DiversityNursing Blog

AMERICA’S hospitals are the most expensive part of the world’s most expensive health system. They accounted for $851 billion, or 31%, of American health spending in 2011. If they were a country, they would be the world’s 16th-largest economy. And they are in the midst of dramatic change, much of it due to the “Obamacare” health reforms.

The most visible change so far is that big hospital companies are getting bigger. In the latest of a string of recent mergers and takeovers, on June 24th Tenet Healthcare said it would buy Vanguard Health Systems for $4.3 billion including debt. The combined group will have 79 hospitals and 157 outpatient clinics.

Others are going further, turning the industry’s business model on its head. In Massachusetts, Steward Health Care Systems is trying to drive patients out of its hospitals and into cheaper clinics. The pace of change varies from one hospital group to the next. But beneath the shift is an argument—by politicians, insurers, patients and some investors—that the old business ways of hospitals are untenable.

America has more than 5,700 hospitals, with non-profits outnumbering for-profits by nearly three to one. Most of these share a familiar business model: sell as many services as possible at the highest price. This bodes ill for those who pay, whether employers, the government or patients themselves. Doctors receive a fee for each treatment, so there are few financial incentives to keep patients well. And since the health market has the transparency of a concrete bunker—patients usually do not know the price of treatment until after they have received it—American hospital stays are unusually expensive (see chart). It is little wonder that health spending overall accounts for nearly a fifth of GDP.

This dysfunctional system will welcome millions of new patients next year. Obamacare requires everyone to have some form of health insurance from 2014. To that end it expands Medicaid, the government’s insurance scheme for the poor, and subsidises private insurance policies which will be offered via new exchanges to be set up in each American state. More people with insurance should mean more patients seeking treatment, so the reforms would seem to herald a golden era for hospitals. Indeed, hospital shares have soared since the Supreme Court upheld the health law’s constitutionality a year ago.

Nevertheless, hospitals face mounting pressure to change. In recent years the volume of patients at most hospitals has been flat at best. The recession is partly to blame, since sacked workers lose their insurance. The shifting of some treatments to outpatient clinics has undercut some hospital revenues. And employers have increasingly required their workers to make out-of-pocket contributions towards the cost of their health care, which makes them a bit less likely to seek treatments.

Obamacare itself is not all good news for hospitals. It will bring revenue from newly insured patients. But it will also cut the rates the government pays for Medicare, the health scheme for the old. By 2019 these will cancel each other out, reckon analysts at Bank of America Merrill Lynch. And the Medicare cuts already announced may not be the last. The reforms may create fewer new patients than expected: some people may ignore Obamacare’s “mandate” to buy insurance, since the penalties are small. State and federal officials are scrambling to get the exchanges ready in time. Some Republican governors are refusing to expand Medicaid.

Obamacare also includes incentives for hospitals to provide quality, rather than quantity, of care for publicly insured patients. Medicare will penalise hospitals that discharge patients only for them to return within 30 days. Groups of doctors and hospitals can apply to be designated as accountable-care organisations, or ACOs, which will be rewarded for keeping the cost of Medicare patients’ treatments below a certain level. (They thus have broadly similar aims to health-maintenance organisations, or HMOs, a type of private health plan that pays a fixed fee to doctors and hospitals for the patient’s care).

Last month the Obama administration opened another line of attack on hospital costs by publishing their price lists. These showed huge variations. In practice, insurers negotiate special rates, and these remain mostly hidden. But scrutiny of prices is likely to intensify, as more members of employers’ health schemes are forced to shop around for treatments.

Physician, know thy costs

The reforms, and the other pressures on the hospitals, have prompted them to launch a big efficiency drive. The well-respected Cleveland Clinic is offering shared medical appointments: a doctor tells several patients how to manage diabetes, rather than counselling them individually. Robert Kaplan and his colleagues at Harvard Business School are helping hospitals measure their costs. Many do a poor job of recording how much each type of treatment costs them in terms of doctors’ and nurses’ time, materials consumed and so on.

Hospitals are also seeking economies through dealmaking. All sorts of combinations are being seen, says Martin Arrick of Standard & Poor’s, a credit-rating agency: big, stockmarket-listed chains like Tenet and Vanguard are merging; Catholic hospitals are getting ecumenical with non-Catholic ones; and non-profit outfits are partnering with for-profits. There were more than 200 such deals in 2011-12, according to Irving Levin Associates, a research firm. This does not include many purchases by hospitals of doctors’ clinics.

The combined Tenet and Vanguard will have hospitals and clinics across 16 states. This will make it easier to standardise clinical practice, get discounted supplies and make the most of investment in new medical technology. Most important, a bigger firm will have more clout in negotiating prices with health insurers.

The most seismic shift, however, is the move away from the fee-for-service model. How can a hospital profit from delivering fewer services, when it is organised to deliver more? HCA, a quoted company with 156 hospitals in 20 states, is all but ignoring the question. Vanguard is one of few listed chains to have started looking for answers, including taking part in ACOs.

Steward, which is only three years old, seems to be the most ambitious in embracing change. It was created when Cerberus, a private-equity firm, bought a struggling chain of Catholic hospitals in 2010. Steward does not aspire to have the best hospitals in America—indeed it sends its most complex cases to a rival medical centre in Boston. What it wants to offer is good, convenient, reasonably priced care. Steward has signed up as a Medicare ACO and also has contracts with private insurers that reward it for keeping patients well as opposed to paying it by quantity of treatments. The company has 11 hospitals, up from six in 2010, and a network of 2,900 affiliated doctors, up from 1,100.

Steward is making efforts to ensure that patients do not suffer expensive relapses: nurses scroll through records to confirm that patients have collected their prescriptions and had their check-ups; more home visits are being made to recently discharged inpatients. But it is unclear overall whether such efforts will boost profits, or indeed lower America’s health spending, let alone both. Large hospital chains, thanks to their clout with insurers, are more likely to raise prices than cut them. Steward’s prices are lower than Massachusetts’s most expensive hospitals, but higher than those of some competitors.

As for ACOs, they have had a good start: more than 250 have been formed so far. But their success is difficult to predict. ACOs are responsible for the costs of a given set of patients, but those patients can seek treatments outside the group of providers that form the ACO. This may make it hard to contain their costs.

George Clairmont, who leads a doctors’ group that partners with Steward, is excited by the prospect of a new era. “We are part of a major change in health care that we haven’t seen since the beginning of the 20th century.” But like a novel treatment for a chronic ailment, the cure for America’s bloated hospital industry will need careful monitoring for side-effects.

by Courtney H. Lyder

In a recent editorial in The New York Times, Theresa Brown wrote about how clinical hierarchies and the impact of conflict between nurses and physicians can be deadly for a patient. She said "when doctors and nurses don't get along, it's the patient who suffers."

A lot of studies show that poor communication is linked to adverse patient outcomes. For example, of the 1,243 sentinel events reported to the Joint Commission in 2011, communication problems were identified in 60 percent.

By its very nature, healthcare is complicated; it is a rapidly changing environment and unpredictable. Professionals from a variety of disciplines can care for a patient during a 24-hour period, which can limit the opportunities for face-to-face communication.

Physicians and nurses are expected to work together, not only practicing side by side, but interacting to achieve a common goal: the health and well-being of the patient. But there are several factors that can make effective communication between nurses and physicians particularly difficult to achieve, including historic tension; conflicting viewpoints based on education, training, communication style; and terminology and existing communication processes that are inefficient at best.

With the focus of healthcare moving increasingly to the team approach, it becomes even more critical for physicians and nurses to work in collaboration. Higher education institutions including UCLA and the University of Virginia, for example, are working to improve how nurses and physicians work together before they enter the clinical environment.

The University of Virginia now requires interprofessional education for its nursing and medical school curriculums. Courses, training modulus and even faculty members are shared across both disciplines. Medical and nursing students are taught to respect each other's areas of expertise.

In the Fall of 2008, the UCLA School of Nursing and the David Geffen School of Medicine at UCLA, introduced a pilot program to integrate nursing students (in this case advanced practice students) and third-year medical students. The result was an innovative program that focused on content, such as communication with patients, ethics, behavioral medicine and other psychosocial issues. The idea was to get the two groups working together sooner rather than later so students from both schools could develop team-building skills, increase their awareness of each other's roles and get used to working together in making decisions to improve patient outcomes.

Our initial results indicated the students found the experience to be of great value. In addition to assisting students with their clinical decision-making skills, the discussions that took place during the course provided an excellent forum in which the nursing and medical students gained a better mutual understanding.

I believe collaborations like this represent the future of medical and nursing education. No two groups of health professionals are more interrelated in practice, and by starting here, we allow them to understand each other and to grow up together as students.

We are now taking the next step by creating assessment tools to evaluate interprofessional competencies not only in the classroom but in clinical practice settings as well. Tools such as an iPad app will allow instruction leaders to assess actual collaborative practices through observations and walk-throughs in clinical settings. Our ultimate goal is to disseminate the tools with a wider community.

Patient safety needs to be our top priority. Successful delivery of healthcare needs to be interdependent and respect shown for the education and knowledge of each team member. Interprofessional education is an excellent start.

Courtney H. Lyder is dean and professor of the UCLA School of Nursing, professor of Medicine and Public Health as well as Executive Director of the UCLA Health System Patient Safety Institute and Assistant Director of the UCLA Health System.

By DEREK THOMPSON 

Here's what that graph (via Brookings) says. In the last ten years, job growth in America's non-health-care economy has been dreadful. Just 2.1 percent total -- or barely 0.2 percent per year. (Yes, that's point-two percent annual growth.) In that time, the U.S. health care sector has grown more than ten-times faster than the rest of the economy, adding 2.6 million jobs.

There are a couple stories that branch off from this graph. One is the unchecked growth in health care prices over the last few decades, which has made the medical industry the one truly recession-proof job engine of the economy. Two is the concentration of job growth in local service industries shielded from the global supply chain. And three (related) is the sad decline in construction and manufacturing jobs. 

Let's pull back the lens to 1990 and take a picture. Take a look at the growth of health care employment (in red) and the decline in construction and manufacturing employment (in blue).

According to the BLS, the two fastest-growing jobs in the next decade -- by far -- will both be in health care: personal care aides and home health aides.

I'd prefer not to muddy a clear statistical observation here with a provocative claim that health care's relentless, unstoppable employment growth is a goodthing or a bad thing, exclusively, because it's certainly both -- an emergency source of recession-era employment and a symptom of health care inflation. I knew health care had been the most important driver of national employment over the last few years, but I had never seen the case made so starkly.

Source: The Atlantic

By Debra Wood 

While among the most rewarding professions, nursing is not without its challenges. Nurses are exposed to numerous risks, sometimes with life-changing or life-ending consequences, such as nurses who died during the SARS outbreak or lost their lives falling asleep at the wheel after a long shift. Most adverse events are more mundane, but a back injury can end a career and a needlestick can pose serious health risks. 

To keep you healthy and safe, NurseZone.com queried a panel of experts who share this list of 10 reminders and tips on how to minimize the chance of nursing job-related injury or illness:

1. Clean your hands 

“Wash your hands to prevent illnesses’ spread,” said Arvella Battick, MSN, RN, PHN, an instructor at Everest College in Anaheim, Calif.

When it comes to illnesses, my number one rule is to wash your hands, agreed Jumi Harris, MHA, MT (ASCP), manager of ancillary services at Levindale Hebrew Geriatric Center and Hospital. It “sounds very basic, but this is the best way to avoid getting sick.”

2. Use the lift and transfer equipment 

My number one way to avoid injuries on the job is to use lift devices instead of trying to lift a patient or resident manually, said Harris, adding, “Sometimes a nurse may think it’s too time consuming to get and use a lift or that the person is not too heavy. However it only takes one wrong move to injure yourself, so my advice is always use a lift device with the proper training and protocols.”

Renee Watson, RN, BSN, CPHQ, CIC, manager of infection prevention and epidemiology at Children’s Healthcare of Atlanta, added that nurses should use the appropriate equipment to lift anything heavy, such as soiled linen bags. 

3. Watch for hazards and practice good body mechanics 

Practice ergonomics and good body mechanics, suggested Watson. 

Battick recommended nurses watch for hazards and keep the environment free of clutter. If there’s something on the floor, pick it up. Don’t just step over it. 

Nurses should wear supportive shoes and watch for fall risks for themselves, not just their patients, advised Nick Angelis, CRNA, MSN, author of How to Succeed in Anesthesia School (And RN, PA, or Med School). Changing positions and muscle movements helps minimize pain and discomfort over time. Rotate tasks between hands, he added, and avoid hunching over to chart or care for a patient; elevate the patient’s bed, or, when documenting, find a place to sit or stand straight. 

4. Speak up and step up 

Whether dealing with a potentially violent patient or just needing a hand to move someone or something, ask a colleague for help. 

“It’s safer to transfer with two people,” said Battick, but she acknowledged that help is not always available. 

On the other hand, step up and offer your assistance to peers, as well.

5. Get vaccinated for the flu 

People working in hospitals, clinics and other care settings are at greater risk of acquiring the flu and of transmitting the disease to patients and peers.

Influenza is a contagious disease that could spread by simply sneezing and coughing, explained Tanielle Sterling, MSN, NP, clinical program manager for employee health at The Mount Sinai Medical Center in New York. “Combating the myth of getting the flu through vaccination is the biggest challenge in improving compliance rates. By getting the flu vaccine, you protect yourself and may avoid spreading influenza to your patients, colleagues and your family.” 

6. Immunize against other pathogens 

Immunize the body and keep good immune health, advised Watson at Children’s Healthcare of Atlanta, which requires nurses stay current with hepatitis B, tetanus and diphtheria, the measles, mumps and rubella series and influenza vaccinations. 

“Hepatitis B infection is an occupational health hazard that is preventable by vaccination,” Sterling said. “All direct-care providers should be screened for hepatitis B surface antibody and offered the vaccine series. Education on the importance of completing the series and infection control practices helps to heighten awareness, change practice and attitudes towards vaccination.”

The Centers for Disease Control and Prevention’s (CDC’s) Advisory Committee on Immunization Practices recommends health care workers be vaccinated against the highly infectious hepatitis B, a bloodborne pathogen that can remain infectious on surfaces in the environment for at least a week. The vaccine produces a protective antibody response in more than 90 percent of people after the third dose. 

Healthcare workers born in 1957 or later without serologic evidence of immunity or prior vaccination should receive the measles, mumps and rubella series, varicella, and tetanus and diphtheria vaccines. 

7. Practice safe needle handling 

Do not recap needles, and use needless connection systems, advised Watson. 

Each year, hospital-based health care personnel experience 385,000 needlestick- and sharps-related injuries, according to the Occupational Safety and Health Administration (OSHA). This equates to an average of about 1,000 sharps injuries per day in U.S. hospitals.

Mary Foley, PhD, RN, chairperson of the Safe in Common campaign to prevent needlestick injuries, called it essential that nurses and other members of the health care industry work together to raise awareness of these types of injuries and find ways to prevent them in the future. 

“Nurses need to be sure that the safety mechanism on needlesticks is automatic and will not interfere with normal operating procedures and processes,” Foley said. “Activation of the safety mechanism should also not create additional occupational hazards or cause additional discomfort or harm to the patient. Perhaps most importantly, the used safety devices should provide convenient disposal and mitigate any risk of reuse or re-exposure of the nonsterile sharp. Following these rules will help to ensure that nurses are safe from the threat of needlestick injuries so that they can remain healthy and active for their patients.”

8. Don personal protective equipment (PPE) as appropriate 

Take no shortcuts when it comes to protection against bloodborne pathogens. Always select and wear the appropriate gloves, gowns, masks, eye protection and other items to prevent exposure to patients’ body fluids. Such equipment places a barrier between the hazard and the nurse. 

Children’s Healthcare of Atlanta promotes using PPEs when clinicians know or suspect the patient has a communicable disease. Watson advised, “If it’s not your wet, put something between you and it,” and “protect your eyes, nose and mouth from coughing.”

9. Get plenty of sleep 

Multiple studies, including “Fatigue, Performance and the Work Environment: A Survey of Registered Nurses,” published in the Journal of Advanced Nursing in 2011, from the University of Missouri in Columbia, have found that fatigue negatively influences nurse performance. 

In the book, Patient Safety and Quality: An Evidence-Based Handbook for Nurses, Ann E. Rogers, PhD, RN, FAAN, associate professor at the University of Pennsylvania School of Nursing in Philadelphia, warned that “in addition to jeopardizing patient safety, nurses who fail to obtain adequate amounts of sleep are also risking their own health and safety.” She pointed to the risk associated with drowsy driving, the increased chance of accidents of all sorts and that one’s immune system rarely works at peak performance when the body is tired. 

10. Practice good self-care 

Physical health requires overall wellness and staying strong, Watson said. Children’s in Atlanta promotes a holistic approach that includes daily exercise, good nutrition and fitness. It offers fitness classes and unit-based stretch breaks. Buddy coverage often is available for nurses who want to take a quick walk or class. Wellness includes obtaining psychosocial support when needed, particularly after dealing with emotionally taxing situations, such as participating in debriefings after traumatic incidents or seeking professional help through an employee assistance program. 

When you’re sick, stay home and rest, Battick added.  

Angelis recommended “exercising, packing nutrient dense foods for lunch; ingesting probiotics, either as supplements or in foods such as kefir or traditionally cultured vegetables; and staying well rested are all ways nurses can keep their immune systems in great shape against the barrage of germs that assault us daily.”

© 2013. AMN Healthcare, Inc. All Rights Reserved. 

By Christina Orlovsky

Ask a young girl what she wants to be when she grows up, and top answers are often a teacher or a nurse, which are professions that have been associated with women throughout history. Ask a young boy the same question and neither answer is likely to be given.

Ask Christopher Lance Coleman, PhD, MS, MPH, FAAN, and he’ll tell you that inequity has to change.

Coleman, an associate professor of nursing and multicultural diversity at the University of Pennsylvania School of Nursing in Philadelphia and the author of Man Up! A Practical Guide for Men in Nursing, is a strong advocate for recruiting males into the nursing workforce and empowering them to pursue leadership roles. His new book serves as a roadmap for men seeking to break into the predominantly female nursing profession.

“I believe men need a guide, a blueprint to use to navigate through the complexity of specialty choice and a culture where, frankly, a gender disparity still exists,” Coleman explains. “This is an opportunity of a lifetime for men not only to change the face of nursing in the 21st century, but also to reshape the public image that nursing is a women’s profession.”

In fact, while the most recent numbers show that men are still a clear minority in the nursing field, an uptick is occurring. According to a 2012 U.S. Census Bureau study, “Men in Nursing Occupations,” which presents data from the 2011 American Community Survey, the percentage of male nurses has more than tripled since 1970, from 2.7 percent to 9.6 percent. Of the 3.5 million employed nurses in 2011, 3.2 million were female and 330,000 were male. It’s a change, but, if you ask Coleman, it’s not enough.

“The startling thing is how underrepresented men still are in areas of leadership,” he says. “While the numbers of RNs has increased, when you look at the profession as a whole--heads of nursing, academia--we are still so far underrepresented. This is significant for males going through school looking for role models and seeing predominantly female leaders. I want men to know this is a viable profession and there are tremendous opportunities out there.”

Coleman believes the greatest opportunities for change are in younger men, who even at the high school level should do their research and start the conversation with their parents about the opportunities that exist for them in nursing. Ethnic minority groups, he adds, are particularly critical.

“Many ethnic minority groups, even today in 2013, still think of nursing as only a woman’s profession,” he says. “That racial disparity needs to be taken away.”

Coleman hopes that his book also opens up a dialogue among current male registered nurses. Empowering male RNs to continue to climb the ladder to leadership roles where they can influence change and serve as a new face of the nursing profession, he says, can encourage them to become the mentors male RNs need to help them succeed.

Another conversation that needs to occur in order to influence a culture shift is one between female nurses who may stereotype their male counterparts as only necessary for heavy lifting or things they “can’t” do.

“That’s a stereotype that hurts women and hurts the profession,” Coleman explains. “We don’t want nursing to be seen as a profession of the weak, we want it to be seen as a profession of the strong, because nurses are strong. We all need to do a better job of marketing ourselves--stop stereotyping and typecasting males and do more education in the hospital setting about gender diversity.”

Many men, after all, possess all the qualities required to be good nurses.

“Passion; someone with a tremendous amount of integrity; leadership skills; with a natural curiosity about the world; someone who is unafraid to take on issues that perhaps have challenged them in the past; someone who could treat someone at the end of the day how they want to be treated; and someone who cares to change the world we live in--those characteristics are essential and they transcend gender,” Coleman concludes. “Those are things I’d like to see in anyone who is interested in entering our noble profession.” 

© 2013. AMN Healthcare, Inc. All Rights Reserved. 

By Betty Reid

Source: NY Times

By Alexandra Wilson Pecci

Source: Health Leaders Media 

For many nurses, leaving high school doesn't mean leaving the bullies behind. Bullying has been called nursing's "dirty little secret," but judging by the numbers, it's hard to believe it could be kept secret at all.

Most women can relate in some way to the 2004 Lindsay Lohan movie Mean Girls, in which her character encounters a group of bullying high school girls who say things like this: "Half the people in this room are mad at me, and the other half only like me because they think I pushed somebody in front a bus."

But while most women can leave memories like this behind when they graduate from high school, for those who enter nursing and become victims of nurse-on-nurse bullying, leaving high school hasn't made the mean girls disappear; they're just wearing scrubs now.

Bullying has been called nursing's "dirty little secret," but judging by the numbers, it's hard to believe it could be kept secret at all.

Twice as many nurses as other Americans have experienced bullying in the workplace. According to study of 612 staff nurses in theJournal of Nursing Management, 67.5% had experienced bullying from their supervisors, while 77.6% had been bullied by their co-workers. Compare that to the 35% of Americans outside healthcare who've reported workplace incivility, says the Workplace Bullying Institute.

Not only is bullying among nurses an issue, it's one that most nurse managers aren't equipped to handle properly, according to Cheryl Dellasega, PhD, RN, CRNP, co-author with Rebecca Volpe of the new book Toxic Nursing: Managing Bullying, Bad Attitudes, and Total Turmoil.

Bullying "is a huge problem now in the workplace," Dellasega tells me. "I think a lot of nurse managers don't get a lot of training in conflict resolution."That's especially true when they have little more management experience than any of their co-workers but were promoted to the role because they have a bachelor's degree and a few extra years of seniority, Dellasega says.

Dellasega's new book is a follow-up her to When Nurses Hurt Nurses: Recognizing and Overcoming the Cycle of Nurse Bullying, and aims to help managers and administrators understand and deal with bullying among their nurses.

In order to write the new book, the authors not only conducted a literature review, but also reviewed hundreds of blogs written by nurses about situations of conflict. By doing so, Dellasega and Volpe were able to identify key themes and scenarios that are common to bullying, as well as which groups of people were commonly involved in bullying.

Finally, the authors interviewed nurse management experts to give insight into dealing with such situations. "There were different pockets of nurses who seemed to be really engaged in the situation, as either a victim of the aggressor," Dellasega says. For example, new nurses are often victims.

"I think that brand new, young nurses [are] sort of the classic targets," Dellasega says. Often, these nurses are idealistic about their work and excited about how they're going to make a difference, but the older, established, more jaded nurses engage in bullying to knock them down a little. In fact, Dellasega says, sometimes the young nurses' preceptors are the ones who are doing the bullying because they feel like the role is a thankless one.

"I know that even…the literature…supports that preceptors often don't feel well prepared to do the job and often don't want to do the job," she says.

Another group of nurses who are often bullied are part-time, agency, or floater nurses who are picked on because they're not part of the regular nurses' clique.

Yes, clique. Dellasega says the regular nurses who are in the clique often make rude or sarcastic comments to or about the new person, or even go so far as not sharing supplies. Even nurses who come in from other floors can be left of out, even though they're just there to help.

Dellasega says that the cliques and bullying in a hospital comes with the same kind of baggage that most of us thought we left behind in high school. But for nurses, there's the added stake of patient safety. Although studies haven't explicitly linked increased bullying to decreased patient safety, research does say that happier nurses do their jobs more effectively. (Conversely, nurse burnout is linked to higher healthcare-associated infection rates).

"It's not a big leap to figure that when you go into work… if there's a toxic environment… you won't be able to give your full attention to patient care," Dellasega says.

Bullying also leads nurses to call in sick more often in order to take mental health days. Abusive behaviors can even cause nurses to develop post-traumatic stress disorder, anxiety, depression, or insomnia, a Joint Commission survey has found. Hospitals can also lose valuable employees to bullying and many nurses have left their jobs because of it.

"Things get to a point where they just can't take it," Dellasega says. Sometimes nurses feel like they're "going into the battle zone every day."

Nurse managers shouldn't let things get to that point. Managing relationships should be day-to-day work, not something that only happens during moments of high tension.

"Don't wait for it to get to the point that there's explosive conflict," Dellasega says.

Just as Dellasega discovered which nurses and situations tend to breed bullying, she and her co-author also discovered which environments are healthy. Bullying is rarer when there is a sense of teamwork, collaboration, and authentic communication with coworkers.

Dellasega says the ideal nurse manager is transparent, letting the staff ask questions and answering honestly, even if the answer is "I don't know, but I'll find out."

Feelings of empowerment are also important to reduce bullying and satisfaction. And upper hospital management should provide appropriate training for new nurse manager about how to effectively and positively deal with bullying.

Finally, Dellasega says nurses managers should monitor their own behavior to ensure that they're not engaged in bullying themselves, even if inadvertently. For example, sighing heavily after someone speaks could be interpreted as negative. Other behaviors to watch out for are favoritism, certain body language, gossiping, and speaking in a raised voice.

"I think nurse manager have to really monitor their own behavior and be cognizant of anything they might do," Dellasega says. "The nurse manager sort of sets the standards.

Shannon Patel, RN, BA, CCRN, CMC, PCCN, manager of the heart failure program at AtlantiCare Regional Medical Center in Galloway, N.J., and an RN-to-BSN student at the Rutgers School of Nursing–Camden (N.J.), led a team at the hospital’s Heart Institute that developed a new smart phone app that helps patients manage heart disease and stay out of the hospital.

The WOW ME 2000mg app helps patients, caregivers and family members identify and manage symptoms of heart failure, according to the release.

"This tool was designed to cross the healthcare continuum and has allowed our organization to deliver very important self-management education," Patel said in the release.

The WOW ME 2000mg app reminds patients to weigh themselves; measure their output of fluids; walk and be active; take their medications; evaluate signs and symptoms; and limit sodium intake to 2,000 mg or less, with 1,500 mg being optimal. The app prompts users with reminders and allows them to enter information about how they are managing their symptoms. It also links them with AtlantiCare’s Heart Failure Resource Team and other providers. Patel said in the release that many heart failure programs around the country are struggling to find ways to successfully teach heart failure self-management techniques. She said there is no standardized approach to reinforcement of the information taught to patients and that oftentimes patients receive differing and conflicting information depending on where they go for treatment.

"This tool standardizes heart failure self-management for patients," Patel said in the release.