BACKGROUND AND OBJECTIVES: The Commonwealth of Pennsylvania passed the Caregiver Advise, Record, Enable (CARE) Act on April 20, 2016. We designed a study to explore early implementation at a large, integrated delivery financing system. Our goal was to assess the effects of system-level decisions on unit implementation and the incorporation of the CARE Act's three components into routine care delivery. RESEARCH DESIGN AND METHODS: We conducted a multisite, ethnographic case study at three different hospitals' medical-surgical units. We conducted observations and semi-structured interview to understand the implementation process and the approach to caregiver identification, notification, and education. We used thematic analysis to code interviews and observations and linked findings to the Promoting Action on Research Implementation in Health Services framework. RESULTS: Organizational context and electronic health record capability were instrumental to the CARE Act implementation and integration into workflow. The implementation team used a decentralized strategy and a variety of communication modes, relying on local hospital units to train staff and make the changes. We found that the system facilitated the CARE Act implementation by placing emphasis on the documentation and charting to demonstrate compliance with the legal requirements. DISCUSSION AND IMPLICATIONS: General acute hospitals will be making or have made similar decisions on how to operationalize the regulatory components and demonstrate compliance with the CARE Act. This study can help to inform others as they design and improve their compliance and implementation strategies.
(Figure 1) The 1996 AJN Patient Care Survey that ran in our March issue is expected to yield more than 10,000 responses from nurses across the country. Preliminary findings, based on the first 5,000 responses, substantiate the declining quality of health care and nursing dissatisfaction (see AJN Newsline, page 69).The survey results are emerging at a critical time, in the wake of the Institute of Medicine report, the NLRB decision, and growing public awareness of the "deskilling" of American hospitals. Whether through the New York State Nurses Association's television infomercials, the Pittsburgh Post-Gazette's investigative series on the use of unlicensed personnel to replace RNs, or Redbook magazine's article on consumer self-protection in hospitals, the public is beginning to realize that entering a hospital is risky business these days, and that the RN is their most vigilant advocate. For years, we have all been caught up in a game of verbal volleyball, with nurses alleging that fewer RNs at the bedside and hospital restructuring are shortsighted solutions geared to economic gain, with no assurance of quality care or safety. The opposing argument (as absurd as it seems to nurses) is that neither is there proof that more qualified personnel ensure better outcomes. Though anecdotal evidence and survey method continue to dominate the research, nursing's voice is growing louder and the reality we describe more explicit. The AJN survey contributes substantially to this evidence. As the public responds to our message, it becomes derelict to postpone action because of the absence of more formal research. (This is not to deny that a research agenda exists here.) Rather, our experience, credibility, and tradition of service speak volumes and deserve to be taken seriously. It is a ready criticism that nurses have a jaded perspective on health care reform, that eroding job security, and inevitable change have prompted negativism. The profession's historic response to personal jeopardy and privation doesn't support this thinking. Generations of labor organizers that have targeted staff nurses can verify that, given fair economic rewards, RNs will rarely speak out on their own behalf. Instead, they are best moved to militancy and action when the safety of their patients is at stake. Traditionally, they've had little to lose. There was always another job to be found, and nurses have been socialized in altruism and subservience. But more recent times are different and more painful, and many nurses have been reticent to speak out about patient safety. Intimidation and the threat of job loss are common. Vengeance falls hard on the shoulders of the single parent, the part-time student, the family breadwinner. The AJN survey preserves anonymity. Without fear of reprisal, respondents describe a workplace in which fewer RNs are caring for more patients (and these patients are more acutely ill than ever), working with more unlicensed assistive personnel, and with supervisory responsibility that should increase proportionately. The survey also reveals substantial losses among nurse-managers and executives, not unexpected given current business trends, but especially troubling to nurses who need a supportive environment to facilitate their practice. The absence of outcomes evidence becomes a myth as respondents document increases in consumer complaints, work-related injuries, patient complications, and incidents and accidents including medication errors, nosocomial infections, and skin breakdown. Most of these developments are byproducts of an unsafe environment, and they're becoming as significant to the informed consumer as they are to the concerned professional. Assistive personnel were introduced so that nurses could concentrate their time in the service of their patients. Yet, our survey respondents report that they have considerably less time to spend on direct care, interdisciplinary, collaboration, coordination of care, teaching, and comfort measures. Overwhelmingly, nurses deny that assistive personnel have improved the quality of care at their institutions. In fact, most claim that the quality of care being delivered does not meet their professional standards, a disturbing finding when you consider that job satisfaction is highly dependent on the ability to believe in the intrinsic value of the work you do. The AJN survey has given the nursing profession an opportunity to speak out with one strong voice, exposing the turmoil and pain the health care industry inflicts on the public when its priorities are poorly defined and its leaders choose to ignore the common sense and decency of those professionals most intimately involved in patient care.