Nursing Process

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[music playing] welcome to caucus new jersey i'm steve adubato you know the affordable care act or so called obamacare is in full effect. and it's cley having a very big impact on the healthcare system including the need for more advanced

nurses. here to discuss the expanding role of nursing and the bigger healthcare picture we have judy schmidt who is the president of the new jersey nurses association doctor sheryl slonim chief nursing officer at

holy name medical center melissa sirola is an adjunct professor in the department of nursing at caldwell university and finally maureen sweeney-mcdonough vice president of the administrative services for

the newark community health centers i want to thank all of you for joining us. you know right before we got on the air and by the way there's gonna be a lot of great information in terms of the websites you can go to to get more information

right before we got on the air i said you know the aca the affordable care act otherwise known as obamacare, it's expanded the role of nursing and some of you have said nurses have always been very important in fact in some ways >>[laughter]

>>we're not in charge but we drive a lot of the healthcare system. fair to say? >>that's very correct >>talk about it >>i think nurses have really been at the forefront because we're the ones that take care of the patients. the ones that

are at the bedside. the ones that tell the doctors exactly what's going on with the patient and consult with the physician on what the right treatment plan is for. and that's what the nurses with bachelor degrees that do that. advance practice nurses take it a step forward

and begin the treatment for the patients. >>well what exactly is an advanced practice nurse? >>well it's someone who has advanced education how much? let's talk spefically >>okay so

>>a nurse okay break this down for us >>levels of education >>so masters prepared >>okay >>at least masters prepared going for the >>absolutely >>doctorate of nursing

practice model >>as we move forward in the profession but just to make it clear so the bachelors nurse starts is really the bedside nurse at first and then as they advance their degrees and get to the masters level they can become an advanced

practice nurse >>does the new law require does the federal government through the aca the affordable care act require that nurses have greater education? >>no >>it doesn't >>it doesn't?

>>it just increases the need as 300,000 new jersey residents have now gotten insurance on the marketplace there are more people coming into care and the need to be seen as there so a lot of like for newark community health center the... we're at capacity

so you're looking for more advanced practice nurses to assist the physicians and to work to provide wellness and prevention and things like that as more people are now comign in for services so the need you know for advacned practice nurses

is definitely there >>and the more expanded role now >>talk about that >>the more expanded role now for nurses the education is changing we're bringing them up to the level of a doctorate level in their education so

that they can go out and practice much more independently because the need is there for them to practice independently and i think we have to stop thinking of even our bsn's as bedside nurses >>bsn's?

>>bsn's >>bachelors >>a bacheors of nursing >>do you think we all know the acronyms here [laughter] >>excuse me >>there's so many in nursing >>go ahead >>bachelor's of science and

nursing are >>what should be the entry level and that's been debated we talked about this from since the early 60's >>sure >>we haven't been able to establish >>that's right

>>the bsn as the entry level for nurses there's still other ways to get into the nursing field but even the bachelors nurses are not bedside nurses because the jobs are not at the bedside anymore. the jobs are out in the community. the jobs are in so many diverse

locations that we tell our students don't expect to go into the hospitals when all of us graduated from nursing school we all went right into the hospitals those jobs were waiting for us we went you literally showed up and said what unit do you want to

work on and we went to work >>you make it sound like nursing isn't nursing anymore? >>well it's very different it's a different model >>well nursing is just different, we're doing in home care we can do almost a full icu type treatment for a

patient in the home >>and 30 years ago? 20 years ago? >>couldn't happen? never could happen >>not even possible >>not even possible? >>the technology wasn't there >>yeah

>>the technology moves from the fee for service sorry as the healthcare industry >>say that again since we moved >>as healthcare moves from the fee for service model to more value... >>explain what that means, fee for service model you come in

and? >>well a typical, you get paid for the services that you provide >>got it >>as now it's more value based payment with all of these accountable care organizations and these

initiatives, you're getting paid to keep people out of the hospital so decrease length of stay decrease admissions therefore the role of the nurses is not the traditional at the bedside it's more outside in the community keeping people out of the hospitals which

provides different challenges so you're actually required to be a different kind of nurse talk about it >>well we're actually judged by patient satisfaction and by our core... at least in e acute care setting where i'm working, we're judged by

our core measures. how well >>and real core measures explains what that means? >>core measures are our quality indicators for how well we do with certain diagnoses. so we're being reimbursed and we're being >>by whom? the federal

government? >>by the federal government the payers. by how well we make our patients happy and how well we score outcomes we're judged on outcomes >>and so how does that change the job of a nurse?

>>well the nurses clearly have to work quicker they have to be more astute their critical thinking skills have to be more exact because we need to move the patient through the system swiftly, and safely with quality as the overall goal

>>so i'm curious about this for someone who went into nursing, there's two different things i'm thinking of here one, with the change in the federal law, the affordable care act and we're doing this program as we go into november of 2014 the 2nd

enrollment period is happening november 15th into february but that's... there'll be more people enrolling which means the demand will be even greater. but i got two things going on in my head. one, for the nurses... for the new nurses who come into the

profession at least they have an idea or they think they know what they nursing profession is gonna be under the new guidelines but what about for the nurse who's been around for 20-25 years if not more. he or she now is having to adapt to this

new healthcare environment how challenging is that? for that person? >>i think it's very challenging but i will say that nursing will not change. nursing is a assessment. it's planning. it's implementing an evaluation we call that the nursing

process and it doesn't matter what setting you're in, if you'e acute care setting, you're out in the community, you're doing navigation, navigating means taking the patients through the healthcare is very complex it's a very complex process there's lots of opportunities

lots of places to go, there needs to be someone to guide the public on how to get through healthcare and we want to become a more healthy environment, that's what nursing is all about >>so as a patient, let's look at from a patient's point of view

first of all do we as patients most of us think it's simpler than it really is? >>i think you do until you have have an illness >>until you experience it >>and then you realize how complicated it is. such as a patient who... a woman who

has breast cancer, when she gets the diagnosis, she's stunned. doesn't know what to do, doesn't know where to go. it's the nurse that's gonna navigate her through the process of making her appointments. >>it's not the physician?

>>it's usually not the physician because he's so busy running from >>he or she? >>he or she from one patient into another it's the nurse that's gonna make the appointments with the patient >>he or she is the navigator?

>>the navigator >>the coordinator of care >>a specific law >>the coordinator >>it's ours... >>the nurse is the co... i hate to use the football analogy, the nurse is the quarterback?

>>but does the role of nurse quarterback change with the advent of the afordable care act? is it harder to be a quarterback in this...? >>it becomes more complex it becomes more complex >>because? >>because there's so many

avenues that we need to take in order to move the patient through a continuum of care to focus on wellness rather than trying to you know affect changes from a disease specific state we want a wellness specific state >>and focus on outcomes

so say you're talking about nursing education, so how does that nursing education change when you're trying to get students ready to go out and be this kind of nursing quarterback if you will in this increbly complex environment that he or she

has never even faced in the first place? >>so the curriculum changes >>the curriculum actually changes >>is the curriculum changing >>absolutely yes >>in nursing schools as quickly as, jump in

>>absolutely there are courses now there are courses in leadership that were never taught and when we were >>healthcare policy was never taught >>how to be a nurse leader how to run

>>how to be a nurse leader? >>yes. what is leadership? how do you lead other nurses? >>hold on back up devil's advocate. someone says i signed up for nursing i didn't sign up for leadership i signed up to be a nurse >>and all nurses are leaders

>>if i wanted to sign up for business school >>i get a leadership course that's what i would do you say? >>see the changes when we were in nursing school we were told go and take care of the patient and don't think of anything else, we were told

to take care of the patient make them happy and do the disease specific things that were part of the nursing process >>right >>now i take the nursing process with my students and i teach them how to

acvocate for healthcare how to navigate through the healthcare system, they have to understand who the payers are because that's going to effect not the care that we give but where it's given how it's given the reimbursement all of that so

>>what does that have to do with leadership? >>they need to know that they need to be leaders in this environment and understand how to take the patient through that and how to be the advocate for the patient they need to

understand how to lead >>they're not only the person that was directed to they're now the directors. they're navigating they're bringing the patient through they're leading the way, it's not the leader as in nursing where it was a manager of a unit it's now the

nurse that's the manager of the patient with the healthcare >>does it require and it's so interesting because i do a fair amount of outside of this work >>mm hmm >>my other part of my life

my professional life has to do with a lot of leadership development and i love working with nurses because i do find them to be natural.... i shouldt say natural born leaders but naturally responsive to leadership coaching and they do understand the need for

>>yes absolutely >>for being in, the need to be a leader but here's what i'm struck by. do you feel that there is a need to be even more assertive i'm bordering on the word aggressive i don't want to use it here more assertive than ever before in this current

post aca environment? as a nurse leader the need to be more assertive as an advocate on behalf of patients as you navigate the system, more assertive as you're communicating negotiating navigating on behalf of patients you believe that?

>>i do believe that >>well i think that you definitely are the voice of the patient and i think people who are coming into the healthcare system have worn out they don't have experience navigating the system so they really don't even know

where to begin they're at square one so you really do have to take these newbies for lack of a better word from point a to point c >>what makes it particularly challenging to navigate in this environment today? >>it's very fragmented

the healthcare... >>fragmented? what does that mean? break it down? >>the care is moving from that silo to now the new paradigm shift which is the continuum of care so before there was... >>well you're using phrases

like continuum of care i don't think the average person even knows what that means >>okay well let me explain that so we're together working with physicians in say the aco environment okay the accountable care organization >>it's an aco the accountable

care organization go ahead >>okay so physicians and hospitals are forming relationships bonds that before didn't exist >>hold back up, hospitals and physicians weren't on the same team before? what? >>i can make a wonderful

analogy >>i wish i could take credit for it i was at a conference and i heard it but you know what a parallel play is with children, in a sandbox? >>parallel play, two kids playing together >>yes

>>they... they're playing together in a sandbox but they're really not playing together >>but they're not playing together? >>they're playing side by side >>that's how physicians and hospitals have always worked

now because of affordable care we're bound to join together and become partners >>meaning you have no choice? by... you have no choice? >>because of the way the healthcare system is being driven, it's a totally different paradigm

>>how is that working? >>so far well that's why i said to you at the beginning of the show the jury is out cause we're seeing how that's working... it's new. >>and what is the role of nurses in the formally what was formally parallel play

as you argue between hospitals and physicians and then where is the place for nurses in this? >>to knit the entire system together for the patient >>you're the glue? >>we are the glue >>the physician most... i don't want to generalize from your

experience i know it's anecdotal i don't know what studies are out there on this it's too soon >>anecdotally, do you find most physicians responsive to the role that nurses play as you describe as being the glue as being the quarterback the

players who keep things together in the sandbox? >>many do >>most do? >>i think they have to because things are changing >>they have to? >>well because things are changing so rapidly and they

have got... they've gotten so busy that they have to rely more and more on the nurse and enable her to do more and him or her to do more and more independently so >>so nurse practitioners...? >>nurse practitioners >>which are?

>>advanced practice nurses >>are most physicians supportive of the idea of nurse practitioners doing more in terms of actual clinical procedures that had previously only been done by physicians but now there aren't enough primary care

physicians, are most physicians saying yup, let's have nurses do those things because we need them? is that what we're hearing? >>it depends >>it depends? >>it really depends >>well i think

>>well what's the law right now? >>it really does depend >>the law is that you can't do t >>oh it's changing the regulations are changing >>can most advanced practice nurses right? >>practice independently? yes

>>practice independently? >>you just have to have a physician... >>oh you have to have a physician sign off on certain things? >>well you have to have a collaborative agreement >>a collaborative agreement

>>so that you don't have to work in the same place at the same time but you have to have somebody if you need to have a question that you can pick up the phone and run something by them >>does that make any sense? >>yes it does

>>so it's working? >>it is working >>doctors and nurses love each other don't they? >>i think by and large yes >>by and large >>they do >>they're a good team >>relatively close

>>we're a good team >>okay so you have to work together on behalf of the patients >>absolutely patient comes first >>but as we begin to wrap up the show i'm curious about this, on behalf of the patient

the patient really actually doens't want to know any of this you know that right >>the patient doesn't want to know what's going on with the hospital the medical staff the nursing staff, they only want to know are you gonna help me? are you going to help

my family member get better? >>and that's what nursing is >>nursing makes that seamless so the patient doesn't even realize they're being moved the system, and it makes it as easy as possible for the patients, that's the core of nursing

>>the coordinator of all the care >>and that hasn't changed that's been consistent over the years >>it's just the setting that's changed, we've gone from an acute care hospital environment to a community

based environment, from a chronic illness to a wellness >>prevention >>and prevention >>well hold on but where is the place for people who are still chronically ill? >>they still are, and nursing will still continue to help

those chronically ill patients to hopefully move them towards a more wellness based so that they're not going back into the hospitals every 30 days that they're being taken care of in the community by physicians advanced practice nurses and other healthcare

professionals in a community setting and not in the hospitals >>because you're also reimbursed or not >>based on the degree to which a patient and who has been treated at a hospital goes back to that hospital for the same >>diagnosis

>>diagnosis or not >>and penalized >>you can't >>help us understand that what's that all about? >>that's part of the and the rules that are coming down through medicare and medicaid for all cause

readmissions within 30 days if you're readmitted for the same diagnosis within 30 days the hospital won't be reimbursed for that or the physician or if you have any admission for what they call ambulatory sensitive conditions around heart

failure and copd so >>copd? >>chronic obstructive pulminary disease so basically the payers are saying they're making the lines drawing the lines >>payers meaning the federal >>the medicare or the

insurance carriers medicare medicaid are saying what they will and will not pay for so they're really dictating who how people practice how hospitals practice how providers practice whether it's nurse practitioners or physicians. and the shared

savings like through medicare and holy name is an aco are paying the shared savings based on these quality metrics and if you hit them or not so is really driving how nurses' roles change too to do the i's and cross the t's on those different quality metrics

because there's a dollar attached to it >>so could we use... chf which is congestive heart failure as an example >>so we discharge the patient and we move them through as quickly as possible right based on what are the

reccommendations are and the >>best practices >>best practices gold standards and so forth we discharge them they go home but they go to a home that perhaps has hotdogs in the refridgerator and canned soup >>their home

>>in their own home >>well you can't control what they do in their home >>which is where the nurse comes in >>where? what does a nurse have to do with it? >>because the post acute services nurse which may be

home care can go into the home evaluate what's in the home go into the cubbards see what's high in sodium to keep that patient out of the hospital and safe >>that's the role of the nurse? >>in the post aca environment?

>>today it is >>we haven't... hold on >>safety checks environment all of that >>don't we have a nursing shortage and let me ask you do we have enough nurses to do what you just described? >>right now

>>you go into people's homes and to help monitor what they're eating and how they're living and whether they're doing the things necessary to reduce the odds that they will come back to the hospital because they've done the wrong thing

>>it's happening now and it's also being supplemented by telehealth where we can put monitors and different types of scales >>scales in the home >>blood pressure machines where they can take their blood pressure and they can

>>ipads >>transmit it directly to the nurses so we can do it >>tablets >>so there's all this technology >>how much is technology driving all of this? >>a lot

>>absolutely when the technology didn't exist the patient stayed in the hospital because we couldn't do this care at home >>because this technology was in the hospital >>we have the ventilators that we can put in patient's

homes now which didn't exist we have small little ventilators that i can put on a four year old as a backpack and send them to school, that didn't exist 20 years ago >>but how much, even though nurses are playing a greater role than ever before

when it comes to healthcare and the post aca environment doesn't this also say that a large part of the outcomes that patients experience falls on patients? >>yes people have to be responsible >>i mean and why don't be

candid about the fact that a lot of folks out there are saying help me get better doctor help me get better nurse and if i don't somehow you screwed up? i mean no seriously >>they don't do that anymore >>it's about setting self

management goals for the patient and finding out what's important to them >>talk to folks about what you do in your organization with respect to that >>it's all about patient education and trying to determine what's important

for the quality of life for that patient >>is it harder to do in certain communities? >>it is absolutely >>describe that >>well it has a lot to do with their health literacy level >>describe where you serve

>>i serve in a newark community so we have seven health centers five in newark one in irvington and one in east orange >>all urban? >>and it's definitely >>harder to do this in urban >>definitely

>>the health literacy the literacy levels the educational levels are lower >>what would be the correlation between as you were just calling it health literacy and health outcomes? >>there's a big disparity between the two

>>because there is a bigger need to educate and these are a lot of immigrant populations new to the country >>language? >>language barriers a lot of creole speaking and spanish speaking >>cultural issues with diet

>>does it make the role of a nurse even greater in such a situation? and in the health centers there's a higher there's less rn's registered nurses and a lot more lpn's >>explain that and the health centers in the few minutes we

have left there are fewer >>registered nurses bachelor prepared so you have more that are liscenced practical nurses due to budget constraints you know it's just part of it so in the hospitals you see the registered nurses at the

bedside unless you have experience you can't get a job in the hospital >>wow >>so it's a bit of a vicious cye >>i think we're in a transition period >>what does that mean? >>we're an acute based health

care system everything is hospital hospital hospital >>but that's not what just i, we spent 28 minutes talking about everything's moving out of the hospitals >>it's all moving out but it's moving out very slowly the health centers are a great

progress towards bringing patients out into the community but we still have the hospitals and as hospitals transition to lower and lower census we'll see more and more community based healthcare centers of advanced practice nurse practices more

physician practices and then slowly you'll see less and less hospitals and more and more community based health care >>you believe that? you believe there will be fewer hospitals? you believe that? >>i do >>i do i believe that the walls

of the hospital are shinking because this paradigm shift is happening it's happenig slowly as judy said >>slowly >>but yes it's happening >>because it's just the nature of where healthcare is being delivered?

>>of where it's shifting to >>where it's being paid for >>and that's not even a good or bad thing it's just the way it is? >>pretty much i mean that's the environment we're in now with this whole new system >>and nurses are more

important than ever before? >>than ever before >>and it comes at a time when as you said the primary care physician numbers are dropping. that's where the need is coming from and they widen the gap >>and that's not gonna get

better anytime soon. talk about that in the couple minutes in a minute left >>yeah i mean and you know i can't speak specifically to why there's less primary care >>it's just the way it is >>physicians it's more of specialty interests less

people are going into medicine for various and sundry >>i think it's also... >>reasons >>the time it takes for a physician to prepare as many as six to eight years >>so the cost is very expensive >>the cost for that

>>so i think we're gonna see a lot less primary care physicians a lot more specialties and that's the ideal location for again advanced practice nurses to provide >>primary care fully >>primary care >>keeping people healthy

>>so ultimately as we continue to debate oh why don't we have more primary care physicians we need to have more primary care physicians you know how do we change the medical school environment all that can go on but in the end nurses continue to play this incredibly

important role particularly post the affordable care act and we are so glad that you and your colleagues are there every day taking care of the rest of us and serving as the quarterback taking care of our healthcare. thank you so much. great job.

>>thank you >>the preceding program has been a production of the caucus educational corporation celebrating over 25 years of broadcast excellence and thirteen for wnet njtv

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