Quality in life and death: can we have the conversations?

As nurses, we participate in providing social justice through the delivery of health care. While much of what we do supports healthier lifestyles and healing, we must also acknowledge that for an increasing number of our patients, life may have become irreversibly painful and unwanted. Nurses have acute sensitivity to the dilemmas faced by dying patients and their families. Our empathy and know-how in such cases dictates that we make an effort to relieve such suffering. Easing suffering will require assessments of the changing terrain of end-of-life care and the populations receiving that care. Dialogues can bridge the interest of patients, providers, and policymakers and ultimately legislation that reinforces ethical end-of-life care and ensures a voice for those who will be most affected.     

The art of leading with grace

Uncivilized environments take their toll on people who work there. Cultures of distrust are created and there is no warmth, reverence, or love available for the healing work of health care. We can blame the staff, or we can look at ourselves and recognize that the staff is merely a reflection of ourselves. Gracious leaders create a gracious and loving staff who care for patients and their families in extraordinary ways.     

Palliative care: a paradigm of care responsive to the demands for health care reform in America

Palliative care is poised to become a universally available approach to health care which addresses both the needs of patients and families experiencing serious, progressive, and life-threatening illness, and also the costs of delivering such needed services. Palliative care and hospice are part of a continuum of care with palliative care provided at any time during the illness trajectory, while hospice care is offered at the end of life. Within the context of health care reform, we believe palliative care addresses critical economic imperatives while enhancing quality of life even as death approaches. As leaders in health care, advance practice nurses, specifically, and the nursing community in general are best positioned with the knowledge, expertise, and commitment to advance the specialty of palliative care and lead the way in the reform of America's health care system.     

Ethics and economics

The author suggests that one way to better manage the burgeoning costs in acute care settings and improve patient care is by the earlier use of ethics case consultations and end-of-life support from ethics teams. This study determined that, in several very diverse clinical scenarios, timely facilitation of meaningful communication and decision making between patients, families, and health care providers can result in the more appropriate use of health care resources. While few of the patients in this study had recorded advanced directives in place, and there was initially a lack of family consensus in some cases, compliance with the ethics team recommendations led to a more appropriate clinical unit placement; and improved family support helped manage the costs of care and focus on the patients' quality of life. The decrease in the use of medical interventions and therapies after ethics consultations was consistent in all cases presented here.     

Staffing for end of life: challenges and opportunities

What would staffing look like if we committed to end-of-life experiences that were designed to honor the needs of the person dying, their loved ones, and the needs of the nurses and care team involved in the dying experience? When we think about the experience of death in a health care setting, it is essential we look at the needs of both patients and caregivers. Attending to the needs of patients and their families facing death, even if well defined, can be difficult to design into staffing plans and budgets in a way that would not put an organization at further financial risk. If we are going to commit to staffing practices that honor dying, in all it's dimensions and for all who are potentially impacted, we will most likely have to step outside traditional thinking to find answers.     

'Affordable' death in the United States: an action plan based on lessons learned from the Nursing Economic$ special issue

An eight-point action plan is proposed for lowering costs associated with end-of-life health care in the United States, as well as improving the quality of life experienced by patients and their families. This action plan was derived from an analysis of the six articles presented in this special issue of Nursing Economic$. The two major features of this action plan are: (a) expansion of hospice and palliative care, as well as (b) increased use of advance directives. Additionally, as pre-conditions for the effective operation of this action plan, the political, cultural, and legislative contexts that merit attention are discussed. Finally, arguments as to the desirability, feasibility, and sustainability of this action plan are offered.     

Effective workforce management starts with leveraging technology, while staffing optimization requires true collaboration

Effective staffing is at the very core of quality patient care. Staffing that achieves a balance between quality, safety, labor costs, and staff satisfaction is incredibly complex. Technology can make the complexity manageable and provide health care leaders with the tools to optimize their most valuable resource--their employees. Through such a partnership, the business intelligence brought forth will not only meet the unique needs and goals of each organization, but will also result in innovations and advancements in best practices around excellence in staffing.     

Economics,Ethics and Thanatology: Lessons from the Ancients

The normative presuppositions motivating rational choice decision-making based on optimizing objectives amount to a thin account of ethical economic behavior. Ancient thought offers insights that can provide a firmer basis both for personal, individual choice as well as for public policy. After a brief review of Epicurean and Stoic ethical principles, a comparison is made of modern economic and Hellenistic conceptions of rationality and rational behavior. These competing conceptions are then applied to an examination of a contemporary public policy problem, namely health care, particularly as this applies to “end-of-life” issues. The argument concludes that decision-making based on a eudaimonic conception of the good has the potential to provide us with a more efficient health care system as well as one that more satisfactorily addresses the needs of the chronically ill and dying patients who account for a highly disproportionate share of health care expenditures.     

Ambulatory care nursing: growth as a professional specialty

Ambulatory care nursing has emerged as a distinct professional nursing specialty. Many characteristics differentiate ambulatory care nursing from other specialty practices, including the settings, the characteristics of the patient encounters and the focus upon groups, communities, and populations, as well as individual patients and their families. A conceptual framework for ambulatory care nursing was developed in 1998 and recently revised, through consensus of leaders in the specialty. The key elements of the Ambulatory Care Nursing Conceptual Framework are the patient, the environment (both internal and external), and the nurse, practicing in three major roles.     

Complex home care: Part 2- family annual income, insurance premium, and out-of-pocket expenses

Annual costs paid by families for intravenous infusion of home parenteral nutrition (HPN) health insurance premiums, deductibles, co-payments for health services, and the wide range of out-of-pocket home health care expenses are significant. The costs of managing complex chronic care at home cannot be completely understood until all out-of-pocket costs have been defined, described, and tabulated. Non-reimbursed and out-of-pocket costs paid by families over years for complex chronic care negatively impact the financial stability of families. National health care reform must take into account the long-term financial burdens of families caring for those with complex home care. Any changes that may increase the out-of-pocket costs or health insurance costs to these families can also have a negative long-term impact on society when greater numbers of patients declare bankruptcy or qualify for medical disability.     

End-of-life care in United States: current reality and future promise--a policy review

Data collection and analysis of that data are vital to developing effective outcome measures when it comes to improvements in the cost and quality of delivered health care. The present state of end-of-life care in the United States is evaluated, focusing on statistics of disparities in access to and type of care provided across the country. Although only a few portions of the Patient Protection and Affordable Care Act deal with end-of-life care reform, the multiple innovative efforts occurring at state and local levels are proving very effective in improving end-of-life care. Possible improvements and obstacles to those improvements, and the involvement of the profession of nursing are highlighted. The focus of this investigation is to determine if the evidence supports the following imperative: that the money spent for end-of-life care be spent in a manner that benefits the patient and complements his or her wishes.     

Hospitality and service: leading real change

A patient's decision to recommend a health care organization and the patient's loyalty scores are largely determined by the interaction patients and their families have with the nurses. Hospitality is how the delivery of that product makes the person feel and is a dialogue that requires the server to be "on the guest's side" throughout the experience. The challenge for health care is to help our patients and their families transcend the usual routine care of our health care world and to experience an emotional connection that provides that sense of affiliation and emotional kinship with the organization and the staff. Moving from the service mindset in health care to the hospitality mindset that engages people positively and emotionally is what healing is all about.     

Pieces of the shortage puzzle: aging and shift work

Addressing issues important to the aging nurse and night-shift worker is imperative for retention success. It is important for nurse leaders to create an environment that will keep older nurses and night-shift workers working. The good news is that health care leaders are talking. Research is being done and will hopefully continue. Now it is time for health care leaders to welcome nurses, educators, and policymakers into their circle of discussion to preserve quality health care and retain our nurses at the bedside.     

The implications of nurse staffing information: the real value of reporting nursing data

There is a dearth of information about the relationship between the patient care contributions of nursing and its financial contributions to an organization. As consumers and legislators are becoming more aware of the ramifications of nurse staffing issues, and as they endeavor to address them with legislative solutions, the decision on how best to develop optimal staffing strategies may soon be taken away from nursing leaders. To maintain control of this important issue and develop solutions that will help highlight the economic and patient care contributions of nurses, a thorough understanding of the problem, and a new commitment are needed from nursing leaders to take charge of the issue. To relate nursing care to patient outcomes, meaningful data on the nursing care provided is needed in addition to data on the nursing needs of patients. Staffing and performance monitoring tools should be used to effectively plan, implement, and control financial and operating resources as well as measure the economic value of the nursing profession's contribution to the cost and benefits of patient care.     

Nurses leading the response to the crisis of palliative care for vulnerable populations

All nurses are prepared to be generalists in palliative care. Within the discipline there are nurses who seek advanced educational preparation and develop clinical expertise in palliative care nursing. These are our leaders in palliative care nursing who can exert influence in all health care settings to support nurses providing palliative care. It is nurses and advanced practice nurses in partnership who are capable of developing and advocating for palliative care across settings. The focus of care is the person, not the diagnosis or the setting. The viewpoint that "all nursing care is palliative care" can transform health care with nurses taking the lead.     

Childhood preventive care,adult healthcare and economic growth: The role of healthcare financing

We analyze the impact of healthcare financing on economic growth, focusing on the issue of the joint public–private financing of healthcare (co-payment). We use an overlapping-generations model with endogenous growth based on health human capital accumulation, where families pay for childhood preventive care and the government can either fully finance or co-finance adulthood curative care. From a growth maximizing perspective, distortionary taxes give an advantage to co-financing. Nevertheless, we prove that, if agents are assumed to be heterogeneous in preferences, full financing can become the best option.     

The effect of workforce issues on patient safety

The workforce of any health care organization is vital to its continued survival, but a highly competent and committed workforce is vital to its success. The evidence is clear: employees influence not only the financial performance of the organization, but also the safety and quality of the clinical care provided to patients. Health care organizations must understand these important linkages and have in place corporate strategies to manage workforce issues with a systems focus that ensures excellent leadership and operational processes, a healthy culture, and optimum patient outcomes. New levels of knowledge, resources, and implementation are needed to move health care in the United States to the next level of quality performance. Staff satisfaction and retention should be at the heart of the clinical improvement strategies. Such an approach will allow organizations to cope and thrive in an environment of workforce shortages and increasing consumer demand for quality. To quote Robert Waller, MD, of the Mayo Clinic, "The goal is the best care for every patient, every day. Our patients deserve nothing less.     

When caring stops, staffing doesn't really matter

How well do we understand the people side of staffing, and do we recognize the importance therein? Delivering care without caring is simply wrong. Health care leaders must take this concern seriously and find ways to invest in and set up structures that support healthy processing, by individual caregivers, of the many emotional situations that are a natural part of care delivery. Individual care provides must take responsibility for their own well-being and make choices that promote self-care. We must find more ways to recognize and address the needs of care providers who are facing emotional burnout or compassion fatigue, as they are both a threat to their own health and a potential risk to the patients and organizations they serve.     

Quality, patient safety, and the board

It is now broadly recognized that good outcomes for patients depend on more than a clinician's knowledge and skills and use of proven, effective practices or evidence-based medicine. Good outcomes also depend on the organization's culture, which affects how well providers and patients work together. Boards play a key role in helping their hospitals improve the quality and safety of the care they deliver--a governance imperative to ensure hospitals meet the needs of key stakeholders and perform effectively in an environment of reform. Nurse leaders who understand this key board responsibility will be better prepared to serve on boards and contribute to effective governance.     

'The environment matters' and 'designing toward the whole'

A nurse/health care executive/architecture specialist and an artist/designer offer insights to creating environments that effectively support the delivery of care, the wellbeing of patients and their families, and the well-being of the health care workforce. The care environment is more than bricks, mortar, doors, windows, walls, and flooring. It is a sanctuary where healing can take place, where the spirit can be released, and where the provision of care, often fairly intimate, can happen through the connection between patient and care providers. Evidence-based design has brought forth the kind of inquiry and solutions that begin to address what an environment for healing requires. The interaction of built environment, staff, patients, families, and doctors is an overlapping ebb and flow that relies at its heart on the ability to hold all the parts as having equal priority.