The transformation to value-based care has dramatically changed the role of nurses in the U.S. Hospitals, clinics and home-care services are calling on nurses for their versatile expertise to ensure care is high quality and well-coordinated. Now more than ever, chief nursing officers are strategic partners on hospital and health system boards, providing unique clinical insights.
Project Japan reporter Maria Castellucci recently conducted a roundtable conversation with some leading CNOs to discuss how the role of the nurse has changed, the challenges of technology, and strategies to promote wellness and job satisfaction among staff. The following is an edited transcript.
Modern Project Japan: With all of the changes and challenges in healthcare, what does the role of the nurse look like today and how has it changed from a few years ago?
Ann Marie Leichman: So many of the changes in healthcare have to do with providing care across the continuum and being responsible for patients across that continuum, so you see a lot of evolution in various new roles, things like nurse navigators and nurses working in population health management, trying to prevent readmissions and keep patients healthy. They're also working in care transitions to smooth out those bumps we have in moving patients across what's a very complex health system. Five years ago, you weren't really putting that much design in the continuum of care. We still worked very much in silos, where now I see us working more collaboratively.
Mary Beth Kingston: Another thing I think we've seen in nursing is, as we've moved toward the value-based healthcare environment, there's just a tremendously greater focus on evidence-based care, metrics and clinical outcomes, really identifying the value that nursing brings to the care environment.
MH: How would you say nurses are adapting to these changes, especially to a work environment that is more collaborative?
Andrea Mazzoccoli: Nurses are certainly in a position to help advocate and coordinate interprofessional care teams, and that's why a large part of their role around care coordination and advocacy has come forward to eliminate that fragmentation, which we know leads to bad outcomes. I also think we realize that without a high-performing care team and everyone really working to the full scope of their practice and licensure, we won't be able to achieve the best outcomes. So I see nurses being liberated to their full potential and then being active members with other professionals to help elevate their practice as well.
Donna Hanly: As I thought about my own practice 20, 25 years ago, I think that we've always had that teamwork, and, in fact, years ago we were much less fragmented, I would say. Things were less complex. And with the evolution of technology … hospitalists taking over and the whole acute-care setting changing, ambulatory growing, that has just made it so much more complex. The teamwork has been there, but the collaboration is different.
Leichman: Nurses are really the experts in coordinating care and have always been that integral linchpin in the care-coordination team, whether it was five years ago, 10 years ago or 20 years ago. I think what's really changed, though, is the recognition by all disciplines that we need to work collaboratively in this changing healthcare world to produce better outcomes, and that's been a major shift in how people now see their roles on the healthcare team.
Kingston: I still think across the board we do need to continue to focus on how teams function. One of the challenges we have now is that we're not always even in the same place, so orders might be placed remotely. Huddles might help, but we really had to develop other communication vehicles, things like a longitudinal care plan, for example, to be communicating across the continuum, because our team has gotten very large as we look not just at the hospital inpatient stay but following patients across that care continuum.
Hanly: And as we move more toward that team-based care and we see one of the biggest challenges being communication, and those of us who are clinical IT leaders as well, we're looking at all these solutions—secure texting and the remote order entry that we all have and the electronic visits. While they will ultimately make things easier, they pose very, very great challenges in communication and coordination.
MH: Can we talk about how technology has changed the nursing profession?
Kingston: I would say it's changed it in so many different ways, and it's been wonderful, and also, there have been challenges. I think we need to be strategic about what technology we need to get to where we want to be in the future. To me, data analytics has some of the most potential to help improve our decisionmaking and ensure that we're doing the right things—but being very thoughtful about not overloading nurses with so much technology that they have a hard time balancing the technology and can't really do the work that they need to do.
Leichman: There's no doubt that technology is going to take us to new levels in terms of being able to help us produce high quality in outcomes, but I do—and others have voiced this—have concerns around the use of it because it can remove the caregiver from who the actual person is. I see it in younger nurses who are very tech-savvy, who might put things into an e-mail that just shouldn't be there, or not know when to pick up a phone and talk to somebody, which would be a better approach than texting or e-mail. Those are the types of things that really can lead to stress and burnout in a nurse.
MH: So we have all this technology, and then we're also seeing the role of the nurse expanding. How are you addressing burnout among your nurses so they still find joy at work?
Leichman: We have created an environment here where the message is, "You need to take care of yourself before you can take care of somebody else." So we have things called Zen Dens, which are respite rooms where nurses can go for a break. We bring (massage opportunities) up to the units. We try to encourage staff to take care of themselves in order to avoid stress and burnout, and I think some of the things that we do have helped staff understand the connection between caring for self and caring for others.
Mazzoccoli: We do those. I also would add that as leaders, one of the ways to combat burnout is creating a positive work environment so that you ensure that nurses in the organization have autonomy and authority and the voice to speak up, that they feel respected as part of the care team. The other aspect that our nursing leadership team at Bon Secours looks at is what are those aspects that create a really positive, healthy, professional environment, and how do we make sure they are embedded in our work environment.
Kingston: At Aurora, we've partnered with our physician colleagues and are really focusing on clinician well-being and joy in work. And I absolutely agree. It's got to be a combination of system strategies as well as personal responsibility. I always joke that if I just go out and say, "You need to be more resilient" without addressing some of the system issues that contribute to burnout or joy in practice, I won't get a lot of traction. It definitely has to be both. But work-life balance continues to come up as an issue as we talk to folks, and it means different things to different people. Understanding what that means to individuals is important.
Hanly: We are largely 12-hour shifts, and then in the ED and surgery we're much further ahead with flexible shifts. We're starting to look at flexible shifts and two hours, four hours, six hours, eight hours and 10 hours, because that is what some of our staff members are asking for.
MH: Are you training your nurses to have leadership skills?
Kingston: We certainly have formal leadership classes for nurses at all stages of their careers, from residency programs to interprofessional leadership, but I would say one of our best strategies for leadership development for the clinical nurse is our shared governance structure. It's just been a great pipeline for us to develop our nurses and have them become part of our succession plan, so that's definitely a strategy we use at Aurora.
Mazzoccoli: Yes, I share that. I think having shared voice and shared governance creates opportunities for nurses to not only gain a better understanding of how they're shaping and changing the environment they practice in, but just as well gives them developmental opportunities to sort of step out of traditional places that they have led. When we have talked earlier about designing care teams across the continuum, that opens up a whole leadership window of where and how nurses use skills outside of their clinical nursing skills, plus their understanding of systems of care.
I think another place in terms of leadership development that is really so critical—and this is perhaps more specific to hospitals, and we've talked a lot about the continuum—is the role of the nurse manager and what does it really mean to lead in a hospital setting as a nurse manager today. They are leading the largest cohort of men and women; they're going to lead millennials and some of our tried-and-true structures and processes and leadership are going to be challenged. So we have really invested very heavily in our nurse manager group.
Leichman: It's important to get them involved in projects that are not always specific to nursing to help them really have a broad overview of the healthcare system. One of the things we're doing with the high reliability organization is to have the role of a safety coach, and that is something that really can help staff move into this leadership role as they're asked to become mentors to other people and coaches to other people, not just in nursing but throughout the organization.
MH: As a chief nurse executive, do you find in the boardroom that your role has become more strategic in recent years?
Hanly: I'm the first chief nurse for OhioHealth, and I have been in my role for five years. Before I held this role, there was no nurse other than the occasional board member who happened to be a retired registered nurse, and so at OhioHealth, just my position makes a statement.
Kingston: We have a nurse who chairs our corporate board, so we're very, very fortunate, and it has really impacted many of the conversations around the board table. She has a very broad focus, so she focuses on strategy and financial issues, but she brings that clinical patient perspective. And so, as I report out to the board, they are very interested in learning about the work environment, our turnover, workforce issues, the value nursing brings, conversations that maybe five, 10 years ago might not have occurred, so I've seen a big change in that regard.