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Easing the Strain

Teresa Kuta Reske

Teresa Kuta Reske, in the nursing simulation lab at Elms College, said many nurses were influenced in their career choice by care they or a loved one received.

Teresa Kuta Reske loves nursing.

She said that on more than one occasion when speaking with BusinessWest recently for this special HCN section celebrating nurses, and especially recent nursing graduates beginning to enter the workforce.

As interim dean of the Elms College School of Nursing and director of the college’s Doctor of Nursing Practice program, she also loves seeing that passion develop in students.

“We prepare nurses with the skills and knowledge it requires to be in the nursing workforce, but when partnered up in the hospital setting, with students having clinical experience and being mentored by these organizations, they’re learning about what nurses contribute to patient care, watching nurses in action, and seeing systems come together,” Reske said, adding that there’s only so much students can learn in a simulation lab; they learn to form their own professional identity when training inside the healthcare system.

She noted that many students gravitate to the profession because of positive experiences with nurses, either for themselves or a loved one. In other cases  they were influenced by a parent’s career in the field. But that passion also quickly gets tempered by the realities of an increasingly challenging job.

“When we build a strong nursing workforce, it begins with education. And educators are tasked with teaching the new demands of the healthcare system,” Reske said, with factors ranging from population-health concerns to a more interdisciplinary focus in patient care. “Learning to become a nurse means understanding the realities of the nursing workforce today.”

Those realities come at a time when staffing shortages have increased stress on nurses. At a time when the annual Gallup Honesty and Ethics poll, released in January, ranks nursing as the most trusted profession for the 21st year in a row, nurses are feeling strain.

In fact, the American Hospital Assoc. (AHA) reports that about 100,000 registered nurses left the workforce during the past two years due to stress, burnout, and retirements, and another 610,388 intend to leave by 2027, according to a recent study by the National Council of State Boards of Nursing (NCSBN).

“The pandemic has stressed nurses to leave the workforce and has expedited an intent to leave in the near future, which will become a greater crisis and threaten patient populations if solutions are not enacted immediately,” said Maryann Alexander, NCSBN’s chief officer of Nursing Regulation. “There is an urgent opportunity today for healthcare systems, policymakers, regulators, and academic leaders to coalesce and enact solutions that will spur positive systemic evolution to address these challenges and maximize patient protection in care into the future.”

Among other recommendations to strengthen the healthcare workforce, AHA has urged federal lawmakers to invest in nursing schools, nurse faculty salaries, and hospital training time; enact federal protections for healthcare workers against violence and intimidation; support apprenticeship programs for nursing assistants; increase funding for the National Health Service Corps and the National Nurse Corps; and support expedition of visas for foreign-trained nurses.

For its part, Baystate Health said the Gallup poll is worth celebrating.

“The honor comes as nurses throughout the country, including here at Baystate Health, continue to deal with the effects of a nationwide nursing shortage and the emotional impact that the COVID pandemic has had on nurses,” said Joanne Miller, chief Nursing executive for Baystate Health and chief Nursing officer at Baystate Medical Center. “I am proud to say that, since the beginning of the pandemic, every nurse at Baystate Health has fulfilled our promise of advancing care and enhancing lives.”

Today’s nearly 4.4 million registered nurses in the U.S. constitute the nation’s largest healthcare profession, and the field offers a wide range of opportunities to those considering a career, including practicing as clinicians, administrators, researchers, educators, and policymakers.

In 2022, Baystate Health welcomed more than 900 nursing students into clinical placements from nursing programs at American International College, Bay Path University, Elms College, Holyoke Community College, Greenfield Community College, Springfield Technical Community College, UMass Amherst, and Westfield State University.

Linda Thompson, left, and Holyoke Community College President Christina Royal

Westfield State University President Linda Thompson, left, and Holyoke Community College President Christina Royal shake hands after signing a dual-enrollment nursing program agreement.

Newly graduated registered nurses (with less than 12 months of clinical nursing experience) can apply to its 10-month paid nurse residency program. During that time, they work directly with a unit preceptor and nurse educator for clinical instruction combined with classroom-style seminars and skills/simulation sessions. The collaborative learning approach is designed to provide the knowledge base and skillset needed to successfully transition into the role of a professional nurse.

Reske said professional experiences like these demonstrate the need for collaborative practice. “They’re not alone but working with other teams, providing patient care where everyone is thinking about how to improve the patient’s health and experience, looking at that patient’s values and experiences.

“We’re preparing students to understand the complex realities of healthcare today,” she went on. “Nurses can really make a unique difference by looking at patients through the nursing lens with a more holistic view.”


Satisfaction Suffers

While all this is meaningful work, many nurses feel there’s a long way to go to reach ideal job satisfaction. According to the annual “State of Nursing in Massachusetts” survey conducted by the Massachusetts Nurses Assoc. (MNA), bedside nurses feel undermined in their ability to provide quality care by understaffing and assigning unsafe numbers of patients, which fuels the flight of nurses away from the profession and leads to hospitals relying on expensive travel nurses to fill the void. Among the survey data:

• 85% of nurses say hospital care quality has deteriorated over the past two years;

• 53% say hospitals that rely on travel nurses have worse care;

• 71% of nurses say their biggest obstacle to delivering quality care is understaffing and/or having too many patients at one time; and

• 88% of nurses support legislation limiting the number of patients assigned to a nurse at one time.
That last statistic rises to 98% when only new nurses are surveyed, demonstrating that nurses are entering the field with eyes wide open to to the impact of staffing challenges.

Rather than causing the staffing crisis, said Katie Murphy, a practicing ICU nurse and president of the MNA, “the COVID-19 pandemic has simply laid bare a system already broken by hospital executives. The industry claims it cannot find nurses, but the data shows there are more nurses than ever. There is not a shortage of nurses, but rather a shortage of nurses willing to work in these unsafe conditions.”

“Nurses throughout the country, including here at Baystate Health, continue to deal with the effects of a nationwide nursing shortage and the emotional impact that the COVID pandemic has had on nurses.”

This year’s survey featured an all-time high number of nurses saying hospital care quality has gotten worse over the past two years. The survey has tracked this number since 2014, when it was 38%. In 2023, 85% of nurses saw care quality decline, up two points from last year, 30 points from 2021, and 46 points from 2019. This troubling trend tracks with survey results showing increased numbers of nurses who do not have enough time to give their patients the care and attention they need and who are forced to care for too many patients at one time. In 2023, 72% of nurses saw both of those issues as “major challenges,” up 11 and 13 points from 2021.

Newer nurses are disproportionately feeling the impact. Sixty-three percent of nurses with five or fewer years of experience say understaffing is their biggest obstacle to providing quality care, compared to 56% of all nurses. Of those nurses planning to leave the field within two years, 67% of newer nurses say they will find work outside of healthcare, compared to 31% of all nurses.

Colleges are doing what they can to draw new nurses into the pipeline. For example, Holyoke Community College (HCC) and Westfield State University (WSU) recently announced a new pathway for individuals to earn both an associate degree and bachelor’s degree in nursing simultaneously or in a streamlined manner by combining the curricula of both programs. The concurrent program is the first in the Commonwealth.

“The concurrent ADN-to-BSN pathway is an innovative approach to nursing education,” WSU Executive Director of Nursing Jessica Holden said. “It enables students to earn their ADN while simultaneously completing coursework that counts toward their BSN. This integration of education allows for a more efficient and streamlined approach to nursing education that is advantageous to some students.”

The concurrent nursing program will help address the nursing shortage by increasing the number of students who can get into a bachelor of nursing program and allow them to earn their degree faster.

According to a Massachusetts Health Policy Commission report, “registered-nurse vacancy rates in acute-care hospitals doubled from 6.4% in 2019 to 13.6% in 2022, with especially high vacancy rates in community hospitals. Employment in nursing and residential care facilities has not recovered since 2020 and remained below 2018 levels.”

HCC Director of Nursing Teresa Beaudry explained that “we had to meet with the Massachusetts Board of Registration in Nursing, who had to approve it, and they’re equally as excited as we are to create another pathway for nurses to advance in their education and a different way for those students who might not be able to get into a bachelor’s of nursing program.”


A Question of Balance

In fact, moving up in the profession is a significant draw to many aspiring nurses. Most area colleges and universities with nursing programs have master’s and doctoral programs structured in such a way that nurses can work full-time while earning advanced degrees that will open up more doors and set them on track to be nursing managers, educators, administrators, or work in other roles.

“Usually, nurses return for an advanced degree,” Reske said. “They begin to look at, ‘what can I contribute in practice? What attracts me? Is it working in an ambulatory-care setting or rehabilitation, or as a nurse leader or a nurse educator? Maybe I want to be a nurse practitioner.’ The opportunities for nurses are amazing.”

And the education they’re getting — both in the classroom and in the field — must prepare them for the new complexities of medical care today, she added.

“Nurses definitely have to deal with more complex issues — speak the language of finance, speak the language of marketing, speak the language of population health. All those require additional learning beyond the classroom. You’re connecting practice to knowledge and knowledge to practice, and learning how to apply that.”

In short, it’s a challenging time to be a nurse, and also a time of great opportunity. Whether their love of nursing outweighs the stresses is a question for every professional in the field — and those questions are not going away any time soon.

Healthcare News Special Coverage

Living in Their World

Beth Cardillo calls them ‘fiblets.’

These are things that are said to someone with dementia that … well, do not represent the whole truth, or even a portion of it, at least to the person making that statement.

But to that person suffering from Alzheimer’s or one of the many other forms of dementia, it is the truth as they see it in their world. “It’s not a lie,” she said of these fiblets. “It’s an OK thing to tell people with memory issues.”

She offered up an example.

“Let’s say someone’s husband has been dead for 20 years; she might say, ‘I’m not going out shopping, I’m waiting for my husband to get home,’” noted Cardillo. “A fiblet would be … ‘oh, he just called; his tooth is hurting him and he’s going to see a dentist. Why don’t you and I go out for a ride and go to the grocery store?’”

“You’re going to tell someone that their husband died over and over again, every day?” she went on, asking that question rhetorically before answering it poignantly. “I mean, why would I want to do that? It’s cruel.”

Indeed, and fiblets are a good example of how those caring for and simply around individuals with dementia regularly should try to live in their world, rather than constantly try to pull them into the ‘real’ world. It’s also an example of the kind of work that Cardillo has made into a career, or at the least the latter stages of one.

Beth Cardillo

Beth Cardillo

Her latest move comes as a part-time social worker for a unique program called Baystate House Calls. As that name suggests, it’s a program operated by Baystate Health that involves healthcare professionals making house calls to older adults. It includes a physician, nurse practitioner, nurse, social worker, and community health worker, team members who will visit individuals in their home to assess their needs and provide recommendations.

The initiative concentrates on what administrators call the 4Ms — ‘mobility,’ ‘what matters,’ ‘medication,’ and ‘mind.’

It focuses not only on those in need of help and services, but caregivers as well, said Cardillo, adding that her work, and that of her colleagues, takes them to every corner of Springfield. And while she is helping seniors and caregivers with a wide variety of issues from substance abuse to falls to depression, much of her work involves those with memory issues.

And, increasingly, it involves what is known as habilitation therapy (HT), a holistic approach to dementia care that focuses on the abilities that the person still has, rather than what they have lost, and can reduce difficult symptoms.

“It focuses on everything positive — it focuses on people’s strengths, not their weaknesses,” she said of HT, adding that it brings caregivers and patients closer together as they work on daily tasks, makes those suffering from dementia feel respected and valued, reduces stress among caregivers, and creates positive emotional experiences that bring comfort and happiness.

“The reality therapy is for us to learn to live in their reality, not for them to live in our reality of our world. That’s probably the biggest lesson there is.”

Cardillo was recognized by BusinessWest and its sister publication, HCN, with a Healthcare Heroes Award in 2021 in the category of Community Health for her work during her years as executive director at Armbrook Village in Westfield to create ‘dementia-friendly’ communities and help others better understand — and communicate with — those suffering from memory loss.

For this HCN Monthly Feature and its focus on Memory Care, we talked with her at length about the importance of understanding what is reality that for those with dementia — and enabling them to thrive, as much as possible, in that reality.


Reality Check

Cardillo told BusinessWest that, years ago, she and others involved with providing memory-care services would offer to those with dementia what was called, by some at least, ‘reality therapy.’

“We would say, ‘no, no, no, you’re wrong — today’s Thursday, or today’s this, and tomorrow is that,’ she said, correcting wrong statements and answers to questions whenever the need arose. “But what we’ve learned is that it doesn’t matter. The reality therapy is for us to learn to live in their reality, not for them to live in our reality of our world. That’s probably the biggest lesson there is.”

Helping others live in the reality of those with dementia is a big part of the work Cardillo has been involved with over the years, especially at Armbrook, but also now as a social worker. She said that to make this leap — and it is a leap for most — it begins with education and an understanding of the disease and how it impacts people.

It robs them of short-term memory and the ability to do certain things — from driving to cooking to reading. But it doesn’t, or shouldn’t, take from them the things that are important to them, and have been important throughout their lives, be it what they did for a living, or travel, music, pets, or a love of the movies.

Cardillo recalled the case of a long-retired college professor who had (and still has) a passion for the New York Times and carries it with her daily.

“Some days, it’s upside-down,” said Cardillo. “But it doesn’t matter; that was her identity. Those are they types of things you don’t want to change; you don’t want to correct people.”

Overall, she said it’s important to treat those with dementia with respect and to not embarrass them with ‘reality’ questions or constant corrections concerning what day it is and what members of the family are no longer alive.

“It doesn’t matter if they say it’s Tuesday and it’s really Sunday. It just doesn’t matter. So, we don’t want to correct people. Does it matter if Mr. Smith thinks it’s a different day? Is that going to change the world? No. If he thinks it’s Christmas tomorrow, that’s OK. Why take that joy away?”

“Just because you have Alzheimer’s doesn’t mean you’re stupid,” she explained. “It doesn’t mean you can’t read people’s emotions. “I know people who will say to family members, ‘what’s my name? What’s my name?’ Why are you saying that to them? It embarrasses them. They know you have a connection. Is it because you think that if they know your name, they’re having a good day and that makes you feel good?

“Because it doesn’t matter if they know your name,” she went on. “It doesn’t matter if they say it’s Tuesday and it’s really Sunday. It just doesn’t matter. So, we don’t want to correct people. Does it matter if Mr. Smith thinks it’s a different day? Is that going to change the world? No. If he thinks it’s Christmas tomorrow, that’s OK. Why take that joy away?”

She recalled the case of a woman who told her that she was pregnant at 66. Instead of correcting her, Cardillo said she simply told her, ‘if that’s true, you’re going to make history.’

“You laugh about it with her, because she tells me these wacky stories,” she went on. “Her parents have been dead, but she’ll say, ‘oh, my mother wants you to come over for dinner.’ “I’ll say, ‘oh, how is your mother? I like your mother; tell her I said hello.’

“Her husband, on the other hand, keeps saying, ‘your mother is dead!’” she continued. “We need to stop that because it doesn’t matter. She doesn’t remember and she doesn’t care, and in in her head, her mother is alive. That’s fine. Who does it hurt?”

Overall, she said it’s important to try to communicate with a positive spin, rather than a negative one.

Indeed, instead of telling someone with dementia that they are not supposed to be going outside, when they suggest that they want to do so, one should instead stay positive and suggest that this person can sit outside when the weather is better.

As she talked about those suffering from dementia and how those caring for them should approach daily conversation and activities, Cardillo said it is important to keep them engaged and to focus “on what they can do, not what they can’t do.”

This brings her back to the concept of habilitation therapy, which, she believes, has benefits, and many of them, for those living with memory loss, their caregivers, family, and friends.

“It’s important to keep people meaningfully busy and not just silly busy,” she told BusinessWest, adding there is a big difference between the two.

Elaborating, she said that television is not a good option.

“We don’t want to put people in front of a TV all day, because it’s … not good,” she said. “It doesn’t make them happy campers. It doesn’t mean that TV is bad, just not as a babysitter all day.”

Instead, such individuals should be involved in activities that speak to who they are, who they were professionally, and what interests them.

“It’s really important to know what people did in their work,” she explained, “because they still retain some of those skills, and it’s still a part of who they are as an identity. For those who were teachers, give them papers to correct; you come up with things that they can do.

“I had someone whose father was a retired electrician,” she went on. “He had a manual of electrical … something; it was bigger than the New York City phonebook. He looked through those pages every day. I don’t know if he knew what was in it — I sure didn’t — but that gave him comfort.”

And some form of comfort is what those caring for people with dementia should be trying to provide each day, she said, adding that this can be done through HT, emphasizing the positive, and, yes, focusing on what those with dementia can do, not what they can’t.



Bottom Line

Summing up what she tells those caring for people with dementia, Cardillo said it is simply that reality is in the eyes — and mind — of the beholder.

And if we really want to help those with this disease, we have to at least try to live in their world, rather than make them live in ours. It’s not an easy assignment, especially when one is asked the same questions over and over, day after day, but it’s the key to those on both sides of the equation being able to thrive.