What is “best nursing care?” Deconstructing the business model driving healthcare


The current feature on the AJN blog “Off the Charts” is a post titled “The Limitations of Rating Nursing Care by Customer Surveys.”  Since I have, for many long years, decried the practice of basing the evaluation of nursing care on patient satisfaction surveys, I jumped at the opportunity to read this post!  Of course we need and want to know how patients perceive the care we provide, but how we obtain this information, and what we do with this, is a key factor.  Since this approach derives fundamentally from the corporate business model, and is now practiced in the context of this model, the substance, use and outcomes of this practice are deeply flawed when examined from a NurseManifest perspective.  The example the author, Juliana Paradisi gives as an example of her best safe and compassionate nursing care involves a woman in extreme distress who “fired” her as her nurse –  a situation in which she could not break through the barriers inherent in the patient’s distress, but provided a level of care that was exemplary.

Even though the overarching business model that governs healthcare now is probably not going to go away soon (Ha!) – we can raise awareness of the limitations that this imposes on our practice, select specific actions to take to place these practices into context, and work to achieve whatever changes we can make.  We can start with addressing the question: “What is best nursing care” from the perspective of the values in the Nursing Manifesto.  There is no single answer to this question – but there are insights to be gained by thinking, talking and writing the ideas that arise from it. Once we have expressed our ideas, we can examine new and better ways to document our care, and continue to address the limitations of the existing practices that fail to document and support our best practices.

We welcome your ideas here – and stories about the times you provided what you think is the best nursing care!

off the charts

Full Practice Authority for APRNs in the U.S. Veteran’s Administration


On December 14, 2016 the U.S. Department of Veteran’s Affairs issued a final ruling authorizing full practice authority of Certified Nurse Practitioners (CNP), Clinical Nurse Specialists (CNS), or Certified Nurse-Midwifes (CNM) in the VA system.  This final ruling does aprn-scales_lgnot include Certified Registered Nurse Anesthetists (CRNA), but is inviting commentary on “on whether there are access issues or other unconsidered circumstances that might warrant their inclusion in a future rulemaking.”  This is a huge victory – one that serves the interests of the patients who receive care through the V.A.  As stated in the ruling:

This rulemaking increases veterans’ access to VA health care by expanding the pool of qualified health care professionals who are authorized to provide primary health care and other related health care services to the full extent of their education, training, and certification, without the clinical supervision of physicians, and it permits VA to use its health care resources more effectively and in a manner that is consistent with the role of APRNs in the non-VA health care sector, while maintaining the patient-centered, safe, high-quality health care that veterans receive from VA. (https://www.federalregister.gov/documents/2016/12/14/2016-29950/advanced-practice-registered-nurses)

Various physician groups, including the American Medical Association, have registered strong opposition to this ruling, which in part is responsible for the exclusion of CRNAs (see Forbes report here).  Part of the objection from some physicians is the claim that full practice authority for APRNs (i.e. APRNs can practice without physician supervision within the scope of APRN practice) is that physician-nurse collaboration is undermined. Those of us who follow the politics of this relationship recognize the absurdity of this claim, but nonetheless, this very current situation reminds us that we still have a long road ahead in establishing nursing’s sovereignty over our own practice.  For more about the long-standing physician opposition to initiatives such as this, see the excellent 2012 report on the ‘Truth About Nursing

If you are inclined to comment on the exclusion of CRNAs from this ruling, you must do so by January 13, 2017. Here are details about how to comment:

Written comments may be submitted: Through http://www.Regulations.gov; by mail or hand-delivery to Director, Regulations Management (02REG), Department of Veterans Affairs, 810 Vermont Avenue NW., Room 1068, Washington, DC 20420; by fax to (202) 273-9026. Comments should indicate that they are submitted in response to “RIN 2900-AP44-Advanced Practice Registered Nurses.” Copies of comments received will be available for public inspection in the Office of Regulation Policy and Management, Room 1068, between the hours of 8 a.m. and 4:30 p.m., Monday through Friday (except holidays). Call (202) 461-4902 for an appointment. (This is not a toll-free number.) In addition, during the comment period, comments may be viewed online through the Federal Docket Management System (FDMS) at http://www.Regulations.gov.

Have you ever considered being on a Board?


Here at the NurseManifest project, we have tended to emphasize grass roots, “on the street” kinds of activism to bring our deepest nursing values into everyday experience.  But manifesting nursing values needs to happen everywhere, and one of the spheres whereconference-table this is vitally important is in the Board Rooms, large and small.  Lisa Sundean, who is one of our NurseManifest bloggers, is embarking on her dissertation project to explore nurses on Boards, and in the interest of sharing her work wide and far, she has established website and blog – SundeanRN.org!  Her first blog post is now available, explaining why this is vitally important!  I highly recommend that you read her post: What do Boards Have to do with Nursing?  And if you have never considered serving in this capacity, think about it now!  We need to be manifesting nursing everywhere – at the bedside, the chairside, the curbside, and yes, the board side!

The Power of Nursing


On January 24th in the early morning hours my husband Brian woke me up because he said his left arm was hurting and he was nauseated.  After I gave him two aspirin we rushed to the ED of our regional hospital….He had a myocardial infarction in process.  The cardiac cath team was called, and an amazing interventional cardiologist performed a balloon angioplasty to open up the blocked artery.  After Brian was stabilized in the CVICU he was transferred to the CV Step Down unit to wait for surgery.  On January 29th the cardiothoracic surgeon performed a CABG x 4 and Brian was discharged on February 3rd.  It was quite an ordeal.  There are always lessons we learn when we are the recipients of health care.

As you can imagine this has been a life-altering event for both of us. During this critical time every person that we encountered and every circumstance that occurred, big and small, mattered to us.  I can honestly say that Brian and I experienced the most excellent care that I could ever imagine, and this made a significant difference in his healing and my experience as a family member.

The nursing staff at this hospital were wonderful. We know that nurses are the heart and soul of any hospital. Every single nurse that we encountered was knowledgeable, skilled, attentive and compassionate.  They were truly person and family-centered.  Every one of them asked how she/he could be helpful to us.  Watching the nurse caring for Brian immediately after surgery in the CVICU was amazing to me.  It was like watching the conductor of a symphony.  Her technological competence was incredible…she monitored everything moment by moment, while continuing to focus on Brian as a person experiencing this critical event, and on me as a wife fearful of what was happening.  When I was waiting for news of Brian’s condition during surgery, several of the staff stopped in to encourage me and to give me updates if they could.  This was so meaningful to me.  When Brian was recovering, the CVICU staff pushed and encouraged him and did anything they could to make me comfortable.  All the staff on the step-down unit exquisitely cared for Brian, supported us and made us feel “at home”.  I’m so grateful to the nursing staff for creating the healing environment where this level of care happens.

We often hear about the horrors of poor nursing care, so I wanted to share this story of hope and encouragement with everyone.  I am so proud to be a nurse because of the profound difference we make in the lives of people in the most vulnerable moments of their lives.  Yes, our cardiologist and surgeon saved Brian’s life, but the nurses were equally biogenic (life-giving) to both of us.  They preserved our dignity, prevented complications, prepared us for discharge, facilitated a smooth transition, allayed our anxieties, relieved our pain, provided comfort, lifted our spirits with laughter, gave us critical information, challenged him to do more than he thought possible, instilled hope for the future, involved us in choices, and took the time to listen to our fears and rants.

P.S. Brian is in cardiac rehab now and is recovering.

Never ever ever underestimate the power of nursing. We transform lives by healing through caring.

Celebrating recovery with Brian!

Celebrating recovery with Brian!

Call to Action for 2016 NurseManifest Study: Request for Co-Creators


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a quote from The Lorax by Dr. Seuss

You are invited to comment, collaborate, and co-create a global NurseManifest research project, to be carried out later this year.

Previously in 2002 and 2003 we asked nurses what it was like to practice nursing, and what changes they envision to create the conditions for ideal practice, using emancipatory methods.

For 2016 I propose we explore the topic of excellence in nursing care, from the perspective of patients and caregivers, using Appreciative Inquiry.

With a blog readership of over 7,500 people, we now have the capacity to carry out the international study envisioned by the NurseManifest Project founders over a decade ago, and make a global impact through our collective action.

Some critical questions we might ask include:

  • What is like to be the recipient of excellent nursing care?
  • What specifically about your nursing care experience made it excellent?
  • How would healthcare be different if every nursing interaction was excellent?
  • What would it take to create a healthcare system where excellent nursing care is the norm?

Some opportunities to participate include:

  • Host a conversation group with patients and family members who have received care from a single health care organization or network of providers.
  • Host a conversation group with patients and family members who have received care related to a specific condition or life event.
  • Host a conversation with a community group, with co-workers, or even with your own family.

Some ideas for dissemination:

  • Present at national and international conferences in 2017
  • Develop a series of manuscripts for peer-reviewed journals
  • Turn the findings into a book
  • Use the findings to inform a public service campaign about nursing and policies impacting nurses

Please add your ideas in the comments section below this blog entry or write to Olga Jarrín at olga.jarrin@rutgers.edu by June 1, 2016 – in time to have a shared protocol and IRB approval in place for interviews and focus groups to begin in September, 2016.

For more information about Appreciative Inquiry see the website: Appreciative Inquiry Commons. Case Western Reserve University, Weatherhead School of Management. April 18, 2016. *Note: This repository of information Includes Appreciative Inquiry resource materials in 22 languages. https://appreciativeinquiry.case.edu