‘You have to main­tain ad­e­quate staffing to pre­serve safety’

Modern Healthcare - - Q&A -

Since last June, Pam Cipriano has served as the elected pres­i­dent of the Amer­i­can Nurses As­so­ci­a­tion, the na­tion’s largest nurse as­so­ci­a­tion, rep­re­sent­ing 3.1 mil­lion reg­is­tered nurses. She is a re­search as­so­ciate pro­fes­sor at the Uni­ver­sity of Vir­ginia School of Nurs­ing. She pre­vi­ously served as se­nior direc­tor for health­care man­age­ment con­sult­ing at Gal­loway Ad­vi­sory by iVan­tage, and as chief clin­i­cal of­fi­cer and chief nurs­ing of­fi­cer for the Uni­ver­sity of Vir­ginia Health Sys­tem, Char­lottesville. Mod­ern Health­care Edi­tor Mer­rill Goozner re­cently spoke with Cipriano about the chang­ing role of nurses, hos­pi­tal staffing cuts, nurses’ wages and ef­forts to re­duce oc­cu­pa­tional in­juries. This is an edited tran­script.

Mod­ern Health­care: What changes are U.S. nurses go­ing through to­day?

Pam Cipriano: We have been very fo­cused on im­prov­ing qual­ity and safety in the hos­pi­tal and home en­vi­ron­ments. There are lots of dis­in­cen­tives as well as in­cen­tives to pro­vide bet­ter care and bet­ter out­comes. Nurses are very at­tuned to the fact that the whole eco­nomic equa­tion of how providers get paid is de­pen­dent on im­prov­ing qual­ity. Also, nurses have been masters of care co­or­di­na­tion for a long time. When we think about care mov­ing to set­tings other than hos­pi­tals and wellorches­trated tran­si­tions, nurses are the key in mak­ing that hap­pen. Nurses are op­er­at­ing more and more in care-co­or­di­na­tion roles such as case man­agers or nav­i­ga­tors.

MH: We are see­ing a lot of the hos­pi­tals try­ing to cut back on staff or to hold down costs. Is this af­fect­ing the pro­fes­sion?

Cipriano: We are very con­cerned about the cur­tail­ing of staff. One way is ac­tual re­duc­tions in force, and the other is not fill­ing po­si­tions when there are va­can­cies. If a hos­pi­tal is experiencing a down­turn in vol­ume, we would ex­pect that they would ad­just staff ap­pro­pri­ately. But that is not al­ways hap­pen­ing. One of our clear di­rec­tives is you have to main­tain ad­e­quate staffing to pre­serve safety. Re­search shows the amount of nurs­ing care for hos­pi­tal pa­tients keeps them from all kinds of com­pli­ca­tions, af­fects the mor­tal­ity, and af­fects the out­come and over­all qual­ity of life and mor­bid­ity of pa­tients. One of our key mes­sages to our hos­pi­tal ad­min­is­tra­tors is to make sure you have ad­e­quate staffing and in­volve your nurs­ing staff and nurse lead­er­ship in de­cid­ing those staffing pat­terns.

We also are fo­cus­ing on the ed­u­ca­tion and re­di­rect­ion that nurses need to work in ar­eas other than the hos­pi­tal. We rec­og­nize that as a coun­try we want to re­duce our de­pen­dence on hos­pi­tals. We want to pro­vide care in the home, in the com­mu­nity and through pri­mary-care med­i­cal homes. So nurses are tak­ing up new roles and look­ing at how they can move from the hos­pi­tal to th­ese other venues. We don’t want to di­lute any ex­per­tise in th­ese other ar­eas. There is a false no­tion that pa­tients aren’t as sick out­side the hos­pi­tal and (care­givers) don’t need the same level of ed­u­ca­tion and ex­pe­ri­ence. We have to make sure that nurses in out­pa­tient ar­eas are be­ing key de­ci­sion­mak­ers with pa­tients and fam­i­lies and are co­or­di­nat­ing care. Nurses are a big part of the safety net.

MH: Are hos­pi­tal ad­min­is­tra­tors pro­vid­ing op­por­tu­ni­ties for nurses in mak­ing the tran­si­tion to those other en­vi­ron­ments?

Cipriano: In the set­tings where an ad­min­is­tra­tor has an in­te­grated sys­tem, yes. That is one of the nice at­tributes when you have an in­te­grated sys­tem of care, where the hos­pi­tal has its own clin­ics, long-term­care fa­cil­ity and other am­bu­la­tory-care venues. They have a de­sire to main­tain a strong work­force, so hav­ing op­por­tu­ni­ties to move staff within those ar­eas is some­thing that is done rou­tinely.

MH: What are the is­sues driv­ing nurses to take or­ga­nized la­bor ac­tions?

Cipriano: Nurs­ing lead­ers need to have open dia­logue with their man­age­ment. It is a team sport. Nurs­ing wages are very in­ter­est­ing. If you look at the long-term pat­tern and ad­just for in­fla­tion, they have risen very slightly. Other jobs have a much higher en­try. In the IT world, col­lege grad­u­ates are prob­a­bly go­ing to out­earn nurses by al­most

dou­ble, at the same level of ed­u­ca­tional back­ground.

But even more im­por­tantly, we want to make sure the work­ing con­di­tions are ap­pro­pri­ate so nurses have op­por­tu­ni­ties for rest and respite and that they are not be­ing asked to work too many hours, be­cause we know fa­tigue con­trib­utes to po­ten­tial er­rors. So it is a com­bi­na­tion of a fair salary and a healthy work en­vi­ron­ment.

MH: What is the ef­fect of more men en­ter­ing the nurs­ing field?

Cipriano: Not quite 10% of nurses are men. A re­cent study found that men are ac­tu­ally out-earn­ing women. It is trou­ble­some that we see a gen­der dif­fer­ence, even in nurs­ing, that has been al­most ex­clu­sively fe­male for many years. I re­ally can’t ex­plain what that study found. But we have had cyclic nurs­ing short­ages for years, and we are ig­nor­ing 50% of the pop­u­la­tion if we are not re­cruit­ing men to be­come nurses. So it’s been pos­i­tive to have more men en­ter­ing nurs­ing, be­cause that di­ver­sity is im­por­tant.

MH: An is­sue that has come up re­cently is oc­cu­pa­tional safety and health for nurses, es­pe­cially back prob­lems re­lated to lift­ing pa­tients. What is your or­ga­ni­za­tion do­ing about this?

Cipriano: Nurses rank fifth na­tion­ally in terms of jobs sub­ject to mus­cu­loskele­tal in­juries, with nurse as­sis­tants rank­ing sec­ond. There are a lot of in­juries ev­ery year, and some can be ca­reer-end­ing. So we give nurses a cou­ple of dif­fer­ent mes­sages. One is, do not man­u­ally lift a pa­tient. In the old days, peo­ple were ed­u­cated that if you used good body me­chan­ics, you could avoid an in­jury. That is re­ally not true. To­day, we say you should be able to deploy aids, from sim­ple fric­tion re­duc­tion sheets to ceil­ing lifts. Some or­ga­ni­za­tions still have lift teams. They think if they hire big, burly guys, that will be the so­lu­tion. But it’s not safe for any­body to rely on that. So we say that nurses should work with their ad­min­is­tra­tion on com­plete poli­cies and re­sources for mov­ing pa­tients. You must stop and say, “I need to use th­ese as­sis­tive de­vices be­cause if I’m hurt, I can’t take care of other peo­ple.” And we don’t want to put a pa­tient in a sit­u­a­tion that they could be dropped or they could get a skin tear be­cause they are be­ing moved in­ap­pro­pri­ately.

MH: One of the mantras we hear in health­care is that all pro­fes­sion­als need to be work­ing at the top of their li­cense. Do you see that as a threat or op­por­tu­nity for nurses?

Cipriano: We see it as an op­por­tu­nity. It’s re­ally im­por­tant that we ex­am­ine all the roles that are part of a health­care team. We see the value of the nurse in out­pa­tient ar­eas and home care as the co­or­di­na­tors of care. While we rec­og­nize that many fam­ily mem­bers have been care­givers, we also em­brace the com­mu­nity health worker con­cept. We are go­ing to need a lot more peo­ple to be part of that ar­ray of care­givers on the team if we are go­ing to keep peo­ple at home and healthy, as we see a larger aging pop­u­la­tion. So we are not look­ing at it as a threat. But we want to make sure that ap­pro­pri­ate de­ci­sions are made about who con­sti­tutes that team. Who is the most ap­pro­pri­ate care­giver? How can we bring needed ser­vices to the pa­tient and fam­ily? Nurses are still a very im­por­tant part of that.

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