'You have to maintain adequate staffing to preserve safety'

Since last June, Pam Cipriano has served as the elected president of the American Nurses Association, the nation's largest nurse association, representing 3.1 million registered nurses. She is a research associate professor at the University of Virginia School of Nursing. She previously served as senior director for healthcare management consulting at Galloway Advisory by iVantage, and as chief clinical officer and chief nursing officer for the University of Virginia Health System, Charlottesville. Modern Healthcare Editor Merrill Goozner recently spoke with Cipriano about the changing role of nurses, hospital staffing cuts, nurses' wages and efforts to reduce occupational injuries. This is an edited transcript.

Modern Healthcare: What changes are U.S. nurses going through today?

Pam Cipriano: We have been very focused on improving quality and safety in the hospital and home environments. There are lots of disincentives as well as incentives to provide better care and better outcomes. Nurses are very attuned to the fact that the whole economic equation of how providers get paid is dependent on improving quality. Also, nurses have been masters of care coordination for a long time. When we think about care moving to settings other than hospitals and well-orchestrated transitions, nurses are the key in making that happen. Nurses are operating more and more in care-coordination roles such as case managers or navigators.

MH: We are seeing a lot of the hospitals trying to cut back on staff or to hold down costs. Is this affecting the profession?

Cipriano: We are very concerned about the curtailing of staff. One way is actual reductions in force, and the other is not filling positions when there are vacancies. If a hospital is experiencing a downturn in volume, we would expect that they would adjust staff appropriately. But that is not always happening. One of our clear directives is you have to maintain adequate staffing to preserve safety. Research shows the amount of nursing care for hospital patients keeps them from all kinds of complications, affects the mortality, and affects the outcome and overall quality of life and morbidity of patients. One of our key messages to our hospital administrators is to make sure you have adequate staffing and involve your nursing staff and nurse leadership in deciding those staffing patterns.

We also are focusing on the education and redirection that nurses need to work in areas other than the hospital. We recognize that as a country we want to reduce our dependence on hospitals. We want to provide care in the home, in the community and through primary-care medical homes. So nurses are taking up new roles and looking at how they can move from the hospital to these other venues. We don't want to dilute any expertise in these other areas. There is a false notion that patients aren't as sick outside the hospital and (caregivers) don't need the same level of education and experience. We have to make sure that nurses in outpatient areas are being key decisionmakers with patients and families and are coordinating care. Nurses are a big part of the safety net.

MH: Are hospital administrators providing opportunities for nurses in making the transition to those other environments?

Cipriano: In the settings where an administrator has an integrated system, yes. That is one of the nice attributes when you have an integrated system of care, where the hospital has its own clinics, long-term-care facility and other ambulatory-care venues. They have a desire to maintain a strong workforce, so having opportunities to move staff within those areas is something that is done routinely.

MH: What are the issues driving nurses to take organized labor actions?

Cipriano: Nursing leaders need to have open dialogue with their management. It is a team sport. Nursing wages are very interesting. If you look at the long-term pattern and adjust for inflation, they have risen very slightly. Other jobs have a much higher entry. In the IT world, college graduates are probably going to out-earn nurses by almost double, at the same level of educational background.

But even more importantly, we want to make sure the working conditions are appropriate so nurses have opportunities for rest and respite and that they are not being asked to work too many hours, because we know fatigue contributes to potential errors. So it is a combination of a fair salary and a healthy work environment.

MH: What is the effect of more men entering the nursing field?

Cipriano: Not quite 10% of nurses are men. A recent study found that men are actually out-earning women. It is troublesome that we see a gender difference, even in nursing, that has been almost exclusively female for many years. I really can't explain what that study found. But we have had cyclic nursing shortages for years, and we are ignoring 50% of the population if we are not recruiting men to become nurses. So it's been positive to have more men entering nursing, because that diversity is important.

MH: An issue that has come up recently is occupational safety and health for nurses, especially back problems related to lifting patients. What is your organization doing about this?

Cipriano: Nurses rank fifth nationally in terms of jobs subject to musculoskeletal injuries, with nurse assistants ranking second. There are a lot of injuries every year, and some can be career-ending. So we give nurses a couple of different messages. One is, do not manually lift a patient. In the old days, people were educated that if you used good body mechanics, you could avoid an injury. That is really not true. Today, we say you should be able to deploy aids, from simple friction reduction sheets to ceiling lifts. Some organizations still have lift teams. They think if they hire big, burly guys, that will be the solution. But it's not safe for anybody to rely on that. So we say that nurses should work with their administration on complete policies and resources for moving patients. You must stop and say, “I need to use these assistive devices because if I'm hurt, I can't take care of other people.” And we don't want to put a patient in a situation that they could be dropped or they could get a skin tear because they are being moved inappropriately.

MH: One of the mantras we hear in healthcare is that all professionals need to be working at the top of their license. Do you see that as a threat or opportunity for nurses?

Cipriano: We see it as an opportunity. It's really important that we examine all the roles that are part of a healthcare team. We see the value of the nurse in outpatient areas and home care as the coordinators of care. While we recognize that many family members have been caregivers, we also embrace the community health worker concept. We are going to need a lot more people to be part of that array of caregivers on the team if we are going to keep people at home and healthy, as we see a larger aging population. So we are not looking at it as a threat. But we want to make sure that appropriate decisions are made about who constitutes that team. Who is the most appropriate caregiver? How can we bring needed services to the patient and family? Nurses are still a very important part of that.