KMA Launches Offensive Counter-Attack Against APRNs

Direct from an email. First tornados, now this! Help Kentucky out!

IF YOU THOUGHT HB 4 WAS BAD, TAKE A LOOK AT SB 190!

KMA LAUNCHES OFFENSIVE COUNTER-ATTACK AGAINST APRNs

KMA has launched its counter-attack by having Sen. Carroll Gibson (R-Leitchfield) file SB 190 on Thursday. SB 190 The bill is very cleverly drafted, as it never uses the word "supervision”, but puts the description and execution of both Collaborative Agreements and the relationship between physician and NP in their (physician) licensing statute – KRS 311.

Perhaps even more alarming and damaging are the sections dealing with the Collaborative Agreements. The legislation not only puts the physician in the position of defining the NP’s scope of prescriptive authority, but also defining the NP’s scope of practice. The latter is specifically referenced in the bill with regard to diagnosis, test ordering, analysis, and recommending referrals. In other words, if SB 190 becomes law, the collaborating physician could use the CAPA to put limits on your practice!!

In the sections describing the CAPA-NS and for the CAPA-CS, the bill spells out requirements that have never before been included in the CAPA’s: notifications by the physician to their licensing board (KBML) of any change in the CAPA or in the NP’s scope of practice. Also referenced are mechanisms for communication, meetings between the physician and the NP and the minimum number of charts to be reviewed and cosigned by the physician.

The bill goes on to state that the collaborative agreements are "required in the interest of patient health and safety”. Another section of the bill tells the KY Board of Nursing (KBN) how they are to handle complaints about the physician conduct with the CAPAs!

TAKE ACTION NOW: IT’S A ONE-TWO PUNCH: Call the Legislative Message Line – 1-800-372-7181 – and leave a message for all Senators: "Please oppose SB 190. It would put Nurse Practitioners out of business. And please support SB 187, Sen. Hornback’s Nurse Practitioner bill to increase access to quality health care.”

And please try to get more letters of support from physicians. Click here for new sample letters.

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Kentucky Coalition of Nurse Practitioners & Nurse Midwives

1017 Ash Street - Louisville, KY  40217

PHONE:  502.333.0076
EMAIL:  kcnpnm@kynp.org
WEB:  www.kcnpnm.org 

Interprofessional Education and Practice

The Association of American Medical Colleges (2012) put out this press release last week that falls in line with our discussion topic, especially for those interested in using your DNP role as an educator:  


Six Leading Health Education Associations Unite to Form a New Organization Focused on Interprofessional Education and Practice (click to read more)


Washington, D.C., February 15, 2012—Six national health professions associations have formally joined to create the Interprofessional Education Collaborative (IPEC), a new national organization that will focus on better integrating and coordinating the education of nurses, physicians, dentists, pharmacists, public health professionals, and other members of the patient health care team to provide more collaborative and patient-centered care. The founding members include the American Association of Colleges of Nursing, the American Association of Colleges of Osteopathic Medicine, the American Association of Colleges of Pharmacy, the American Dental Education Association, the Association of American Medical Colleges, and the Association of Schools of Public Health. 

The new IPEC organization will formalize the collaborative work that began three years ago and led to the release of a May 2011 report, “ Core Competencies for Interprofessional Collaborative Practice” (click to read the report).  This seminal document identified individual-level core competencies needed by all health professionals to provide integrated, high-quality care. Disseminated broadly to health professions schools, the report has sparked a wave of implementation efforts by educators looking to prepare clinicians to meet contemporary practice standards.

As a stand-alone entity, the new IPEC will provide leadership around national initiatives to advance interprofessional education (IPE) and share information on IPE best practices and collaborative practice innovations. A growing body of work demonstrates that shared learning experiences among health professions students across disciplines can improve health outcomes. Leading authorities including the World Health Organization, the Institute of Medicine, the Robert Wood Johnson Foundation, and the Josiah Macy Jr. Foundation, among others, have all identified IPE as an effective way to enhance the preparation of the health care workforce and improve care delivery. 

In May, IPEC will sponsor its first faculty development institute, “ Building Your Foundation for Interprofessional Education.”  The program will enable faculty from across the health professions to meet with peers in plenary and interactive learning sessions focused on building strong programs for team-based learning. Registration will open on February 22.    

The six IPEC organizations also are founding members of the Institute of Medicine’s Global Forum on Innovation in Health Professional Education, which is set to launch later this month.  Inspired in large part by the 2010 Lancet Commission report, “Health Professionals for a New Century,” this forum will convene stakeholders to illuminate issues in health professions education and support an ongoing, innovative mechanism to incubate and evaluate new ideas.

Interprofessional Education Collaborative (2011). Core competencies for interprofessional collaborative practice. Retrieved from http://www.aacn.nche.edu/education-resources/IPECReport.pdf 

Association of American Medical Colleges (2012). Six leading health education associations unite to form a new organization on interprofessional education and practice. Retrieved from https://www.aamc.org/newsroom/newsreleases/273754/120214.html

Theory for Thursday

When I first heard the words "nursing theory," I snickered.  I thought it was yet another example of the white cap club trying to stake a piece of unnecessary territory when they should be changing a bandage or administering an enema.  Seriously, how much of a theory do you need beyond "take care of the patient?" As with many other moments on my nursing education journey, a little dose of the real world to go along with the literature took care of my ignorance. I hope. The following is a report on one of my favorite theorists, Afaf Meleis, who's work on transitions has provided guidance for those times in practice when there is no map.

Meleis: Transitions Theory Evaluation

Transition is an emerging middle range nursing theory that emphasizes the role of the nurse in facilitating healthy individual role sufficiency. While straightforward in concept, transitions theory contains multiple components that have changed over time and encompass more than assisting a patient adjust to new changes in health status. Fawcett (2005) provides an appropriate framework for analysis and evaluation for the developing transitions theory as conceptualized by Afaf I Meleis.

Analysis

Origins
     Meleis first became interested in nursing theory during her master’s studies when she researched the role of meaningful and informative interactions between caregivers with patients and their families (Meleis, 2007). After attending several types of support groups, she found the transition processes were similar whether the group concerned family planning, grief, or illness. Her doctoral dissertation focused on the importance of role clarity through dialogue and interaction in couples planning to start a family. Through her research, she concluded that the major role of the nurse was to prepare the patient to cope well with developmental, situational, and health transitions (Meleis, 2008). Her research focused on people who made poor transitions and on nursing interventions that could facilitate better outcomes. Meleis began forming her role transition theory and created the first concept map in 1984 (Meleis, 2007) with a revision in 2000 (Meleis, Sawyer, Im, Messias, & Schumacher, 2000).
     Meleis (2010) suggests change is addressed in some manner in every nursing theory citing Peplau and Travelbee as examples of how to find growth and meaning though the change of illness, Roy’s adaptation model, patterning from Rodgers and Newman, and change in self-care ability from Orem. The act of caring for a patient using nursing therapeutics incorporates transition as a vital component. Transition theory was formulated to promote healthy evolutions and well-being in individuals by using nursing and social support. The nurse provides education, skills, and strategies for the patient and family to understand and cope with the experience of transition. This theory explains the transition experience as a change from one role to another with individuals having unique circumstance that may facilitate or inhibit the ability to define and master a new role and integrate it into their identity (Meleis, 2007). By providing an understanding of the nature of transition, conditions that potentially facilitate or inhibit positive change, and patterns of response, the nurse has a framework for preventing role insufficiency and anticipating the patient’s physical and psychosocial needs required for successful transition.
     In the initial conception of role transition theory, Schumacher and Meleis (1994) listed time and nature of change as one of the properties of nature in transitions. Later, Meleis, Swayer, Im, Messias and Schumacher (2000) added awareness, engagement, and critical points. Indicators of healthy transition included subjective well-being, role mastery, and well-being of relationships (Schumacher & Meleis, 1994) which were later altered and incorporated into process and outcome indicators (Meleis & Sawyer et al. 2000). There were also changes in and additions to the use of terms including roles, role stress, multiple role stress, transitional gender roles and coping, especially when the theory was used in disciplines other than nursing.
Unique Focus
     Meleis (2010) transition theory focuses on the period of evolution from what has been to what will be and is best classified as a developmental theory. It concentrates on the transition of the individual, family impact and involvement, the role of the nurse in facilitating the transition, and cultural, societal, and community support. Areas of theory application include change in health status; change in social support and relationships, such as relocating to a new city, becoming a parent, or loosing a friend; when an individual looses familiar reference points as with immigration to a new country or nursing home placement; or when there are new needs or an inability to meet old needs in familiar ways.
Content
     Positive role transition is facilitated or inhibited by nursing intervention and personal, social and community conditions. Transition addresses person, nursing, health, and environment (Meleis, 2007). The person is identified as anyone preparing for or involved in a current transition, be it motherhood, immigration, or puberty with a specific focus on women as the central figure in transition (Meleis & Rogers, 1994). Nursing is addressed in either a facilitative manner by providing well-planned interventions and follow-up, or in an inhibitive manner though apathy, generic treatment planning, or insensitivity. A change in health status may be well managed and integrated into an individual’s identity through education and positive outlook, or be managed poorly as a result of negative attitude, denial, or lack of knowledge (Van & Meleis, 2003). Social, cultural, political, and personal environment are addressed as necessary supportive components to healthy transitions (Jones, Zhang, & Meleis, 2003).

Evaluation

Explication
     Afaf I Meleis grew up in Egypt and received her nursing degree from the University of Alexandria in 1961 (Meleis, 2008). After briefly teaching nursing in Egypt, she immigrated to the United States where she received her master’s degrees in both nursing and sociology from the University of California Los Angeles. She completed her dissertation “Self concept and family planning” in 1968 and was awarded her doctoral degree in medical and social psychology. Meleis has authored numerous journal articles and is an international keynote speaker in women’s health, doctoral nursing programs, and health care research. She served as a university professor in the United States, Kuwait, and Australia, and is currently the Margaret Bond Simpson Dean of Nursing at the University of Pennsylvania. Her teaching methods focus on organization of nursing knowledge, health transitions, and international nursing.
Transition theory assumes there are universal properties in transition that include change in identity, roles, relationships, behavior patterns, structure, function, and dynamics (Meleis, 2007). Transitions naturally occur throughout life but are not always predictable or sequential and a variety of multiple changes may occur simultaneously. Nurses facilitate, inhibit, or ignore transitions directly affecting the outcome. Personal, cultural, social environmental factors also influence the outcome of a transition.
Comprehensiveness of Content
     Role transition addresses person, nursing, health, and environment (Meleis, 2007). The person is identified as anyone preparing for or involved in a current transition, be it motherhood, immigration, or puberty with a specific focus on women as the central figure in transition (Meleis & Rogers, 1994). Nursing is addressed in either a facilitative manner by providing well-planned interventions and follow-up, or in an inhibitive manner though apathy, generic treatment planning, or insensitivity. A change in health status may be well managed and integrated into an individual’s identity through education and positive outlook, or be managed poorly as a result of negative attitude, denial, or lack of knowledge (Van & Meleis, 2003). Social, cultural, political, and personal environment are addressed as necessary supportive components to healthy transitions (Jones, Zhang, & Meleis, 2003).
     There are four types of transitions: developmental, situational, health-illness, and organizational (Meleis, Sawyer, Im, Messias, & Schumacher, 2000). Developmental transitions are those that occur in the normal process of growth and maturity and include milestones such as puberty, parenthood, and menopause. Situational transitions may be unexpected or sudden such as widowhood or a car accident. Health-illness involves a medical change such as a spinal cord injury, cancer, or autism. Organizational transitions refer to changes in delivery systems including leadership, policy, and administration. Single patterns transitions occur once or one at time such as a developmental milestone. Multiple patterns can occur more than once as with childbirth, marriage or death of a loved one. Sequential patterns occur one after another while simultaneous patterns may be a mix of transition types occurring at the same time. Patterns may or may not be related to each other (Meleis et al., 2000). Nursing interventions, especially those involving education, have an influence on awareness, engagement, change and difference, and critical points and events (Meleis et al., 2000).
     A number of transition conditions are discussed in the literature. Personal conditions include meanings, cultural beliefs, socioeconomic status, and preparation for the individual. Entry into a psychiatric facility can mean abandonment, powerlessness or failure to a newly admitted patient and manifest itself as anxiety or resentment (Aroian & Prater, 1988). Conversely, admission could represent an opportunity to manage a disorder and accept medical and lifestyle assistance. Cultural beliefs and attitudes toward transition should be acknowledged, addressed, and accommodated by culturally competent nurses. The birth process in American born women is different from Arab American women who are often more modest, subordinate to men, and do not regard planning as an important aspect of childbirth (Meleis & Sorell, 1981). The experience of menopause in middle-class or wealthy American women differs from low income Korean immigrants who tend to report fewer symptoms and discount menopause as an unimportant transition (Im, Meleis, & Lee, 1999). Nursing home entry is often a difficult and varied transition; personal preparation and knowledge may hinder or help both the person in transition and the supporting family (Rossen & Knafl. 2003).
     Communities with productive and safe recreation outlets, educational facilities, and accessible health care facilitate effective transitions. Adolescents moving from a comfortable, supportive, and familiar community to a new area of the country are at risk for ineffective role integration and substance abuse (Puskar, Kathryn, & Martsou, 1994). Societal conditions that impact transition include federal and state programs, laws, and cultural norms. A society that seeks to reduce the amount of the population who smokes tobacco may institute bans and offers cessation programs and incentives, thereby making it easier for the individual to quit. Societies who revere the elderly may have less elder abuse and nursing homes then in those who have more negative attitudes toward aging and home care (Davis, 2005).
Once the nature and conditions of transition have been identified, there are patterns of response an individual will exhibit. Process indicators help evaluate and predict the success of a transition and guide the nurse in developing interventions to help plan and meet goals. These indicators include feeling connected, interacting, location and becoming situated, and developing confidence and coping (Meleis et al., 2000). The nurse assists in facilitating these response patterns by providing individually tailored interventions, education, action plans, and community resources. The nurse takes into consideration the conditions and nature of the transitions before forming an intervention plan. The ongoing evaluation of process indicators and response patterns guide future interventions. Outcome indicators are marked by mastery and fluid integrative identities (Meleis et al., 2000). That one copes with and accepts the diagnosis, treatment, and remission of cancer demonstrates mastery of a role. For an individual to identify themselves as a survivor, a parent, and an accountant exemplifies role integration.
     Although there are several components to transition theory, the theoretical propositions and relational statements are clear and concise. Transition leads to the development of a new role. Understanding the properties of specific transitions guides the nurse in planning effective interventions to assist the patient in adapting to a change in identity. If transition conditions in personal, societal and communal spheres are facilitative, the individual and their family will develop positive patterns of response. Promotive nursing interventions increase the amount of positive process indicators. The more process indicators and individual possesses, the greater the ability to master and integrate the transition into their self-concept (Meleis & Sawyer et al. 2000).
Logical Congruence
     Transition theory aligns well with the partnership model of health care and holistic practice of nursing. A patient should be informed about every procedure they undergo, every medication they take, and every viable treatment option available. It is the professional responsibility of health care providers to increase the patient’s knowledgeable about the current process and feel empowered in the management of their condition. Encouraging patients to enlist as many tools as possible to manage their conditions including family support, community group therapy, online resources, and mind-body techniques provides autonomy and aids the practice of cultural competence. This theory puts responsibility on the nurse to educate, use critical thinking to develop effective treatment strategies that involve patient and family, and assess effectiveness of strategies. Social values are covered in relation to how an individual perceives and is assisted by society. Americans expect knowledgeable, courteous, ethical health care providers and this theory implies that nurse will exhibit these behaviors. This theory was born using a variety of cross-cultural observations and research on transitions. Provided the nurse refrains from assumptions regarding meaning to the patient and his or her own personal bias, transition theory is applicable among many diverse worldviews and nursing areas.
Generation
Meleis intended the transition theory to be used in practice, education and research specific to nursing and healthcare. Transition is moderate in scope and defines a facet of nursing practice. It is classified as a middle range theory because it is not precise and restricted enough for situational or practice theory, but too limited in scope and abstraction to be considered a grand theory (McEwen & Wills, 2002). It is also used as a framework for developing situation specific theories (A. I. Meleis, personal communication November 2008; Nelson, 2006). While conceived for the field of nursing, role transition is a theme in sociology and psychology that is applied in works concerning women and cultural issues (Meleis & Rogers, 1987; Im et al. 1999). In these applications, different inconsistent terminology and meaning made comprehension and identifying major concepts difficult. Due to Meleis’ (2008) profusion of published journal articles, it was cumbersome and confusing to differentiate between those articles that discussed transition as a theory rather than a cultural or developmental process. As this theory evolves and more elements are added, parsimony decreases.
Credibility
Social Utility. Transition theory is used in areas such as psychiatry (Aroian & Prater, 1988), long-term care (Davis, 2005), cardiac rehabilitation (Dracup, Meleis, Baker, & Edlefsen, 1985), and motherhood (Sawyer, 1999) to either prepare an individual for change, or evaluate the effectiveness of intervention prior to or following a particular transition. It has been used to guide research and develop situation-specific interventions in the sibling experience of childhood cancer (Wilkins & Woodgate, 2006) and transition to adulthood in adolescents with developmental disorders (Pearson, 2002). Transition theory is currently used as a framework in undergraduate and graduate nursing programs at institutions including University of Connecticut and University of Pennsylvania (A. I. Meleis, personal communication, November 2008). Transition may be adapted from nursing and used for changes in social and political spheres such as the recent health care reform act.
Social Congruence.  Transition theory is a cross-cultural, adaptable theory that can be used by nurses and other health care professionals to elicit positive role integration in an individual, family, organization, or community. While the origins are based in nursing, the social and psychological aspect of application makes this a useful framework for multiple disciplines. Using this model to prepare for, understand, and anticipate change, increases the probability of successful transition.
Social Significance.  Those who are prepared for change are more apt to accept a new role to the benefit of their family and community. When people are knowledgeable, adapt easily to changes, and are able to integrate a new role into their self-concept with a sense of well-being, society benefits. The world is moving toward globalization in several arenas including healthcare and the environment. This theory provides strategies for society and individuals to have healthy transitions through knowledge and use of available resources. An understanding of universal properties of these transitions assists in devising successful strategies in international social, political, and health policies.
Contribution to Nursing
     Role transition clarifies and specifies the major role of the nurse. It assists the nurse in assessing areas of vulnerability, readiness, environment, and support. It demonstrates that education prior to, during and following transition increases the likelihood of successful role integration. It also provides a framework for planning nursing interventions with the goal of healthy stability. In a study involving the sibling experience with childhood cancer, nurses used transition theory to develop educational interventions that allowed the sibling to understand the disease process and provide support to enhance the therapeutic outcome for the affected sibling (Wilkins & Woodgate, 2006). When transition theory was applied to the recovery process in major depression, Skarsater and Willman (2006) concluded transition planning facilitated health, recovery and quality of life. The role of the nurse in preparing parents for the discharge of their children from hospital care to homecare validated that education and preparation for transition led to healthy and adaptive outcomes ( Weiss, Johnson, Malin, Jerofke, Lang, & Sherburns, 2008).

Summary and Recommendations

Meleis provides a detailed framework to execute successful role transition by illustrating and describing the role nurses have been playing for decades. As an evolving theory, there remain issues of consistency and clarity when researching the origins and evolution of concepts. There is also a lack of relevant data in relation to men and a need for expanded theory testing. Despite these shortcomings, role transition is an adaptable theory that has applications beyond the scope of nursing practice.

The IRB (Exempt) Stamp of Approval

As any of you following along may have guessed, my DNP project involves an investigation into the current practices of social networking among mental health providers and suggestions for appropriate use. I hope to get a diverse response base and would appreciate help with dissemination to nurses, psychiatrists, psycologists, therapists, and social workers. I spoke on this topic at the APNA conference, but have made some significant revisions to the questionnaire since then. I would appreciate any mental health professional willing to take the time to fill out the survey and pass it along to colleagues:

https://www.surveymonkey.com/s/OneDNP


Thanks!

Finals Done and Final Thoughts

The last full week of on-campus learning has come and gone. I find myself both excited and wistful about graduation in May.  Perhaps I have overdosed on sappy Christmas movies and am feeling overly-sentimental, but I feel enormously lucky to have met the peers and mentors I have through the course of the program. But without further blubbering, here is the on-campus week in review:

Psych Seminar
This seminar was aimed at getting folks to narrow down their capstone and start drafting an abstract for APNA. In a move that labeled me teacher's pet, Dr. Cunningham shared the abstract I submitted for 2011 as an exemplar and talked about my prowess as a writer.  Apparently, writing 200 words a day is a prescription for improving writing skills - the blogging comes in handy in more ways than I thought! Since I cannot re-use my own work, I am investigating ideas for how to integrate Traditional Chinese Medicine modalities in to Psych Nursing practice. Based on the feedback I received on the APNA forum, it looks like a practice roundtable might be in order for 2012.

Health Care Economics
Never a dull moment, I did not have to attend this session for the 2.5 points, but I just love the debates that always crop up when Dr. Thomson and Dr. Carter are at the front of the room. While most of us agree that primary care should not be done by physicians and some sort of interdisciplinary comprehensive healthcare exam would be useful for parity purposes, I am in the camp that believes the American Board of Comprehensive Care (aka the third step of the USMLE) is NOT the appropriate answer. One of my pediatric NP classmates was quite persuasive on the matter of differing education and role between MDs and NPs that makes the ABCC test prejudicial in favor of physicians. As she pointed out, many pediatricians cannot pass the PNP board exam.  Moreover, NP education focuses on prevention and primary, community based care, whereas MD education focuses on tertiary, hospital-based acute-care.  It would be far more logical to embed a standards-of-care module into the respective exams for independent healthcare providers with a uniform minimum pass-rate. Whoever can design that will make a fortune.

Evaluation of Practice
A few bumps in the road on this course, which is expected given this is the first year of the re-design. I know from being at the front of the classroom that there are some brands of student that feel the first draft of the syllabus is a sacred tomb not to be altered for anything less than plague, pestilence, or flood. Me, I roll with the changes to make the changes work for me. I also do not  interpret that which is not graded as that which is necessary, and there were a number of ungraded assignments in this course. The end result found me reviewing my Improvement Science project with Dr. Mona Wicks, Associate Dean of Research, who not only provided enormous encouragement and essential edits to my project, but taught me a valuable lesson in professional reflection. I must remind myself I do NOT need a PhD no matter how tempting it sounds!

Clinical Management of Mental Health Disorders
Despite reviewing strategies on how to get out of doing our presentations, we all went backed-down and went through with it.  All of the consultation process were unique and well done. Here is ours for any future students in need of some ideas:

Sexual Abuse Prevention Consultation

View more presentations from Jaclyn Engelsher

Worth the Price of Tuition

Every week in clinical I learn something new, but this week was full of particularly intriguing one-liners. Learning is not always quantifiable, but for those that question the value of obtaining yet another advanced practice degree to do what you already do, I raise the possibility that the educational process may at minimum make you think differently than you have been thinking. And thinking changes practice. 


I just don't feel the way I do. 
     - LPN (just chew on that one for a moment!) 


The trouble is not that people change, but that they don't
      - Patient insight


Anywhere else it would be called assault instead of rock'n'roll
     - Paient insight


The truth of everything is known when you achieve it
     - PTSD fear awareness group


It's not hypocritical if you want to believe it
     - Spontaneous response from patient session (something I need to work on)

Anyone can pay for knowledge, but belief has no price tag 

     - Reflective practice insight after patient session

My First Sponsored Term Paper

I probably should have put a disclosure statement on the bottom of my Health Economics final since Kronos did pay the $1500 conference fee and $200/night hotel room for me to research the topic. All perks aside, you can't argue with cost savings, if they are indeed cost savings since they are very secretive on how much they charge for timekeeping solutions and automation. I am sure there is some kind of business story in there, but that is not my area.

What was surprising was how few nurses were present during the healthcare sessions. Pardon my prejudice, but HR and payroll representatives reporting on the success of a system is not as convincing as hearing it from the people who use it daily to run the hospital, especially when we are talking about a group of people who are generally hesitant to accept change (but are also a lot more fun). Interestingly, I have had about five or six conversations on workforce development technology in the past few weeks that makes me think I should ask for a kickback from the Kronos. . . but I will settle for an invite to the 2012 conference in Las Vegas!

Here is the analysis in all of it's glory . . . note the comments in red at the bottom :)

Cost-Benefit Analysis of Workforce Management Technology

Jaclyn Engelsher

University of Tennessee Health Science Center

          Since the 1960’s, increased productivity and decreased labor costs have contributed to the adoption of employee self-scheduling in hospital and healthcare systems (Hung, 2002). While the majority of nurse managers continue to use paper sign-ups and e-mailed spreadsheets as the scheduling platform, an increasing number of facilities are implementing workforce management technology programs that deliver web-based and mobile solutions to optimize labor cost, manage absenteeism, and minimize compliance risk (Mercer, 2010). Development companies claim the savings generated from cost-effective staffing pay for the total cost of ownership, generate additional revenue, and improve patient and provider satisfaction. With the current unstable economic environment and implementation deadlines for healthcare initiatives approaching, hospital financial offers are searching for cost containment tools to help manage labor costs, the largest component of net operating hospital revenue (Williams, 2008). A cost-benefit economic analysis of workforce management technology will determine impact on cost, productivity, and compliance in the healthcare setting.

Background

          In few other industries are outcomes more linked to staffing than in 24-hour healthcare operations. The fluctuating nature of patient acuity and needs dictate the skills sets and ratios necessary to deliver high quality of care. The nation faces a new nurse attrition rate of up to 25%, a workforce where the median age is 48.9 years, and an anticipated need for over three million nurses within this decade (Bernard Hodes Group, 2011). Absence contributes to 35% of annual payroll costs, 9% of which is attributed to incidental and extended absences (Mercer, 2010). Whereas the cost of planned absences can be budgeted, unplanned absences from casual sick-days to FMLA leave result in lost time with the average employee missing 5.4 days per year. For a staff of 500, this results in a loss of 783 workdays per calendar year and up to a 29% decrease in productivity. The Fair Labor Standards Act places burden of proof on the employer for alleged violation. Just to go to court for an alleged FMLA violation costs employers an average on $150,000 per case (Kronos Incorporated, 2011).
          When staffing levels fall below patient requirement by as little as eight work hours under optimum ratio, risk to patient safety and mortality increases up to 6% (Needleman et al., 2011). Units delivering increased care hours by staff with the most applicable skill set to the patient population results in lower rates of infection, failure to rescue, length of stay, and decubitus ulcers (Blegen, Goode, Spetz, Vaughn, & Park, 2011). When considering the expense of recruitment, training, productivity loss, sentinel events, and coverage labor, turnover can costs employers up to $64,000 per nurse (Jones & Gates, 2007). Staffing and communication are the top two areas for improvement reported by nurses with shift and work-life balance ranking in the top five reasons for recruitment and retention (Bernard Hodes Group, 2011).
          Employee self-scheduling increases job satisfaction by providing choice and control over work-life balance and has a beneficial impact on primary and secondary health outcomes in staff (Joyce, Pabayo, Critchley, & Bambra, 2010). While most hospitals offer some variation for employee input into scheduling, the manual process of can be cumbersome, inequitable, and result in hours of management time lost trying to fill open shifts with the best staff member at the lowest cost (Mercer, 2010). Workforce development technology companies have integrated automation into self-scheduling systems to reduce labor costs and compliance risk while increasing productivity and patient care. Unlike the unit binders or email requests, the technology can be expensive and require hors of training to master. A cost-benefit analysis is the first step to determine if implementing an automated self-scheduling solution is an appropriate intervention for an individual healthcare system or facility.
Cost-Benefit Economic Theory
          Santerre and Neun (2010) explain cost-benefit analysis (CBA) as a decision-making tool that estimates the total cost and expected benefits of a proposed health policy, intervention, or technology. When the net benefit is greater than the estimated sum of direct and indirect costs, implementation would be recommended. Implementation may also be recommended if the costs and benefits are equivalent, depending on if emphasis of value is placed more on the cost or the benefit. Implementation is unlikely in the event the cost significantly outweighs the benefit. While the CBA can help direct an organization toward solutions that maximize benefit and minimize cost, inaccurate calculations, unaccounted for expenses, and unfulfilled outcomes may occur.
          Direct costs are narrowly calculated, predictable expenses directly attributed to the proposed product or service. In workforce development technology, these include purchase or rental of hardware, training time, service agreements, licensing fees, updates, and installation. Training on workforce development software takes an average of 2 hours for users up to one-two days for managers (Kronos Incorporated, 2011). Training can be delivered remotely, as part of new employee orientation, or by company representative site-visits. Most companies do not publish pricing data due to the tailoring required for each individual organization, variable incentives, and negotiating flexibility. Conservative cost estimates range from $50 per month for limited functionality in small hospital systems, to $100,000 per licensed user for sophisticated solutions. Indirect costs are associated with the proposed product or service, but are not clearly traceable or quantified. Obsolescence, system malfunctions, hardware replacement, software updates, re-training, and sub-optimal utilization, are indirect costs that are difficult to predict and calculate. Examining how various solutions have functioned in like-organizations and reviewing consumer reports of products can help with estimation.
          Outcome benefits are commonly measured in time, money, or satisfaction. A substantial benefit of workforce management technology implementation is reduction in the cost of absence. The benefits paid as a result of absence, such as sick or vacation time, may not significantly vary, however productivity loss from using a less efficient replacement can improve by as much as 5% of payroll by reducing use of overtime employees, agency staff, redistribution among coworkers, or reallocation of work to the supervisor (Mercer, 2010). In a hospital employing 500 nurses with an average salary of $43,000, this results in a savings of nearly $370,000 per year. When Norton Healthcare implemented the Kronos workforce productivity and analytics tool, they saved $5.5 million in labor costs among their 9,700 employees in their first year (Kronos Incorporated, 2008).
          Timekeeping tools decrease labor expense by analyzing patterns of absenteeism and tardiness, labor laws, time-off accrual, and use of agency staff. When using the Kronos mobile scheduler, 70% of open shifts are filled within five minutes of sending a text alerts (Kronos Incorporated, 2011). University of Utah Healthcare saw an 80% drop in agency labor cost the first year of use and the community-based Arch of Baltimore saved $900,00 in total labor costs. Ford Healthcare Systems replaced the office “white-board” with Shiftboard’s online nurse scheduling software which decreased time spent in recruitment, applicant review, and payroll, which aided their expansion into three neighboring states (Shiftboard, 2009). After implementing API Healthcare’s solutions, Coffee Regional reduced overtime cost by $625,000, eliminated $3000 in payroll error, and increased staffing efficiency to a level where for every two retiring nurses, only one replacement was required (API Healthcare, 2010). Data analytics in these solutions allow managers to ensure consistent application of scheduling policies by providing equal opportunity for employees to request time-off, fill open shifts, swap shifts, and be considered for first-cut.
Recommendations
          Workforce development technology should be implemented for organizations that need to maximize operating efficiency of healthcare delivery and decrease compliance risk. To determine potential, an organization must first calculate the cost of absence, compliance violations, sentinel events, and turnover that can be attributable in part to inefficient staffing. Staff input regarding current scheduling procedure and preferred solution platforms must be elicited to determine level of interest and resistance. Review of patient surveys should focus on complaints that effect loyalty such as time spent with providers, staff attitudes, and quality of care. Once the benefits have been quantified, a budget can be created in which to research available workforce management technology. Pricing data varies from between companies and it is important to keep in mind that all direct costs are negotiable and competitive. Once the CBA has been completed, a cost effectiveness analysis can be performed to compare relevant competing solutions.
References
API Healthcare (2010).  Case study: Coffee regional medical center. Reterieved from http://www.apihealthcare.com/_asset/r80vgj/API_CSCR-0310-Coffee_Regional.pdf

Bailyn, L., Collins, R., & Song, Y. (2007). Self-scheduling for hospital nurses: an attempt and its difficulties. Journal of Nursing Management, 15(1), 72-77.

Blegen, M., Goode, C., Spetz, J., Vaughn, T., & Park, S. (2011). Nurse staffing effects on patient outcomes: safety-net and non-safety-net hospitals. Medical Care, 49(4), 406-414.

Bernard Hodes Group, (2011). RNs at risk: Understanding key tenure points. Retrieved from http://www.hodes.com/rns-at-risk

Hung, R. (2002). $uccess $tories. A note on nurse self-scheduling. Nursing Economic$, 20(1), 37-39.

Jones, C. & Gates, M., (2007).  The costs and benefits of nurse turnover: A business case for nurse retention. The Online Journal of Issues in Nursing, 12(3)

Joyce, K., Pabayo, R., Critchley, J., & Bambra, C. (2010). Flexible working conditions and their effects on employee health and wellbeing. Cochrane Database Of Systematic Reviews, (2)

Kronos Incorporated. (2008).  Norton Healthcare leads change for consumer transparency with help from Kronos. [Press Release] Retrieved from http://www.businesswire.com/news/home/20080623005101/en/Norton-Healthcare-Leads-Charge-Consumer-Transparency-Kronos

Kronos Incorporated. (2011). Does my staffing level matter? Using analytics to correlate staffing with risk and quality events. Unpublished paper presented at Kronosworks 2011: The World’s Leading Workforce Information Exchange, Orlando, FL.

Mercer, (2010). Survey on the Total Financial Impact of Employee Absences. Portland, OR: Mercer Health and Benefits LLC

Needleman, J., Buerhaus, P., Pankratz, V., Leibson, C., Stevens, S., & Harris, M. (2011). Nurse staffing and inpatient hospital mortality. New England Journal Of Medicine, 364(11), 1037-1045.

Santerre, R.E. & Neun, S.P. (2007). Health economics: Theories, insights, and industry studies (5th ed.). Mason: Thomson South-Western. 6

Shiftboard, Inc. (2009). Case study: Nurse scheduling Ford Healthcare Systems. Retrieved from http://www.shiftboard.com/casestudies/Shiftboard-Online-Nurse-Scheduling-Ford-Healthcare.pdf

Williams, J. (2008). A team approach to cost containment. Healthcare Financial Management Association Magazine. Westchester, IL

You have a good idea but clearly the actual data are very short. Most of what you could find to report is information from the company.  This is always suspicious – they are selling a product.  As you saw, finding all the costs are a problem and limit your ability to do a cost-benefit analysis although you tried.

Background = 10  Application of theory = 8 Conclusions/Recommendations = 9 Grammar = 10 Total = 37 (out of 40)

Occupy With Grace

From the Engage with Grace rally to revolutionize end-of-life planning . . . 


Occupy With Grace

Once again, this Thanksgiving we are grateful to all the people who keep this mission alive day after day: to ensure that each and every one of us understands, communicates, and has honored their end of life wishes.

Seems almost more fitting than usual this year, the year of making change happen. 2011 gave us the Arab Spring, people on the ground using social media to organize a real political revolution. And now, love it or hate it - it's the Occupy Wall Street movement that's got people talking.

Smart people (like our good friend Susannah Fox) have made the point that unlike those political and economic movements, our mission isn't an issue we need to raise our fists about - it's an issue we have the luxury of being able to hold hands about.



It's a mission that's driven by all the personal stories we've heard of people who've seen their loved ones suffer unnecessarily at the end of their lives.


It's driven by that ripping-off-the-band-aid feeling of relief you get when you've finally broached the subject of end of life wishes with your family, free from the burden of just not knowing what they'd want for themselves, and knowing you could advocate for these wishes if your loved one weren't able to speak up for themselves.

And it's driven by knowing that this is a conversation that needs to happen early, and often. One of the greatest gifts you can give the ones you love is making sure you're all on the same page. In the words of the amazing Atul Gawande, you only die once! Die the way you want. Make sure your loved ones get that same gift. And there is a way to engage in this topic with grace!

Here are the five questions, read them, consider them, answer them (you can securely save your answers at the Engage with Grace site), share your answers with your loved ones. It doesn't matter what your answers are, it just matters that you know them for yourself, and for your loved ones. And they for you.



We all know the power of a group that decides to assemble. In fact, we recently spent an amazing couple days with the members of the Coalition to Transform Advanced Care, or C-TAC, working together to channel so much of the extraordinary work that organizations are already doing to improve the quality of care for our country's sickest and most vulnerable.

Noted journalist Eleanor Clift gave an amazing talk, finding a way to weave humor and joy into her telling of the story she shared in this Health Affairs article. She elegantly sums up (as only she can) the reason that we have this blog rally every year:

For too many physicians, that conversation is hard to have, and families, too, are reluctant to initiate a discussion about what Mom or Dad might want until they're in a crisis, which isn't the best time to make these kinds of decisions. Ideally, that conversation should begin at the kitchen table with family members, rather than in a doctor's office.

It's a conversation you need to have wherever and whenever you can, and the more people you can rope into it, the better! Make this conversation a part of your Thanksgiving weekend, there will be a right moment, you just might not realize how right it was until you begin the conversation.

This is a time to be inspired, informed - to tackle our challenges in real, substantive, and scalable ways. Participating in this blog rally is just one small, yet huge, way that we can each keep that fire burning in our bellies, long after the turkey dinner is gone.

Wishing you and yours a happy and healthy holiday season. Let's Engage with Grace together.




To learn more please go to www.engagewithgrace.org.This post was developed by Alexandra Drane and the Engage With Grace team.

The Sandusky Teaching Moment: Unfortunate Silence

It started with a many suspicions and a random post of the Penn State fan forum.

Perhaps more accurately, it started with molestation and loyalty to the institution over the community.

The ongoing reports out of Penn State for the past two weeks have brought forth discussions and elicited strong emotions from those in every sphere of my life.  At first, I started quoting the standard mandatory reporting regulations for sexual assault and how Child Protective Services, at least in Kentucky, do not accept third-party reporting - it has to come from the victim, the witness, or the individual the victim or abuser discloses to. I thought Joe Paterno's retirement at the end of the season announcement was bold and bordering on arrogant, and was exceedingly irritated that many news reports focused on his firing and the unfortunate silence that led to the end of a great coach's career. I did not graduate from a university with a BCS championship-claiber football program, so I have a hard time relating to the initial student protests of his ousting in light of the allegations.

More details concerning the access Jerry Sandusky had to the facilities after his employment immediately brought forth the thought "this is beyond cover up - there are probably others paying in kind to have access to these boys or to keep quiet." With records missing from Sandusky's charity Second Mile, non-communication with the university lawyer following McQueary's report to Paterno, District Judge and Second Mile contributor Leslie Dutchot letting Sandusky go home without bail, Sandusky's interview with Bob Costas where he admitted to showering with the boys appropriately, and police reports on victims going back to 1998, the rabbit hole gets deeper and deeper.

Teaching Moments
In the real world, these kinds of stories are opportunities for all of us to open the dialogue on healthy relationships. Since this story broke, I have asked many of my patients with young children if they have had these conversation and if this story has affected the family in any way. Most report a heightened sense of awareness and want to introduce or re-empasise body rights and choice. This article provides several useful tips: How to Talk to Your Child About Molestation For the teen or tween: Talking to Teens about Paterno, Penn State, and the High Price of Bystanding.

Every state is different, however mandatory reporting for teachers, healthcare professionals, and law enforcement are generally standard. Some states extend the duty to report to all residents, but this is not typically well known. To look up the statues that apply to you, visit State Laws on Reporting and Responding to Child Abuse and Neglect.

The "coach" position is a gray area, as evidenced by Penn States's policy that you report to your superior before reporting to the police or emergency teams. While it is in the rhelm of possibility that a federal mandatory reporting act could pass as a result of this tragedy, the Center for Ethical Youth Coaching posted an excellent guide for action when a coach, or anyone, witnesses child abuse: Procedures for Handling Abuse

May communities have domestic violence and sexual assault shelters that provide community outreach.  The Center for Women and Families is one of our city's greatest gifts and they provide information on spotting, preventing, and healing from these traumas: Educational Brochure Library

Of course, no OneDNP post would be complete without a nursing mention. When stories of abuse break like this, many victims relive their own traumas and can experience setbacks, especially when in the midst of therapy. It is important when providing care that nurses are aware of the effects of vicarious trauma and transference issues. To learn more about preventative healing and self-care, visit Reveal, Release, Reconnect

Remember that silence kills mind and body. The arguments many nurses make to avoid reporting peers for issues such as substance abuse  - ruining a peer's career, not wanting one's name connected with the report, fear of retaliation or disbelief, looking bad on the profession, practice, or organization - are the same reasons the powers at Penn State rationalized their silence. And no, it's not different.

Highlights from APNA 25: Psych Nurses Have More Fun

This was my second year attending the American Psychiatric Nurses Association annual conference, and the experience again renewed my enthusiasm for live CEU events. There were plenty of excellent speakers, exhibition (sales) booths, and poster presentations, but that is not what makes this a must-do yearly event. It is the camaraderie within the profession and the fact psych-nurses know the importance of having a good time. Here are a few of my personal highlights.

   

Venue: Disneyland Hotel

An excellent location to blend education and fun. Although the place was under construction and wi-fi was a bit spotty, the staff managed to make it magical. We had an awesome renovated room in adventure tower with a view of the evening fireworks. Since we were not run ragged with sessions and the conference ended early on Saturday, there was plenty of time to explore downtown Disney and the parks without the need for car rental or long monorail/bus rides. There were excellent places to eat (Napa Rose for high-brow, Trader Sam's for sips and apps), wonderful spa (ask for Carlos), and a fine collection on shops with live music until 10 or later every night. There were plenty of pens and pads along with a good selection of breakfast and boxed lunch choices. And Pluto, of course!



    

Inspiration: Jean Watson

Her presentation Caring Science and Psychiatric Nursing: Relationship and Emergence of Human Spirit included a singing bowl meditation and an honest discussion on how PMH nurses can use authenticity, interconnectedness, and belonging as instruments of healing.  While speaking on esoteric topics is commonplace in my CAM conferences, I was delighted her powerful delivery made it into an area that does not like to stray far from evidenced-based practice. "Being" is not a concept easily researched through science!  Jean was referred to often throughout the rest of the conference - I gave her a nod in my presentation on the role social networking plays in world connectedness - and she had a huge line of folks waiting to shake her hand following her talk. I studied her middle-range theory of human caring in my MSN program, but there is nothing like a personal illustration by the creator to bring life to a concept that seems more simple and obvious on paper than it does in clinical practice. Watson Caring Science Institute


Mentorship: Pat Cunningham
My advisor won this year' award for excellence in practice and we whooped it up when they presented her award. What is amazing about Pat from a student perspective is her ability to individually listen to each of us, evoke the best practice and thought out of ourselves, and to use that blunt humor so characteristic of the best psych nurses. I imagine her patients feel the same way!

Trend: Integrative Therapies

Last year there were a few posters that addressed CAM use by nurses and I was excited, but this year saw an explosion! Mindfulness training, supplement and nutrition use, and schools of nursing integrating various CAM certifications as part of their psych-np programs are just some of the new blends of therapies to benefit our patients.  I found out one of my current teachers has been using hypnotherapy with some of her pediatric clients and a former psychiatrist colleague has been instrumental in establishing integrative practices in the Long Beach VA's mental-health program. I am excited that the future may hold a number of niches I fit into without having to carve them out on my own. There may be opportunities to expand NP ability to practice certain CAM therapies as part of their scope of practice similarly to how MDs already have, and I would love to be a part of making that happen.

 
   

Coolest Product: Mindability
This product was cool for 2 reasons. First, all the promo literature was on a flash drive that I was able to use to store my presentation when I could not find mine (it resurfaced in my backpack yesterday). Second, the rep gave me a fun wallet card targeted to control emotional reactions. It included some great phrases such as:

• "If I'm reading this, it means I'm more upset than is good for me."
• "However I'm feeling is exaggerated"
• "Whatever I am thinking is distorted." 
• "Whatever I'm thinking about saying or doing, DON'T, until I calm down."

If reality TV stars had these in their pockets, there would be no reality TV stars! In all seriousness, this brought out a new idea for PTSD group I hope to use during clinical soon.

   

International Perspective: Holland
While a group of use were relaxing by the pool area in between sessions, a fellow nurse from Holland decided to sit and chat with us. I found it interesting that while the US is trying to establish mental health parity, in Holland, they have decided those with mental illness will now have to pay over-and-above the standardized government health insurance rate for supplemental coverage if they want psychiatric services. We also had an interesting conversation about different nursing roles and marijuana bars.

Obligatory Gala: California Dreamin'

Hosted on Adventure lawn, the Friday night reception was included in the conference registration rather than having to purchase separately. An excellent buffet and cash bar (boo!) was well staffed, and the all-dentist band made for a wild evening. The dance floor was defiantly too small for this crew as all-ages crowded it and boogied down. Later we went to my room for a wine tasting wind down that resulted in one of my classmates deciding to commit to the ascot. Pittsburgh better watch out in 2012!