texa s nu r s e s .o rg
TEXASNURSING M A G A Z I N E Cultivating
Joy at Work
T N A : E m p o w e r i n g Te x a s N u r s e s t o a d v a n c e t h e p r o f e s s i o n | S P R I N G 2 0 1 9
SPRING 2019 Volume 93, Number 2 EDITOR IN CHIEF: Cindy Zolnierek, PhD, RN, CAE MANAGING EDITOR: Kanaka Sathasivan, MPH 4807 Spicewood Springs Rd., Bldg 3, Suite 100, Austin, TX 78759-8444 P: 800.TNA.2022 or 512.452.0645; F: 512.452.0648 tna@texasnurses.org | texasnurses.org
MISSION Empowering Texas Nurses to advance the profession
BOARD OF DIRECTORS OFFICERS: Jeff Watson, DNP, RN, NEA-BC, President Tamara “Tammy” Eades, DNP, MSN, RN, Vice President Kleanthe Caruso, RN, MSN, NEA-BC, Secretary Gayle Dasher, RN, PhD, ANP-BC, Treasurer DIRECTORS: Tina Cuellar, PhD, RN, PMHCNS-BC Melinda Hester, DNP, RN Donna Wallis, MBA, MSN, RN Patricia Freier, MSN, RN-BC, RCIS Shakyryn Napier, DHSc, MSN, RN, CPN
TNA DISTRICT AND PRESIDENT Dist.1:
VISION Nurses transforming health TEXAS NURSING (ISSN 0095-36X) is published quarterly— Winter, Spring, Summer, Fall—by the Texas Nurses Association, 4807 Spicewood Springs Rd., Bldg 3, Suite 100, Austin, TX 78759-8444 Periodical postage is paid in Austin, Texas. One-year subscriptions: $25 (nursing schools, libraries, hospitals, non-nurses, out-of-state nurses), foreign $30; single copy $2.50. Subscription is not available to non-member Texas nurses. Some back issues may be viewed online at texasnurses.org. PUBLISHING PARTNER Monarch Media & Consulting, Inc. P: 512.680.3989 or 512.293.9277; F: 866.328.7199 monarchmediainc.com | chellie@monarchmediainc.com Advertising inquiries: call Chellie Thompson at 512.293.9277. TEXAS NURSING is indexed in The Cumulative Index to Nursing and Allied Health Literature and in the International Nursing Index. 16mm, 35mm microfilm, 105mm microfiche, article copies available from University Microfilms International: 1.800.521.3044 Statements of fact and opinion are made on the responsibility of the authors alone and do not imply an opinion on the part of the officers or the membership of TNA.
Dist. 3: Margie Dorman-O'Donnell, margie.dormanodonnell@cookchildrens.org, District Staff: Jamie Gilbert, jamiegilbert@texashealth.org Dist. 4: Jackie Michael, michaels@uta.edu, District office: Pat Pollock, P.O. Box 764468, Dallas, TX 75376; 972.435.2216; d4tna@flash.net; tnad4.org Dist. 5: David Burzynski, president.tnad5@gmail.com Dist. 7: Crissie Richardson, crissag98@gmail.com, District office: P.O. Box 1482, Belton, TX 76513, tnadistrict7@gmail.com Dist. 8: Linda Juenke, 830.739.7028, ljsoaringeagle3@gmail.com Dist. 9: Tina Cuellar, tinaatutmb@aol.com, District office: Melanie Truong, 7324 Southwest Freeway, Suite 2-1453, Houston, TX 77074; 713.523.3619; tna9@tnadistrict9.com; tnadistrict9.com Dist. 11: Linda Treitler, linda.treitler@mwsu.edu Dist. 17: Cindy Keese, 361.332.1643, cakeese@aol.com Dist. 18: Darla Smith, darla.smith3@stjoe.org Dist. 19: Colleen Marzilli, cmarzilli@uttyler.edu Dist. 35: Chrystal Brown, 903.434.8302, cbrown@ntcc.edu At-large: Contact TNA, 800.862.2022, ext. 129, brichey@texasnurses.org
POSTMASTER Send address changes to TEXAS NURSING, 4807 Spicewood Springs Rd., Bldg 3, Suite 100, Austin, TX 78759-8444 ARE YOU MOVING? Need to change your address? If so, provide it quickly and easily in the Members Only section of the TNA website, texasnurses.org. Or mail your new address—at least six weeks prior to your move— to Texas Nurses Association headquarters. We’ll make sure your TEXAS NURSING makes the move with you. FEEDBACK EMAIL OR LETTER GUIDELINES TEXAS NURSING will select emails/letters on the basis of readership interest and relevance to current nursing/health care events. TEXAS NURSING reserves the right to edit all letters. Guide: Limit to 200 words; focus on single issue; include writer’s name, mailing address, and daytime phone. Send to: editor@texasnurses.org. Copyright 2019 © Texas Nurses Association
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Clarissa Silva, clarissa2277@att.net, Terry Acosta, shadowmon@sbcglobal.net
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Cultivating Joy at Work
Happy Nurse —
12
8
Happy Patient
JOY
STEALING
A Nurses Guide to Working After a Board Order VALUE
SAFETY NURSING
22
QUALITY
UTILIZATION MANAGEMENT The Intersection Between Quality, Safety, Value, and Nursing
16 Contents IN EVERY ISSUE
FEATURES
5
10
15
18
20
PRESIDENT’S NOTES
SMALL TOWN; BIG CONSEQUENCES
HAPPY NATIONAL NURSES WEEK!
CONNECTING THE DOTS
Joy in Our Work
Two Nurses Arrested for Doing the Right Thing
Four Million Reasons to Celebrate
What TNA's DNP Policy Fellowship Can Do For You
PREVENTING SUICIDE BEYOND PSYCHIATRIC UNITS
6
May is Mental Health Month
TNA MEMBER NEWS Kudos
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S P R I N G 2 019 | T E X A S N U R S I N G M AGA Z I N E
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President’s Notes Jeff Watson, DNP, RN, NEA-BC
JOY IN OUR WORK Remembering to Value the Love and Human Connectedness that Makes this Work Joyful ON A LATE SUMMER SATURDAY afternoon, all of my immediate family members and numerous family friends packed into my mother’s hospital room. We had assembled to bear witness to the transition of life. Little space remained in the room when the 7 pm nurse opened the door. As she squeezed through, she joked, “Do y’all think we can get anybody else in here?” People began to move out of the way, but she encouraged all of us to stay put. She teased that God had given her long legs for this very reason as she climbed over us to my mom. As she completed her assessment, I watched her face for the telltale signs that the moment I dreaded was near. But all that I saw was a joyful, loving kindness as she went about her work. When she had finished, she tenderly placed her hands on the sides of my mother's face and said, "Bernice, I'll be with you throughout the night." As I heard those words, I embraced them and welcomed her comforting affirmation. The evening gave way to night, and those assembled who had shared a part of their life journey with my mother said their final goodbyes. With each departure, the silence was fortified as those of us remaining withdrew into our soundless sorrow. The hours passed, and only my siblings and I lingered. A dense sadness had settled over the room, like heavy disorienting fog. Deep into the night, the long-legged nurse returned, carrying a fresh pot of coffee and sleeve of foam cups. She looked around the room and then asked if she could spend her break time with us. No one objected. She passed around the cups, and then filled each
All of this happened because a single nurse, who loved her work, made a pot of coffee and spent 30 minutes of time listening to people she didn’t know. one with the hot coffee, serving herself last. Pulling up an empty chair, she reached over, took our mother’s hand and said, “Tell me about your mama.” And we did. Story after story poured from each one of us. There were tears, and there was laughter, a lot of laughter. Occasionally, she would ask a question, but mostly, she just listened. After she returned to work, we continued telling stories to one another: reminders of the vibrant life we had all shared. I had been a nurse for more than 25 years when my mother passed away. It took me several years after that to fully appreciate what that nurse did for my mother that summer night. We believe that the last of our senses to fade during the dying process is hearing. The nurse that night demonstrated the joy she had in her work by making sure my mom heard the stories of her life as witnessed by her children. My mother heard how much she was loved and how much she would be missed. She heard that she was a great mother and that we would be okay. All of this happened because a single nurse, who loved her work, made a pot of coffee and spent 30 minutes of time
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listening to people she didn’t know. Contemporary nursing theorist Dr. Jean Watson says, “Increasingly we learn that burnout is not because we care too much, but because we wall ourselves off and close off our hearts. We close off our very source of love and the human connectedness that gives us the life-generating force for this work.” Sometimes the work gets overwhelming, and we find ourselves simply moving from one task to the next. There will always be obstacles to climb over, but I hope that nothing keeps you from connecting to the joy of your work. I hope that you never suffer from a lack of joy and that you will always be able to access the sacred healing gifts that are foundational to our work. May we all take time to rest and to reflect on the meaning of our profession. This summer, I hope you will tell the stories that connect us. They are the stories of life; they are the stories that matter. Peace, Jeff i REFERENCE: Watson, J., Malkin, G., & Alvarez, D. (2006). The caring moment. On Care for the Journey: Messages and Music for Sustaining the Heart of Healthcare [CD]. Boulder: Companion Arts.
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TNA MEMBER NEWS SPOTLIGHT ON YOU KUDOS Congratulations to Eloisa G. Taméz, RN, PhD, FAAN, recipient of the FD200 Award as Diplomat. The event was held at the Library of Congress and sponsored by descendants of Frederick Douglass and the Antiracist Research Institute at American University in Washington, DC. Taméz is professor and associate dean for student affairs in the School of Nursing at the University of Texas Rio Grande Valley. Taméz has practiced nursing throughout the United States, Puerto Rico, Central America and South America. She held various positions through her commission in the United States Army Reserve, Nurse Corp, the Department of Veterans Affairs and various private sector health care organizations.
ANNOUNCING THE NPD COMMITTEE The Texas Nurses Association (TNA) Nursing Professional Development (NPD)
Committee is charged with assessing, identifying, analyzing, planning, designing, developing, implementing and curating TNA’s continuing nursing education content and nursing professional development activities to equip and prepare Texas Nurses to meet the challenges of the 21st century health care industry. Please welcome the members of this new committee: Chair: Pat Morrell, DNP, RN, NEABC, Director of Nursing Practice and Development at CHRISTUS Health System (35 years of nursing experience) Lydia Butcher, BSN, RN-BC, CVRN, Continuing Nursing Education Coordinator at HCA Houston, Gulf Coast Division, Primary Nurse Planner at Clear Lake Regional (32 years of nursing experience) Liffy Cherian, MSN, RN, APRN, AGCNS, BC, OCN, Clinical Nurse Specialist and Clinical Nurse at UT Southwestern University Hospitals (23 years of nursing experience) Nisha Cherian, MSN, RN, Professor Med-Surg/Pediatrics at San Jacinto Community College (16 years of nursing experience)
Lee Ann Harrison, MSN. RN-BC, Nurse Education Specialist at Houston Methodist (31 years of nursing experience) Denise McNulty, MSN, MS-HAS, NEBC, REN-BC, Director of Education and Primary Nurse Planner at Houston Methodist Willowbrook (36 years of nursing experience) Jackie Michael, PhD, RN, APRN, WHNPBC, Clinical Assistant Professor at UT Arlington and TNA District 4 President (30 years of nursing experience) Matthew Perales, MSN(c), BSN, RN, Administrator/Director of Nursing, Access Quality Therapy Services (6 years of nursing experience)
If you are a Texas Nurses Association member and you’ve, been promoted, received an award, or been elected or appointed to a board or community organization, we’d like to hear from you. Please send submissions to editor@ texasnurses.org.
GET THE KNOWLEDGE YOU NEED TO LEAD! At the TNA Policy Summit, June 7, you’ll be the first to get a breakdown on the 86th Legislative Session. Build insight into the trends, workforce demographics, issues, and influencers of care delivery and advocacy in the nursing practice environment. You’ll also get to build your own experience by choosing from breakout sessions on Environments of Practice, Emerging Practice and Nursing Roles, Quality, Safety, and ValueBased Health Care, Person-Centered Care and Collaborative Decision-Making—considering technological, economic, social, and political trends within each topic. Our goal is to generate diverse perspectives to shape future nursing policy. Help us be your voice at the Capitol!
Registration closes May 31. Visit texasnurses.org/house to learn more and view the schedule.
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JUNE 7, 2019
Texas Nurses Association
Policy Summit June 7, 2019 Georgetown, TX
Empowered Nurses advancing the profession
It takes a Texas-sized effort Sign up to use the Texas Prescription Monitoring Program as a prescriber or a prescriber’s delegate. Working together, nurses and doctors can leverage the information provided through the PMP to make more informed prescribing decisions. It is important to review every patient’s prescription history before prescribing opioids, benzodiazepines, barbiturates, or carisoprodol. The PMP is one of the best tools we have for preventing prescription drug misuse, but it only works if we use it.
Sign on before you sign off.
Happy Nurse —
Joy
Happy Patient
Cultivating Joy at Work
By Sha McCoy, DNP, APRN, ACNS-BC, AAHIVS
A JOYFUL WORK ENVIRONMENT in health care can improve patient safety, outcomes, overall experience, and costs.1 While employers are starting to recognize the importance of joy at work, many health care professionals struggle with finding joy in the workplace. The historical acceptance of disrespect, bullying, and even physical violence in the health care workplace has created a culture of silence and fear rather than joy.2 To meet the demands of an evolving health care system, team members at all levels must collaborate and improve the work environment to better strengthen the workforce providing care.
WHY IS JOY IMPORTANT TO NURSING? In the nursing context, joy is an emotion of pleasure and satisfaction as the result of meaningful action.2 For nurses, working in a toxic environment precludes joy in work, which leads to suffering at the individual and patient level and has an overall negative impact on the profession.3 Nurses working in environments detrimental to joy often experience symptoms such as increased anxiety or depression, lack of sleep, loss of appetite, headache, and frequent illnesses.4 Nurses experiencing a disconnect from their work environment are also more likely to display a decrease in efficiency and productivity.1 Subsequently, patients suffer when
nurses are disengaged and dissatisfied in the workplace.
THE IMPACT OF JOY BEYOND NURSING Over the last few years, research has associated workplace concerns such as high turnover, patient safety, financial vitality, clinical outcomes, and overall patient experience with burnout, a state of exhaustion or low sense of personal accomplishment from work, which can lead to a lack of joy.3 The nursing profession loses one-third of new registered nurses within the first year of practice due to burnout.2 Working to make the nursing work environment more conducive to joy could reduce the amount of dissatisfaction experienced by new graduates entering the workforce and further mitigate the nursing shortage and prevent unnecessary costs.
For perspective, mid-career physicians (in contrast to early-career) were more likely to leave their practice out of frustration to pursue a career that did not involve direct patient contact, or was outside of medicine all together.5 The cost of replacing one physician leaving practice, and on-boarding a new physician following a prolonged vacancy has been estimated to cost an organization $1,262,297.00.6 In addition to the direct cost associated with turnover, there is also a noted increase in indirect expenditures from higher rates of medical errors and mal-
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practice claims during these periods.3 While more research is needed to further explore the financial impact the lack of joy and burnout may have on an organization, this issue concerns everyone as it affects safety, quality, and health care performance in all workplaces.
A JOYFUL JOURNEY The Institute for Healthcare Improvement Framework for Improving Joy in Work describes joy as being more than absence of burnout or a concern of individual wellness; it is created by the system and occurs across the organization.1 Identifying the pathway to joy is not a one-time event. It is an ongoing collaborative effort to ensure employers and employees stay engaged through organizational changes to successfully maintain a joyful environment. One of the questions asked in the IHI Framework is “What matters to you?” The question was designed to help leaders and colleagues at all levels in an organization engage in conversation to better understand the barriers to joy in work and ways to address those findings. Admittingly, finding joy is easier said than done as we often spend more time stating our dislikes, rather than clearly expressing our desires. On my personal journey, not only have I learned to identify my non-negotiables, I am comfortable communicating those needs without feeling guilty or worrying
Maintaining joy is a critical component to providing high quality, cost-effective care. about being judged for having certain requirements. Asking “what matters to you” is a good, open-ended way to start laying a foundation to build on as organizations seek to grow and create a new culture filled with meaning and purpose.
nent to increasing patient safety and improving outcomes. However, the shift in focus from quantity to quality health care will be difficult to achieve without strengthening the workforce providing the service.
In my work with individuals who are incarcerated and diagnosed with HIV, Hepatitis C, or both, maintaining joy is a critical component to providing high quality, cost-effective care. Managing chronic conditions within a large complex system requires a multidisciplinary team effort with a high level of respect for what each profession contributes to patient care.
“Pleasure in the job puts perfection in the work.” —Aristotle i
While there is a tremendous amount of autonomy in my practice, we constantly evaluate and improve upon work processes with input from colleagues at various levels. The organization encourages and supports professional growth, and the culture overall aligns with my values. These attributes have added joy to this leg of my journey. Helping nurses and health care providers at every level identify the characteristics that help them perform at their highest potential is critical as the health care industry demands better care that is cost-effective. Improving joy at work is often overlooked as a critical compo-
Sha McCoy, DNP, APRN, ACNS-BC, AAHIVS, serves as an advanced practice registered nurse and HIV specialist with the University of Texas Medical Branch/Correctional Managed Care. She received her Doctor of Nursing Practice degree in May 2019 from the University of Texas Health Science Center at Houston and is a member of Sigma Theta Tau International Honor Society of Nursing. McCoy is a DNP Policy Fellow with TNA and member of the APRN Committee.
REFERENCES 1. Institute for Healthcare Improvement. (2017). IHI framework for improving joy in work. Retrieved from http://www.ihi.org/resources/Pages/IHIWhitePapers/ Framework-Improving-Joy-in-Work.aspx 2. National Patient Safety Foundation. (2013). Through the eyes of the workforce: Creating joy, meaning, and safer health care. Retrieved from https://c.ymcdn.com/ sites/npsf.site-ym.com/resource/resmgr/LLI/ThroughEyes-of-the-Workforc.pdf 3. Dyrbye, L., Shanafelt, T., Sinsky, C., Cipriano, P., Bhatt, J., Ommaya, A., & Meyers, D. (2017). Burnout among
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Our Fabulou s Team! #awesomed ay #TXnurs es health care professionals: A call to explore and address this underrecognized threat to safe, high-quality care. National Academy of Medicine (NAM) Perspectives. Retried from https://nam.edu/burnout-among-healthcareprofessionals-a-call-to-explore-and-address-thisunderrecognized-threat-to-safe-high-quality-care. 4. Vahey, D., Aiken, L., Sloane, D., Clarke, S., & Vargas, D. (2004). Nurse burnout and patient satisfaction. Medical Care, 42(2), 1-18. doi: :10.1097/01. mlr.0000109126.50398.5a 5. Dyrbye, L., Boone, S., Satele, D., Sloan, J., & Shanafelt, T. (2013). Physician satisfaction and burnout at different career stages. Mayo Clinic Proceedings, 88(12), 1358-1367. doi: https://doi.org/10.1016/j. mayocp.2013.07.016 6. Association of Staff Physician Recruiters (ASPR). (2012). What you don’t know can cost you: Building a business case for recruitment and retention best practices. Retrieved from https://www.aspr.org/page/696
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SMALL TOWN; BIG CONSEQUENCES Two Nurses Arrested for Doing the Right Thing By Cindy Zolnierek, PhD, RN, CAE THIS ARTICLE CONTINUES our Winkler Co. 10-year retrospective. Read the introductory article in the Winter 2019 issue of Texas Nursing. It was a June afternoon in 2009 when Clair Jordan, Texas Nurses Association (TNA) executive director, called Jim Willmann—then TNA director of governmental affairs—and me, Cindy Zolnierek—then director of practice—into her office and shared with us a letter the Texas Medical Board (TMB) had sent to the Winkler County District Attorney. The letter admonished DA’s office for issuing an arrest warrant for two nurses accused of sending an anonymous complaint to the Texas Medical Board regarding a physician, Rolando Arafiles, MD. We were incredulous—there had to be more to the story. But there wasn’t. That afternoon, Willmann and I spoke with nurse practitioner Naomi Warren, who worked with Arafiles in the Winkler County Rural Health Clinic and had also complained to the TMB regarding his practice. She outlined the efforts she, Anne Mitchell, RN, (hospital compliance officer and medical staff coordinator) and Vickilyn Galle, RN, (hospital quality improvement and utilization review coordinator) had taken to raise their concerns with the medical director, hospital administrator, and the board of directors to no avail. Out of a sense of duty to their patients they felt they had no choice but to report Arafiles to the TMB. When we then spoke with Galle, we heard a very calm yet relieved voice on the phone line, filled with hope. Willmann and I listened to an eerie tale of small-town politics gone bad. This rural community with a 15-bed critical access hospital was desperate for physicians and apparently willing to “look the other way” to keep providers, namely Arafiles, in the community. After all, he had community ties. Arafiles reportedly was good friends and golfing buddies with Sheriff Robert Roberts and county attorney Scott
Tidwell. As a distributor of nutritional supplements, Arafiles had also partnered with the Sheriff for his business. Arafiles was affable and loved by the community. Yet, he was also under a TMB order for questionable practices in Victoria in 2007. To us, the unthinkable had occurred: Two nurses were charged with felony offenses for making a good faith report to the TMB. Discovering warrants had been issued for their arrest, Galle and Mitchell turned themselves in on felony charges of “misuse of official information” for reporting a physician to the TMB. The complaint had been made anonymously as Mitchell and Galle correctly believed that their jobs were at risk if their identities were known. When Arafiles received notification of the complaint, which identified patient record numbers related to practice concerns, he alerted Roberts that he was being harassed. Roberts used the case numbers to obtain patient names implicated in the complaint and sent deputies to interview patients to discover who had filed the complaint. This was a dead end.
TNA and nurses across the country were outraged. How could nurses, fulfilling their duty to patient safety, face felony charges? Roberts then underhandedly obtained a copy of the anonymous complaint made by Galle and Mitchell to the TMB in which the nurses stated that they were “over 50, female, and employed by this facility since the 1980’s.” In the small town, these details were enough for him to narrow the potential complainants to two nurses. He obtained a search warrant to seize Galle’s and Mitchell’s computers and found their copy of the letter to the TMB.
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Tidwell issued arrest warrants for Galle and Mitchell under Texas Penal Code §39.06 for misuse of official information—a third degree felony which carries potential penalties of up to 10 years imprisonment and a $10,000 fine. The nurses turned themselves in and posted a $5,000 bond. Both were fired by the hospital. TNA and nurses across the country were outraged. How could nurses, fulfilling their duty to patient safety, face felony charges? TNA established a legal defense fund, raising over $50,000 from nurses, physicians, and attorneys across the country. Willmann started to work closely with Galle’s and Mitchell’s defense attorneys, ensuring they were well informed on Texas nurse advocacy protections and assisting with expert witnesses for hearings. And TNA members provided support to Galle and Mitchell throughout the ordeal. Ultimately, charges against Galle were dropped. In February 2010, Mitchell went to trial. But she didn’t go alone. The courtroom was filled with nurses wearing apricot ribbons in support of Mitchell—a nurse advocate for patient safety. In the next two 2019 issues of Texas Nursing, we will look at the full trial and experience of the Winkler County nurses, and what impact the event continues to have on nursing practice ten years later. i
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JOY
STEALING How to Stop Peers from Making You Dread the Workplace THEODORE ROOSEVELT CLAIMED that “comparison is the thief of joy,” but what if the real thief of joy is a colleague? In health care, especially in nursing, there is an underlying and pervasive negative culture of incivility in the workforce. Incivility and lateral violence in nursing has been estimated at 10-15% higher than that of other professions, and 90% of new nurses reported incidents of incivility or bullying from other nurses.1,2 Bullying is a hot topic of discussion across the world, not only in the nursing profession but within society at large. Organizations such as the American Nurses Association, The Joint Commission, and the Occupational Safety and Hazard Administration have all recognized incivility as a form of workplace violence and have published position statements or white papers describing the issue and the negative effects associated with the culture. The National Institute for Occupational Safety and Health distinguishes four types of workplace violence and describes Type III as “worker on worker,” inclusive of bullying and uncivil conduct.3 These ubiquitous experiences with incivility and bullying occur across positions,
By Amanda Chappell, MSN, RN
demographics, and geographical locations. Type III violence occurs in rural hospitals, has been identified in prestigious academic settings, and is seen among leaders in prominent organizations. Nurses in all settings are at risk for exposure to workplace violence, both physical and nonphysical, and no particular setting is immune from experiencing the negative implications of these behaviors.4
JOY THREAT: THE BULLY With one-third of nurses experiencing bullying behaviors in the workplace, bullying deserves attention at all organizational levels: bedside to boardroom.4 There is no clear definition of bullying, but in general terms, bullying can be described as repetitive, targeted, and disruptive actions that attempt to cause harm. Bullies may or may not intend to cause harm, humiliation, or discomfort in those they target, and in some cases may not realize their behaviors are harmful. For the targeted, effects range from psychosocial disturbances, such as excessive worrying, depression, or posttraumatic stress disorder, to more severe physical issues, such as sleep disturbance, stomach ulcers, or migraines.2
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Strategy:
Establish clear zero-tolerance policies with clear definitions, secure reporting structures, and processes for escalation by victims.5 Start with self-awareness: Are you the bully? Ask peers for input. Seek professional help through an employee assistance program.2
JOY THREAT: THE UNCIVIL PEER The range of behaviors classified as uncivil are broad, but incivility is defined as “one or more rude, discourteous, or disrespectful actions that may or may not have a negative intent behind them.”6 Incivility can be experienced in a variety of ways and has a lasting impact on organizational culture, engagement, and resiliency among nurses.7 Uncivil behaviors include actions of intolerance such as impatience, unwillingness to assist or engage, eye rolling, disrespectful actions, passive-aggressive behavior, or impoliteness. Nurses employed in organizations with cultures that tolerate acts of incivility can experience loss of productivity, decreased job satisfaction, and compromised patient safety.8 A key difference between bullying
and incivility is the power differential between individuals. Incivility is experienced laterally with peers, whereas in bullying situations, there is often a disparity in perceived power or influence.
Strategy:
Be a role model for positive communication.1 Nursing can be a high-stakes and stressful career choice. Consider cognitive rehearsal training to prepare for difficult conversations. Hold peers accountable for their actions.6 Nursing leadership style is a key driver of a positive work environment. Create space for open, honest communication, and follow up when employees express concerns.8
JOY THREAT: THE TALL POPPY CUTTER “You don’t have to unscrew another’s lightbulb in order to shine.” Tall Poppy Syndrome is a theory used to describe the feeling that successful or high-performing individuals in an organization need to be “cut down” and “put in their place.” “Tall Poppies” possess commendable qualities that may be viewed as a threat by envious “poppy clippers.” “Poppy clippers” may act out in uncivil ways in an attempt to decrease self-esteem in others or discredit them to compensate for insecurity.9
Strategy:
Practice Emotional Intelligence: Self-awareness, self-management, social awareness and relationship management are skills that can keep “poppy clipping” behaviors at bay and generate awareness of negative behaviors.10
JOY THREAT: THE CREDIT-TAKER Another act of incivility that occurs in professional cultures is taking credit for another’s work, ideas, or effort. In academic situations this could appear as scholarly kleptomania, and in clinical environments it could be taking credit for another person’s intervention. Credit-takers can create distrust, apathy, decreased feelings of self-worth, and reduced productivity.11
Strategy:
Establish clear boundaries in work groups and talk about roles and expectations. Participate in retreats or teambuilding exercises to strengthen bonds and trust.11 When confronting a colleague: assume positive intent, and first seek understanding without accusation. Role model: Give more credit to others, and they will reciprocate.
This “silent epidemic” of incivility, bullying, and workplace violence is heading to the forefront of conversations in the health care industry, and it is time that our profession adopted a culture of tolerance, understanding, and care for one another. With strong statements of zero tolerance from professional organizations and employers alike, nurses have more support than ever to generate a culture in the workforce that is supportive and kind. The first place to start is within: Find the joy in your practice, cherish it, and choose it. i Amanda Chappell received her Master of Science in Nursing from The University of Texas Cizik School of Nursing and member of the Sigma Theta Tau International honor society. She started her nursing career in 2009 in the Neonatal Intensive Care Unit after graduating from Galveston College. After earning her undergraduate degree from Louisiana State University in 2013 she worked in the Recovery room at Memorial Hermann Texas Medical Center. Chappell has been an active member in TNA District 9 since 2016 and is a 2019 delegate and member of the Workplace Advocacy committee.
ADDITIONAL RESOURCES: Free Online Course: https://www.cdc. gov/niosh/topics/violence/default.html OSHA Guidelines: https://www.osha. gov/Publications/osha3148.pdf Bullying Resources: http:// stopbullyingtoolkit.org FOOTNOTES 1. Kaiser, J. A. (2016). The relationship between leadership style and nurse-to-nurse incivility: Turning the lens inward. Journal of Nursing Management,25(2), 110-118. doi:10.1111/jonm.12447 2. Thompson, R. (2019). What if you're the bully? American Nurse Today,14(1), 22-25. 3. The National Institute for Occupational Safety and Health (2019) Workplace violence prevention for nurses Retrieved from https://wwwn.cdc.gov/wpvhc/ Course.aspx/Slide/Unit1_5 4. Spector, P. E., Zhou, Z. E., & Che, X. X. (2014). Nurse exposure to physical and nonphysical violence, bullying, and sexual harassment: A quantitative review. International Journal of Nursing Studies,51(1), 72-84. doi:10.1016/j.ijnurstu.2013.01.010 5. The Joint Commission (2018) Sentinel event alert: Physical and verbal violence against health care workers Retrieved from https://www.jointcommission. org/sea_issue_59/ 6. American Nurses Association. Violence, Incivility, & Bullying. Retrieved from https://www.nursingworld. org/practice-policy/work-environment/violenceincivility-bullying/ 7. Fountain, D. M. (2017). Impact of Bullying on RN Engagement in Hospitals. POJ Nursing Practice & Research,1(1), 1-8. doi:10.32648/2577-9516/1/1/003 8. Smith, J. G., Morin, K. H., & Lake, E. T. (2017). Association of the nurse work environment with nurse incivility in hospitals. Journal of Nursing Management, 26(2), 219-226. doi:10.1111/jonm.12537 9. Mancl, A. C., & Penington, B. (2011). Tall Poppies in the Workplace: Communication Strategies Used by Envious Others in Response to Successful Women. Qualitative Research Reports in Communication,12(1), 79-86. doi:10.1080/17459435.2 011.601701 10. Bradberry, T., & Greaves, J. (2009). Emotional intelligence 2.0: The world’s most popular emotional intelligence test. San Diego, CA: TalentSmart. 11. Heinrich, K. T. (2017). Scholarly JoyStealing. Nurse Educator,42(1), 2-4. doi:10.1097/ nne.0000000000000303
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S P R I N G 2 019 | T E X A S N U R S I N G M AGA Z I N E
PAC DONATION
$
TEXAS NURSE PAC is the officially-sponsored political action committee (PAC) of the Texas Nurses Association. We contribute to candidates on both sides of the aisle and last year, 12 out of 14 campaigns we supported were successful.
T EX AS PEER ASSISTANCE
PROGRAM FOR NURSES
Recovery Support for Nurses TPAPN PARTICIPATION Need help with recovery? Worried about a peer’s behavior? Have questions about substance use or mental health? TPAPN provides resources, expertise, case management, and peer support for nurses. We encourage early intervention to prevent nursing practice violations and Board of Nursing disciplinary actions, and we use a personalized approach to help nurses prioritize their health and maintain their practice. Contact us to refer yourself or a peer, or just to get your questions answered. Call 1-800-288-5528 or visit tpapn.org.
tpapn.org
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Help TNA refresh its financial PAC resources to help candidates that support nursing and health care. Our goal is $200,000. If every member donated just $20, we could exceed our objective and have a fighting chance at the Capitol!
Consider an automatic monthly contribution or a onetime donation and help us support candidates who support nurses. Give at texasnurses.org/PAC. With your support, TNA can better the nursing profession through the legislative process.
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HAPPY NATIONAL NURSES WEEK! 4 MILLION REASONS TO CELEBRATE was the 2019 National Nurses Week theme— and 320,000 of those remarkable nurses live right here in the Lone Star State. We know that nurses are celebrated daily by patients and their families who are grateful for the wonderful care you’ve given, and we want to officially wish each and every one of you Happy Nurses Week and hope you enjoyed the well-deserved celebrations going on around the state. National Nurses Week was first celebrated in 1954 marking the 100th anniversary of Florence Nightingale’s mission to Crimea. The time of the celebration has changed over the years, and below are some interesting historical highlights of the progression of National Nurses Week: 1954 – National Nurses Week was celebrated from October 11-16
1974 – The International Council of Nurses (ICN) declared May 12 as “International Nurses Day” which is also Florence Nightingale’s birthday. 1982 – A joint resolution of the United States Congress was affirmed designating May 6 as “National Recognition Day for Nurses.”
National Nurses Week was first celebrated in 1954 marking the 100th anniversary of Florence Nightingale’s mission to Crimea.
1990 – The ANA Board of Directors expanded recognition of nurses to a week-long celebration, declaring May 6-12 as National Nurses Week. 1997 – At the request of the National Student Nurses Association, the ANA Board of Directors designated May 8 as National Student Nurses Day. i
Representing Nurses in Austin Since 1980 in Administrative Law Proceedings Before the: TEXAS BOARD OF NURSING AND
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A Nurses Guide to Working After a Board Order Q&A with V. Yvette Cheeks
respond to unusual situations and scope of practice issues in a way that protects our patients and our practice. What is the biggest misconception nurses have about the BON? That the BON is either “out to get you” or there to completely protect and support you. The truth is neither. As our regulatory body funded by state taxes, it is the BON’s mission to protect the practice of nursing and ensure the safety of the public through ethical, competent behavior by the licensees. What is the biggest obstacle facing nurses with board orders?
“Remember, you are not just the decisions of one day.” V. YVETTE CHEEKS MSN, RN, is the founder of Professional Healthcare Education Services, Inc (PHES). Through her work with PHES, and her clinical experience, Cheeks has a deep understanding of BON compliance and regulatory issues. She offers education, resources, referrals, and consultations on confidential license issues for nurses with board orders, or those simply returning to work or shifting direction. She is a member of TNA District 9. Please tell us a little bit about how you helped found PHES and what inspired it. PHES was founded in 2001 to respond to a need not being met. While many hospitals fo-
cused on new grads, nurses that wanted to change direction, to return to clinical practice after a few years, or that have made an error and needed assistance, found it difficult to find work. BON processes can be confusing to nurses. Why is it so important for nurses to understand how it works? The BON is our regulatory body and governs our practice. It is critical nurses place value on their license and the rules it comes with. Our degrees prepare us in many ways, but not always for situations that can arise in our professional and personal lives. We all need to take time to understand how to
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Nurses are often unaware of the board's investigatory process. Each nurse should read the Nursing Practice Act’s rules and regulations, position statements and quarterly newsletters for updates. If ever involved in an investigation, they need to know their rights and make themselves aware of the options available to them. What is the biggest misconception nurses with board orders have about returning to practice? Nurses sometimes believe if they simply sign an order, it will be over and okay. But some of the wording on the order can prevent a nurse from being easily employed. Many nurses wish they had considered legal counsel or had liability insurance that covers their legal fees for BON investigations, not just legal cases. What is the typical experience of a nurse returning to work after a board order?
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The experience varies depending on the practice error. Unfortunately, many employers view these nurses as unhirable. Nurses should expect many “no’s” before someone is willing to hire them. What advice do you have for employers contemplating hiring a nurse with a BON record? Facilities sometimes believe it will be a liability for them, or that it will put a “flashlight on them,” when they have faults of their own to work on. I would recommend employers look at each situation individually. Many nurses that have made practice errors are disciplined by the board, so they would not repeat their errors. These nurses never want to hear from the BON again. They often will make excellent employees as they are headed in the right direction and are now in need of some compassion. What advice do you have for nurses in job interviews when explaining a record with the BON? Be honest and forthright. Take responsibility for your part in the error and discuss your usual safe practice, mitigating factors that applied to this excursion from usual practice, and what you would do in the future if the same situation were to happen. Talk about the steps you have taken to improve your practice. Remember, you are not just the decisions of one day. Keep up with practice standard changes and be timely and accurate with documentation. You can recover from these setbacks and lead a successful career. i
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CONNECTING THE DOTS
What TNA’s DNP Policy Fellowship Can Do For You By Cyndi B. Kelley, MSN, RNC-LRN
AS A NEONATAL NURSE and a Doctor of Nursing Practice (DNP) student, I have spent the last two and half years immersed in a world impacted by the opioid crisis. Infants who are exposed to opiates during their mother’s pregnancy can experience withdrawal symptoms known as neonatal abstinence syndrome (NAS). The practice of separating these mothers and infants is a significant hurdle in our ability to provide appropriate NAS care. Partnerships between health care providers and government agencies can have a huge effect on reducing lengths of hospital stay and improving overall outcomes for both the mother and her infant. I have seen our little patients lie alone in their room for up to 63 days because governing agencies have determined the mother should not be able to visit or care for her infant. However, my firsthand experience has convinced me that mothers, even with a history of drug misuse, should be afforded the opportunity to provide care for their infants until the moment they are deemed unsafe. Through my DNP Policy Fellowship with Texas Nurses Association (TNA), I have been able to connect the dots to understand how federal policy influences hospital practices. This process has been a great way to merge my studies with my practice. The fellowship opened opportunities for me to improve policies within my service line and transform nursing practices to support a mother becoming an active participant in her infant’s care during NAS treatment.
STUDYING MATERNAL MORTALITY AND MORBIDITY IN TEXAS Upon acceptance into the policy fellowship, I joined TNA’s Maternal Morbidity and Mortality Task Force. Its aim is to monitor current topics regarding maternal morbidity and mortality
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Upon acceptance into the policy fellowship, I joined TNA’s Maternal Morbidity and Mortality Task Force. As I participated in the task force, I came to understand a bigger picture of the opioid crisis. and advocate for legislation aimed at improving the care of women during and after pregnancy to eliminate death and complications related to pregnancy. As I participated in the task force, I came to understand a bigger picture of the opioid crisis. In December 2018, President Trump signed the “Preventing Maternal Deaths Act” into law, which funds maternal mortality review committees in all 50 states, allowing them to collect data on factors contributing to maternal mortality during and after child birth.1 “The United States has the highest maternal mortality rate of any high resource country—and it is the only country outside of Afghanistan and Sudan where the rate is rising.”2 States were tracking morbidity and mortality statistics, but most were poor at (or not at all) reviewing and addressing the underlying causes of these negative outcomes. Between 2000 and 2009, the maternal mortality rate in Texas was on a steady incline. After failing to pass legislation in 2011, the Senate passed SB 495 in 2013, bringing the TNA Maternal Mortality and Morbidity Task Force to fruition. This task force studies state trends in maternal mortality and severe maternal morbidity, reviews individual cases of maternal death, and makes recommendations to reduce the incidence of mortality and morbidity.3
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PUTTING PREVENTION INTO PRACTICE The Alliance for Innovation on Maternal Health (AIM) is a national initiative to improve maternal safety and outcomes in the U.S. Their purpose is to eliminate preventable maternal mortality and severe morbidity in the U.S. AIM works with state and hospital-based teams to improve maternal health outcomes by using evidence and data driven initiative bundles. At the state level, the Texas Department of State Health Services partnered with the AIM and the Texas Hospital Association to develop the TexasAIM initiative.4
Participating in the fellowship has provided me the knowledge and experience to improve our patients’ health outcomes, streamline how we provide care, and improve the lives of the littlest patients in the communities we serve. length of stay, and save money.
Hospitals across the state can join the initiative and utilize the evidence-based maternal safety bundles to standardize the care of pregnant women, thereby improving outcomes and reducing morbidity and mortality of this patient population. The bundles currently established include the Obstetric Hemorrhage Bundle, Obstetric Care for Women with Opioid Use Disorder, and the Severe Hypertension Bundle.
Being able to incorporate my DNP fellowship project with my neonatal work has broadened my understanding of health policy from federal law to organizational policy. Participating in the fellowship has provided me the knowledge and experience to improve our patients’ health outcomes, streamline how we provide care, and improve the lives of the littlest patients in the communities we serve. i
The hospital I work for joined the TexasAIM initiative and started the process of adopting the evidence-based practice bundles. My eye is on the Obstetric Care for Women with Opioid Use Disorder, which is a comprehensive package including readiness tools such as education and training for clinical and non-clinical staff. We will use this bundle to draft our maternal and infant care policies including baseline education modules. The aim is to provide education on the understanding of opioid use disorders as a chronic disease, reducing stigmas and biases, trauma-informed care, and neonatal abstinence syndrome.
ADDITIONAL RESOURCES: Download the Maternal Discharge Handout in English and Spanish at texasnurses.org/resources.
This education package will elevate the knowledge base for all staff and physicians to the same level of understanding. From there, our maternal/newborn policy council will draft new treatment policies, protocols, or guidelines for the care of pregnant and postpartum women with a history of opioid use disorders and their exposed infants who suffer from NAS. By standardizing our practices, we will optimize outcomes, reduce the hospital
Cyndi B. Kelley, MSN, RNC-LRN, is a nurse manager in the special care nursery at Texas Health Presbyterian Hospital of Dallas. She is earing her DNP at The University of Texas Tyler and is a 2018-2019 Texas Nurses Association DNP Policy Fellow.
FOOTNOTES: 1. 115th Congress. (2018, December 21). Preventing Maternal Deaths Act of 2018 (H.R.1318). Retrieved from Library of Congress website: https://www.congress.gov/ bill/115th-congress/house-bill/1318/text 2. Council on Patient Safety in Women's Health Care. (2018). Alliance for Innovation on Maternal Health Program. Retrieved from https://safehealthcareforeverywoman. org/aim-program/ 3. Texas Department of State Health Services. (2016). Maternal mortality in Texas: Using precision public health to improve maternal outcomes. Retrieved from Texas Health and Human Services website: https://dshs.texas.gov/mch/MaternalMortality-and-Morbidity-Task-Force/.aspx 4. Department of State Health Services (DSHS). (2019). TexasAIM. Retrieved from https://dshs.texas.gov/mch/TexasAIM.aspx
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Preventing Suicide Beyond Psychiatric Units By Kathy Grimley-Baker, DNP, MS, NP, RN, CNL MAY IS MENTAL HEALTH MONTH, and nurses have a key role to play in preventing suicide, not just in psychiatric units. Although a previous suicide attempt is considered the best predictor of suicide, many patients who die by suicide in an inpatient hospital setting don’t have a psychiatric history or a history of suicide attempts.1,2 Nurses on nonpsychiatric units should know who is at risk and what clinical steps they can take to keep their patients safe.
WHO’S AT RISK? Of voluntarily reported inpatient suicides, 14.25% occurred while a patient was on a medical-surgical, intensive care, oncology, or telemetry unit.3 Although estimates vary, the risk of suicide in patients with cancer and in cancer survivors is reportedly higher than that of the general population.4-6 The root cause of suicide attempts is a lack of initial assessment risk, lack of repeat assessments, and inadequate management of at-risk patients.7,8 Identifying patients at high risk is the key to preventing inpatient suicides. Although no method can currently be used to reliably predict imminent suicide risk, many nurses use a standardized evidence-based screening tool at their hospitals to assess risk for self-harm on initial admission.8
risk should be referred to an outpatient behavioral health care provider and given the national suicide prevention telephone number. Even when high-risk patients have dedicated observation, nurses should continue their purposeful rounds to serve as a safety double check.11
WHAT DOESN’T WORK? Although nurses can and have asked patients to sign no-harm contracts, the literature doesn’t support this intervention; it can give staff a false sense of security, and the evidence doesn’t show that these contracts decrease risk.12 Avoiding the topic doesn’t reduce the risk of suicide either. Some nurses believe the myth that asking a patient about suicide could “plant a seed” and trigger a suicide attempt.13 Nothing could be further from the truth. A literature review of 13 articles published from 2001 to 2013 found that talking about suicide can reduce suicidal ideation.14 Most patients encountering a shocking diagnosis or poor prognosis welcome the chance to share their anxiety, fears, and concerns, and they look forward to learning ways to get through it. Patients don’t usually volunteer this information, so don’t be afraid to dig deep and ask patients directly. Follow-up questions might include:
For instance, when a patient says they are “better off dead,”9 nurses should then assess whether they are passively or actively suicidal (with a plan or intent). Initiate the hospital safety protocol, notify the health care provider, and contact the available mental health staff.10
Patients found to be acutely suicidal should be under continuous observation and have a psychiatric consult. Those at lower
Direct patient quotes should be documented in the patient’s medical record.
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“How long have you felt this way?” “Does any stressor or trigger lead to these feelings?” “What things are worth living for?”
RISK FACTORS FOR SUICIDE Besides a cancer diagnosis or a history of cancer and access to lethal means, other risk factors for suicide include a history of:6,16-27
Previous suicide attempts Traumatic head injury Epilepsy
HIV infection Chronic pain or illness Dementia Parkinson's disease Multiple sclerosis Bariatric surgery Psychiatric illness
INSTITUTIONAL CHANGE In general, nurses need to explore patient-care areas for any concealed risks. Beyond initial and periodic assessments of suicide risk, nurses should do additional safety checks in patient rooms. For example, bathrooms in a medical-surgical area can be an unsafe environment because they contain potentially harmful objects.15 Upon discharge, provide all patients with National Suicide Prevention hotline numbers (1-800-273-TALK or 1-800-273-8255) as well as community resources for patients and families. i REFERENCES
Hopelessness and impulsivity Military service Suicide in the family Childhood abuse and other adverse childhood experiences
Download TNA's Suicide Prevention Resource Guide at texasnurses.org/ resources. 22. Sabodash, V., Mendez, M.F., Fong, S., & Hsiao, J.J. (2013). Suicidal behavior in dementia: a special risk in semantic dementia. American Journal of Alzheimers Disease and Other Dementias. 28(6), 592-599. 23. Lee, T., Lee, H.B., Ahn, M.H., et al. (2016). Increased suicide risk and clinical correlates of suicide among patients with Parkinson’s disease. Parkinsonism & Related Disorders, 32, 102-107. 24. Brenner, P., Burkill, S., Jokinen, J., Hillert, J., Bahmanyar, S., & Montgomery, S. (2016). Multiple sclerosis and risk of attempted and completed suicide—a cohort study. European Journal of Neurology, 23(8), 1329-1336.
1. Knoll JL IV. (2012). Inpatient suicide: identifying vulnerability in the hospital setting. Psychiatr Times. Retrieved from www.psychiatrictimes.com/suicide/inpatientsuicide-identifying-vulnerabilityhospital-setting.
25. Bhatti, J.A., Nathens, A.B., Thiruchelvam, D., Grantcharov, T., Goldstein, B.I., & Redelmeier, D.A. (2016). Self-harm emergencies after bariatric surgery: a population-based cohort study. JAMA Surgery, 151(3), 226-232.
2. McBroom S. (2013). Reducing inpatient suicide risk in the hospital setting. Compass, 12(13), 1-4.
26. The Joint Commission. (n.d.). Take 5. Evaluating and responding to suicide risk [podcast]. Retrieved from http://hwcdn.libsyn.com/p/f/2/0/f20ca04d05a67c41/ Take_5_Suicide_Risk.mp3.
3. The Joint Commission. (2010). A follow-up report on preventing suicide: focus on medical/surgical units and the emergency department. Sentinel Event Alert, 46, 1-4. 4. Dalela, D., Krishna, N., Okwara, J., et al. (2016). Suicide and accidental deaths among patients with non-metastatic prostate cancer. BJU Int.,118(2), 286-297. 5. Kam, D., Salib, A., Gorgy, G., et al. (2015). Incidence of suicide in patients with head and neck cancer. JAMA Otolaryngology Head Neck Surgery, 141(12), 1075-1081. 6. Fang, F., Fall, K., Mittleman, M.A., et al. (2012) Suicide and cardiovascular death after a cancer diagnosis. New England Journal of Medicine, 366(14), 1310-1318. 7. The Joint Commission. Sentinel Event Data Summary: February 9, 2016. Retrieved from www.jointcommission.org/assets/1/18/2004-2015_SE_Stats_Summary.pdf. 8. Jayaram, G. (2014). Inpatient suicide prevention: promoting a culture and system of safety over 30 years of practice. Journal of Psychiatric Practice, 20(5), 392-404. 9. Giddens, J.M. & Sheehan, D.V. (2014). Is there value in asking the question “Do you think you would be better off dead?” in assessing suicidality? A case study. Innovations in Clinical Neuroscience, 11(9-10), 182-190.
27. Schreiber, J. & Culpepper, L. (2017). Suicidal ideation and behavior in adults. UpToDate. Retrieved from www.uptodate.com.
This article originally appeared in the March 2018 issue of Nursing © 2018 Wolters Kluwer Health, Inc., and has been adapted for this publication. This risk management information was provided through partnership with Nurses Service Organization. Reproduction without permission of the publisher is prohibited. For questions, send an e-mail to service@nso.com or call 1-800-247-1500. www.nso.com.
10. The Joint Commission. (2016). Detecting and treating suicide ideation in all settings. Sentinel Event Alert, 56, 1-7. 11. Kelley, C. (2017). Time management strategies: purposeful rounding and clustering care. Academy of Medical-Surgical Nurses, 26(1). 12. O’Connor, E., Gaynes, B., Burda, B.L., Williams, C. & Whitlock, E. (2013). Screening for suicide risk in primary care: a systematic evidence review for the U.S. Preventive Services Task Force (Report No. 13-05188-EF-1. Rockville, MD: Agency for Healthcare Research and Quality. 13. Stop a Suicide Today. (n.d.). Retrieved from http://stopasuicide.org. 14. Dazzi, T., Gribble, R., Wessely, S., & Fear, N.T. (2014). Does asking about suicide and related behaviours induce suicidal ideation? What is the evidence? Psychological Medicine, 44(16), 3361-3363. 15. Mills, P.D., Watts, B.V., & Hemphill, R.R.. (2014). Suicide attempts and completions on medical-surgical and intensive care units. Journal of Hospital Medicine, 9(3), 182-185. 16. Simpson, G.K., Tate, R.L., Whiting, D.L., & Cotter, R.E.. (2011). Suicide prevention after traumatic brain injury: a randomized controlled trial of a program for the psychological treatment of hopelessness. Journal of Head Trauma Rehabilitation, 26(4), 290-300. 17. Fralick, M., Thiruchelvam, D., Tien, H.C., & Redelmeier, D.A. (2016). Risk of suicide after a concussion. Canadian Medical Association Journal, 188(7), 497-504. 18. Hesdorffer, D.C., Ishihara, L., Webb, D.J., Mynepalli, L., Galwey, N.W., & Hauser, W.A. (2016) Occurrence and recurrence of attempted suicide among people with epilepsy. JAMA Psychiatry, 73(1), 80-86. 19. Beghi, E. (2016). Addressing the burden of epilepsy: many unmet needs. Pharmacological Research, 107, 79-84. 20. Passos, S.M., Souza, L.D., & Spessato, B.C. (2014). High prevalence of suicide risk in people living with HIV: who is at higher risk? AIDS Care, 26(11), 1379-1382. 21. Fleehart, S., Fan, V.S., Nguyen, H.Q., et al. (2014). Prevalence and correlates of suicide ideation in patients with COPD: a mixed methods study. International Journal of Chronic Obstructive Pulmonary Disease, 10, 1321-1329.
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SAFETY
VALUE
NURSING QUALITY
UTILIZATION MANAGEMENT The Intersection Between Quality, Safety, Value, and Nursing By Edtrina Moss, PhD, RN-BC, NE-BC
THE NEXT DECADE OF THE 21ST CENTURY is quickly approaching, and nurses continue to shape the profession and the overall health care landscape by advocating for patients and advancing policy, equity, and access concerns to improve the health of our communities. Nurses are the largest segment of the health care workforce and serve as the backbone of the industry.
Many hospital organizations have adopted an interdisciplinary team approach to providing care in the acute care setting. The direct care nurse is an integral team member in the healing and recovery of our sickest populations during a hospital stay in an acute care setting. However, nursing care has evolved into more than the required knowledge, skills, and experience to care for the hospitalized client at the bedside. While nurses find a lot of joy working at the bedside, nurses have much to offer in other specialties.
THE ROLE OF THE DIRECT CARE NURSE IN UTILIZATION MANAGEMENT The U.S. health system has shifted its focus to improving the quality, safety, and value of health care services, all while reducing costs and unnecessary expenditures. Nurses are now
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at the frontlines of this intersection between quality, safety, value, and nursing care. Through the process of utilization management (UM), health care purchasers use evidence-based criteria or guidelines to manage costs. Nurses must know and understand the necessity of good stewardship of hospital resources while improving outcomes. Many hospital organizations have adopted an interdisciplinary team approach to providing care in the acute care setting. The interdisciplinary team consists of health professionals from various disciplines (nursing, medicine, social work, case management, UM, rehabilitation, and pharmacy) and the patient. By working collaboratively, they address the complex care needs of the patient and facilitate effective care coordination and transition management. Team collaboration often occurs during team huddles or rounds to ensure the patient is at the center of decision-making and provides input. Direct care nurses advocate for patients and work closely with other disciplines to eliminate barriers to appropriate resource utilization and transition of care. Nurses have first-hand knowledge of challenges with bed availability as it relates to transition of care and barriers to timely and effective discharge, such as lack of caregiver support and resources. Direct care nurses also communicate information that may warrant a transition in level of care, including discharge. By using the nursing process, registered nurses assess patient conditions and evaluate subtle changes to make recommendations for additional treatment or services. The direct care nurse
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articulates and documents the appropriateness and effectiveness of care, treatment, and services provided daily.
THE ROLE OF THE UTILIZATION MANAGEMENT NURSE UM nurses are generally bachelor’s-prepared registered nurses who possess a broad range of clinical knowledge and expertise, with two or more years of acute care nursing experience. They use their clinical knowledge, expertise, and critical thinking to interpret policies, guidelines, procedures, and criteria. The role of the UM nurse is to prospectively and concurrently assess and evaluate all forms of health care services and procedures—including the optimal use of facilities—to maintain health and safety, improve quality, and increase the value of health care resources needed. In contrast, a utilization review nurse takes a retrospective evaluation approach of the appropriate services, procedures, and facilities to validate medical care and treatment. However, both rely heavily on appropriate clinical documentation to make decisions and recommendations that impact the quality, effectiveness, efficiency, and financial integrity of the organization. UM nurses use evidence-based guidelines created by third-party vendors, such as MCG Health and Change Healthcare, to support clinical decision-making, reduce care delays, and reduce hospital length of stay. Utilization management processes are designed to ensure patients are at the right point of care, at the right time, the first time. The process helps the provider decide when services, procedures, and facilities are medically necessary. Use of these evidence-based criteria and processes help organizations identify opportunities to improve clinical workflows, interoperability, patient access, and financial performance.
This is the most exciting time to be a nurse! There are more nurse leaders and innovators than ever to forge the path and drive initiatives to improve quality and safety. Organizations that employ utilization management nurses include health care insurance plans, hospital health care systems, outpatient clinical settings, and government entities. This is the most exciting time to be a nurse! There are more nurse leaders and innovators than ever to forge the path and drive initiatives to improve quality and safety. More than 100 specialty areas of practice exist for nurses to provide care at the bedside as well as explore alternative nursing paths in this ever-changing environment. What does this mean for the future of nursing? It means nurses have the option to follow their passion in their career! Visit texasnurses.org/news for our ongoing series on UM nursing and other articles on unique career paths for nurses. i Edtrina Moss, PhD, RN-BC, NE-BC works as the interim program manager for patient safety and as a utilization management RN at the DeBakey VA Medical Center in Houston. She has more than 20 years of nursing experience, starting with her Licensed Vocational Nurse Certification, Associates Degree, and Bachelor of Science. She holds a Master of Science degree from Drexel University, and earned her PhD in 2018 from Texas Woman’s University. She has been a member of TNA since 2002.
Rewarding Careers Join a team that is making a difference!
W
e offer predictable work schedules, set caseloads and an excellent benefits package, including: n New higher starting salaries for RNs n Health and retirement benefits n Paid vacation leave and up to 15 paid holidays a year n Shift differential pay
Find an exciting and challenging career in one of 23 health and specialty care locations across Texas.
Contact:
Apply online: hhs.texas.gov/about-hhs/jobs-hhs
18D0738
Laura Hunter atof Aging Texas Department and Disability Services laura.hunter@hhsc.state.tx.us
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