Re-Centering Nursing Care to Meet the Needs of Patients and Families: A Call for Executive Action
Across the globe, substantial deficits in nursing care delivery threaten outcomes for patients in diverse care settings, including acute care hospitals, long-term care, and home and community-based services. A March 2023 International Council of Nursing cross-national study reported pooled estimates of nurses’ psychological distress between 40%–80% and intention-to-leave rates at 20% or higher (Buchan and Catton, 2023). Multiple factors have contributed to these crisis-level deficits: chronic understaffing, proliferating workloads, increased verbal and physical violence directed at nurses, and unsupportive work environments (Medvec et al., 2023). These factors worsen moral injury (knowing what the correct course of action is but being unable to take it) and lead to repetitive cycles of burnout, disengagement, and resignation. Nurses are critical to the continued operation of health care systems, and their satisfaction directly impacts improved patient care, with research showing that patient satisfaction scores are higher in hospitals with lower rates of nurse burnout and improved working conditions (Brooks Carthon et al., 2021). Without bold and decisive executive actions, the authors of this manuscript fear that the immediate nurse vacancy crisis will persist and worsen. Health care systems are ailing, and they are in urgent need of healing. Aligned with the National Academy of Medicine’s (NAM) National Plan for Health Workforce Well-Being, this manuscript outlines the need for bold changes to address this crisis in nursing care through two historical examples, a current successful innovation from Singapore, and a call to action for health system executives and other leaders to support, promote, and enable these bold experiments to avert additional personnel losses and improve patient outcomes (NAM, 2022b).
Bold Changes are Required, and Historical Examples Can Help
Few health systems have addressed today’s challenges with bold reforms to care delivery. Historically, impactful innovations that have provided truly needed foundational change have emerged during crises. For example, in 1975, in response to a painful, persistent nursing shortage, Beth Israel Hospital Chief Nursing Officer Dr. Joyce Clifford partnered with the hospital’s president, Dr. Mitchell Rabkin, to set a bold new vision for nursing (Clifford and Horvath, 1990). Primary nursing—a model whereby one registered nurse assumes the majority of care needs for a patient—met early resistance from Beth Israel’s physicians and employees. Yet, Clifford and Rabkin’s work became a global model for high-quality nursing care, resulting in unprecedented levels of nursing job satisfaction, waiting lists for open nursing positions, and superlative patient outcomes (Aiken et al., 2009).
Another similarly bold change was the recent restriction of duty hours for physicians in training (medical residents). Amid widely publicized cases of patient harm and increased concerns for resident safety, the Accreditation Council for Graduate Medical Education enacted bold reforms in 2003 and again in 2011, which capped resident duty periods and shift lengths, and required additional breaks between shifts (ACGME, 2017). Despite roughly equivocal patient outcome impacts, a meta-analysis suggests these reforms are associated with improved resident well-being (Sephien et al., 2022). While unpopular at the time, leaders now recognize the importance of these structural changes on the physician workforce and have continued to test and enhance innovative approaches to delivering care while optimizing working conditions for physicians in training (Birkmeyer, 2016).
These two bold experiments illustrate that it is sometimes necessary to fundamentally alter how health care operates to improve patient care and support and protect health care workers. Despite discomfort and unpopularity early on, these bold experiments became integrated into routine health care operations. They also contributed to improved patient care and health care worker outcomes. It is time to launch similar bold experiments in nursing care delivery that are centered on the needs of patients, families, and communities, while simultaneously addressing systemic failures in nurses’ working conditions to achieve the ambitious goals of sustained positive work environments and recruitment and retention of a diverse and inclusive health workforce outlined in the National Plan.
Novel Partnerships are a Promising Approach to Impactful Change
The two examples listed above highlight historic innovations in the hospital sector. Nurse vacancies in long-term care, home, and community-based settings are less studied and potentially more problematic. An aging patient population, coupled with a shift in delivering complex treatments outside of acute care hospitals, compels innovative models to serve patients and families in these settings. A novel and bold approach to patient-centered care outside of acute care facilities in Singapore can be helpful in understanding the types of innovations that are necessary to truly revolutionize the health care system and protect and support nurses.
Similar to the rest of the world, Singapore has an increasingly aging population. Keeping everyone healthy and robust throughout life has never been more important, especially given health threats such as climate change and future pandemics.
One initiative—the Health District at Queenstown—incorporates recommendations from UN Decade of Healthy Ageing: Plan of Action 2021–2030 and the NAM Global Roadmap for Healthy Longevity (NAM, 2022a; Tergesen, 2022; UN, 2020). This is a whole-of-society initiative, co-led by the Housing and Development Board, the National University Health System, and the National University of Singapore. The Health District aims to harness the resources and expertise of the public, social, and private sectors in a real-world, location-based district to codesign effective, scalable, and sustainable programs that increase healthy and purposeful longevity, strengthen intergenerational cohesion, and enable a community for all ages, allowing residents to age in place with long-term care within their homes and communities, among families and friends.
Nursing is critical to the success of this model, with community nursing playing a leadership role in preventive health and community-centered care delivery. Nurses are a key component of interprofessional care teams that include health and social care professionals. These care teams are embedded within public housing in the Health District, enabling development of trust and meaningful relationships between residents and the team. The integrated efforts of the Alice Lee Center for Nursing Studies at the National University of Singapore and Community Nursing in the National University Health System generate a learning cycle to ensure that nurses have the skills to develop person-centered, longitudinal care within the community. Health professions schools need to prepare students with new interdisciplinary skill sets to enable and promote effective communication with the services that address the social determinants of health, including housing and other components of the environment, employment, education, and digital access. Nurses can play a key role as the trainers and implementors of procedures and technologies to make these innovations feasible. There is substantial value for technology as an enabler and force multiplier to keep older people independent and functional, nudge the population toward healthy behaviors, and allow the delivery of care into communities and the home. To bridge historic divides between formal health care services and broader societal supports, health care teams can work jointly with designers and engineers to optimize user interfaces for residents, caregivers, and service providers (all of whom are becoming older); determine criteria for efficacy; and advocate for affordability.
Systems Will Reap the Benefits of Bold Actions
In the current health care landscape, health care executives walk into work every day and struggle to meet basic operational goals due to a dearth of available staffing. They are repeatedly called to address meritorious quality complaints from patients, families, and their employees. Patients and families are not blind to the current crisis—they know that care is often not meeting basic standards for safety and quality (Graham, 2022). In the current state, bold solutions are often rejected because executive teams rely on existing inflexible structures and outdated financial frameworks. As examples, flexible scheduling models and shared clinical practice roles between schools of nursing and health systems would provide more experienced nurses with opportunities to remain clinically engaged while also mentoring and preparing the future workforce. Employers could experiment with more flexible schedules and roles to accommodate changes in nurses’ personal circumstances. Dynamic patient assignment systems would ensure that staffing decisions are based on clinical evidence for benefit instead of short-term financial targets. Advanced practice nurses could deliver expert care regardless of the patient’s physical location. Systems could fund innovation centers for nurse-led developments in care delivery and population health. A more nuanced value proposition for bold experiments in care delivery is simple: patients, families, and communities will directly benefit from a reinvigorated health care workforce that takes pride in their services. Compellingly, after such bold actions, care will likely be less expensive to deliver than the current state due to reduced spending on temporary staffing and ongoing employee recruitment and orientation.
A word of caution: major efforts to transform health care operations in the 1990s were guided primarily by economic considerations. In the 1990s, health care consultants dismantled professional nursing models and boosted the use of unlicensed personnel to reduce costs (Norrish and Rundall, 2001). These efforts often lacked signals of clinical efficacy and did not undergo rigorous evaluation. The net results were deteriorations in patient outcomes and demoralized health care teams, an overall net negative for the entire health care ecosystem. Any new solutions must be centered on the needs of patients and families, guided by clinicians, and carefully evaluated with patient, organizational, and employee outcomes.
The authors of this manuscript concur with colleagues Linda Aiken and Peter Buerhaus, who, at the 2022 American Academy of Nursing national conference, called for a “moonshot” effort to drive innovations in care delivery across the many diverse settings in which nurses serve. The glaring absence of bold experiments, led by multidisciplinary teams with robust evaluation plans, increases the likelihood of persistent and pernicious nurse vacancies. The authors issue this call to action for health system executives to join forces with physician and nursing leaders to create this moonshot for transformative change. Executives need to harness the creativity of their expert clinicians to propose and test innovations. Next, leaders can forge partnerships with public and private funders to launch projects that have the potential to transform care delivery in ways that center on the needs of patients and families and enable clinicians to focus their efforts on the populations they serve. Such efforts have the potential to achieve population-level health improvements and a sustainable and vibrant health care workforce.
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