurse managers before the nurse begins his or her contract.
"I let them know ahead of time that we're giving [them] an international nurse, and this may be the first time they've ever seen [opioid addiction or overdose] so they may want to debrief with them afterwards," she says.
After the nurse completes orientation, the pulse-check calls continue biweekly for the first year of the contract. After the first year, there are monthly classes for the remainder of the assignment, which last about two-and-a-half years.
David also checks in with the nurse managers every two weeks during orientation and every month for the length of the assignment.
3. Coping Skills
During the pulse checks, David also asks how the nurses are coping with caring for this population of patients.
"On the psychological side, we have to [understand] those issues that nurses feel and help them through them," she says.
"I had a nurse call me about six months ago. She was a single mom of young kids and she had two or three overdoses in the ER every shift and she had nobody to talk to about this," David says.
Constantly caring for patients who overdose can wear on the entire nursing staff.
"At [some of] the hospitals I've spoken to, when they do RN engagement surveys they found many nurses were calling off or even leaving the hospital thinking it was going to be brighter at another hospital because of all these overdoses," she says. "They were calling off because they couldn't sleep. Or they were having challenges and they just didn't want to go back for another shift."
"I had a nurse call me about six months ago. She was a single mom of young kids and she had two or three overdoses in the ER every shift and she had nobody to talk to about this."
—Jennifer David
David recommends that hospitals provide debriefing with a crisis intervention team for nurses immediately after an overdose.
"Do it during a shift. Don't wait until the next day," she says.
If one of the Avant nurses reports he or she cared for a patient with an opioid overdose, David asks the clinician some of the following questions:
Was this your first overdose patient?
What was your role in caring for that patient?
Did the hospital have a crisis intervention or support teams?
Do you have any questions?
How are you feeling?
If the nurse says he or she is struggling, Avant will put the clinician in touch with its employee support team.
