The Journal of the New York State Nurses Association, Vol. 46, Number 2 by New York State Nurses Association

THE

JOURNAL of the New York State Nurses Association

Volume 46, Number 2 ditorial: Through Changes and Transitions: The Skills and Attitude Necessary for n ENurses to Embark on the Journey by Meredith King-Jensen, MSN, MA, RN; Dana Deravin Carr, DrPH, MS, MPH, RN-BC, CCM; Caroline Mosca, PhD, MSN, RN; Coreen Simmons, PhD-c, DNP, MSN, MPH, RN; Audrey Graham-O’Gilvie, DNP, ACNS-BS; Anne Bové, MSN, RN-BC, CCRN, ANP; and Seth Dressekie, MSN, RN, NP

n High-Quality Care Transitions Promote Continuity of Care and Safer Discharges

by Dana Deravin Carr, DrPH, MS, MPH, RN-BC, CCM

n Night Shift Work and Weight Gain Among Female Filipino Nurses

by Raymundo Apellido, PhD, RN, CCRN

n Nurse Entrepreneurs: The Real Independent Practice of Nursing

by Carol Lynn Esposito, EdD, JD, MS, RN-BC, NPD; Lucille Contreras Sollazzo, BSN, RN-BC, NPD

Article: A Changing Landscape: The Need to Remove Legislative Barriers on n Opinion Nurse Practitioners

by Cynthia S. Miller, BSN, RN

n What’s New in the Healthcare Literature: Clinical Guideline Updates n CE Activity: Night Shift Work and Weight Gain Among Female Filipino Nurses

THE

JOURNAL of the New York State Nurses Association

Volume 46, Number 2

n Editorial: Through Changes and Transitions: The Skills and Attitude......................... 3 Necessary for Nurses to Embark on the Journey

by Meredith King-Jensen, MSN, MA, RN; Dana Deravin Carr, DrPH, MS, MPH, RN-BC, CCM; Caroline Mosca, PhD, MSN, RN; Coreen Simmons, PhD-c, DNP, MSN, MPH, RN; Audrey Graham-O’Gilvie, DNP, ACNS-BS; Anne Bové, MSN, RN-BC, CCRN, ANP; and Seth Dressekie, MSN, RN, NP

n High-Quality Care Transitions Promote Continuity of.................................................................... 4

Care and Safer Discharges

by Dana Deravin Carr, DrPH, MS, MPH, RN-BC, CCM

n Night Shift Work and Weight Gain Among Female Filipino Nurses...........................12 by Raymundo Apellido, PhD, RN, CCRN

n Nurse Entrepreneurs: The Real Independent Practice of Nursing................................26 by Carol Lynn Esposito, EdD, JD, MS, RN-BC, NPD; Lucille Contreras Sollazzo,

BSN, RN-BC, NPD

n Opinion Article: A Changing Landscape: The Need to Remove .....................................40 Legislative Barriers on Nurse Practitioners

by Cynthia S. Miller, BSN, RN

n What’s New in Healthcare..................................................................................................................................................43 Clinical Guideline Updates

n CE Activity: Night Shift Work and Weight Gain..........................................................................................45

Among Female Filipino Nurses

THE

JOURNAL of the New York State Nurses Association

The Journal of the New York State Nurses Association Editorial Board

Audrey Graham-O’Gilvie, DNP, ACNS-BC Chief of Education/Designated Learning Officer Veterans Administration Hudson Valley Health Care System Montrose, NY

Anne Bové, MSN, RN, BC, CCRN, ANP Clinical Instructor New York, NY

Dana Deravin Carr, DrPH, MS, MPH, RN-BC, CCM Senior Care Manager/Transitions Care Coordinator Jacobi Medical Center Bronx, NY

Seth Dressekie, MSN, RN, NP Human Resources Administration NYC Dept. of Social Services New York, NY

Meredith King-Jensen, MSN, MA, RN Quality Management Specialist Veteran’s Administration Bronx, NY

Coreen Simmons, PhD-c, DNP, MSN, MPH, RN Professional Nursing Practice Coordinator James J. Peters VA Medical Center Bronx, NY

Caroline Mosca, PhD, MSN, RN Faculty Program Director – Team Lead BS/MS Nursing Program Excelsior College Albany, NY

Carol Lynn Esposito, EdD, JD, MS, RN-BC, NPD, Co-Managing Editor Lucille Contreras Sollazzo, BSN, RN-BC, NPD, Co-Managing Editor David Gray, Editorial Assistant

The information, views, and opinions expressed in The Journal articles are those of the authors and do not necessarily reflect the official policy or position of the New York State Nurses Association, its Board of Directors, or any of its employees. Neither the New York State Nurses Association, the authors, the editors, nor the publisher assumes any responsibility for any errors or omissions herein contained. The Journal of the New York State Nurses Association is peer reviewed and published biannually by the New York State Nurses Association. ISSN# 0028-7644. Editorial and general offices located at 131 West 33rd Street, 4th Floor, New York, NY, 10001; Telephone 212-785-0157; Fax 212-785-0429; Email info@nysna.org. Annual subscription: no cost for NYSNA members; $17 for nonmembers. The Journal of the New York State Nurses Association is indexed in the Cumulative Index to Nursing, Allied Health Literature, and the International Nursing Index. It is searchable in CD-ROM and online versions of these databases available from a variety of vendors including SilverPlatter, BRS Information Services, DIALOG Services, and The National Library of Medicine’s MEDLINE system. It is available in microform from National Archive Publishing Company, Ann Arbor, Michigan. .

Journal of the New York State Nurses Association, Volume 46, Number 2

n EDITORIAL Through Changes and Transitions: The Skills and Attitude Necessary for Nurses to Embark on the Journey The only constant in life is change. Ready or not, we all go through numerous transitions in our lives—leaving high school to go to nursing school, changing jobs, getting married, having children, and aging. Ready or not, we all go through numerous transitions in our lives—leaving high school to go to nursing school, changing jobs, significant life changes, and aging. This issue of The Journal will offer readers articles for thought on transitions we might all face throughout our life cycles and careers. In the article “High-Quality Care Transitions Promote Continuity of Care and Safer Discharges,” improvements in transitioning patients with chronic illnesses between healthcare practitioners, settings, and home as a patient’s condition and care needs change are discussed. Similarly, in the article “Night Shift Work and Weight Gain Among Female Filipino Nurses,” the challenges of nurses transitioning between day and night shift work and the associated weight gain experienced by night shift workers are addressed. Lastly, in the article “Nurse Entrepreneurs: The Real Independent Practice of Nursing,” the opportunities and challenges for nurses transitioning into a new career and role as a nurse entrepreneur are presented. During times of transition, when your world seems to be in flux, when old patterns and ways of doing things have collapsed, you may feel uncertain, unsteady, and unequipped, but remember that at these transitional stages you are also most malleable to change. Transitioning is a time of opportunity, a time to explore, brainstorm, and consider the skills and knowledge you need to acquire before your life begins to naturally solidify into new patterns. Transitions are those unique times when we toss off the old, but have not yet stepped into the new. While the circumstances are always different, the skills and attitudes necessary to successfully move ahead are always the same, namely being positive, patient, and proactive. A new journey awaits! Meredith King-Jensen, MSN, MA, RN Dana Deravin Carr, DrPH, MS, MPH, RN-BC, CCM Caroline Mosca, PhD, MSN, RN Coreen Simmons, PhD-c, DNP, MSN, MPH, RN Audrey Graham-O’Gilvie, DNP, ACNS-BS Anne Bové, MSN, RN-BC, CCRN, ANP Seth Dressekie, MSN, RN, NP

Journal of the New York State Nurses Association, Volume 46, Number 2

High-Quality Care Transitions Promote Continuity of Care and Safer Discharges Dana Deravin Carr, DrPH, MS, MPH, RN-BC, CCM

n A bstract

The care transition process is an essential part of healthcare delivery affecting patients and families, healthcare providers, and healthcare systems. The care transition, when instituted at the right time and in the right setting, has the powerful effect of smoothing a patient’s journey across the care continuum in a safe and effective manner, as well as informing the development of best practice guidelines (Dusek, Pearce, & Harripaul, 2015). Interdisciplinary collaboration, communication, and care coordination are among the vital components that support the care transition process. As such, these components are indispensable in assisting nurses and other healthcare professionals in understanding their roles and responsibilities as they work toward promoting a safe and positive care transition outcome. Today, healthcare systems across the country are carefully evaluating many care transition initiatives in order to adopt and/or develop their own best practices. When implemented at the right time and in the right way, care transitions enhance care delivery, improve patient outcomes, and move organizations toward successful attainment of the triple aim: better health, better care, and lower cost through improvement. This article defines and describes the care transition process and its potential to influence continuity of care and patient safety. When actively incorporated into patient care delivery, both during and post hospitalization, this process builds collaborative patient-centered relationships, which in the long term may have the positive effect of troubleshooting post-discharge problems, thus mitigating potentially avoidable readmissions.

What Are Care Transitions? The concept of care transitions has been on the healthcare radar since the early 2000s. Dr. Eric Coleman (2004) defined care transitions as a set of actions designed to ensure care coordination and continuity as patients transfer between different locations or different levels of care within the same location. Over time, this definition remains essentially unchanged. Accordingly, Clark, Doyle, Duco, and Lattimer (2016, p. 3) in their Joint Commission publication, “Transitions of Care: The need for a more effective approach to continuing patient care,” similarly noted that a care transition refers to the movement of patients between healthcare practitioners, care settings, and home.

Although one episode of care might entail many transitions, much of the literature describing these transitions shows they are coordinated pathway(s) through and across healthcare systems. Such transitions can be manifold—from department to department, institution to institution, and/or from facility to home (Cobler, Wang, Stout, Piejak, & Rodts, 2017; Deravin Carr, 2008; Coleman, 2004). Among most commonly seen patient care transitions are those occurring during the hospital admission process— between the emergency department (ED) and inpatient units—and again at discharge to the community. Figure 1 provides an example of the multiple transitions of care that can occur within healthcare systems.

Dana Deravin Carr, DrPH, MS, MPH, RN-BC, CCM, Jacobi Medical Center, Bronx, New York 4

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High-Quality Care Transitions Promote Continuity of Care and Safer Discharges

Figure 1. Patient transition points for individuals living with dementia.Reprinted from “Evidence-Based Interventions for Transitions in Care for Individuals Living With Dementia,” by K. B. Hirschman & N. A. Hogson, 2018, retrieved from doi:10.1093/geront/gnx152. Copyright 2018, The Gerontologist. 58(suppl_1):S129-S140

Over the past decade, healthcare executives and healthcare providers have gained an increased understanding of how the care transitions process can enhance patient care and patient safety. Targeted interventions employed throughout the hospital stay and continued post discharge help ensure a patient’s continued connectivity to the healthcare team. Interestingly, research conducted by health policy experts has shown poor transitions to be a major contributor to poor quality and waste. Lack of integrated processes siloed care delivery and layers of processes often bewilder and frustrate patients, families, and providers (Burton, 2012). Recognizing the negative effect of poor care transitions, in 2013 the federal government established the Hospital Readmissions Reduction Program (HRRP) through Section 3025 of the Affordable Care Act (ACA) (Centers for Medicare & Medicaid Services [CMS], 2012). This program requires Medicare to reduce payments to hospitals with relatively high readmission rates for patients in the traditional Medicare program. The HHRP is a permanent component of Medicare’s inpatient hospital payment system and applies to most acute care hospitals (Boccuti & Casillas, 2017). Although many healthcare providers have felt the financial sting associated with these penalties, others view them as an opportunity for strategic change, hence the move toward care transitions programs. As a result of HRRP and support from other Medicare-inspired projects such as the Community-based Care Transitions Program (CCTP) (CMS, 2011), many healthcare organizations developed a new mindset by initiated programs that would not only provide tailored interventions for patients post discharge, but also potentially improve both clinical and financial outcomes as well as patient satisfaction. The processes associated with care transitions are designed to ensure safe and effective continuity of care as clients experience a change in health status, care needs, healthcare providers, and/or location of care. Although all transitions are important to exacting patient-centered quality when it comes to readmissions, the facility-to-home transition appears to be a time

frame of increased vulnerability for high-risk patients (Dharmarajan et al., 2013; Deravin Carr, 2008). As a result, many hospitals have implemented care transition interventions that are consistently employed throughout each transfer point of hospitalization and post discharge. A recent 3-year, grant-funded study conducted across the six busiest EDs in the public hospital facilities of the New York City Health and Hospitals Corporation (NYCHHC) demonstrated the benefits and lessons learned from ED care management staffing. The principal aim of the ED Care Management Program was to reduce subsequent acute care utilization after an initial ED visit. Additional goals were to successfully embed care management teams within the ED setting, leverage the ED visit as an opportunity to engage otherwise hard-to-reach patients, and increase linkages to primary care and community resources to address ongoing non-emergent care needs longitudinally. When patients were admitted to acute care, ED care managers effectively transitioned patients to inpatient care managers, who in turn enabled team-based transition interventions that included postdischarge follow-up support (Roy, Reyes, Himmelrich, Johnston, & Chokshi, 2018). Patients who were not admitted were transitioned to primary care and/or skilled home care services accordingly. The NYCHHC study followed an earlier study conducted by the RAND Corporation (Morganti et al., 2013) that also demonstrated interesting outcomes when EDs in hospitals across the country added an RN case manager or discharge planner to the interdisciplinary care team. Outcomes from the RAND study reflect improved communication, improved patient flow, and decreased inappropriate admissions. Emergency department case managers focus on patients’ medical needs and collaborate with social workers also assigned to the ED on psychosocial issues, including domestic violence, child abuse or elder abuse, and neglect. Often, staff members intercede and arrange home services when a physician wants to admit a patient who truly does not require inpatient care.

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High-Quality Care Transitions Promote Continuity of Care and Safer Discharges

At the other end of the care spectrum, outcomes from the literature describe patients as having greater vulnerability during the post-discharge, 30-day period (Dharmarajan et al., 2013; Nelson & Pulley, 2015). In their review of more than 3 million discharges of Medicare patients, Yale University researchers found readmissions remained frequent throughout the first month after a hospitalization. Although a high percentage of 30-day readmissions occurred relatively soon after hospitalization, readmissions remained frequent during days 16 through 30 post discharge, and included a wide range of medical conditions regardless of patient age, sex, or race (Dharmarajan et al., 2013). Furthermore, Nelson and Pulley (2015) also noted one in five Medicare enrollees is readmitted to the hospital within 30 days and the readmission rate for patients discharged to skilled nursing homes is even higher—25% are readmitted within 30 days. Such readmissions cost the U.S. healthcare system approximately $17 billion annually, not including post discharge visits to EDs or urgent care settings (Burton, 2012). Such findings likely reflect the experiences of many hospitals, and, as a result, healthcare systems nationwide have implemented some type of care transition initiative including, but not limited to, telephonic support as well as skilled home care services. Successful initiatives are comprehensive, extend beyond the hospital stay, and have the flexibility to respond to individual patient needs (Kansagara et al., 2016). Having a framework for patient-centered care delivery is essential to developing a flexible program that addresses the essential needs of patients; this added support may help patients through the first 30-day post-discharge period. Increasingly, as care transition initiatives gain in popularity, researchers have conducted systematic reviews that document the effectiveness of various care transition platforms (Hirschman & Hodgson, 2018; Kansagara et al., 2016; Dusek, Harripaul, & Lloyd, 2015). Consistent findings demonstrate that generally and across different intervention types, patient populations, and settings, successful programs tend to be more comprehensive and involve more aspects of the care transition, including actions that transpire before and after the hospital discharge. Team collaboration, communication, and coordination are recurrent themes throughout the interdisciplinary process, and as such, are essential components of the care transition process; all participants, including the patient, are process owners. Incorporating patients and caregivers into the interdisciplinary team process throughout a hospitalization helps establish a network of support for the post-discharge period. Patient and caregiver engagement may begin in the ED (depending on the patient’s status), but undoubtedly should take place once the patient is admitted. No single specific transitional care activity has been shown to decrease hospital admissions effectively, but an array of activities linked to transitional care principles can reduce short- and long-term readmission risk (Nadzam, 2017). High-quality transitional care programs have been shown to enhance patient safety and reduce hospital readmissions for high-risk patients. Whichever care transition intervention a healthcare organization employs, the role of nurses is a powerful one in ensuring that patients receive the most appropriate care and follow-up. In most instances, the

Having a framework for patient-centered care delivery is essential to developing a flexible program that addresses the essential needs of patients; this added support may help patients through the first 30day post-discharge period.

nurse is both the first (through the triage process) and the last (providing discharge education) healthcare professional to touch a patient. The nurse’s role is integral in many of the well-established transitional care programs, and these have shown consistent benefit in reducing hospital readmissions. Such programs provide tools and best practices on which new programs can be modeled. Moreover, provisions in the ACA offer a carrot-and-stick approach to transitional care by offering reimbursement opportunities for programs that reduce readmissions (the carrot) and imposing penalties on hospitals with high readmission rates (the stick) (Guterman, 2013; Burton, 2012). In addition, the Joint Commission’s Hospital National Patient Safety Goals, survey activities, and educational services also address care transitions (Nazdam, 2017). These processes serve as important guides that can supplement an organization’s already established initiatives and enhance current transition processes.

Specific Care Transition Models While the ideas and initiatives around care transitions are manifold, this article speaks to proven models that have demonstrated positive outcomes in reducing both healthcare costs and readmissions. These include the Care Transitions Intervention Model (Coleman model), the Transitional Care Model (Naylor model), and the Better Outcomes for Older Adults through Safe Transitions (BOOST) model, all described by Deborah Nazdam (2017) as follows:

Care Transitions Intervention Model Eric Coleman’s Care Transitions Intervention Model is a 4-week program designed to foster patient engagement and promote a smooth transition from the hospital or skilled nursing facility to the home. It has been shown to decrease re-hospitalizations. The Coleman model rests on four pillars: medication self-management, maintenance of a personal health record, primary care physician follow-up, and alertness to red flags as described in Table 1.

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High-Quality Care Transitions Promote Continuity of Care and Safer Discharges

Table 1 The Four Pillars of Care Transition Intervention

The “Four Pillars” of Care Transition Intervention  Patient is knowledgeable about medications and has a



Medication self-management



U se of a dynamic patient-centered record (Personal Health Record – PHR)



P atient understands and utilizes a PHR to facilitate communication and ensure continuity of the care plan across providers and settings.



Primary care provider (PCP) or specialist follow-up



P atient schedules and completes follow-up visit with the PCP or specialist and is empowered toward self-advocacy.



Knowledge of red flags



P atient is knowledgeable about indications that their condition is worsening and how to respond.

medication management system.

Note. Reprinted from “The Care Transitions Intervention: A Patient-Centered Approach to Facilitating Effective Transfers Between Sites of Geriatric Care,” by C. Parry, E. A. Coleman, J. D. Smith, J. Frank, & A. M. Kramer, retrieved from https://caretransitions. org/four-pillars/, copyright 2013, Home Health Services Quarterly, 22(3):1-18

In practice, a transition coach focuses on the patient’s self-identified goals and helps the patient develop self-management skills. The relationship is relatively short, spanning only the 4-week intervention period, and the coach doesn’t assume home care or case management responsibilities. Coaching starts in the hospital, where the coach describes the transitional care program, obtains the patient’s consent to participate, and introduces the Coleman personal health record (PHR). This record guides the patient in documenting medication and other medical information and generates a list of questions for the healthcare provider. A home visit is scheduled within 72 hours of discharge. During the home visit, the coach assists the patient with a pre-/posthospitalization medication review and addresses any discrepancies. The patient develops his or her own list of questions for the primary care provider (PCP). The coach and patient review the discharge plan and update the PHR. Finally, the coach discusses symptoms and drug side effects and establishes an alert-and-response system. After the home visit, three follow-up calls take place to address the patient’s remaining medication questions, discuss the outcomes of follow-up PCP visits, describe available support services, and assist with scheduling additional follow-up appointments (as needed).

Transitional Care Model Dr. Mary Naylor is the architect of the Transitional Care Model, which was developed after many years of clinical research (Naylor et al., 1994, 1999, 2004). This intervention involves a 1- to 3-month period of interventions with high-risk, older adults to prevent hospital readmissions. An advanced practice registered nurse (APRN) performs a pre-discharge patient assessment, and then collaborates with a hospital team to develop a transitional care plan. Post discharge, the APRN makes multiple home visits, uses telephone

outreach throughout the transitional care period, and promotes information transfer between the acute care and primary care settings by accompanying the patient to the first primary care follow-up visit. The cornerstones of this model are patient engagement, goal setting, and communication with patients, families, and healthcare team members. The APRN helps the patient identify early signs and symptoms of a worsening condition to expedite prompt intervention and avoid future hospitalization. Patients with specific risk factors are good candidates for this care model.

Better Outcomes for Older Adults Through Safe Transitions (BOOST) Project BOOST was developed by a team of payers, regulators, and leaders in healthcare transitions and hospital medicine (the Society of Hospital Medicine) to improve the quality of care transitions (Hansen et al., 2013). This model focuses on discharge processes and communication with patients and receiving providers. Project BOOST involves discharge planning, medication reconciliation, patient and family communication, and PCP communication before discharge. It includes post-discharge telephone follow-up (including facilitating appointment scheduling). Patient-centered discharge instructions actively involve the patient in his or her own care. Project BOOST aligns evidence-based interventions with specific problems identified by the 8Ps tool, which identifies problems with medication, psychological concerns, principal diagnosis, physical limitations, poor health literacy, poor social support, prior hospitalization and palliative care, and then maximizes patient involvement in the plan of care through concise, patient-centered discharge instructions tailored to the patient’s literacy level. The instructions include the reason for hospitalization, red flags signaling complications, follow-up appointments, post-discharge care,

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High-Quality Care Transitions Promote Continuity of Care and Safer Discharges

key contact information, and space for the patient to list questions for the PCP. Before discharge, nurses use the teach-back method to review this information with the patient. Patient and caregiver engagement through use of communication strategies such as motivational interviewing,

collaboration, care coordination, and validation are essential to maintaining the patientâ&#x20AC;&#x2122;s active participation in the treatment plan and care process (Deravin Carr, 2016). For more information about these and other care transition models, the following websites as shown in Table 2 are of value.

Table 2 Care Transitions Model Information Websites Transitional Care Model: www.transitionalcare.info Care Transitions Program: www.caretransitions.org Project BOOST: www.hospitalmedicine.org/BOOST Project RED: www.bu.edu/fammed/projectred/index.html National Transitions of Care Coalition (NTOCC): www.ntocc.org United Hospital Fund of NYC: www.nextstepincare.org Note. Website information and associated articles are further noted in the References section.

While no one program is a panacea, perhaps the better programs are a compilation of the best components care transition models. It should be said that transitional care programs are resource-intensive and are most likely to be effective when targeting individuals with the highest readmission risk. Patient factors that pose a higher risk for readmission include active comorbid medical conditions, previous acute care hospitalizations and ED visits, older age, lack of family/social support, poor access to healthcare services, substance abuse, poor health literacy, and functional limitations

(Nazdem, 2017). Too often, a patient is the only one to receive selfmanagement education, even though family caregivers are primary in providing the actual care. It is important that, whenever possible, family members are included in the care transition and education process. Of note, unplanned weekend discharges also create high-risk situations for some patients due to a lack of available support services, such as skilled nursing and/or aide services, durable medical supplies and equipment, and/ or special pharmaceuticals. Many of these issues are detailed in Table 3.

Table 3 Challenges to Effective Care Transitions

Patient Lack of a primary care provider Limited or no insurance coverage Inability to pay for medication/ copays Language barriers Poor health literacy/inability to read

Hospital Lack of resources and financial incentives to sustain discharge programs Standardized discharge papers not personalized or in language of patient Resistance to change by clinicians

Long wait times while calling health centers

Financial pressure to fill beds as soon as they are empty

Late discharge; less effective teaching to patients who are anxious to leave

Homeless patients with nowhere to go Inadequate shelter systems

Sustaining care continuity can be a formidable task for safety-net hospitals in large urban centers where subpopulations are often culturally diverse and socioeconomically challenged. Issues such as poor access to healthcare, inadequate housing, and poor food resources present challenges for patients and the healthcare professionals caring for them. Recently, the transitioning of uninsured/underinsured and undocumented populations has become a growing and equally concerning matter. Large urban areas tend to draw undocumented and homeless populations. It is not uncommon to find urban hospitals unable to transition very ill homeless, uninsured, and 8

Medical Team Busy medical team; discharge receives low priority in the work schedule of inpatient clinicians Discharge is relegated to the least experienced team member Last-minute test and/ or consultations resulting in delay of final discharge plan and medication list Inaccurate medication reconciliation Discharge medication reconciliation started on the day of discharge

undocumented persons that, for a variety of reasonsâ&#x20AC;&#x201D;such as the need for ongoing hemodialysis or the requirement of life saving careâ&#x20AC;&#x201D;impede the discharge process, thereby placing undue pressure on our healthcare systems (Butcher, 2017; Roberts, 2012). Effective teamwork and creativity are essential in planning for these types of care challenges. At its best, communication before, during, and after the care transitions process creates opportunities that answer important questions while ensuring and confirming the timely delivery of essential patientrelated information. This requires that healthcare providers use proactive

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communication skills, which are foundational to building influence and trust throughout a patient’s hospitalization and beyond. Communication, a core competency for all healthcare professionals, supports collaborative practice and ensures patient-centered care and patient safety (Suter et al., 2009). As patients are being discharged “quicker and sicker” than ever before, proactive communication should occur in such a manner that the transferring and receiving parties have an opportunity to clarify the patient’s care needs by asking and responding to relevant questions (Qian, Russell, Valiyeva, & Miller, 2011). This exchange of information can be face-to-face or, in the case of patients transferring from unit to unit, to outside facilities or home with home care services, information flow can be best managed via transfer summaries, discharge summaries, fax and/or telephone (Jackson et al., 2016). It is important to note, however, that although discharge summaries are a common means of communication between inpatient and outpatient providers, numerous studies have shown they may lack relevant information, e.g., lab and test results, relevant medical information, and/or incomplete medication profiles, which are important for planning continued care (Krialani, Jackson, Schnipper, & Coleman, 2007). Therefore, the continued

availability of certain team point person(s)—nurse, social worker and/or case manager—can ensure communication clarity, thoroughness of clinical information, and follow up as needed.

Conclusion Transitions across the care continuum can increase a patient’s vulnerability and exposure to adverse events. Keen attention to care transitions is essential to ensuring continuity of care and patient safety. The ability of caring healthcare professionals to effectuate a smooth, patientcentered journey across many levels of care is grounded in their powerful role as facilitators of the care transition process and their understanding of how effective transitions add value to the patient care experience. Team and patient-centered communication, collaboration, and care coordination are among the most effective methods utilized in ensuring a patient’s safe passage across the care continuum. Building trust in our healthcare delivery system and our healthcare professionals helps ensure best practices and best outcomes.

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High-Quality Care Transitions Promote Continuity of Care and Safer Discharges

n References Boccuti, C., & Casillas, G. (2017). Aiming for fewer hospital U-turns: The Medicare Hospital Readmission Reduction Program. Kaiser Family Foundation–Issue Brief. Retrieved from http://files.kff.org/ attachment/Issue-Brief-Fewer-Hospital-U-turns-The-MedicareHospital-Readmission-Reduction-Program Burton, R. (2012). Improving care transitions. Health Policy Brief. Retrieved from https://www.healthaffairs.org/do/10.1377/hpb20120913.327236/ full/ Butcher, L. (2017). Why Hospitals Are Housing the Homeless. Hospitals & Health Networks. Retrieved from https://www.hhnmag.com/ articles/7818-why-hospitals-are-housing-the-homeless

myocardial infarction, or pneumonia. Journal of the American Medical Association, 309(4), 355-363. doi:10.1001/jama.2012.216476 Dusek, B., Pearce, N., Harripaul, A., & Lloyd, M. (2015). Care transitions. Journal of Nursing Care Quality, 30(3), 233-239. doi: 10.1097/ NCQ.0000000000000097 Guterman, S. (2013). Wielding the carrot and the stick: How to move the U.S. health care system away from fee-for-service payment. The Commonwealth Fund. Retrieved from https://www. commonwealthfund.org/blog/2013/wielding-carrot-and-stick-howmove-us-health-care-system-away-fee-service-payment

Centers for Medicare & Medicaid (CMS). (2012). The Hospital Readmissions Reduction Program (HRRP). Retrieved from https://www.cms.gov/medicare/medicare-fee-for-service-payment/ acuteinpatientpps/readmissions-reduction-program.html

Hansen, L. O., Greenwald, J. L., Budnitz, T., Howell, E., Halasvamani, L., Maynard, Williams, M. V. (2013). Project BOOST: Effectiveness of a multihospital effort to reduce rehospitalization. Journal of Hospital Medicine, 8(8), 421-427. Retrieved from https://www. journalofhospitalmedicine.com/jhospmed/article/127035/project-boost

Centers for Medicare & Medicaid (CMS). (2011). Community-based Care Transitions Program. Retrieved from https://innovation.cms.gov/Files/ fact-sheet/CCTP-Fact-Sheet.pdf

Hirschman K. B., & Hogson, N. A. (2018). Evidence-based interventions for transitions in care for individuals living with dementia. The Gerontologist, 58(suppl_1), S129-S140. doi:10.1093/geront/gnx152

Clark, K., Doyle, J., Duco S., & Lattimer, C. (2016). Hot Topics: Transitions of Care. Joint Commission Resources. Retrieved from https://www. jointcommission.org/assets/1/6/TOC_Hot_Topics.pdf 2/19/2013

Jack, B., & Boston University/Boston Medical Center (2014). Project RED (Re-Engineered Discharge). Retrieved December 6, 2018, from https:// www.bu.edu/fammed/projectred/index.html

Cobler, J., Wang, G., Stout, C., Piejak, J., & Rodts, M. F. (2017). Information sharing. Orthopedic Nursing, 36(1), 36-44. doi: 10.1097/ NOR.0000000000000310

Jackson, P. D., Biggins, M. S., Cowan, L., French, B., Hopkins, S. L., & Uphold, C. R. (2015). Evidence summary and recommendations for improved communication during care transitions. Rehabilitation Nursing, 41(3), 135-148. doi:10.1002/rnj.230

Coleman, E. A., & Berenson, R. A. (2004). Lost in Transition: Challenges and opportunities for improving the quality of transitional care. Annals Internal Medicine, 141(7), 533-536. doi:10.7326/0003-4819141-7-200410050-00009 Coleman, E. A., & Roman, S. P. (2015). Family caregiver’s experiences during transitions out of hospital. Journal for Healthcare Quality, 37(1), 12-21. Retrieved from https://caretransitions.org/care-transitionsfor-patients-and-family-caregivers/ Coleman, E., Fenley, R., Golden, R. L., Cummings, E, Millheiser, A. E., Levine, J., Sobolewski, S. (2014). A Family Caregiver’s Guide to Care Coordination. United Hospital Fund. Retrieved from https://www. nextstepincare.org/uploads/File/Guides/Care_Coordination/Care_ Coordination.pdf Deravin Carr, D. (2008). Effective care transitions. Nursing Management, 39(1), 25-31. Deravin Carr, D. (2016). Motivational interviewing supports patientcentered care and communication. Journal of the New York State Nurses Association, 45(1), 39-42. Dharmarajan, K., Hsieh, A. F., Zhenqiu, L., Bueno, H., Ross, J. S., Horwitz, L. I., Barreto-Filho, Krumholz, H. M. (2013). Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute

Kansagara, D., Chiovaro, J. C., Kagen, D., Jencks, S., Rhyne, K., O’Neil, M., Englander, H. (2015). So many options, where do we start? An overview of the care transitions literature. Journal of Hospital Medicine, 11(3), 221-230. doi:10.1002/jhm.2502 Krialani, S., Jackson, A. T., Schnipper, J. L., & Coleman, E. A. (2007). Promoting effective transitions of care at hospital discharge: A review of key issues for hospitalists. Journal of Hospital Medicine, 2(5), 314323. doi:10.1002/jhm.228 Morganti, K., Bauhoff, S., Blanchard, J. C., Abir, M., Smith, A., Vesely, J., Iyer, N. (2013). The evolving roles of emergency departments. Santa Monica, CA: RAND Corporation. Retrieved from https://www.rand. org/pubs/research_briefs/RB9715.html Naylor, M. D., Brooten, D. A., Campbell, R. L., Jacobsen, B. S., Mezey, M. D., Pauly, M. V., & Schwartz J. S. (1999). Comprehensive discharge planning and home follow-up of hospitalized elders. Journal of the American Medical Association, 281(7), 613-620. doi:10.1001/jama.281.7.613 Naylor, M. D., Brooten, D. A., Campbell, R. L., Maislin, G. M., McCauley, K. M., & Schwartz, J. S. (2004). Transitional care of older adults hospitalized with heart failure: A randomized, controlled trial. Journal of the American Geriatric Society, 52(5), 675-684. doi:10.1111/j.1532-5415.2004.52202.x

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High-Quality Care Transitions Promote Continuity of Care and Safer Discharges

Naylor M. D., Brooten, D. A., Jones, R., Lavizzo-Mourey, R., Mezey, M., & Pauly, M. (1994). Comprehensive discharge planning for the hospitalized elderly: A randomized clinical trial. Annals of Internal Medicine, 120(12), 999-1006. PMID: 8185149. Retrieved from https:// www.nursing.upenn.edu/ncth/research/hospital-to-home/ Nazdam, D. M. (2017). Safe passages through transitions of care. Joint Commission Resources. Retrieved from https://www.jointcommission. org/toc/aspx/pdf Nelson, J. M., & Pulley, A. L. (2015). Transitional care can reduce hospital readmissions. American Nurse Today, 10(4). Retrieved from https:// www.americannursetoday.com/transitional-care-can-reduce-hospitalreadmissions/ NTOCC. (2008-2018). National Transitions of Care Coalition About Us Knowledge and Resource Center. NTOCC seven critical interventions. Retrieved from http://www.ntocc.org/AboutUs/ KnowledgeResourceCenter/tabid/144/Default.aspx Parry, C., Coleman, E. A., Smith, J. D., Frank, J., & Kramer, A. M. (2003). The care transitions intervention: A patient-centered approach to facilitating effective transfers between sites of geriatric care. Home Health Services Quarterly, 22(3), 1-18. Retrieved August 12, 2018, from https://caretransitions.org/four-pillars/

Qian, X., Russell, L. B., Valiyeva, E., & Miller, J. E. (2010). “Quicker and sicker” under Medicare’s prospective payment system for hospitals: New evidence on an old issue from a national longitudinal survey. Bulletin of Economic Research, 63(1), 0307-3378. Retrieved from https://pdfs.semanticscholar.org/1f68/8db2a0fe069783249930e5133 559b88a9bdd.pdf Roberts, S. (2012, January 2). Nowhere to go, patients linger in hospitals, at high cost. The New York Times. Retrieved August 12, 2018, from https://www.nytimes.com/2012/01/03/nyregion/nowhere-to-gopatients-linger-in-hospitals-at-a-high-cost.html Roy, S., Reyes, F., Himmelrich, S., Johnston, L., & Chokshi, D. A. (2018). Learning from a large-scale emergency department care management program in New York City. New England Journal of MedicineCatalyst. Retrieved August 15, 2018, from https://catalyst.nejm.org/ ed-care-management-program-nyc/ Suter, E., Arndt, J., Arthur, N., Parboosingh, J., Taylor, E., & Deutschlander, S. (2009). Role understanding and effective communication as core competencies of collaborative practice. Journal of Interprofessional Care, 23(1), 41-51. DOI: 10.1080/1356182080238579

Journal of the New York State Nurses Association, Volume 46, Number 2

Night Shift Work and Weight Gain Among Female Filipino Nurses Raymundo Apellido, PhD, RN, CCRN

n A bstract

There are increasing numbers of overweight and obese nurses working the night shift. The purpose of this correlational and crosssectional study is to determine if there are statistically significant associations between insufficient sleep, abnormal eating patterns, working 12-hour shifts, the number of years working night shifts, age, stress, marital status, nursing units, decreased physical activity, and the level of weight gain among female Filipino nurses working the hospital night shift. The theoretical foundation of this study was to locate evidence, evaluate evidence, assess evidence, and develop an informed decision model. An online survey through Survey Monkey™ was used to access nurses for a convenient sampling. Data were analyzed using Spearman correlation, multiple regression, and analysis of variance (ANOVA). According to study findings, there were significant associations between insufficient sleep, abnormal eating patterns, marital status, 12-hour shifts, the number of years working on night shift, and an increase in body mass index (BMI). The implications for social change include information so that nurses can better understand the negative implications of night shift work on health. At the organizational level, this study provides information for administrators and nursing leaders that can be used to facilitate change in policies by improving working conditions for nurses.

Introduction Shift work, particularly night shift work, is an increasing part of a nurse’s working schedule. Night shifts allow services to be provided around the clock and helps to meet the demands of consumers in many businesses and industries, including healthcare, transportation, law enforcement, communication, and manufacturing (Ramin et al., 2015). Healthcare providers, such as nurses, provide 24-hour patient care services in hospitals on different shifts. Nurses opt to work the night shift for various reasons, including family obligations, babysitting issues, returning to school, and night differential pay. However, despite their work-related knowledge of health promotion, health education, and disease processes (Buss, 2012), nurses are often unaware of the negative health implications of working night shifts (Boughattas et al., 2014; Buja et al., 2013; Deori, 2012; Lin et al., 2012). Night shift workers experience insufficient sleep, tiredness, and an inability to recover between shifts (Patterson, Buysse, Weaver, Calloway, & Yealy, 2015). Furthermore, Kim, Jeong, and Hong (2015) reported that insufficient sleep, even for one night, could cause energy expenditure and metabolic imbalance associated with weight gain. Additionally, insufficient sleep can increase food consumption (Depner, Stothard, & Wright, 2014) by creating a need to replace sleep loss and energy by consuming more food (Spaeth, Dinges, & Goel, 2013). Researchers have found that night shift nurses are at an increased risk of weight gain. Hawkes et al. (2015) observed that attitudes and behaviors concerning food and body weight vary by culture. However, researchers have not focused on the increased risk of weight gain in female Filipino nurses

working the night shift. This study was designed to explore the relationship between night shift work and weight gain among female Filipino nurses. The implications of this study for positive social change include providing information that might facilitate changes in policies and working conditions to promote the health and well-being of nurses. Enhancing the health of the nursing workforce on the night shift and promoting sleephygiene initiatives could prevent the development of conditions associated with weight gain, such as heart disease, hypertension, diabetes, stroke, and some forms of cancer (Center for Disease Control and Prevention [CDC], 2014). Also, according to the CDC (2014), the expected medical costs for overweight people were $1,429 higher per person annually than the costs of those of normal weight. Therefore, enhancing the health of the nursing workforce on the night shift and promoting sleep-hygiene initiatives may have implications for decreased healthcare expenditures.

Background of the Study Researchers have addressed the factors associated with an increased risk of weight gain among female nurses who work the night shift. Han, Trinkoff, Storr, Geiger-Brown, and Park (2012) and Amani and Gill (2013) reported that stress and lack of sleep during night shifts contributed to nurses’ weight gain. Nurses who worked 12-hour night shifts suffered increased fatigue due to insufficient sleep (Han et al., 2012). Insufficient sleep, coupled with the abnormal eating habits of night shift nurses, led to weight gain (Buja et al., 2013). Nahm, Warren, Zhu, and Brown (2012)

Raymundo Apellido, PhD, RN, CCRN, is an Administrative Nursing Supervisor at Saint Barnabas Hospital Health System Bronx, New York, and a Staff Nurse ICU Northwell Health at Plainview, New York 12

Journal of the New York State Nurses Association, Volume 46, Number 2

Night Shift Work and Weight Gain Among Female Filipino Nurses

discovered that 53.8% of their participants missed meals because of busy work schedules. In addition, 72.2% of the respondents indicated that they felt they were not engaging in enough exercise (Nahm et al., 2012).

gain and weight-related medical conditions among female Filipino nurses. However, researchers have yet to focus on female Filipino nurses and night shift work as it relates to weight gain. This quantitative study will examine the connections between night shift work and weight gain among female Filipino nurses working in a community hospitals in the United States.

Weight gain among night shift nurses is measured by using BMI, and being overweight is defined as having a BMI of 25 or greater, while obesity is defined as a BMI of 30 or greater (CDC, 2012, 2015; World Health Organization [WHO], 2015). Huth, Eliadis, Handwork, Englehart, and Messenger (2012) Purpose of the Study revealed that 27.5% of the 97 night shift nurses they studied had a BMI of The purpose of this quantitative study was to gather information on 30 or above. Huth et al. also found that night shift nurses’ quality of sleep whether insufficient sleep, abnormal eating patterns, stress, nursing units, was lower than the sleep quality of day shift nurses. Additionally, Marqueze, working 12-hour shifts, age, marital status, number of years on night shift, Soares, Lorenzi-Filho, and Moreno (2012) revealed and decreased physical activity are linked to weight that working night shifts was associated with gain among female Filipino nurses working the Researchers have found that greater weight gain than working day shifts and night shift in a community hospitals in the United night shift nurses are at an that their participants had significant increases States. Researchers have shown high correlations in their BMI compared to day shift nurses. increased risk of weight gain. between night shift work and weight gain (Asaoka According to Theorell-Haglöw, Berglund, Janson, et al., 2013). However, little is known about how However, researchers have and Lindberg (2013), both short and long sleeper the factors of night shift work relate to weight gain not focused on the increased night shift nurses were centrally obese and had among female Filipino nurses. Challenges of night risk of weight gain in female shift work include insufficient sleep, poor sleep greater neck circumference. Short sleepers were Filipino nurses [and] this study quality, poor eating habits, stress, 12-hour shifts, and more centrally obese than the long sleepers were. was designed to explore the limited physical activity, which may all be related to relationship between night weight gain among female Filipino night shift nurses Problem Statement (Asaoka et al., 2013; Lin et al., 2014). Marqueze et al. shift work and weight gain The increasing numbers of overweight and (2012) suggested that further studies are needed to among female Filipino nurses. obese nurses working night shifts are becoming investigate the relationships between the short sleep the focus of occupational researchers. Researchers durations of night shift nurses and weight gain. Also, have conducted studies on weight gain among nurses from many countries. further investigation is required on the onset of related metabolic syndromes These countries include South Africa, Australia, the United Kingdom, New of weight gain, such as diabetes, hypertension, and high cholesterol levels. Zealand (Phiri, Draper, Lambert, & Kolbe-Alexander, 2014), Japan (Amani & Gill, 2013; Asaoka et al., 2013; Nagashima, Masutani, & Wakamura, 2014), the Republic of Korea (Jung & Lee, 2015), Malaysia (Coomarasamy, Wint, Research Questions and Hypotheses Neri, & Sukumanran, 2014), the United States (Buss, 2012; Han et al., 2012; Research Question 1: What statistically significant associations are there Huth et al., 2013), Brazil (Marqueze et al., 2012), Taiwan (Lin et al., (2012), between insufficient sleep, abnormal eating patterns, and the level of weight Europe (Saksrik-Lehouillierm, Bjorvatn, Hetland, Sandal, & Moen et al., 2012), gain among female Filipino nurses working the night shift in the hospital? and Canada (Smith, Fritschi, Reid, & Mustard, 2012). Lozano-Kühne, Aguila, H01: There are no statistically significant associations between insufficient Manalang, Chua, Gabud, and Mendoza (2012) argued that because of the sleep, abnormal eating patterns, and level of weight gain among female increase of business process outsourcing (BPO) in the Philippines, especially Filipino nurses working the night shift in the hospital. contact and call center work, research on shift work is becoming increasingly H 1: There are statistically significant associations between insufficient a important. However, researchers have not focused on weight gain among sleep, abnormal eating patterns, and level of weight gain among female female Filipino nurses working the night shift. Because norms about food Filipino nurses working the night shift in the hospital. and body weight vary from culture to culture (Hawkes et al., 2015), it is Research Question 2: What statistically significant associations are there important to gain information on this cultural population concerning weight between working 12-hour shifts, number of years working on the night gain among night shift nurses. shift, and the level of weight gain among female Filipino nurses working Obesity has become one of the most common health problems the night shift in the hospital? worldwide (Zimberg et al., 2012). The WHO (2015) reported that around H02: There are no statistically significant associations between working 121.9 billion adults 18 years and older were overweight and that 600 million hour shifts, number of years working on the night shift, and level of weight were obese. In the United States alone, 78.6 million are reportedly obese gain among female Filipino nurses working the night shift in the hospital. (CDC, 2015, 2014). Because of the prevalence of unhealthy weight gain in night shift nurses, researchers are focusing on the occupational-related Ha2: There are statistically significant associations between working 12weight gain associated with night shift work. For example, Asaoka et al. hour shifts, number of years working on the night shift, and level of weight (2013) found connections between night shift work and weight gain among gain among female Filipino nurses working the night shift in the hospital. female night shift nurses in Japan. In Brazil, night shift nurses experienced Research Question 3: What statistically significant associations are there poor sleep quality and reduced access to quality food choices (Marqueze between age, marital status, and the level of weight gain among female et al., 2012). Working night shifts could also lead to unhealthy weight Filipino nurses working the night shift in the hospital? Journal of the New York State Nurses Association, Volume 46, Number 2

n Night Shift Work and Weight Gain Among Female Filipino Nurses H03: There are no statistically significant associations between age, marital status, and level of weight gain among female Filipino nurses working the night shift in the hospital.

culture and ethnicity of female Filipino nurses, the findings of this study is not generalizable to other populations in other settings. Further study is needed on this population to compare findings to studies on other populations.

Ha3: There are statistically significant associations between age, marital status, and level of weight gain among female Filipino nurses working the night shift in the hospital.

Because the methodology of the study is cross-sectional using questionnaire surveys, causal links between other variables cannot be identified. The purpose of the study was to gather statistical data from female Filipino night shift nurses and the occupational factors they may face that lead to weight gain. Such factors included poor sleep quality, short sleep duration, stress, limited physical activity, and patterns of eating to compensate lost energy. Participants who were excluded from the study were those who had worked fewer than three years on night shifts, worked per diem (once a week), had a family history of being overweight, those taking medications (such as steroids) for chronic medical conditions, and those in supervisory or educator roles.

Research Question 4: What statistically significant associations are there between stress, nursing units, decreased physical activity, and the level of weight gain among female Filipino nurses working the night shift in the hospital? H0 4: There are no statistically significant associations between stress, nursing units, decreased physical activity, and level of weight gain among female Filipino nurses working the night shift in the hospital. Ha4: There are statistically significant associations between stress, nursing units, decreased physical activity, and level of weight gain among female Filipino nurses working the night shift in the hospital.

Nature of the Study In this study, a quantitative, correlational, cross-sectional design was employed, with data collection conducted via survey. Correlational researchers assess the linear association between two or more variables in a non-experimental study, and also determine the degree of relations between variables (Welford, Murphy, & Case, 2012). When using cross-sectional design, the data are collected at a single point in time (Sedgwick, 2014). Surveys are the most common method of data collection in quantitative research.

Limitations One limitation was the potential subjectivity of participants’ weight and height reporting used to calculate their actual BMI measurement; the BMI of the study’s population was based solely on participants’ self-reported height and weight. Consequently, the effects of social desirability bias may come into play. Social desirability bias refers to participants sometimes answering in ways to appear favorably in the eyes of others rather than answering truthfully (Krumpal, 2013), especially in studies on topics difficult for individuals to address, such as weight gain. Consequently, self-reported weight gain may be subject to social desirability bias.

The combination of Pearson and Spearman correlations was used to address the research questions. Correlations were used to examine the relationship between the characteristics of female Filipino nurses and weight gain. The significant variables were placed into a multiple linear regression to examine the predictive nature of these characteristics in the prevalence of weight gain.

Other limitations include self-reported hours of sleep duration, sleep quality, degree of physical activity, and food consumption to replenish lost energy. Probability sampling was another limitation in this quantitative study, because this type of sampling does not reflect the larger population. In addition, there were other potential biases in the study. In addition, while the focus on a cultural population and cultural background can reveal attitudes toward diet, consumption, food choices, and physical activity, findings from this study cannot be generalized to other populations.

Assumptions

Sample Procedure

The study began with the assumption that female Filipino nurses who work night shift have the same risk of becoming overweight and obese as nurses of other cultures and races. However, this assumption cannot be demonstrated to be true because no research has been conducted on night shift work and weight gain among this population. In this quantitative study, it was assumed the participants provided the most accurate information to the questionnaire. After participants were informed of the nature of the study, as well as of the confidentiality of the data collected, it was assumed that the participants answered truthfully and honestly so that the validity of the data is highly regarded for statistical analysis. The BMI of this population was calculated solely on participants’ self-reported height and weight, and BMI was treated as a valid and accepted measurement for level of weight gain.

The sample for the study consisted of a group of female Filipino nurses working the night shift. Convenience sampling was used in the recruiting process, as participants were selected based on their proximity and accessibility to the researcher (Etikan, Musa, & Alkassim, 2016). Participants were excluded based on the following criteria: male Filipino nurses working as registered nurses, those who were younger than 30 years old or older than 62 years old, and those who had gestational weight gain before starting work as a registered nurse, or were overweight prior to working as a nurse. Additionally, those who had worked fewer than three years on night shift, worked per diem (once a week), had a family history of being overweight, were taking medications (such as steroids) for chronic medical conditions, and those in supervisory or educator roles were excluded.

Scope and Delimitations

Data Collection

The researcher focused on female Filipino nurses who were working the night shift in community hospitals in the United States. The demographic characteristics of the participants included age, marital status, education, and the number of years nurses have worked the night shift. Because of the specifics of

The study was approved by the Institutional Review Boards of Walden University and the New York-Presbyterian Hospital Queens. Data were collected through the Internet via Survey Monkey™ from March 27, 2017, to April 15, 2017. Initially, there were 115 female Filipino registered nurses

Journal of the New York State Nurses Association, Volume 46, Number 2

Night Shift Work and Weight Gain Among Female Filipino Nurses

recruited to participate in the study who were conveniently selected from the records in the nursing office of New York-Presbyterian Hospital Queens. Upon evaluation for inclusion in the study, 17 registered nurses were excluded, two were on medical leave, four were on orientation, and 11 were employed less than three years and were younger than 30 years old. Invitations were sent to 98 eligible participants through their respective hospital emails on March 20, 2017. Data were collected from 75 participants’ responses. Prior to analysis, the data were screened for missing cases and outliers. There were a total of seven removals made due to participants not answering completely to a majority of the questionnaire’s items. Outliers were examined by calculation of standardized values, or z-scores. Z-scores falling outside the range ± 3.29 standard deviations away from the mean were considered outliers. One case was subsequently removed for an outlying response. After reductions, the data were analyzed from the complete responses of 67 participants.

disturbance. The PSQI has previously demonstrated acceptable reliability for the overall scale, a = .83 (Buysse, Reynolds, Monk, Berman, & Kupfer, 1989).

Pittsburgh Sleep Quality Index

Frequencies and Percentages

The Pittsburgh Sleep Quality Index (PSQI) contains 19 self-rated questions regarding sleep quality. Sample questions include, “During the past month, when have you usually gone to bed at night?” and “During the past month, when have you usually gotten up in the morning?” A combination of free response and multiple choice items were used. The PSQI generates seven scores that correspond to subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleep medications, and daytime dysfunction. Combining the factors together generates a global score, ranging from 0-21. A PSQI global score greater than 5 is typically considered to be evidence for significant sleep

Perceived Stress Scale The Perceived Stress Scale (PSS) 14 contains 14 self-rated survey items regarding stress. Sample items include, “In the last month, how often have you been upset because of something that happened unexpectedly?” and “In the last month, how often have you felt nervous and stressed?” The PSS-14 scores were obtained by a sum of all 14 items. Seven items were reverse scored prior to calculating the composite scores. Total scores can range between 0-56. The PSS-14 has previously shown an acceptable level of reliability, a = .78 (Cohen, Kamarck, & Mermelstein, 1983).

Results Frequencies and percentages were examined for the nominal and ordinal level variables. Ages 30-34 years old represented the most among the participants (n = 14, 21%) followed by ages 46-50 years old (n = 13, 19%). A majority of participants were married (n = 50, 75%). A majority of the samples were employed full time (n = 61, 91%) and had a BSN (n = 55, 82%). Most of the participants worked night shift (n = 63, 94%) and had shifts extending 12 hours (n = 62, 93%). Most of the participants worked in the critical care units (n = 24, 36%) or medical surgical units (n = 29, 43%). A majority of the participants previously worked the night shift before transferring to the day shift (n = 45, 67%). Frequencies and percentages are presented in Table 1.

Table 1 Frequency Table for Nominal Variables

Variable

30-34 years old

35-40 years old 41-45 years old

9 10 13

13 15 19

9 12

13 18

4 50 11 2

6 75 16 3

61 6

91 9

4 55

6 82

Age

46-50 years old 51-55 years old Over 55 years old Marital Status Divorced Married Single Widowed Employment Status Full Time (75.0 hours per 2-week pay period) Part Time (37.5 hours per 2-week pay period) Nursing Education Associate Degree in Nursing or Diploma in Nursing BSN

Journal of the New York State Nurses Association, Volume 46, Number 2

n Night Shift Work and Weight Gain Among Female Filipino Nurses Table 1 Frequency Table for Nominal Variables (con't) MSN or MS Work Night Shift No Yes Shift Extended to 12 Hours No Yes Specialty Unit Critical Care Units (ICU, CCU, ER, CVRU) Labor and Delivery Unit (Mother and Baby) Medical-Surgical Unit Operating Room/Recovery Room/Cardiac Catheterization Laboratory Telemetry Unit Worked Night Before Changing to Day Shift Never No Yes Length of Working Current Shift 3-5 years 6-10 years 11-15 years 16-20 years 21-35 years Hours of Sleep 3 hours or less 4 hours 5 hours 6 hours 7 hours and above Sleep Quality Poor Fair Good Very good Missed Meal Breakfast Dinner Lunch Snack 16

Journal of the New York State Nurses Association, Volume 46, Number 2

4 63

6 94

24 4 29 2 8

36 6 43 3 12

4 18

6 27

20 9 11 11 16

30 13 16 16 24

4 20 28 11 4

6 30 42 16 6

15 33 18 1

22 49 27 1

11 33 16 7

16 49 24 10

Night Shift Work and Weight Gain Among Female Filipino Nurses

Table 1 Frequency Table for Nominal Variables (con't) Missed Meal Frequency Always/all the time Most of the time Sometimes Not at all Physical Activity High Low Moderate Exercise After Work Never Once a week Sometimes Twice a week Thrice a week Descriptive statistics were examined for the continuous level variables. Global PSQI scores ranged from 1.00 to 12.00 with M = 4.42 and SD = 2.22. As evidenced by Figure 1, global PSQI scores were slightly skewed to the right. Perceived stress scores ranged from 8.00 to 33.00 with M = 23.07 and SD =

10 25 30 2

15 37 45 3

1 23 43

1 34 64

12 2 39 10 4

18 3 58 15 6

5.51. As evidenced by Figure 2, perceived stress scores were slightly skewed to the left. BMI values ranged from 18.20 to 32.89 with M = 25.18 and SD = 2.91. As evidenced by Figure 3, BMI values were approximately normal in distribution. Table 2 presents the findings of the descriptive statistics.

Table 2 Descriptive Statistics of Continuous Variables

Continuous Variables

Min

Max

Global PSQI Perceived Stress Scale BMI

1.00 8.00 18.20

12.00 33.00 32.89

4.42 23.07 25.18

4.42 5.51 2.91

12.0

10.0

20.0

Frequency

8.0

Frequency

15.0

10.0

4.0

5.0

0.0

6.0

2.0

.00

2.00

4.00

6.00

8.00

Global PSQI Figure 1. Distribution of global PQI score

10.00

12.00

0.0

5.00

10.00

15.00

20.00

25.00

30.00

35.00

Perceived Stress Figure 2. Distribution of perceived stress score

Journal of the New York State Nurses Association, Volume 46, Number 2

n Night Shift Work and Weight Gain Among Female Filipino Nurses 25.0

Frequency

20.0

Occupational factors, such 15.0

as insufficient sleep between shifts, abnormal eating habits, working 12-hour

10.0

shifts, and extended years of working the night shift had 5.0

significant associations with weight gain and BMI.

0.0

15.00

20.00

25.00

30.00

35.00

BMI Figure 3. Distribution of BMI values

Detailed Analysis To address Research Question 1, a series of Spearman correlations were conducted to examine the two-way associations between average hours of sleep between shifts, sleep quality, frequency of missed meals at work, global PSQI, and BMI. There was a statistically significant association between average hours of sleep between shifts and BMI (rs = .35, p = .004). There was a moderate positive relationship between average hours of sleep between shifts and BMI. There was a statistically significant association between sleep quality and BMI (rs = .25, p = .043). There was a small positive relationship between sleep quality and BMI. There was a statistically significant association between frequency of meals missed while working and BMI (rs = .28, p = .024). There was a small positive relationship between frequency of missed meals while working and BMI. The null hypothesis (H01) for Research Question 1 was partially rejected. Due to the low sample size used in the research, there is a lack of statistical power in the findings (Williams & Bornmann, 2016). Therefore, the significant and nonsignificant findings

Table 3 Spearman Correlations between Insufficient Sleep, Abnormal Eating Patterns, and BMI

interpretation must be construed with caution. Table 3 presents the findings of the Spearman correlations. To address Research Question 2, a series of Spearman correlations were conducted to examine the two-way associations between working the night shift, a shift extending to 12 hours, the length of time in the current shift, and BMI. There was a statistically significant association between the length of time working the current shift and BMI (rs = .30, p = .014). The sign and strength of the coefficient suggests there is a moderate positive relationship between the length of working current shift and BMI. Working the night shift and having shifts extend to 12 hours did not show a significant association with BMI. Due to the significant association between working night shift and BMI, the null hypothesis (H02) for Research Question 2 was partially rejected. Due to the low sample size collected for the research, there is a lack of statistical power in the findings (Williams & Bornmann, 2016). Therefore, the significant and nonsignificant findings interpretation must be taken with a level of caution. Table 4 presents the findings of the Spearman correlations.

Table 4 Spearman Correlations between Working Night Shift, Shift Extending to 12 Hours, Length of Time in Current Shift, and BMI

BMI Average hours of sleep between shifts Sleep quality Frequency of missed meals while working Global PSQI

BMI

.35 .25 .28

.004 .043 .024

.05

.713

Working night shift Shift extending to 12 hours Length of time in current shift

Journal of the New York State Nurses Association, Volume 46, Number 2

.02 -.04 .30

.855 .723 .014

Night Shift Work and Weight Gain Among Female Filipino Nurses

To address Research Question 3, a Spearman correlation was conducted to examine the two-way associations between age and BMI. Age was not statistically associated with BMI level. The findings of the correlation are presented in Table 5.

Table 5 Spearman Correlations Between Age and BMI

To address Research Question 4, a series of Spearman correlations were conducted to examine the two-way associations between stress, decreased physical activity, and BMI. Perceived stress and physical activity did not have a significant association with BMI. The findings of the Spearman correlations are presented in Table 8.

Table 8 Spearman Correlations Between Perceived Stress, Physical Activity, and BMI

BMI Age

.22

.069

BMI Perceived Stress Physical Activity

-.03 -.13

.832 .289

An analysis of variance (ANOVA) was conducted to examine for differences in BMI by marital status. The continuous dependent variables in this analysis corresponded to BMI. The independent grouping variables in this analysis corresponded to marital statusâ&#x20AC;&#x201D;single, married, divorced, and widowed.

An analysis of variance (ANOVA) was conducted to examine for differences in BMI by specialty unit. The continuous dependent variables in this analysis corresponded to BMI. The independent grouping variables in this analysis corresponded to specialty unitâ&#x20AC;&#x201D;medical surgical unit, telemetry unit, critical care units, operating room, and labor unit.

The results of the ANOVA were statistically significant for marital status (F(3, 63) = 7.09, p < .001, partial n2 = .252), suggesting that there were statistical differences by marital status. Through examination of post hoc tests via Tukey comparisons, it was determined that married participants had significantly higher BMI levels in comparison to single and divorced participants. Due to significant differences in marital status, the null hypothesis (H03) was partially rejected. Because of the low sample size collected for the research, there is a lack of statistical power in the findings. Therefore, the significant findings must be interpreted with a level of caution. Table 6 presents the findings of the ANOVA. Table 7 presents the descriptive statistics of BMI by marital status.

The results of the ANOVA were not statistically significant for specialty unit (F(4, 62) = 2.33, p = .066, partial n2 = .131), suggesting that there were not statistical differences by specialty unit. Due to non-significance of the correlations and ANOVA, the null hypothesis (H0 4) for Research Question 4 was not rejected. Because of the low sample size collected for the research, there is a lack of statistical power in the findings (Williams & Bornmann, 2016). Therefore, the nonsignificant findings interpretation must be met with a level of caution. Table 9 presents the findings of the ANOVA. Table 10 presents the descriptive statistics of BMI by specialty unit.

Table 9 ANOVA for BMI by Specialty Unit

Table 6 ANOVA for BMI by Marital Status Source Marital Status

Hypothesis df 3

Error df 63

F 7.09

p n2 <.001 .252

Table 7 Means and Standard Deviations for BMI by Marital Status Continuous Variables

Marital Status Single Married Divorced Widowed

n M SD

11 50 4 2

23.13 26.01 21.67 22.87

2.81 2.51 1.91 4.14

Source

Hypothesis df

Error df

2.33

.066

.131

Speciality Unit

Table 10 Means and Standard Deviations for BMI by Specialty Unit Continuous Variables

Speciality Unit Medical-Sugical Unit Telemetry Unit Critical Care Unit Operating Room Labor Unit

24.37

2.50

8 24 2 4

24.89 26.54 24.80 23.73

4.66 2.20 1.13 3.91

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n Night Shift Work and Weight Gain Among Female Filipino Nurses

Multiple Linear Regression hours of sleep between shifts, sleep quality, frequency of missed meals at work, the length of time in current shift, and marital status. The continuous criterion variable corresponded to BMI.

Expected Cumulative Probability

Regression Standardized Residual

A multiple linear regression was conducted as an ancillary analysis to examine the predictive relationship between the significant variables and BMI. In this analysis, the predictor variables corresponded to average

Regression Standardized Predicted Value

Observed Cumulative Probability

Figure 4. Normal predictive probability plot for BMI level

Results of the overall model of the multiple linear regression were statistically significant (F(5, 61) = 6.58, p < .001, R2 = .350), suggesting that collectively there was a significant predictive relationship between the independent variables and BMI level. The R 2 value indicates that approximately 35.0% of the variance in BMI level can be explained by the predictor variables. Average hours of sleep between shifts (t = 2.05, p = .045), frequency of missed meals while working (t = 2.31, p = .025),

Figure 5. Standardized predicted values versus standardized residuals for the regression on BMI level

and marital status (t = 3.95, p < .001) were significant positive predictors in the model. Because of the low sample size collected for the research, there is a lack of statistical power in the findings (Williams & Bornmann, 2016). Therefore, the significant and nonsignificant findings interpretation must be met with a level of caution. The results of the multiple linear regression are presented in Table 11.

Table 11 Results for Regression with Factors Predicting BMI

Source Average hours of sleep between shifts Sleep quality Frequency of missed meals while working Length of time in current shift Marital Status (reference: single)

Î˛

VIF

0.74 -0.05 0.91 -0.04 3.08

0.36 0.50 0.39 0.22 0.78

.25 -.01 .24 -.02 .47

2.05 -0.10 2.31 -0.19 3.95

.045 .917 .025 .847 <.001

1.34 1.55 1.03 1.30 1.30

Note. F(5, 61) = 6.58, p < .001, R 2 = .350

Journal of the New York State Nurses Association, Volume 46, Number 2

Night Shift Work and Weight Gain Among Female Filipino Nurses

Interpretation of the Findings Evidence was found to indicate there were small positive associations between insufficient sleep and abnormal eating patterns with BMI among female Filipino nurses working the night shift. Because there was a small positive relationship between missed meals and BMI, the null hypothesis was partially rejected. In this study, it was determined that the average hours of sleep between shifts were 5 hours (n = 28, 42%), which showed moderate positive relationship with BMI (rs = .35, p = .004) and also indicated that there was a statistically significant association with BMI (rs = .25, p = .043); the most frequently missed meal was dinner (n = 33, 49%), which indicated that there were statistically significant associations of frequently missed meals with BMI (rs = .28, p = .024). The findings on insufficient sleep between shifts were confirmed with previous studies from Spaeth et al. (2013), who found that short sleep duration had associations with weight gain and increased BMI. According to Geiger-Brown et al. (2012), night shift workers had the shortest sleep duration between shifts compared to day shift workers that increased their risk of the weight gain that lead to an increase in BMI. The findings on quality of sleep were consistent with the previous studies conducted by Boughattas et al. (2014) and Vijayalaxmi et al. (2014), who reported that 60% of night shift workers’ sleep quality was severely compromised and 30% of them complained of insomnia. Also, Kim et al. (2015) found that even a single night of disrupted sleep influenced energy consumption and increased metabolism that promoted frequent eating and increased snacking on high calorie food. The findings on abnormal eating patterns were consistent with previous research from Spaeth et al. (2013), Griep et al., (2014), and Vijayalaxmi et al., (2014), who found that erratic eating patterns of night shift workers increased energy consumption that promoted increased snacking instead of eating a full meal, which was suggestive of metabolic imbalances that lead to weight gain. This study found that 12-hour shifts and the length of time working night shifts had significant associations with BMI. However, having worked extended hours beyond 12 hours did not show significant associations with BMI. The null hypothesis, therefore, can be partially rejected due to significant associations between night shift work and the number of years working a night shift with BMI. In this study, the variables of 12-hour shifts and extended years of working the night shift demonstrated statistically significant associations with BMI (rs = .30, p = .014). The research found (n = 63, 94%) that having continuous 12-hour shifts, and length of time working night shift showed nurses who have worked the night shift for 3-5 years (n = 20, 30%), and nurses who have worked for 21-35 years (n = 16, 24%), had statistically significant associations with increased BMI. In the findings on 12-hour shifts and number of years working the night shift, the significant associations with BMI were confirmed from previous research findings. For example, Kim et al. (2013) found that the longer the nurses worked on the night shift, the greater their risk of becoming overweight and obese. Also, Buss (2012) reported that weight gain was higher among night shift nurses. Other researchers have found that extended years of working the night shift caused health problems (Guo et al., 2013), such as hypertension, diabetes, heart diseases, some forms of cancer, and early disability (CDC, 2015). In addition, Gu et al. (2015) reported that for women who worked a night shift for an extended period of time, it

significantly contributed to weight gain and increased BMI. Furthermore, Kim et al. (2013) found that long years of working the night shift demonstrated significant associations with increased BMI. Also, Vimalananda et al. (2015) found that African-American women who worked the night shift for long durations had significant associations with increased BMI. The ages of female Filipino nurses were found to have no statistical association with BMI. However, married participants had significantly higher BMI levels compared to single and divorced participants. Due to significant differences in marital status, the null hypotheses were partially rejected. In this study, no statistical relationship was found between age and levels of BMI (rs = .22, p = .069); however, the results of the ANOVA were significantly associated with BMI (F(3,63) = 7.08, p < .001. partial n2 = .252). This study’s results on age were not aligned with the previous studies from Letvak et al. (2013), who found that the age of older nurses is a factor that contributes to higher BMI compared to younger nurses. Contrary to the results of this study on age, Vimalananda et al. (2015) found that women younger than 50 years old were more likely to gain weight and become diabetic than those who never work night shifts. Likewise, Boughattas et al. (2014) reported that nurses’ ages influenced sleep quality and duration and were significantly associated with weight gain and changes in BMI. In this study, significant associations were found between marriage and levels of BMI. This result was confirmed in the previous research of Kim et al. (2013), who found that female married nurses were at a significantly higher risk of obesity and being overweight. Mata et al. (2015) found that married women had higher BMI than those who never married. No significant associations were found between stress, nursing units, and decreased physical activity with BMI among female Filipino nurses working the night shift in the hospital; therefore, the null hypothesis was not rejected. In this study, the analysis on perceived stress (rs = .03, p = .832), decreased physical activity (rs = .13, p = .289), and nursing units (F(4,62) = 2.33, p = 066, partial n2 = .131) failed to show significant associations with BMI among female Filipino nurses working the night shift in the hospital. These findings were not aligned with previous studies from Buss (2012), Vijayalaxami, George, and Nambiar (2014), Coomarasamy et al. (2014), and Han, Choi-Kwon, and Kim (2015), who found that stress and night shift work were strongly influenced by unhealthy eating habits causing weight gain. Many studies proved that physical activity has been identified as having tremendous benefits to overall health (Coomarasamy et al., 2014; Peplońska et al., 2014). Decreased physical activity is one of the many important factors that cause weight gain, being overweight, and obesity (Coomarasamy et al., 2014). The study findings failed to show a correlation between decreased physical activity and BMI among female Filipino nurses working the night shift.

Limitations of the Study This study has several limitations. First, due to cross-sectional design, the causality between occupational factors, such as night shifts, meals missed, working a 12-hour shift, quantity and quality of sleep, weight gain, being overweight, and obesity cannot be ascertained (Sedgwick, 2015). Second, this study completely relied on self-reported data, which may be

Journal of the New York State Nurses Association, Volume 46, Number 2

n Night Shift Work and Weight Gain Among Female Filipino Nurses suggestive of data inaccuracy that weakens the studyâ&#x20AC;&#x2122;s validity (Zhang et al., 2017). Social desirability is another factor of bias that leads to underreporting of weight as a determinant of BMI (Sedgwick, 2015). Third, this study has a small sample size and participants were conveniently selected. The result may be choice biases (Etikan et al., 2016). Because the study sample was drawn from one hospital and the heterogeneity of the participants, the findings limit the generalizability to different populations and different cultural groups. Finally, some possible confounders of overweight and obesity were not part of the study, such as dietary habits, smoking, alcohol use, and caffeine use (Letvak et al., 2013). These variables may provide confounding effects related to weight gain and obesity among female Filipino nurses working the night shift in the hospital.

Recommendations This appears to be the first study conducted among female Filipino nurses working the night shift. Because this study employed a crosssectional design, longitudinal and cohort studies are recommended for future studies of this population. This study focused on the night shift on a single population comprised of female nurses. Future cross-sectional study with the day shift and other populations and cultural groups is highly recommended to compare the study result. Literature shows that being overweight and obesity was reported in different countries, such as South Africa, Australia, the United Kingdom, New Zealand (Phiri et al., 2014), Japan (Nagashima et al., 2013), the Republic of Korea (Jung, & Lee, 2015), Malaysia (Coomarasamy et al., 2014), the United States (Huth et al., 2013), Brazil (Marqueze et al., 2013), Republic of Taiwan (Lint et al., 2012), Europe (Saksrik-Lehouillierm et al., 2012), and Canada (Smith et al., 2012). Based upon the results of this study, insufficient sleep, marital status (married), erratic eating patterns, working 12-hour shifts, and extended years of working on the night shift were correlated with weight gain associated with increased BMI among female Filipino nurses. It is recommended that night shift nurses play an active role in promoting their health in order to prevent the development of chronic medical conditions, such as obesity, diabetes, hypertension, stroke, heart disease, and early disability (CDC, 2014; WHO, 2015). It is also recommended that hospital administrators and nursing leaders consider changing policies on working conditions within the organization. Some of the suggested changes in organizational policies include allowing nurses frequent breaks to decrease work fatigue and prevent medication errors (Geiger-Brown et al., 2012; Caruso, 2014); focusing on nutrition and dietary education and providing healthier food choices in the hospital cafeteria (Imes & Burke, 2014); providing working schedules that reduce night shift work (Asaoka et al., 2013); and encouraging

nurses to sleep more than seven hours per day (Caruso, 2014). Finally, nurses should be encouraged to consult with their healthcare providers on a regular basis for optimal health (CDC, 2015).

Implications for Social Change At the individual level, the potential social change as a result of this study is the provision of important information for all nurses to help them understand the negative health implications of night shift work. Nurses are equipped with knowledge on health promotion and disease prevention (Caruso, 2014), but may not be aware of the negative implications of night shift work. Information from this study enables nurses to take care of their health and prevent the development of chronic medical conditions, such as obesity, diabetes, hypertension, heart disease, stroke, some forms of cancer, early disability, and premature death (R. Apellido, personal statement, July 17, 2017). Maintaining and improving the health of the nursing workforce has positive impacts on nursesâ&#x20AC;&#x2122; ability to provide quality care to patients (Caruso, 2014). According to Huth et al. (2012), institution-wide education on the importance of quantity and quality of sleep has positive implications on the health of nurses working the night shift. At the organizational level, information from this study could facilitate change in policies and improve working conditions that promote the health and well-being of nurses as discussed in the previous section. At the local, state, and federal level, providing information for public education and health promotion in the prevention of being overweight or obese may help solve problems with the obesity epidemic. Health promotion and disease prevention at these levels help reduce medical expenditures to the current healthcare system.

Conclusion There is a large body of evidence from previous studies showing that the causes of unhealthy weight gain and obesity are multifactorial. Nurses are equipped with adequate knowledge on health promotion and disease prevention and provide education to their patients as well as the general population. However, this study showed that female Filipino night shift nurses are faced with unhealthy weight gain and increased BMI. Findings from this study proved that occupational factors, such as insufficient sleep between shifts, abnormal eating habits, working 12-hour shifts, and extended years of working the night shift had significant associations with weight gain and BMI. Future research with a larger sample size is needed to validate the findings from this study and further exploration of occupational factors associated with weight gain and obesity among nurses must be conducted in the future. Finally, nurses need to proactively take care of their health so that they can provide quality patient care.

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Night Shift Work and Weight Gain Among Female Filipino Nurses

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Perry, G. S., Patil, S. P., & Presley-Cantrell, L. R. (2013). Raising awareness of sleep as a healthy behavior. Preventing Chronic Disease, 10, 130081. doi:10.5888/pcd10.130081 Phiri, L. P., Draper, C. E., Lambert, E. V., & Kolbe-Alexander (2014). Nurses’ lifestyle behaviors, health priorities and barriers to living a healthy lifestyle: A qualitative descriptive study. BMC Nursing, 13(1), 38. Quist, H. G., Christensen, U., Christensen, K. B., Aust, B., Borg, V., & Bjorner, J. B. (2013). Psychological work environment factors and weight change: A prospective study among Danish health care workers. BMC Public Health, 13(1), 1. doi:10.1186/1471-2458-13-43 Ramin, C., Devore, E. E., Wang, W., Pierre-Paul, J., Wegrzyn, L. R., & Schernhammer, E. V. (2015). Night shift work at specific age ranges and chronic disease risk factors. Occupational Environmental Medicine, 72(2), 100-107. doi:10.1136/oemed-2014-102292 Rebekic´, A., Loncgaric´, Z., Petrov, S., & Maric´, S. (2015). Pearson’s or Spearman’s correlation coefficient—which one to use? Poljoprivreda (Osijek), 21(1), 47-54 doi:10.1847/poljo.21.2.8 Rojewski, J. W., & Lee, I. H. (2012). Used of t-test and ANOVA in career technical education coefficient—which one to use? Poljoprivreda (Osijek), 21(1), 47-54 doi:10.184/poljo.21.2.8

Smith, P., Fritschi, L., Reid, A., & Mustard, C. (2012). The relationship between shift work and body mass index among Canadian nurses. Applied Nursing Research, 26, 24-31. doi:10.1016/j.apnr.2012.10.001 Theorell-Haglöw, J., Berglund, L., Janson, C., & Lindberg, E. (2013). Sleep duration and central obesity in women differences between short sleepers and long sleepers. Sleep Medicine, 13, 1079-1085. doi:10.1016/j.sleep.2012.06.013 Vijayalaxmi, M. K., George, A., Nambier, N. (2014). A study of general health pattern among shiftwork employees in tertiary care hospital. Journal of Academia and Industrial Research, 3(4), 176-183. Vimalananda, V., Palmer, J. R., Gerlovin, H., Wise, L. A., Rosenzwag, J. L., Rosenberg, L., Ruiz Narváez, E. A. (2015). Night shift work and incident diabetes among African-American women. Diabetology, 58, 699-706. doi:10.1007/s00125-014-3480-9 Watson, R. (2015). Quantitative research. Nursing Standard, 29(31), 44. Welford, C., Murphy, K., & Casey, D. (2012). Demystifying nursing research terminology: Part 2. Nursing Research, 19(2), 29-35. Williams, C. (2007). Research methods. Journal of Business & Economic Research, 5(3). Williams, R., & Bornmann, L. (2016). Sampling issues in bibliometric analysis. Journal of Informatics, 10, 1225-1232. Retreived from http:dx.doi.org/10.1016/j.joi.2015.11.004 World Health Organization (WHO). (2015). Overweight and obesity. Retrieved from www.who.int/mediacenter/fachseets/fs311/en/ Zhang, X-C., Kuchenke, L., Would, M., Velten, J., & Margraf, J. (2017). Survey methods matters: Online/offline questionnaire and face-toface or telephone interviews differ. Computer in Human Behavior, 17, 172-180. Zimberg, I., Dâmaso, A., Del Re, M., Carneiro, A. M., de Sa Souza, H., de Lira, F. S., Túlio de Mello, M. (2012). Short sleep duration and obesity: Mechanisms and future perspectives. Cell Biochemistry and Function, 30, 524-529. doi:10.1002.cbf.283

Saksvik-Lehouillier, I., Bjorvatn, B., Hetland, H., Sandal, G. M., Moen, B. E., Mageroy, N., Pallesen, S. (2012). Individual, situational and lifestyle factors related to shift work tolerance among nurses who are new and experienced on night work. Journal of Advance Nursing, 69(5), 1136-1146. doi:10.1111/j.1365-2648.2012.06105.x Sedgwick, P. (2015). Cross-sectional studies: Advantages and disadvantages. Reader in Medical Statistics and Medical Education. doi:10.1136/bmj. g2276 Spaeth, A. M., Dinges, D. F., & Goel, N. (2013). Effects of experimental sleep restriction on weight gain, caloric intake, and meal timing in healthy adults. SLEEP, 36(7), 981-990. doi:10.5665/sleep.2792 Smith, M. R., & Eastman, C. I. (2012). Shiftwork: Health, performance and safety problems, traditional countermeasures, and innovative management strategies to reduce circadian misalignment. Nature and Science of Sleep, 4, 111-132.

Journal of the New York State Nurses Association, Volume 46, Number 2

Nurse Entrepreneurs: The Real Independent Practice of Nursing Carol Lynn Esposito, EdD, JD, MS, RN-BC, NPD Lucille Contreras Sollazzo, BSN, RN-BC, NPD

n A bstract

General trends in population health are having an impact on healthcare and the role of the registered professional nurse (RN) as a unionized nurse entrepreneur within a social justice system. The aging population and mental health disease in the United States is placing increased demand on healthcare. Between 2010 and 2030, the aged will increase by 75% to 69 million in the United States. One in five Americans will be a senior citizen. In 2050, an estimated 88.5 million in the United States will be aged 65 and older, and by 2060, there will be about 98 million older persons. Statistics indicate that 80% of older adults have at least one chronic condition, while 68% have at least two chronic conditions. An estimated 18.1% (43.6 million) of U.S. adults aged 18 years or older suffer from mental illness, and 4.2% (9.8 million) suffer from a seriously debilitating mental illness. These statistics are driving a paradigm shift in the role of RNs as primary care services suppliers and RN entrepreneurs. Increasing numbers of RNs will be needed to care for the growing number of U.S. adults with chronic conditions and geriatric syndromes. These trends will shape and mold the nurse entrepreneur of the future.

Introduction A shift is being made from the biomedical model of illness toward population health management by focusing on assessment, prevention, wellness, and chronic disease management. As a result, the demand for primary care services in New York State is projected to rise over the next five years, due largely to population growth and aging, and to a smaller extent, to expanded health insurance and New York’s history as a gateway for immigration into the United States. Primary care serves four important functions: It enhances access to care for each new medical need; it provides long-term, person-focused (as opposed to disease-focused) care; it facilitates comprehensive care for the majority of a person’s health-related needs; and it integrates coordination of care when it must be sought elsewhere.

Currently, the leading causes of illness, disability, and death in New York are largely preventable. Primary care encounters with healthcare providers are important occasions for addressing preventable illnesses, health promotion, disease prevention, and treatment (Epi, 2011). Nurses, in the role of primary care providers and entrepreneurs are uniquely positioned to promote and provide quality primary care within a social justice system by supporting the development of targeted products and services of a direct care, educational, research, administrative, or consultative nature (Vannucci & Weinstein, 2017). Nurses now have the opportunity to move their skill set beyond the bedside, explore entrepreneurship opportunities, and become drivers and leaders in population health management and equal access to healthcare services for all populations. Nurses now have a unique opportunity to focus on alternative, nursedriven detection and prevention models of care that can provide patients (individuals and families) and other clients, such as industries, schools,

Carol Lynn Esposito, EdD, JD, MS, RN-BC, NPD, is currently employed by the New York State Nurses Association as the Director of Nursing Education and Practice. She also held positions at NYSNA as the Director of Labor Education, and as Associate Director in NYSNA's Labor Program. An attorney with over 25 years experience in the field of medical and nursing malpractice, and 30 years as a nursing educator, Dr. Esposito has been adjunct faculty at Adelphi University School of Nursing; Hofstra University; University of Continuing Education; Dowling College; and Excelsior College School of Nursing. She has authored many articles and text materials on subjects of interest to nurses. Lucille Contreras Sollazzo, BSN, RN-BC, NPD, is currently employed by the New York State Nurses Association as the Associate Director of Nursing Education and Practice. She also has held positions at NYSNA as the Associate Director in NYSNA's Labor Program and as a Nursing Representative in the Labor Program. A nurse for over 30 years, she has worked in many specialty areas and has just completed a Master’s Degree in Nursing Education. 26

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Nurse Entrepreneurs: The Real Independent Practice of Nursing

corporations, etc., with a higher quality of care and life at more affordable prices, and with quicker access. Recent trends in New York’s healthcare include prohibitive rising healthcare costs, continuous changes in healthcare reimbursement rates and allowances, increases in chronic illnesses, an aging population, increases in inequities and disparities in healthcare delivery, and increases in population diversity (Vannucci & Weinstein, 2017). Nurses, with their distinctive skill set, are exceptionally positioned to create advanced and novel approaches to fill the gaps in primary care services that these trends generate.

Health Innovation Plan (SHIP) provide opportunities to shift the focus on New York’s healthcare system to promoting health, preventing disease, and encouraging innovative approaches to the delivery and coordination of primary care. The overarching objective of these programs is to have 80% of the state’s population receiving primary care within an advanced primary care setting, rather than relying on emergency departments to be the first stop in meeting healthcare needs. To drive this change, a statewide, multipayer approach that will align care and payment reform is underway. Core objectives of these programs are as follows:

Natural Fit for Nurses to Be Entrepreneurs

• Engage patients as active, informed participants in their own care, and organize structures and workflows to meet the needs of the patient population.

Nursing is, and always has been, an autonomous, self-governing, self-directed profession, and a distinct scientific discipline with many autonomous practice features. In addition to extensive medical expertise, nurses have a unique, holistic, patient-advocacy focus, a unique scope of practice, and a unique body of knowledge, including special expertise in areas such as health promotion, disease prevention, direct care as ordered, consultation, education, research, and advocacy (Keyes, 2018; The Truth About Nursing, 2015). Yet, many nurses have not considered becoming self-employed or entrepreneurs. Furthermore, the general public may not know about or recognize the independent practices of nurses and nursing. Nurses have always been responsible for the education and counseling of individuals, families, communities, and populations. Nurses have always been responsible for supervising other members of the healthcare team. It is precisely because of these independent roles that nurses are suited to venture out and become nurse entrepreneurs (Keyes, 2018). From the 1940s to the 1970s, the vast majority of nurses were employed by facilities, primarily acute care hospitals. The literature denotes, however, that many nurses have become disenchanted with the restrictions facilities place on nurses’ scope of practice and work, dissatisfied with workplace conditions, and disillusioned with the lack of autonomy the state has given to the profession overall (Sanders & Kingma, 2012). The Institute of Medicine (2010) recognized the need for nurses to seek unique roles that support a varied scope of practice, thereby filling gaps in healthcare in its report “The Future of Nursing: Leading Change.” The report noted that nurses have a vital contribution to make in building a healthcare system that meets the demands for high-quality, safe, patient-centered, affordable, and accessible care. Health reform is increasingly directed to strengthening the healthcare system as primary care shifts to communities (Campbell, 2016). As governments struggle with escalating healthcare costs, cutbacks have been used to manage increasing costs, and seem likely to continue. Today’s nurses are in a pivotal position to address healthcare cost issues through varied entrepreneurial options, such as nurse-led clinics for diseases such as diabetes, mellitus, and other chronic illnesses, geriatric care, mental health conditions, and community case management for patients discharged early from hospitals (Sanders & Kingma, 2012).

The Climate of Healthcare Reform in New York and the Nation Supports Nurse Entrepreneurship The Affordable Care Act (ACA), the New York State Delivery System Reform Incentive Payment (DSRIP) Program, and the New York State

• Actively promote the health of both patient panels and communities through screening, prevention, chronic disease management, and promotion of a healthy and safe environment. • Manage and coordinate care across multiple providers and settings by actively tracking the sickest patients, collaborating with providers across the care continuum and broader medical neighborhood including behavioral health, and tracking and optimizing transitions of care. • Promote access as defined by affordability, availability, accessibility, and acceptability of care across all patient populations. (New York State Department of Health, 2017) Although the need to expand primary care services is widely acknowledged, there is a well-documented concern that primary care practitioners are not well distributed across the state (Center for Health Workforce Studies, 2015). In 2009, 18% of adults (1.1 million New Yorkers) did not have a regular primary care provider (Epi, 2011). As of December 2017, New York State had over 5.8 million individuals living in primary care health professional shortage areas (HPSAs) (Center for Health Workforce Studies, 2018). In response to the current regulatory changes, anecdotally and through trade publications of specialty nursing associations such as the National Nurses in Business Association, nurse entrepreneurship is on the rise. A nurse entrepreneur is considered to be a “proprietor of a business that offers nursing services of a direct care, educational, research, administrative or consultative nature” (International Council of Nurses, 2004, p.4). The importance of social support, membership, and networking through nurses associations, mentorship from association peers, and marketing strategy are reportedly the top items associated with successful nurse entrepreneurs providing direct care as independent practitioners or within nurse-led group practices offering case management, product development, consulting, or educational services (Vannucci & Weinstein, 2017).

Nursing’s Transforming Role to Entrepreneur and the Future Need of the Nursing Workforce The 2016-2026 U.S. Bureau of Labor Statistics employment projections describe occupational demand for RNs. It projected that while the average growth rate and need for all other occupations is 7%, the projected percent change for RNs from 2016-2026 will be 15%. The projected numeric need from 2016-2026 is calculated to be 438,100 practitioners needed to replace those who leave the occupation or retire. Recent research indicates that,

Journal of the New York State Nurses Association, Volume 46, Number 2

Nurse Entrepreneurs: The Real Independent Practice of Nursing

overall, there will be a shortage of 154,018 RNs by 2020, and 510,394 RNs by 2030. In order to deliver safe, quality, patient-centered, accessible, and affordable healthcare to our growing and aging population, nursing services must be delivered dramatically differently at the individual and systems levels. The focus of healthcare must shift from illness to one that prioritizes wellness and prevention, environmental and social triggers of preventable disease conditions, and education. The focus of nursing practice must, therefore, shift from caring only for the current event in the hospital or office to creating care plans and services that maximize a person’s wellness (Salmond & Echaverria, 2017). These requirements have driven changes in the academic and clinical training programs to support the development of nurse leadership and entrepreneurship competencies (Carlson, 2015; Keyes, 2018).

New York’s Aging Population Is Underinsured and Suffers from Chronic Health Conditions Life expectancy in New York increased citywide to 81.2 years in 2015, a jump of 1.5 years since 2006. Among the 1.1 million residents over the age of 65 in New York City, there are more than 1.6 women for every man, making older women one of the city’s fastest-growing demographics (Messina, 2018). New York State residents are aging so rapidly that it has the fourtholdest population in the nation, with 3.7 million people aged 60 and over. New York’s aging population trails California, Florida, and Texas. According to the NYS Office for the Aging, by 2030, 5.2 million people in the state will be aged 60 and older. Of that group, 1.81 million New Yorkers will be aged 75 or older. This will increase the number of older New Yorkers to one in four (Campaneli, 2017) (see Table 1).

Table 1 New York State Population Trends

Population Trends Total Population Ages 5 and over Ages 60 and over Ages 65 and over Ages 75 and over Ages 85 and over Ages 60-74 Ages 75-84 Minority Elderly, 60 and over Ages 65 and over Ages 75 and over Disabled (ages 5 and over) Ages 5-17 Ages 18-59 Ages 60 and over Poverty, (1) age 60+ Below 150% Below 250%

2000

2008

2010

2015

2020

2025

2030

19,000,136 17,763,021 3,211,738 2,452,931 1,180,878 314,771 2,030,860 866,107

19,460,969 18,216,035 3,558,460 2,559,826 1,281,459 403,129 2,277,001 878,330

19,566,610 18,314,451 3,677,891 2,588,024 1,259,873 417,164 2,418,018 842,709

19,892,438 18,619,147 4,027,480 2,851,524 1,242,577 442,958 2,784,903 799,619

20,266,341 18,985,180 4,499,549 3,191,141 1,332,145 454,298 3,167,404 877,847

20,693,354 19,398,722 4,962,734 3,615,695 1,561,652 486,682 3,401,082 1,074,970

21,195,944 19,874,195 5,302,667 4,020,308 1,815,879 566,423 3,486,788 1,249,456

736,742 506,282 196,537

981,360 674,022 285,885

1,062,919 716,078 303,764

1,277,197 872,889 357,680

1,552,380 1,058,974 426,448

1,865,871 1,296,349 537,061

2,180,775 1,574,537 672,261

3,606,192 257,194 2,206,913 1,201,431

3,784,789 246,675 2,206,913 1,331,201

3,831,083 244,978 2,210,226 1,375,879

3,952,167 246,999 2,198,510 1,506,658

4,096,932 252,089 2,161,587 1,683,257

4,253,663 255,876 2,141,246 1,856,532

4,400,598 260,507 2,156,392 1,983,699

352,835 652,365 1,201,110

Note: Association on Aging in New York. (2019). Retrieved from http://www.agingny.org/Portals/13/External%20Documents/NYSAC%20Presentation%201.30.18.pdf

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Nurse Entrepreneurs: The Real Independent Practice of Nursing

The Health Workforce Analysis Guide (HWAG) (2016) indicates that the state’s total population is over 19 million, while New York City has a total population of 8,128,980. Statistically, 18% of city residents are without health insurance and the city has a total emergency room (ED) visits per 10,000 population of 3,480,700. New York City adult residents suffer from chronic conditions, including hypertension (9%), diabetes (9.6%), asthma (9.3%), obesity (21.3%), poor physical health (10%), and poor mental health (9.2%). Compared to the population of 65 and older statewide (14.3%), the Long Island Region, including Nassau and Suffolk counties, has an even higher percentage of elderly (15.4%). Total numbers of the elderly on Long Island exceed 439,500. Similar to the Mohawk Valley Region and Central New York, Long Island has a higher total death rate per 100,000 total population than the state average, and higher rates of death due to heart disease and all cancers (Center for Health Workforce Studies, 2018). The Mohawk Valley Region also has a much higher rate of deaths due to diabetes per 100,000 total population than the state as a whole. Additionally, the rates of total hospitalizations, preventable hospitalizations, and hospitalizations due to chronic lower respiratory disease per 10,000 total population are all higher than state averages (Center for Health Workforce Studies, 2018). The North Country Region has a higher total deaths rate per 100,000 total population than the state as a whole, as well as a higher rate of deaths due to cancer and diabetes. The North Country also has a higher rate of hospitalizations due to chronic lower respiratory disease per 10,000 total population, than the statewide average. Those age 65 and older in the Capital District region have a higher total rate of deaths due to all types of cancer per 100,000 total population than the state as a whole. The Finger Lakes Region has higher rates of total deaths, infant deaths, and deaths due to all cancers per 100,000 population than New York State as a whole (Center for Health Workforce Studies, 2018). The Southern Tier region has higher rates of total deaths, deaths due to heart disease, deaths due to cancer, and deaths due to diabetes per 100,000 total population than statewide averages. In addition, the Southern Tier has greater rates of ED visits and preventable hospitalizations per 100,000 total population than New York State as a whole (Center for Health Workforce Studies, 2018).

New York’s Population Suffers from Mental Health Conditions Every year, more than one in five New Yorkers has symptoms of a mental disorder, and in any year, one in ten adults and children experience mental health challenges serious enough to affect functioning in work, family, and school life. The disease burden exceeds that caused by all cancers combined (NYSDOH, 2011). Mental disorders that appear early on, when left untreated, are associated with disability, lack of success in school, teenage childbearing, unstable employment, marital instability, death by suicide, and violence. An estimated 18.1% (43.6 million) of U.S. adults aged 18 years or older suffer from mental illness, and 4.2% (9.8 million) suffer from a seriously debilitating mental illness (HRSA, 2017). Neuropsychiatric disorders are the leading cause of disability in the United States, accounting for 18.7% of all years of life lost to disability

and premature mortality. Moreover, suicide is the 10th leading cause of death in the United States, accounting for the deaths of approximately 43,000 Americans in 2014 (Healthypeople.org, 2018). A New York State law mandating for mental health education to become part of K-12 curricula throughout schools statewide was set to take effect in July 2018 (MHANYS, 2018). New York is the first of two states in the country, along with Virginia, to pass this type of law. According to the Bureau of Health Workforce, New York has 159 total mental HPSA designations and is experiencing a shortage of 57.57% practitioners needed to remove the HPSA designations (HRSA, 2017).

Physical and Mental Health of New York State Residents Drive Healthcare Transformation Chronic physical and mental health conditions are singled out as the major cause of illness, disability, and death in the United States (Salmond & Echevarria, 2017). It is estimated that the cost of chronic conditions will reach $864 billion by 2040, with chronic conditions among older adults being more costly, disabling, and difficult to treat—despite being the most preventable. Based upon these population statistics and current technological trends, RNs may find themselves spending more time in consulting, educating, and chronic care management roles outside of the acute care center, as politicians and healthcare corporations push for more of the in-house acute care monitoring of patients to be done by technology such as smart beds, telemedicine, and robotics (Keyes, 2018).

Populations Trends Drive Healthcare Transformation and Social Justice Entrepreneurship Social justice entrepreneurship focuses on the social mission of the entrepreneur and the attempts to develop a business, not only for economical purposes, but mainly for a social purpose. Social justice entrepreneurs use available resources to facilitate innovative ideas and opportunities that are seen as an answer to the needs of the market and that can also produce social change while developing and improving societies. The social justice entrepreneur, as an agent of change, adopts a mission to create and sustain social value, recognize and relentlessly pursue new opportunities to serve that mission, engage in a process of continuous innovation, adaptation, and learning, and act boldly without being limited by resources currently in hand. Social justice entrepreneurs will demonstrate a heightened sense of accountability to the constituencies served and for the proposed outcomes (Mihalcea, Mitan, & Vitelar, 2012). New York’s population trends coincide with the need for a new type of nurse social justice entrepreneur and a new nurse-led primary care business model. According to the U.S. Census Bureau, all but two counties in New York (both Upstate) have lost population through domestic migration (the movement of residents to other states and counties). Population loss is accelerating in Suffolk County, New York’s largest county outside New York City. Higher domestic migration (up 15% in the past year), a lower birth rate (down 4%), and an increase in the death rate (up 4%) among county residents is driving the trend. The biggest population losses since the last decennial census have been in the Upstate rural counties of Delaware, Hamilton, Schoharie, and Tioga (Empire Center, 2017) (see Figure 1).

Journal of the New York State Nurses Association, Volume 46, Number 2

Nurse Entrepreneurs: The Real Independent Practice of Nursing

Figure 1. Net domestic migration 2010 to 2016 showing that recruiting and retaining New York’s aged population is essential for New York’s economic development and maintaining healthy societies.

New York State’s governor, Andrew Cuomo, has declared that attracting and retaining the elderly and retirees in New York State has become the new export industry of the region, similar to tourism. It is estimated that the over-50 population accounts for a majority of the spending in several categories of goods and services, including healthcare. Direct spending on consumer goods and services, including healthcare, by those ages 50 and over amounted to $5.6 trillion in 2015. Forty one percent of state and local tax revenue has been attributed to consumers over the age of 50 (New York State Association of Counties, 2018). Continuing trends of domestic migration, therefore, would threaten the economic growth and development of the state. Governor Cuomo has articulated his vision for how New York’s policies, programs, and initiatives can support the goal of becoming the first age-friendly state in the nation. In support of this vision, the governor established a Prevention Agenda 2013-2018, steered by an Ad Hoc Leadership Group that includes the New York State Nurses Association. Five priorities are identified in the agenda: • Prevention of chronic diseases; • promotion of healthy and safe environments; • promotion of healthy women, infants, and children; • promotion of mental health and preventing substance abuse; and • prevention of HIV, sexually transmitted diseases, vaccine-preventable diseases, and healthcare-associated infections. (New York State Association of Counties, 2018) To support New York State’s commitment in creating age-friendly communities, the state has set a goal of making 50% of all health systems 30

age friendly within the next five years, which includes the establishment of age-friendly primary care facilities that will be better equipped to provide care to aging New Yorkers with cognitive and other physical and mental disabilities (New York State Association of Counties, 2018).

Scope of Entrepreneurial Options Since a nurse entrepreneur is considered to be a “proprietor of a business that offers nursing services of a direct care, educational, research, administrative or consultative nature” (International Council of Nurses, 2004, p.4), RNs may practice independently, in nurse-led agencies, in collaboration with other healthcare practitioners as their clients, or under the supervision of a physician, nurse practitioner, midwife, dentist, podiatrist clinical nurse specialist, or another APRN. An RN in New York is legally authorized to practice independently and provide the following types of services (New York State Board of Nursing, May 2017): • Perform physical exams and patient assessments to identify and address health problems and unmet patient care needs. • Develop comprehensive nursing care plans and perform nursing interventions to address symptoms, including, but not limited to • grieving •disturbed body image • social isolation • labile emotional control • anxiety • fear • ineffective coping/defensive coping • hopelessness • impaired parenting • impaired resilience • spiritual distress • stress overload

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Nurse Entrepreneurs: The Real Independent Practice of Nursing

• Perform medical treatments (e.g., medication administration, wound care, ostomy care) as prescribed by a collaborating physician, dentist, nurse practitioner, physician assistant, specialist assistant, midwife, or podiatrist. • Provide health teaching and emotional support to help patients and their families adjust to or manage serious or chronic illnesses or injuries. • Supervise care delivered by other healthcare personnel, such as licensed practical nurses, EMTs, Paramedics, and home health aides. • Work with collaborating physicians and other healthcare practitioners to ensure that patients receive appropriate, timely, well-coordinated care. • Conduct health screenings to detect and address signs of early disease or

risk factors for disease and then provide health teaching or make referrals as appropriate. Other entrepreneurial services might include (Sanders & Kingma, 2012): • Development, assessment, and sale of healthcare products and devices; • legal nurse consultive services; • healthcare/policy consultation and publications; and • educational and consultative services. The nurse entrepreneur can assume a multitude of roles directly linked with the professional and business aspects of a practice (Sanders & Kingma, 2012) (see Figure 2).

Roles of nurses in entrepreneurship

Supervisor/Owner

Case Manager

Researcher

Therapist

Consultant

Educator

Clinician

Figure 2. Roles of nurses in entrepreneurship adapted from Sanders & Kingma, 2012

There are several options for nurses who want to start their own businesses and become independent practitioners. In the many roles noted in Figure 2, nurse entrepreneurs can provide a wide range of services,

whether they work for someone else or as an RN owner of a company/ partnership providing the services (see Table 2).

Journal of the New York State Nurses Association, Volume 46, Number 2

Nurse Entrepreneurs: The Real Independent Practice of Nursing

Table 2 Entrepreneurial Options

Entrepreneurial Option

Included Services

The Client

Home Care

chronic care management; services for maintaining flexibility, strength, and balance to keep family member in the home longer; physical therapy for stroke/accident victims

MD, hospital, home care agencies, insurance companies, individuals, families

Immunization Nurse

provision of immunizations

schools, MD, government agencies

Staffing/Recruitment Agency/Private Duty Registry

providing per diem nurses

hospitals, home care agencies, schools, private corporations, individuals, families, over-55 community boards

Lactation/Lamaze Consultant

providing breastfeeding and child birth information

insurance companies, hospitals, MD offices, expecting couples

Holistic Nurse

assessment of overall wellness, nutrition counseling, individuals, families, private corporations acupuncture, massage therapy, reflexology, reiki, crystal therapy, sound therapy, medical qui gong, yoga, meditation

Enterostomal Therapy

provision of enterostomal care, nutrition counseling, insurance companies, hospitals, home care agencies, mobility counseling, teaching individuals, families

Wound Care

provision of wound care, nutrition counseling, mobility counseling, teaching

insurance companies, hospitals, home care agencies, individuals, families

Foot Care

provision of foot care, nutrition counseling, mobility counseling, teaching, reflexology

insurance companies, hospitals, home care agencies, individuals, families

Infusion/IV Therapy

maintenance of bleeding disorders (hemophilia), autoimmune diseases (MS, neuropathies)

insurance companies, MDs, individuals, families

Wellness Coach

education, assessments, nutrition counseling, exercise planning

insurance companies, individuals, families, RN owners

Legal Nurse Consultant

reviewing cases to determine if standards of practice insurance companies, law firms, DAs, hospitals, were adhered to and if a case is viable government agencies

Sexual Assault Nurse Examiner

gather evidence to substantiate civil and/or criminal actions

Life Care Planner

work with people who have catastrophic injuries law firms, insurance companies, HMOs, government and chronic health conditions (chronic pain, immune agencies disorders)

Case Management, Patient Advocate

accompany patients to MD visits, consultative services, insurance navigation, community services navigation, coordination of services

insurance companies, individuals, families

Case Management: Disease Care Manager

education, assessment, care planning, individual patient care

insurance companies, government agencies, individuals, families, RN owners

Case Management: Geriatric Care Management/ Senior Citizen Care Consultant

education, assessment, care planning, individual patient care preventing falls, home modification, strengthening exercises, nutrition consultation, video/telephone monitoring, chronic disease assessments, home visits

individuals, families

Family Nurse Consultant

education, assessment, care planning, individual patient care preventing falls, home modification

individuals, families

Journal of the New York State Nurses Association, Volume 46, Number 2

government agencies, law firms, hospitals, insurance companies, individuals

Nurse Entrepreneurs: The Real Independent Practice of Nursing

Table 2 Entrepreneurial Options, (conâ&#x20AC;&#x2122;t) Nurse Educator: Public

interpreting research literature, validity of commercial information, how to search for reliable information, health coaching, community lecturer, occupational health consultant, management consultant, human resources consultant, prevention programs

TV, radio, Internet

Nurse Educator: Chronic Care Management

preventing exacerbations of asthma/COPD, diabetes, insurance companies, government agencies, coronary artery disease, arthritis, spinal cord injury, individuals, families heart attack, congestive heart failure, depression, allergies

Nurse Educator: Illness Prevention

preventing STDs, flu, lice, providing telehealth services

schools, government agencies, individuals, families

Nurse Educator: Educational Company

create continuing education products

schools, hospitals, MD offices, libraries, individual practitioners, nursing associations

Nurse Medical Sales Consultant

selling medical equipment to be used in hospitals or other healthcare settings, schools, private corporations, selling wellness products, cosmetics, health foods, nutritional supplements

independent practitioners, pharmaceutical companies, insurance companies, medical devices companies

Psychiatric Mental Health Nurse

depression screening, suicide screening, resilience training, work with people to develop social support system, communication skills, mental health education, therapeutic alliance with patients, emotional regulation skills such as meditation and mindfulness

individuals, families, hospitals, MDs, schools

Adult/Child Day Care Facility

high-quality day care

corporate firms, hospitals, attorneys, schools

Researcher

projects aimed at improving health services/status of a target population

corporate firms, hospitals, attorneys, schools

Note: Table showing RN entrepreneurial options, compiled from Keyes, 2018; National Nurses in Business Association, 2018; Sanders & Kingma, 2012; Whelan, 2012

Benefits of Nurse Entrepreneurship Research cites many benefits of nurse entrepreneurship. Vannucci and Weinstein (2017) indicate that nurse entrepreneurs gain psychological empowerment (having a meaning/purpose and impact on the public), personal growth, opportunities for independent decision-making, autonomy, and better self-care skills from their independent practices. Solesvik (2013) identifies economic benefits derived from entrepreneurial activities, the possibility of achieving independence, and achieving specific goals as benefits of entrepreneurship. Other studies show that the need for a flexible work schedule, ability to follow ideas, and having more earnings as reasons for nurse entrepreneurship (Jahani & Fallahi, 2014). Eddy and Stellefson (2009) identified the authority to use personal style and creative flair to carry out a task or to produce free from the policy and procedural constraints of large organizations as a benefit of entrepreneurship. Whatever the benefits of nurse entrepreneurship, todayâ&#x20AC;&#x2122;s nurses have additional opportunities to be innovative and influence the direction of healthcare. The time is ripe, and the time is now for nurses to consider whether an entrepreneurial role could be a good next step in their healthcare career.

The Future of Nursing and Reimbursement Opportunities for RNs The need for nurses to seek unique roles that support a wide scope of practice and which fill gaps in healthcare is recognized in the 2010 Institute of Medicine report. Innovative and creative healthcare provided by entrepreneurial nurses across all health settings is one way of expanding the human influence of innovative healthcare (Wilson, Whitaker, & Whitford, 2012). The Balanced Budget Act of 1997 allowed for third-party payments, such as Medicare, to be paid to nursing entrepreneurs. In addition, New York State Insurance Law, Chapter 996 (1984) provides that every insurer issuing a group policy for delivery of health services in New York and every health service or medical expense indemnity corporation issuing a group contract or a group remittance contract in New York must make available coverage for the services of a duly licensed RN acting within the lawful scope of his/her practice if the services of the RN have been negotiated as being reimbursable under the contract of insurance. This means that

Journal of the New York State Nurses Association, Volume 46, Number 2

Nurse Entrepreneurs: The Real Independent Practice of Nursing

insurance companies are legally required to reimburse for nursing services when the contract between the insurer and the provider of the insurance negotiate for nursing services. Home and office visits, often included in comprehensive coverage such as major medical insurance, are the types of independent RN services envisioned under this legislation. Under a contract providing coverage for home and office visits, the insured would be entitled to coverage for services provided by RNs in the home or in a nurse’s office as long as the service provided is within the lawful scope of practice of the nurse and negotiated under the contract. Chapter 996 is a freedom of choice provision that is intended to provide coverage for nursing services in lieu of physician services. Rates for the nursing coverage may vary depending upon the existing benefits of any given contract to which the “make available” nursing benefit rider may be attached (New York State Department of Financial Services, 1985) (see Notice Provision 1). When the make available nursing benefit has been added to coverage, an insurer cannot limit reimbursement to the RN by making coverage for the services provided by the nurse available only upon the certification or the recommendation of a physician of the need for the nursing services.

Some Examples of Reimbursement Opportunities Under CPT Codes CPT Code 9211 As professions grow and mature, they often expand or adjust their scope of practice to reflect current public needs, clinical realities, professional priorities, and/or fiscal necessities (HWAG, 2016). To meet the present-day primary care needs of patients, the Centers for Medicare & Medicaid Services (CMS) has created new payment codes for care coordination activities that are performed by independently or intradependently practicing RNs that ultimately result in reduced costs and improved patient outcomes. An RN can bill under code 99211 as an “office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician to perform or supervise these services” when the presenting problems are minimal, and typically five minutes are spent performing the services. The average unadjusted 2004 payment from Medicare for a 99211 service is $21. This would equate to only five 99211 encounters with Medicare patients in a week producing a $5,000 per year income for a

The time is now for nurses to consider whether an entrepreneurial role could be a good next step in their healthcare career.

practice. A 99211 office visit does not have any specific key-component documentation requirements (Hill, 2004). Basic guidelines for a 99211 service are as follows: •T he patient must be established. According to CPT, an established patient is one who has received professional services from the physician or NP or PA within the past three (3) years. Code 99211 cannot be reported for services provided to patients who are new. • The RN provider-patient encounter must be face-to-face. For this reason, telephone calls with patients do not meet the requirements for reporting 99211. • An Evaluation and Management (E/M) service must be provided. Generally, this means that the patient’s history is reviewed, a limited physical assessment is performed by the RN, or some degree of decision-making occurs. If a clinical assessment/need cannot be substantiated, 99211 should not be reported. For example, 99211 would not be appropriate when a patient comes into the office just to pick up a routine prescription. • The presence of an MD/NP/PA is not always required. CPT’s intent with the code is to provide a mechanism to report services rendered by other individuals (such as a nurse or other clinical staff member in a nurse-led practice). According to CPT, the staff member may communicate with the collaborating APRN or physician, but direct intervention by the collaborating practitioner is not required. Some examples of billing for a 99211 include asymptomatic urine STD screening, stand-alone HIV counseling and testing, chlamydia treatment with a previously written order, or retesting after treatment for chlamydia or gonorrhea (STD TAC, 2014), monthly B-12 injections, suture removal, dressing changes, allergy injections, and peak flow meter instruction (Hill, 2004).

Notice Provision 1: The home care mandate found in the Insurance Law requires that the home care must be provided by a certified home health agency possessing a valid certificate of approval issued pursuant to Article 36 of the Public Health Law. In addition, the Plan covering the home health service must be established and approved in writing by a physician. The general freedom of choice provision found in Chapter 996 does not supersede the specific requirements incorporated in the home care legislation identifying criteria which must be satisfied in order to qualify for reimbursement. 34

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Nurse Entrepreneurs: The Real Independent Practice of Nursing

CPT Codes 98966-98968 Additionally, an RN who is collaborating with a physician’s or APRN’s group can bill under codes 98966-98968 for non-face-to-face telephone

Procedure Code

services and clinical discussions for assessment and disease management services (Hertz, 2009). These services are denoted as follows:

Type of Service Provided

Procedure Code 98966

Telephone assessment and management service provided by a qualified non-physician healthcare professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion

Procedure Code 98967

Procedure Code 98968

CPT Codes 99487-99489 Codes 99487, 99488, and 99489 are additional codes that an RN can bill under. Code 99487 should be used if non-physician staff members, such as nurse navigators, spend more than an hour in 30 days coordinating care for a patient. Code 99488 covers the same amount of care coordination, but also includes a meeting in person, and 99489 covers additional time spent coordinating care over one hour, in 30-minute periods.

• administration of treatment related to technological dependence (e.g., ventilator, tracheostomy, bi-level positive airway pressure [Bi-PAP], intravenous [IV] administration of medications and fluids, feeding pumps, nasal stents, central lines, dialysis); • monitoring and maintaining parameters/machinery (e.g., oximetry, blood pressure, end tidal CO2 levels, ventilator settings, humidification systems, fluid balance, etc.); and • interventions (e.g., medications, suctioning, IVs, hyperalimentation, enteral feeds, ostomy care, and tracheostomy care).

HCPCS Procedure & Supply Code S9123 Some patients with complex medical diagnoses can now remain at home with the support of skilled nursing care. This care is different than general home health care, which is usually managed by intermittent, brief visits by skilled staff. Skilled hourly nursing care or medically intensive home nursing care refers to complex hourly nursing services provided by an RN in the patient’s home for more than four hours per day. Using code S9123, services are reimbursable if the nursing services are ordered by a licensed physician (MD or DO) as part of a treatment plan for a covered medical condition; there is a physician approved, written treatment plan with specific short- and long-term goals; the nursing services provided are reasonable and necessary for the care of a patient’s illness or particular medical needs; the services provided are within the accepted standards of nursing practice; and the patient’s condition requires frequent nursing assessments and changes in the plan of care that could not be met through an intermittent skilled nursing visit, but only through skilled hourly nursing services. Services that are reimbursed include: • Assessments (e.g., respiratory assessment, patency of airway, vital signs, feeding assessment, seizure activity, hydration, level of consciousness, constant observation for comfort and pain management);

CPT Codes 99490, 99487, 99489, and G9506 Chronic care management services are reimbursable to RNs under CPT codes 99490, 99487, 99489, and G9506 for providing interdisciplinary team care. Some of the services that are reimbursed include the following (see Table 3): • Use of a certified electronic health record (EHR) • Continuity of care with designated care team member • Comprehensive care management and care planning • Transitional care management • Coordination with home- and community-based clinical service providers • 24/7 access to address urgent needs • Enhanced communication (for example, email) • Advance consent (Department of Health and Human Services, 2016)

Journal of the New York State Nurses Association, Volume 46, Number 2

Nurse Entrepreneurs: The Real Independent Practice of Nursing

Table 3 Summary of 2017 CCM Coding Changes

Billing Code

Payment (Nonfacility Rate)

Clinical Staff Time

Care Planning

20 minutes or more of clinical staff time in qualifying services 60 minutes

Established, implemented, revised, or monitored Established or substantially revised

Each additional 30 minutes of clinical staff time

Established or substantially revised

$44-$209

$64

N/A

Established

CCM (CPT 99490)

$43

Complex CCM (CPT 99487)

$94

Complex CCM Add-On (CPT 99489 use with 99487)

$47

CCM Initating Visit*

Add-On to CCM Initiating Visit (G0506)

Billing Practitioner Work Ongoing oversight, direction and management Assumes 15 minutes of work Ongoing oversight, direction, and management + medical decision-making of moderatehigh complexity Assumes 26 minutes of work Ongoing oversight, direction, and management + medical decision making of moderatehigh complexity Assumes 13 minutes of work Usual face-to-face work required by the billed initiating visit code Personally performs extensive assessment and CCM care planning beyond the usual effort described by the separately billable CCM initiating visit

Note: Department of Health and and Human Services. Centers for Medicare & Medicaid Services. (2016). Chronic care management services changes for 2017. Medicare Learning Network, citing CPT only copyright 2016 American Medical Association. Retrived from http://www.cms.gov/Outreach-and-Education/Medicare-Learning

Next Steps in Becoming a Nurse Entrepreneur in New York State A nurse-led entrepreneurial enterprise in healthcare is worth exploring. Nationwide spending on health is projected to grow at an average rate of 5.5% annually and is projected to account for nearly 20% of the nation’s gross domestic product (GDP) through 2026. According to the U.S. Bureau of Labor Statistics, employment in healthcare-related occupations is projected to grow 18% from 2016-2026, much faster than the average for all occupations. Additionally, nearly half of the 20 occupations projected to have the highest percentage increase in employment through 2026 are in the healthcare industry (Lesonsky, 2018). Nurse entrepreneurship is a growing segment of the healthcare industry right now. If starting your own business or expanding your nursing talents into an innovative new way of caring for patients is something you’re interested in, now is a good time to start. But before you spend any time or money on a new service, product or idea, start reading everything you can about nurses who run their own companies and what it’s like to start 36

your own business. Learn about the education or training they received, the financial investment they made, the return on investment they received, and the time commitment it all took. Perhaps most critical at the start of your enterprise is a clear evaluation of what your business will be, who your customers will be, and whether there is a real need for what you will be offering. Next steps might include: • Determining what your niche and expertise is that is exciting and gratifying for you; • developing relationships with nurse practitioners and doctors pertaining to that specialty who are in their own practice or with a healthcare facility; • negotiating rates with insurance companies for reimbursement; • researching billing websites that would work for you; • setting up a system (computer software) to track patient outcomes; • maintaining BCLS and other certifications that are required for the work you are doing;

Journal of the New York State Nurses Association, Volume 46, Number 2

Nurse Entrepreneurs: The Real Independent Practice of Nursing

• looking into additional insurance coverage to protect your business and yourself;

own company as much as the kind of CEO you are. That’s what clients will remember.

• taking some continuing education or college courses on business;

Nurses are facing a world in which global changes are affecting our industry and profession. There are opportunities for innovation that did not previously exist. There are opportunities for independent practice, private practice, joint ventures with physicians or other health professionals, consultancies, staffing businesses, or invention of a new piece of equipment for patient care. Most of all, there are opportunities for personal and professional growth (Sanders & Kingma, 2012).

• determining the taxation status that is best for your business (Corporation, LLC, Proprietor); • networking and look in to nursing entrepreneur organizations; and • thinking about advertising and what would be best for your business.

Conclusion As a nurse, your self-employment and business options are unlimited. Your new job may not bear any resemblance to your old nursing job, but it will certainly build on your nursing knowledge and skills. It’s an empowering thing to say you are the owner of your own business. People pay attention. What will really matter, though, is not being a CEO of your

As the demand for cost-effective, high-quality healthcare services increases, the career opportunities and employment options available to nurses continue to expand. The profession’s challenge is to recognize and seize these opportunities and to continue to create new and vital roles for nurses within the healthcare industry while maintaining high-quality caring functions that are at the heart of nursing (Sanders & Kingma, 2012).

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Nurse Entrepreneurs: The Real Independent Practice of Nursing

n References Campaneli, E. (2017, June 5). State population getting older as young people leave upstate area. The New York Post. Retrieved from https:// nypost.com/2017/06/05/state-population-getting-older-as-youngpeople-leave-upstate-area/ Campbell, K. S. (2016). Enhancing interest and knowledge of how to start a nurse practitioner-led clinic. Doctoral Theses. Paper 21. Retrieved from https://digitalcommons.otterbein.edu/cgi/viewcontent. cgi?article=1022&context=stu_doc Carlson, K. (2015). Nurse entrepreneurship is exploding across the U.S. Network for Pancreatic Organ Donors With Diabetes. Retrieved from http://exclusive.multibriefs.com/content/nurse-entrepreneurshipexplodes-across-the-us/healthcare-administration Center for Health Workforce Studies. (2015). The primary care workforce in New York State. Retrieved from http://www.chwsny.org/wpcontent/ uploads/2015/07/Primary_Care_Brief_July_2015.pdf Center for Health Workforce Studies. (2018). The health care workforce in New York: Trends in the supply of and demand for health workers. Retrieved from http://www.chwsny.org/wpCenters for Medicare and Medicaid Services (CMS). (2016). Chronic care management service changes for 2017. Retrieved from https://www. cms.gov/Outreach-and-Education/Medicare-Learning-NetworkEddy, J. M., & Stellefson, M. L. (2009). Entrepreneurship in health education and health promotion: Five cardinal rules. Health promotion practice, 333-341. Empire Center. (2017, March 23). Upstate population drop continues; 46 of 62 NY counties down since 2010. Retrieved from https://www. empirecenter.org/publications/upstate-population-drop-continues46-of-62-ny-counties-down-since-2010/ Epi Research Report. (2011, November). Health care reform in New York Cityâ&#x20AC;&#x201C;Access to primary care before reform. New York City Department of Health and Mental Hygiene. Retrieved from https:// www1.nyc.gov/assets/doh/downloads/pdf/epi/epiresearch-healthcareaccess.pdf Health Resources & Services Administration (2017). Healthcare professional shortage areas New York State. Retrieved from https://datawarehouse. hrsa.gov/tools/analyzers/HpsaFindResults.aspx Health Workforce Technical Assistance Center. (2016) Health Workforce Analysis Guide. Retrieved from http://www.healthworkforceta.org/ wp-content/uploads/2016/10/HealthHealthy People. (2018). Mental health and mental disorders. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/ mental-health-and-mental-disorders Hertz, A. R. (January, 2009). Practices can bill for phone calls handled by nurses. AAP News, 30(1). Retrieved from http://www.aappublications. org/content/30/1/29.1 Hill, E. (2004, June). Fam. Pract. Manag. 11(6), 32-33. Retrieved from https://www.aafp.org/fpm/2004/0600/p32.html Institute of Medicine of the National Academies. (2010). The future of 38

nursing leading change, advancing health. Retrieved from www.iom. edu/Reports/2010/The-Future-of-Nursing-Leading International Council of Nurses. (2004). Guidelines on the nurse entre/ intrapreneur providing nursing service. Geneva, Switzerland. Jahani, S., & Fallahi, K. (2014). Perceived entrepreneurial motivators by Iranian nurse entrepreneurs: A qualitative study. Quarterly Journal of Nursing Management, 68-77. Keyes, L. (2018, July). Nurse entrepreneur trends. Nurse Entrepreneur Network. Retrieved from http://www.nurse-entrepreneur-network. com/public/727.cfm Lesonsky, J. (2018). 18 healthcare business ideas for passionate entrepreneurs. Retrieved from https://www.fundera.com/blog/ healthcare-business-ideas Mental Health Association (2018). New York will be the first state to require mental health education in schools. Retrieved from https:// mhanys.org/mh-update-1-31-18-new-york-will-first-state-requiremental-health-education-schools/ Messina, J. (2018). Starting later: Realizing the promise of older entrepreneurs in New York City. Center for an Urban Future. Retrieved from https://nycfuture.org/research/starting-later Mihalcea, A. D., Mitan, A., & Vitelar, A. (2012). Generation Y: Views on entrepreneurship. Economia, 15(2), 277-287. Retrieved from https:// www.researchgate.net/publication/268220215_Generation_Y_Views_ on_Entrepreneurship National Nurses in Business Association. (2018). Retrieved from https:// nnbanow.com/ New York State Association of Counties. (2018). The Future of Senior Services in New York State. Fall Legislative Conference. Association on Aging in New York. Retrieved from http://www.agingny.org/Portals/13/ External%20Documents/NYSAC%20Presentation%201.30.18.pdf New York State Board of Nursing. (2017, May). Practice information: Frequently asked questions. Retrieved from http://www.op.nysed. gov/prof/nurse/nursepracticefaq.htm New York State Department of Financial Services. (1985, March 15). Insurance circular letter NO. 8.Retrieved from https://www.dfs.ny.gov/ insurance/circltr/1985/cl1985_08.htm New York State Department of Health. (2011, March). Priority Area: Mental Health/Substance Abuseâ&#x20AC;&#x201C;Mental Health. Retrieved from https://www. health.ny.gov/prevention/prevention_agenda/mental_health_and_ substance_abuse/men tal_health.htm New York State Department of Health. (2017, October 3). Primary care redesign: Perspective from the New York State Department of Health. Retrieved from https://www.hanys.org/behavioral_health/swat/ include/docs/deptofHealth_marcus_friedrich.p Salmond, S. W., & Echavarria, M. (2017). Healthcare transformation and changing roles for nursing. Orthopedic Nursing, 36(1), 12-25. Sanders, E. M., & Kingma, M. (2012). Handbook on Entrepreneurial Practice Nurses Creating Opportunities as Entrepreneurs and Intrapreneurs.

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Nurse Entrepreneurs: The Real Independent Practice of Nursing

Geneva: International Council of Nurses. Retrieved from https://www. icn.ch/sites/default/files/inline files/2012_Handbook_entrepreneurial_ practice_eng.pdf/ Solesvik, M. Z. (2013). Entrepreneurial motivations and intentions: Investigating the role of education major. Education + Training, 253-271. STD TAC (2014). RN billing & coding FAQ: Clinic flow, codes, and levels of service. Retrieved from http://stdtac.org/wp-content/uploads/2016/05/ RN-Billing-FAQ_STDTAC-1.pdf The Truth About Nursing. (2015). Changing how the world thinks about nursing. Retrieved from https://www.truthaboutnursing.org/faq/ autonomy.html United States Bureau of Labor Statistics. (2016-2026). Occupational Outlook Handbook. Retrieved from https://www.bls.gov/ooh/ healthcare/registered-nurses.htm

Vannucci, J. J., & Weinstein, S. M. (2017, September 22). The nurse entrepreneur: Empowerment needs, challenges, and self-care practices. Dove Medical Press. Retrieved from https://www.dovepress. com/the-nurse-entrepreneur-empowerment-needs-challenges-andWhelan, J. C. (2012). When the business of nursing was the nursing business: The private duty registry system, 1900-1940. OJIN: The Online Journal of Issues in Nursing, 17(2), Manuscript 6. Retrieved from http://ojin.nursingworld.org/MainMenuCategories/ ANAMarketplace/ANAPeriodicals/OJIN/Tabl Wilson, A., Whitaker, N., Whitford, D. (2012, May 31). Rising to the challenge of health care reform with entrepreneurial and intrapreneurial nursing initiatives. OJIN: The Online Journal of Issues in Nursing, 17(2), Manuscript 5. Retrieved from http://ojin.nursingworld.org/ MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/Tabl

Journal of the New York State Nurses Association, Volume 46, Number 2

A Changing Landscape: The Need to Remove Legislative Barriers on Nurse Practitioners

Opinion Article: A Changing Landscape: The Need to Remove Legislative Barriers on Nurse Practitioners Cynthia S. Miller, BSN, RN

n A bstract

The shortage of providers in the healthcare field is having many adverse effects on patients. Allowing nurse practitioners to practice at their full scope will help to alleviate this burden and allow for the delivery of high-quality care to patients. Restrictions such as the requirement for a physician to certify the need for home health services puts unnecessary restrictions on nurse practitioners and an unneeded paperwork burden on physicians. Nurse practitioners are highly trained and capable of completing the assessment requirements needed for determining the need for home health services. The Home Health Care Planning Improvement Act of 2019 that is currently in the New York Senate hopes to remove the physicianâ&#x20AC;&#x2122;s requirement and allow nurse practitioners to certify the need for home healthcare.

The changing landscape of healthcare in the United States warrants expansion of nurse practitioners (NPs) legal freedoms to perform their job to the fullest extent of their education and training. Our nation is at a point in healthcare where more primary care providers are needed to meet the ever-expanding needs of the population. According to the Association of American Medical Colleges (2018) the United States could be facing a shortage of up to 120,000 physicians by 2030 (Owens, 2019). Nurse practitioners provide a viable and high-quality solution to meet the need for more providers, especially in the primary care arena. Nevertheless, there are many legislative barriers that need to be overcome before NPs can fully fill the void.

It is essential for nurse practitioners to take a stance against legislative barriers to full scope of practice, and work toward changing regulations. Changes to legislation directly effect how NPs can carry out their duties and these changes need to be originated by motivated NPs, not physicians. Nurse practitioners need to spearhead legislative changes so that the profession can be guided and moved toward a direction of transition and evolution. Using NPs to the full extent of their education and training would alleviate some of the pressure currently on the healthcare system, as well as promote improvement of some of the health indicators established by Healthy People 2020.

Cynthia S. Miller, BSN, RN, is currently attending Dâ&#x20AC;&#x2122;Youville College. She is a Registered Professional Nurse who works at Erie County Medical Center in Behavioral Health. 40

Journal of the New York State Nurses Association, Volume 46, Number 2

A Changing Landscape: The Need to Remove Legislative Barriers on Nurse Practitioners

One of the many regulations that is in need of reform is the Medicare requirement for a physician to certify that a patient is in need of home health services. Currently, a nurse practitioner is not legally permitted to sign the certification for such service. According to Poghosyan (2018) NPs performed over 1.1 million home and domiciliary care visits, which accounted for nearly a quarter of all residential visits to Medicare beneficiaries. Home health services include wound care, physical and occupational therapy, patient and caregiver education, help with activities of daily living, and monitoring serious illness and unstable health status (Brassard, 2012). When patients receive home health services the hospital length of their stays decrease, and nursing home placements can be avoided, which in turn reduces the financial burden on Medicare. Such services are crucial to patients who are homebound or require care after an acute medical incident. Home health services ensure that accessible and high-quality care is delivered to patients. It is well within the scope of practice for a nurse practitioner to assess and determine the need for such services. This is a prime example of how legislation is restricting NPs’ abilities to function to the full extent of their education and training and is leading to less access to high-quality, experienced, and proficient care for patients. In an effort to reduce the fraudulent use of home health services, Medicare now requires a face-to-face visit with a provider to determine eligibility for services. This provider can be a nurse practitioner, clinical nurse specialist or a physician assistant. However, after completing the evaluation of the patient, the provider must present their findings to a physician (Brassard, 2012). The physician then makes the final determination and submits the request. This process creates unnecessary work, delays in care, and increases cost. Physicians’ already have a tremendous paperwork burden and this unnecessary requirement adds to that burden. This process can greatly limit a patient’s access to care. For example, if a physician requires that they be the one to see the patient face-to-face, then a homebound

patient would need to arrange for transportation to the physician’s offices. If an NP operates a private practice, then they must seek out a physician who will sign a certification form. Additionally, home health care agencies also have to seek out a physician for certification requirements. The Institute of Medicine’s (2010) “The Future of Nursing: Leading Change, Advancing Health” report recommends an amendment to “the Medicare program to authorize advanced practice registered nurses to perform admission assessments, as well as certification of patients for home health care services and for admission to hospice and skilled nursing facilities” (Institute of Medicine, 2010, p.1). In response to this recommendation, the Home Health Care Planning Improvement Act of 2019 (S.296) was introduced to the senate on January 31, 2019, by Senator Susan Collins. This bill would allow Medicare payment for home health services ordered by a nurse practitioner, a clinical nurse specialist, a certified nurse-midwife, or a physician assistant to overcome the current law that coverage can only be provided for services ordered by a physician. Nurse practitioners need to support this bill, show a united front, and demand that their state legislators show support for the act in Congress. Nurse practitioners are an asset to the healthcare system. Pushing for legislation that would allow NPs to work to their full scope of practice is not an effort to overrun physicians. Rather, it is a collaborative measure for providers to work together to provide high-quality and highly accessible care to patients. In response to the passage of the 2010 Affordable Care Act and the aging population in the United States, the need for providers in healthcare, and particularly in home health and hospice services, is only going to continue to expand. By transforming the healthcare system and removing barriers to advanced practice nurses, patients will be able to freely access and receive quality nursing care from nurses who are the fundamental home health and hospice service as an alternative to extended hospital stays or nursing home care (Brassard, 2012).

Journal of the New York State Nurses Association, Volume 46, Number 2

A Changing Landscape: The Need to Remove Legislative Barriers on Nurse Practitioners

n References Brassard, A. (2012, July). Removing barriers to advanced practice registered nurse care: Home health and hospice services. AARP Public Policy Institute. Retrieved from https://www.aarp.org/content/dam/aarp/ research/public_policy_institute/health/removing-barriers-advancedpractice-registered-nurse-home-health-hospice-insight-july-2012AARP-ppi-health.pdf Institute of Medicine. (2010). The Future of Nursing Leading Change, Advancing Health: Report Recommendations. Retrieved from http:// nationalacademies.org/hmd/~/media/Files/Report%20Files/2010/ The-Future-of-Nursing/Future%20of%20Nursing%202010%20 Recommendations.pdf

Owens, C. (2019, January 1). Connections: A shortage of doctors. The Berkshire Edge. Retrieved from https://theberkshireedge.com/ connections-a-shortage-of-doctors/ Poghosyan, L. (2018) Federal, state, and organizational barriers affecting nurse practitioner workforce and practice. Nursing Economics, 36(1), 43-45. Retrieved from https://www. nursingeconomics.net/ necfiles/2018/JF18/43.pdf S.296. Home Health Care Planning Improvement Act of 2019. Retrieved from https://www.congress.gov/bill/116th-congress/senate-bill/296

Journal of the New York State Nurses Association, Volume 46, Number 2

n what’s new

IN HEALTHCARE LITERATURE Clinical Guideline Updates Physical Activity Guidelines. (2018, December 3). Medscape. Retrieved from https://reference.medscape.com/viewarticle/905775 Age- and Condition-Related Recommendations  Children

aged 3-5 years: Should be physically active throughout the day to enhance growth and development.

O lder

 Children

aged 6-17 years: Sixty minutes or more of moderate-tovigorous physical activity per day.



Pregnant and postpartum women: At least 150 minutes of moderateintensity aerobic activity weekly.

 Adults: At least 150-300 minutes per week of moderate-intensity aerobic



Adults with chronic conditions or disabilities who are able: Follow key guidelines and perform both aerobic and muscle-strengthening activities.



Regular physical activity reduces the risk of clinical depression, as well as reduces depressive symptoms and symptoms of anxiety.



S trong evidence demonstrates that regular physical activity improves perceived quality of life.



Regular physical activity has been shown to improve cognitive function and to reduce the risk of dementia; falls and fall-related injuries; and cancers of the breast, esophagus, colon, bladder, lung, endometrium, kidney, and stomach. It also helps retard the progression of osteoarthritis, type 2 diabetes, and hypertension.

physical activity, OR 75-150 minutes per week of vigorous-intensity aerobic physical activity, OR an equivalent combination of moderateand vigorous-intensity aerobic activity; muscle-strengthening activities should be performed on two or more days per week.

adults: Multicomponent physical activity to include balance training, aerobic activity, and muscle-strengthening activities.

Sleep, Daily Functioning, and Mental Health 



Strong evidence demonstrates that moderate-to-vigorous physical activity improves sleep quality by decreasing the time it takes to fall asleep; it can also increase deep-sleep time and decrease daytime sleepiness. ognition (e.g., memory, processing speed, attention, academic C performance) can be improved with physical exercise.

Risk of Diseases and Conditions 

egular physical activity minimizes excessive weight gain, helps R maintain weight within a healthy range, improves bone health, and prevents obesity, even in children as young as 3-5 years old.



I n pregnant women, physical activity helps reduce excessive weight gain in pregnancy and helps reduce the risk of developing gestational diabetes and postpartum depression.

Repositioning Patients in Respiratory Distress Recommended. (2019, February 1). Retrieved from https://www.medscape.com/viewarticle/908549?nlid=127682_785&src=WNL_ mdplsfeat_190205_mscpedit_nurs&uac=215663EV&spon=24&impID=1877174&faf=1 The literature announces a new protocol for turning patients with severe acute respiratory distress syndrome (ARDS) onto their stomachs for at least 12 hours a day. Positioning the patient manually should follow the general recommendation of enlisting one person for every 35 pounds of

patient. The benefits of the prone position for patients with ARDS includes better ventilation of the lungs and decreased mortality rates. The procedure is recommended in current practice guidelines (Am J Respir Crit Care Med. (2017). 195, 1253-1263).

Six ‘Obesity-Related’ Cancers on Rise in U.S. Young Adults. (2019, February 4). Retrieved from https://www.medscape.com/viewarticle/908602?nlid=127856_4622&src=WNL_ mdplsnews_190208_mscpedit_nurs&uac=215663EV&spon=24&impID=1879914&faf=1 In the United States from 1995 to 2014, the incidence of 6 of 12 obesityrelated malignancies increased among young adults aged 25-49 years old, according to a new observational study. In young adults, the six obesity-related cancers that increased in incidence were multiple myeloma, colorectal, uterine

corpus, gallbladder, kidney, and pancreatic cancer. Six obesity-related cancers that did not increase in young people were breast, esophageal, gastric cardia, liver, and intrahepatic bile duct, thyroid, and ovarian. Despite the findings, the study is not evidence of a causal relationship between obesity and cancer.

Journal of the New York State Nurses Association, Volume 46, Number 2

Notably, the study’s authors also report that among the six cancers on the rise in the young adults, there was a steeper increase in progressively younger ages (p wald < .05). Cancer incidence trends may have been influenced by the rapid rise in overweight or obesity prevalence in the United States. Between 1980 and 2014, overweight or obesity prevalence

in the United States increased by more than 100% (from 14.7% to 33.4%) among children and adolescents, and by 60% among adults aged 20-74 years (from 48.5% to 78.2%). The study was funded by the American Cancer Society and the National Cancer Institute.

E-Cigarettes Linked to Increased Stroke, MI Risk. (2019, February 5). Medscape. Retrieved from https://www.medscape.com/viewarticle/908725?nlid=127856_4622&src=WNL_ mdplsnews_190208_mscpedit_nurs&uac=215663EV&spon=24&impID=1879914&faf=1 New research suggests the use of electronic cigarettes (e-cigarettes) is linked to a significantly increased risk for “hard” adverse outcomes, such as stroke and myocardial infarction (MI). Study results showed a 71% higher risk of experiencing a stroke, a 59% higher risk for an MI, and a 40% higher risk for angina or coronary heart disease (CHD) for e-cigarette users when compared with nonusers. Users also had twice the rate of smoking regular cigarettes.

The research notes that 3.2% of adults and 11.3% of high school students in the United States reported having used e-cigarettes in 2016. E-cigarette use among young people increased by 900% between 2011-2015. Study results were presented at the International Stroke Conference (ISC) 2019 (Abstract 9, 2019, February 9).

Conditions Treated with Cannabis Often Lack Good Evidence. (2019, February 4). Medscape. Restrieved from https://www.medscape.com/viewarticle/908638?nlid=127856_4622&src=WNL_ mdplsnews_190208_mscpedit_nurs&uac=215663EV&spon=24&impID=1879914&faf=1 Currently, 33 states and the District of Columbia have legalized cannabis for medical use. Nevertheless, according to an analysis published online February 4 in Health Affairs, many conditions that are considered qualifying conditions for cannabis use under state laws have no or insufficient evidence of efficacy, and some have evidence of inefficacy. According to the analysis, such conditions include dementia, glaucoma, hepatitis C, cachexia, irritable bowel disease, and numerous others.  Limited evidence of inefficacy

 Limited evidence of efficacy



glaucoma



anxiety



dementia



post-traumatic stress disorder



HIV/AIDS

 No or insufficient evidence of efficacy

However, the analysts noted that 85.5% of all patient-reported qualifying conditions had either substantial or conclusive evidence of therapeutic efficacy, based on a 2017 report by the National Academies of Sciences, Engineering, and Medicine (NASEM). Chemotherapy-induced nausea and vomiting was also linked with conclusive evidence of efficacy in the NASEM report. Multiple sclerosis and chronic pain had substantial evidence of efficacy. Other levels of efficacy evidence included the following:



arthritis



Tourette Syndrome



hepatitis C



traumatic brain injury



terminal illness



muscular dystrophy



multiple sclerosis



dystonia



chronic pain



cancer



epilepsy



cachexia



Parkinson’s disease



amyotrophic lateral sclerosis



Huntington’s disease



irritable bowel disease

 Substantial evidence of efficacy

 Conclusive evidence of efficacy 

chemotherapy-induced nausea and vomiting

According to the study, chronic pain continues to be the most common qualifying condition reported by patients who use medical cannabis (64.9% in 2016).

Journal of the New York State Nurses Association, Volume 46, Number 2

Activity: Night Shift Work and Weight Gain Among Female Filipino Nurses

Thank you for your participation in Night Shift Work and Weight Gain Among Fem ale Filipino Nurses,” a new 0.5 contact hour continuing education (CE) activity offered by NYSNA. NYSNA members and nonmembers are invited to take part in this activity; you do not need to be a resident of New York State.

answer next to the question number. Each question has only one correct answer. The 0.5 contact hours for this program will be offered until July 30, 2022.

INSTRUCTIONS In order to receive contact hours for this educational activity, participants are to read the article presented in this issue of The Journal, complete and return the post-test, evaluation form, and earn 80% or better on the post-test. This activity is free to NYSNA members and $10 for non-members. Participants can pay by check (made out to NYSNA & please include “CE D6F880” on your check) or credit card. The completed answer sheet and evaluation form may be mailed or faxed back to NYSNA; see the evaluation form for more information. The New York State Nurses Association is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. NYSNA wishes to disclose that no commercial support was received for this educational activity. All planners/authors involved with the development of this independent study have declared that they have no vested interest. NYSNA program planners and authors declare that they have no conflict of interest in this program.

1) Night shift workers experience insufficient sleep, tiredness, and an inability to recover between shifts. a. True b. False 2) It takes at least one week’s worth of insufficient sleep to cause energy expenditure and metabolic imbalance that have been associated with weight gain. a. True b. False 3) Insufficient sleep can increase food consumption by triggering a need to replace sleep loss and energy by consuming more food. a. True

INTRODUCTION Nurses transitioning between day and night shift work can experience adverse health events. Recent studies have found that people who work the night shift are likely burning less energy during a 24-hour period than those on a normal schedule, thus increasing their risk for weight gain and obesity. A recent meta-analysis looking at the data of almost 300,000 individuals found that people who work night shifts are 23% more likely to be obese than those who work standard day shifts. Researchers have known that people who work, and therefore eat, at night when their bodies are biologically prepared to sleep are prone to put on excessive pounds. In large part, the human circadian clock is set by exposure to sunlight. Not getting consistent, uninterrupted sleep or enough sleep (7-9 hours per 24hour period) can increase fatty acids levels, raises cortisol levels (the stress hormone associated with an increase in belly fat), raise blood glucose levels, and promote insulin resistance—significantly increasing the likelihood to develop type 2 diabetes.

b. False 4) Insufficient sleep is associated in the literature with the development of conditions associated with weight gain, such as heart diseases, hypertension, diabetes, stroke, and some forms of cancer. a. True b. False 5) Researchers have found that expected medical costs for overweight people were $1,429 lower annually than the costs of those of normal weight. a. True b. False

OBJECTIVES Upon completion of the article, the reader should be able to: 1. Summarize the research that indicates that night shift work can lead to adverse health events and weight gain. 2. Understand the importance of developing a personal care plan when transitioning from day to night shift work.

6) Having a body mass index (BMI) of 25 or higher constitutes being overweight, and having a BMI of 30 or higher constitutes obesity. a. True b. False

Please answer either True or False to the questions below. Remember to complete the answer sheet by putting the letter of your corresponding Journal of the New York State Nurses Association, Volume 46, Number 2

n CE Activity: Night Shift Work and Weight Gain Among Female Filipino Nurses, continued 7) Poor sleep quality and reduced access to quality food choices are some causative factors of weight gain among night shift nurse workers.

9) Prevention and public health education are the keys to solving the unhealthy weight gain epidemic. a. True

a. True

b. False

b. False 8) Weight gain at the individual level involves attitudes and behavior in personal lifestyle, healthy food choices, and lack of motivation. Environmental factors include working conditions, how food is processed and marketed, and education about food choices and dietary regimes. Genetic factors include predispositions to dietary illnesses and diseases, as well as familial influences and tendencies.

10) Filipino nurses who work night shift have the same risk of becoming overweight and obese as those of other cultures and races. a. True b. False

a. True b. False

Journal of the New York State Nurses Association, Volume 46, Number 2

The Journal of the New York State Nurses Association, Vol. 46, No.2

Answer Sheet Night Shift Work and Weight Gain Among Female Filipino Nurses Note: Contact hours for this program will be offered until June 30, 2022. Please print your answers in the spaces provided below. There is only one answer for each question. First Name: MI: Last Name: Address: City: State: ZIP Code: Daytime Phone Number (include area code): Email: Profession: NYSNA Member # (if applicable):

Currently Licensed in NY state? Y / N (circle one)

License #:

License State:

ACTIVITY FEE: Free for NYSNA members/$10 non-members PAYMENT METHOD Check—payable to New York State Nurses Association (please include “Journal CE” and your CE code D6F880 on your check). Credit card:

Mastercard

Visa

Discover

American Express

Card Number: Name:

Expiration Date:

Signature:

CVV# Date:

Please print your answers in the spaces provided below. There is only one answer for each question.

1._________ 2._________ 3._________ 4._________ 5. _________

6._________ 7._________ 8._________ 9._________ 10._________

Please complete the answer sheet above and course evaluation form on reverse. Submit both the answer sheet and course evaluation form along with the activity fee for processing. Mail to: NYSNA, Attn. Nursing Education and Practice Dept. 131 West 33rd Street, 4th Floor, NY, NY 10001 Or fax to: 212-785-0429 Journal of the New York State Nurses Association, Volume 46, Number 2

Learning Activity Evaluation Night Shift Work and Weight Gain Among Female Filipino Nurses Please use the following scale to rate statements 1-7 below:

Poor

Fair

Good

Very Good Excellent

1. The content fulfills the overall purpose of the CE Activity. 2. The content fulfills each of the CE Activity objectives. 3. The CE Activity subject matter is current and accurate. 4. The material presented is clear and understandable. 5. The teaching/learning method is effective. 6. The test is clear and the answers are appropriately covered in the CE Activity. 7. How would you rate this CE Activity overall? 8. Time to complete the entire CE Activity and the test?

____ Hours (enter 0-99) _____ Minutes (enter 0-59)

9. Was this course fair, balanced, and free of commercial bias?

Yes / No (Circle One)

10. Comments:

11. Do you have any suggestions about how we can improve this CE Activity?

Journal of the New York State Nurses Association, Volume 46, Number 2

THE

JOURNAL of the New York State Nurses Association

Call for Papers

The Journal of the New York State Nurses Association is currently seeking papers. Authors are invited to submit scholarly papers, research studies, brief reports on clinical or educational innovations, and articles of opinion on subjects important to registered nurses. Of particular interest are papers addressing direct care issues. New authors and student authors are encouraged to submit manuscripts for publication.

Information for Authors

For authorâ&#x20AC;&#x2122;s guidelines and submission deadlines, go to the publications area of www.nysna.org or write to journal@nysna.org.

Call for Editorial Board Members Help Promote Nursing Research The Journal of the New York State Nurses Association is currently seeking candidates interested in becoming members of the publicationâ&#x20AC;&#x2122;s Editorial Board. Members of the Editorial Board are appointed by the NYSNA Board of Directors and serve one 6-year term. They are responsible for guiding the overall editorial direction of The Journal and assuring that the published manuscripts meet appropriate standards through blinded peer review. Prospective Editorial Board members should be previously published and hold an advanced nursing degree; candidates must also be current members of NYSNA. For more information or to request a nomination form, write to journal@nysna.org.

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The Journal of the New York State Nurses Association, Vol. 46, Number 2

Articles inside

Opinion Article: A Changing Landscape: The Need to Remove Legislative Barriers on Nurse Practitioners by Cynthia S. Miller, BSN, RN

CE Activity: Night Shift Work and Weight Gain Among Female Filipino Nurses

High-Quality Care Transitions Promote Continuity of Care and Safer Discharges by Dana Deravin Carr, DrPH, MS, MPH, RN-BC, CCM

Night Shift Work and Weight Gain Among Female Filipino Nurses by Raymundo Apellido, PhD, RN, CCRN

Nurse Entrepreneurs: The Real Independent Practice of Nursing by Carol Lynn Esposito, EdD, JD, MS, RN-BC, NPD; Lucille Contreras Sollazzo, BSN, RN-BC, NPD