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Empowering Nurses to Improve Health Care

Blurry photos of nurses working in a hospital
  • The nursing profession was under stress long before the pandemic. How can we better recognize and reward nurses’ contributions?

  • Fellowship and award programs are empowering nurses to use their problem-solving skills and empathy for patients to design solutions to the problems that plague health care

  • The nursing profession was under stress long before the pandemic. How can we better recognize and reward nurses’ contributions?

  • Fellowship and award programs are empowering nurses to use their problem-solving skills and empathy for patients to design solutions to the problems that plague health care

The latest survey from the American Nurses Association tracking the impact of COVID-19, fielded in the midst of January’s Omicron surge, found nearly a quarter of nurses were thinking of leaving their jobs and many said their organizations didn’t value their contributions or care about their well-being. Some nurses have shared their frustrations publicly — describing in graphic terms on Twitter and in the New York Times how chronic understaffing has conspired with high COVID-19 caseloads to create untenable workplaces.

Amid this turmoil, there’s been a quieter movement underway, driven largely by nursing schools, advocacy organizations, and foundations, to recognize and reward nurses’ contributions and empower them to use their problem-solving skills and empathy for patients to design solutions to the problems that plague health care. This issue of Transforming Care looks at the fruits of these efforts.

Sparking Ideas and Developing Leaders: Johnson & Johnson

In 2018, Johnson & Johnson, which has a long history of supporting nurses through scholarships, grants, and training, launched the Johnson & Johnson Nurses Innovate QuickFire Challenge series as a way to solicit and support nurses’ ideas for improving health care. Each challenge has focused on a particular topic: maternal and newborn care, oncology care, COVID treatment, mental health care, and other areas. “We knew from our research that nurses had amazing ideas, but did not have a clear pathway for raising those ideas and moving them forward,” says Lynda Benton, senior director of global community impact at Johnson & Johnson. The QuickFire Challenge gives nurses an opportunity to shape and pitch their ideas; awardees receive grants of up to $100,000, plus mentorship from the company’s experts.

Erin Athey, D.N.P., F.N.P.-B.C., was one of two winners for the challenge calling for ideas that expand access to care. She pitched a concierge model of primary care for residents of Ward 8, which includes some of the poorest neighborhoods of Washington, D.C. The idea grew out of Athey’s experience in a local primary care clinic, where half of her patients routinely didn’t turn up for appointments. “This nine to five, Monday through Friday, take off work, bring your kids model of care doesn’t work for people struggling to pay their bills and take care of their families,” she says.

The company Athey founded, C3: Community Concierge Care, is partnering with the District of Columbia Housing Authority to embed primary care clinics in four public housing sites, each serving from 500 to 800 residents. While a federal program supports some community health centers located in or near public housing, she says there are few such centers in D.C. Her plan is to have public health nurses and community health workers on site and have nurse practitioners available for telehealth or in-person visits.

Athey is partnering with the public housing resident navigators and councils to hear from residents about what they want, including things like same-day appointments and after-hours call lines. She also plans to partner with the social service organizations that are already working in public housing to help meet residents’ needs for food or other supports. “We're trying to get the most hard-to-reach folks, right? So, how do you build that trust?” she says. “Just to be able to ask people are you OK? Do you need anything? If we can be that presence, I think that's going to be big.”

Nurse and managers of the mobile clinic pose for photo with sign

Before launching C3, Erin Athey, D.N.P., F.N.P.-B.C., (right) worked with a local hospital to provide COVID testing and vaccination, as well as H.I.V. testing, to public housing residents. Mecca Brown (left) and Monika Thomas (center) helped manage the mobile clinic.

The Johnson & Johnson Nurse Innovation Fellowship, a two-year program, provides 12 nurses with training and mentoring as they develop a capstone project. One of the fellows, Deidra Heuring, D.N.P., R.N., a staff nurse at St. Cloud Hospital in Minnesota, is using the fellowship to further her goal of increasing awareness of perinatal mental health disorders in parents. These disorders can occur from the time of conception to one year postpartum and may include mood disorders such as depression, bipolar disorder, and postpartum psychosis or anxiety disorders including panic disorders, obsessive compulsive disorder, and post-traumatic stress disorder. Such problems can be common, yet many of those who screen positive for problems don’t receive treatment.

Heuring said she often saw parents struggling in the neonatal intensive care unit, but the issue hit home when her sister needed support after the birth of her third child. “I was grateful that my sister lived in the Chicago area, where she had access to an intensive outpatient program for mothers and babies,” she says. Such specialized programs aren’t accessible in many rural communities, and Heuring heard stories from fellow nurses who struggled to find help: “If a nurse has difficulty accessing care, I can't imagine what's happening to moms in rural communities, or to those who don't speak English.”

As part of the fellowship, Heuring partnered with the nonprofit Postpartum Support International to work toward national accreditation of their perinatal mental health certification program. This would create funding streams for nurses and other clinicians to receive training, since most health care organizations cover staff members’ continuing education when it’s in pursuit of an accredited certification. “If more nurses get certified there will be more touchpoints for patients — one more person looking out for them who can say, ‘You know, there's this great phone line that is free and has Somali or Spanish speakers,’” she says. “There will be more people to say, ‘We can help.’”

Cultivating Scholars and Entrepreneurs: Betty Irene Moore Fellowship

Philanthropist Betty Irene Moore is another major supporter of nurses, an interest that developed from having experienced a near-deadly medication error during a hospital stay. Moore knew that nurses provide the lion’s share of hands-on care and wanted to empower them to solve safety and quality problems. In 2020, the Gordon and Betty Moore Foundation committed $37.5 million for the Betty Irene Moore Fellowship for Nurse Leaders and Innovators, awarded to early and mid-career nurse researchers and entrepreneurs to help them develop a research project. Applicants must have some preliminary data about the impact of their fellowship project; winners are given $450,000 over three years and offered training on topics such as leadership, systems change, and effective communication.

“Mrs. Moore realized that if nurses had, first of all, more power in the system and came at problem solving with a systems engineering perspective rather than one encounter at a time, then the entire health care system could be transformed,” says Heather Young, Ph.D., R.N., a professor at the UC Davis School of Nursing and national director of the fellowship program.

Dawn Aycock, Ph.D., M.S.N., associate professor at Georgia State University’s School of Nursing and one of the first Moore fellows, is using the funds and training to advance her work to prevent strokes among young Black men and women ages 20 to 35. Black people tend to have strokes at younger ages than people of other races and ethnicities, and these strokes can be more disabling and deadly. The majority of strokes can be prevented by reducing risks such as high blood pressure, obesity, and smoking. Aycock’s interest in this topic grew from her experiences caring for patients recovering from strokes and her family history: four of her relatives had strokes, including a grandmother who died and an uncle who afterward lived with paralysis on one side of his body and aphasia. “It was really sad because he had just retired and he had worked so hard to put all of his kids through college,” she says. “He wasn't really able to enjoy his family afterwards.”

In 2014, Aycock created SCORRE (Stroke COunseling for Risk REduction), a program that raises people’s awareness about their personal risk factors for stroke and helps them reduce their risks by eating better, exercising more, or making other changes. Participants receive counseling during their first visit and motivational texts over eight weeks. In a trial of SCORRE, Aycock found that even though Black men tended to have more risk factors than Black women, they believed they were at lower risk and were less likely to make changes to minimize risk.

Through the Moore fellowship, Aycock is finetuning SCORRE to better engage young Black men. She conducted focus groups to learn how SCORRE could best educate and empower them. She’s also been partnering with a graduate research assistant, a young, Black male nurse who’s been recruiting peers to take part in the study. “He's gone to barbershops and community centers and talked with people about the research,” says Aycock. “He also went to some of the barbershops that had helped with recruitment to offer blood pressure screenings as a way of giving back.”

Screenshot of video about Stroke Champions

In the Stroke Champions video that Aycock produced, young adult survivors talk about how their lives have been affected by stroke.

Another Moore fellow, Stephanie Gilbertson-White, Ph.D., A.P.R.N., at the University of Iowa College of Nursing, became interested in how to help people with metastatic cancer and other debilitating conditions manage their symptoms. This led her to become a palliative care nurse at the University of Iowa’s cancer center and to create a mobile app known as OASIS (Oncology Associated Symptoms and Individualized Strategies). Patients can use OASIS to track their symptoms, find strategies to manage them, and connect with peers. It’s built on a database including records from 20,000 cancer patients that enables users to enter their diagnoses and demographic information and explore the experiences of others like them. The goal is to empower patients. “So it's not the oncologist who's saying, ‘We need to manage your fevers and hydration’ — the things that impact their ability to provide chemotherapy,” Gilbertson-White says. “It's really the individual saying, ‘My biggest challenge right now is managing my fatigue.’”

The fellowship has helped Gilbertson-White develop a marketing and business plan to launch the app, which she’ll do in a pilot this fall. Eventually, she thinks OASIS could be used outside of oncology, for example by shedding light on how people with multiple chronic conditions experience their symptoms.

Engaging Frontline Staff: Massachusetts General Hospital

Some health care systems have solicited ideas from frontline nurses for improving their workplaces and patient care. In 2016, Hiyam Nadel, M.B.A., R.N., director of the Center for Innovations in Care Delivery at Massachusetts General Hospital in Boston, launched one such effort. She’d been inspired by a nurse hackathon at Northeastern University, her alma mater. Among the 8,000 health care providers she emailed, who were mostly nurses but also social workers, therapists, and chaplains, she received just 40 submissions, and most didn’t propose solutions but instead suggested more traditional research or quality improvement projects.

In the next round, Nadel and her colleagues solicited ideas in categories that had been suggested by staff, including improving communication with patients and learning about disease processes in real time. This time, they got three times as many proposals. Nurses vote to choose winners, and Mass General’s leaders review all submissions to gain insight into what nurses see as problems.

Winners receive cash prizes (now $10,000, paid for by a local philanthropist) to develop their ideas, along with mentoring from Nadel. One of the winning submissions is an acuity tool that can be used to determine appropriate staffing for different cancer patients; often, nurses felt staffing models didn’t account for variation in patients’ needs. Other winning ideas include an adaptive feeding kit to help ALS patients feed themselves as their motor function declines and a device that lets babies in the NICU hear their parents’ voices. (Babies who spend time in NICUs are prone to speech delays as children.)

During the pandemic, Mass General’s leaders continued to solicit nurses’ feedback, in part through monthly ethics rounds (now named support rounds) that have provided an opportunity for nurses to raise their concerns as they care for COVID patients. Mass General has held more than 300 such rounds. Typically attended by six to 10 nurses, these sessions have served as a release valve and surfaced nurses’ ideas for how to better prepare for the next wave of COVID patients, according to Colleen Snydeman, Ph.D., R.N., executive director, quality, safety & practice. Snydeman leads the rounds with an interdisciplinary team that includes representatives from nursing, ethics, employee assistance, spiritual care, and social work. For example, nurses reported disruptions when their teams had been broken up to staff newly created intensive care units. For the second wave of the pandemic, Mass General kept teams intact. At nurses’ suggestion, the hospital also created protected break rooms where nurses could step away from work, as well as centralized sources of information about evolving protocols.

Spreading Nurse Innovation

Many of the solutions described here were developed by advanced practice nurses, those who earn a master’s degree or higher to pursue research and/or work more independently than registered nurses. This may reflect the emphasis that training programs for advance nursing practice puts on improving health for populations and systems of care.

But there are also efforts to elicit ideas from frontline nurses about how to improve their workplaces and patient care, as not all health systems have the resources to create their own nurse innovation programs. One effort to spread innovation beyond fellowship and award programs is being led by the American Association of Critical-Care Nurses (AACN), which has trained hundreds of nurses across 82 hospitals to serve as change agents.

To take part in AACN’s Clinical Scene Investigator Academy, hospitals pay a nominal fee and nurses receive coaching to work as teams to identify problems and develop new approaches. Recent projects have promoted early recognition of sepsis and helped avoid pressure injuries among COVID patients. Others have surfaced ideas for avoiding burnout or deploying nurses differently. After the academy ends, nurses often continue innovating, according to Marian Altman, Ph.D., R.N., a clinical practice specialist at AACN. “It sounds corny but when you give nurses time and education and say, ‘I believe in you,’ it’s amazing what they can do,” she says.

For more on how the U.S. could fix its nursing crisis, listen to this episode of The Dose podcast.

Publications of Note

Physicians’ Knowledge of the Americans with Disabilities Act Lacking

A survey of physicians in outpatient practices found 35.8 percent reported knowing little to nothing about their legal responsibilities under the Americans with Disabilities Act (ADA), which was enacted more than 30 years ago. Nearly three-quarters (71.2%) answered incorrectly about who determines reasonable accommodations, 20.5 percent did not correctly identify who pays for these accommodations, and 68.4 percent felt that they were at risk for ADA lawsuits. Physicians who felt that lack of formal education or training presented a moderate or large barrier to caring for patients with disabilities were more likely to report having little to no knowledge of their responsibilities under the law. The authors say improvements are needed to educate physicians and make health care delivery systems more accessible and accommodating of patients with disabilities. Lisa I. Iezzoni et al., “US Physicians’ Knowledge About the Americans with Disabilities Act and Accommodation of Patients with Disability,” Health Affairs 41, no. 1 (January 2022):96–104.

SNAP Benefits Reduce Utilization and Spending for Dual Eligibles

A study of North Carolina adults ages 65 and older who are dually eligible for Medicare and Medicaid found those who received Supplemental Nutrition Assistance Program (SNAP) benefits had fewer hospital admissions, emergency department visits, and long-term care admissions over the next 22 months. Total Medicaid spending was also lower ($2,360 per person less); data on Medicare claims and spending were not available for analysis. Seth A. Berkowitz et al., “Supplemental Nutrition Assistance Program Participation and Health Care Use in Older Adults: A Cohort Study,” Annals of Internal Medicine 174, no. 12 (December 2021):1674–82.

Improving the Measurement of Structural Racism to Achieve Antiracist Health Policy

The authors of this Health Affairs article suggest several methodological approaches for characterizing the nature of structural racism and quantifying its effect on public health. Among other recommendations, they call for more empirical research establishing the pathways through which contemporary health outcomes are shaped by historical and present-day forms of structural racism. They also outline several approaches for capturing the multifaceted nature of structural racism, including tapping data sources like the Census Bureau’s Census of Governments, which would shed light on patterns in education funding, police expenditures, cash assistance, and other outlays that influence the health and wellbeing of constituents. Rachel R. Hardeman et al., Improving the Measurement of Structural Racism to Achieve Antiracist Health Policy,” Health Affairs 41, no. 2 (February 2022):17–86.

Detecting and Remediating Bias in Insurer Algorithms

In this Health Affairs analysis, staff of Pennsylvania’s Independence Blue Cross and researchers from Massachusetts Institute of Technology and the University of California Berkeley outline concerns about how machine learning models are developed and used in clinical and business decisions. The authors illustrate how bias can arise in the algorithms used by health insurers to predict disease onset, the likelihood of hospitalization, and medication adherence. Among other strategies, they suggest regular audits to identify and remediate potential biases. Stephanie S. Gervasi et al., “The Potential for Bias in Machine Learning and Opportunities for Health Insurers to Address It,” Health Affairs 41, no. 2 (February 2022):212–18.

Incentivizing Patients to Use Lower-Cost Providers Leads to Some Switching

Researchers found rewarding employees for receiving care from lower-cost providers led to modest increases in the choice of lower-cost providers and modest reductions in prices, with savings concentrated in imaging services, particularly magnetic resonance imaging (MRI) services. In the first year of the program, prices fell by 1.3 percent and in the second year by 3.7 percent. The study relied on data for 3.9 million enrollees in a large health plan. Roughly one in 20 (5.6%) received an incentive payment (ranging from $25 to $500) for the first year and 7.8 percent received an incentive payment the second year. Prices for MRI services fell by 3.5 percent the first year and 6.5 percent the second. Christopher Whaley et al., “Paying Patients to Use Lower-Priced Providers,” Health Services Research 57, no. 1 (February 2022):37–46.

Take-Home Doses of Medications for Opioid Use Disorder Prevented Treatment Disruptions During Pandemic

To retain patients with opioid use disorder in treatment during the pandemic, Canadian prescribers were permitted to increase the number of take-home doses of medications for opioid use disorder such as methadone and buprenorphine/naloxone. Researchers found the practice led to lower rates of treatment interruption or discontinuation for subsets of patients (e.g., those receiving daily and weekly dispensed methadone). They also found no statistically significant increase in opioid-related overdoses over six months of follow up. Tara Gomes et al., “Association Between Increased Dispensing of Opioid Agonist Therapy Take-Home Doses and Opioid Overdose and Treatment Interruption and Discontinuation,” Journal of the American Medical Association 327, no. 9 (March 1, 2022):846–55.

Strategies for Distributing Hospital Patients During Public Health Emergencies

In this commentary in the New England Journal of Medicine, the authors describe how states can use centralized hospital capacity management systems to facilitate the transfer of patients from overwhelmed hospitals to ones with more capacity. They say most states now lack the infrastructure to implement such systems, which require real-time information about bed capacity in all hospitals. They suggest several steps states can take, including requiring hospitals to participate in load-balancing efforts during public health emergencies; establishing statewide transfer centers; implementing policies to protect hospitals and patients from economic losses arising from load-balancing efforts; and refraining from permitting the rationing of medical care until contingency care options have been exhausted. Douglas B. White, Lisa Villarroel, and John L. Hick, “Inequitable Access to Hospital Care — Protecting Disadvantaged Populations during Public Health Emergencies,” New England Journal of Medicine 385, no. 24 (Dec. 9, 2021):2209–11.

Promoting Competition Through Price Regulation

The authors of this Health Affairs piece urge state policymakers to consider using price regulation to foster competition among hospitals. They offer two alternative approaches. The first is applying rate caps to the out-of-network hospital prices paid by commercial insurers. They say this would compel hospitals to negotiate more reasonable in-network rates because they wouldn’t have the option of rejecting a contract in favor of a significantly higher out-of-network rate. The second approach involves instituting flexible, all-payer hospital budgets that cover hospitals’ fixed costs and allow for marginal increases as volume rises. The second approach would avoid having to develop a complex system of regulated prices for hospital services. It would also accommodate the movement of patients between hospitals and reduce the incentive to increase volume. Robert A. Berenson and Robert B. Murray, “How Price Regulation Is Needed to Advance Market Competition,” Health Affairs 41, no. 1 (January 2022):26–34.

Rebound in Ambulatory Care Visits During the Pandemic Varied by Source of Insurance

Researchers tracking ambulatory care service use among patients with different types of insurance coverage found that utilization of six services (emergency department, office and urgent care, behavioral health, screening colonoscopies, screening mammograms, and contraception counseling or HIV screening) fluctuated with each wave of the pandemic and rebounded over time; however, the return to expected rates was lower for patients with Medicaid and those who were dually eligible for Medicare and Medicaid (“dual eligibles”). By the January to February 2021 time frame, overall utilization was at 78.4 percent of expected rates for Medicaid enrollees; 73.3 percent of expected rates for dual eligibles; 90.7 percent of expected rates for the commercially insured; 83.2 percent for Medicare Advantage enrollees; and 82 percent for traditional Medicare beneficiaries. John N. Mafi et al., "Trends in US Ambulatory Care Patterns During the COVID-19 Pandemic, 2019-2021,” Journal of the American Medical Association 327, no. 3 (Jan. 18, 2022):237–47.

Spending on Diabetes Lower When Managed by Primary Care Providers

Researchers found that older adults with diabetes who receive more of their ambulatory care from a primary care physician (PCP) rather than a specialist had lower overall spending and lower rates of hospitalizations, emergency department visits, procedures, imaging, and other tests. Health plan payments to PCPs were $10,326 vs. $14,971 for specialists. Total out-of-pocket costs for patients were also lower ($1,707 vs. $2,443). Spending and utilization were measured for up to three years. David J. Nyweide, Andrea M. Austin, and Julie P.W. Bynum, “Resource Use Among Diabetes Patients Who Mainly Visit Primary Care Physicians Versus Medical Specialists: A Retrospective Cohort Study,” Journal of General Internal Medicine 37, no. 2 (January 2022):283–9.

Minorities Report Significantly Worse Medicaid Managed Care Experiences Than Whites

Researchers found nonelderly Medicaid managed care enrollees in 37 states reported significantly worse care experiences than white enrollees. Among four patient experience measures, the disparities ranged from 1.5 to 4.5 percentage points for Black enrollees; 1.6 to 3.9 percentage points for Hispanic or Latino enrollees; and 9 to 17.4 percentage points for Asian American, Native Hawaiian, or other Pacific Islander enrollees. The authors found the disparities were largely attributable to worse care experiences within the same plan. However, for all outcomes, disparities were smaller in plans with the highest percentages of Hispanic or Latino enrollees. They also found that for some outcomes, there were smaller disparities in plans with the highest percentages of Asian American, Native Hawaiian, or other Pacific Islander enrollees. Kevin H. Nguyen et al., “Racial and Ethnic Disparities in Patient Experience of Care Among Nonelderly Medicaid Managed Care Enrollees,” Health Affairs 41, no. 2 (February 2022):256–64.

Advancing Health Equity as an Explicit Goal of Health System Improvement

The authors of this Journal of the American Medical Association commentary say it’s time to make advancing health equity the fifth aim of health system improvement, alongside improving population health and patient experience and reducing spending and staff burnout. To accomplish this, health care leaders and providers must identify disparities; design and implement evidence-based interventions to reduce them; invest in equity measurement; and incentivize the achievement of equity. Shantanu Nundy, Lisa A. Cooper, and Kedar S. Mate, “The Quintuple Aim for Health Care Improvement: A New Imperative to Advance Health Equity,” Journal of the American Medical Association 327, no. 6 (Jan. 21, 2022):521–522.

Editorial Advisory Board

Special thanks to Editorial Advisory Board member Carole Roan Gresenz for her help with this issue.

Jean Accius, Ph.D., senior vice president, AARP

Anne-Marie J. Audet, M.D., M.Sc., senior medical officer, The Quality Institute, United Hospital Fund

Eric Coleman, M.D., M.P.H., director, Care Transitions Program

Marshall Chin, M.D., M.P.H., professor of healthcare ethics, University of Chicago

Timothy Ferris, M.D., M.P.H., CEO of Massachusetts General Physician Organization and professor of medicine at Harvard Medical School

Don Goldmann, M.D., chief medical and scientific officer, Institute for Healthcare Improvement

Laura Gottlieb, M.D., M.P.H., assistant professor of family and community medicine, University of California, San Francisco, School of Medicine

Carole Roan Gresenz, Ph.D., senior economist, RAND Corp.

Allison Hamblin, M.S.P.H., vice president for strategic planning, Center for Health Care Strategies

Thomas Hartman, vice president, IPRO

Clemens Hong, M.D., M.P.H., medical director of community health improvement, Los Angeles County Department of Health Services

Kathleen Nolan, M.P.H., regional vice president, Health Management Associates

Harold Pincus, M.D., professor of psychiatry, Columbia University

Chris Queram, M.A., president and CEO, Wisconsin Collaborative for Healthcare Quality

Sara Rosenbaum, J.D., professor of health policy, George Washington University

Michael Rothman, Dr.P.H., executive director, Center for Care Innovations

Mark A. Zezza, Ph.D., director of policy and research, New York State Health Foundation

Publication Details



Martha Hostetter, Consulting Writer and Editor, Pear Tree Communications

[email protected]


Martha Hostetter and Sarah Klein, Empowering Nurses to Improve Health Care (Commonwealth Fund, Apr. 7, 2022)