At the American Organization of Nurse Executives 2016 annual conference, nurse leaders share how they are expanding nursing care across the care continuum, to the great benefit of both patients and institutions.
The official theme for this year's American Organization of Nurse Executives annual conference was, "Inspiring leaders," but based on the sessions I attended, an alternative theme could have been, "Nurses: Everywhere You Want to Be."
What I mean by this is that nursing care is no longer strictly task-based and delivered at the bedside.
Instead, nurses have become integral in achieving the goals of the new healthcare environment—value-based care, improved patient outcomes, greater access to healthcare—and they are working their magic throughout the care continuum. Nurses can be found in the C-suite, at the unit level, in the ambulatory setting, on boards, and in the community.
Read on for some of the ways nurses are delivering care across the healthcare landscape.
The Surplus Project
The poster presentation, "Surplus Project: Serving Food Insecure Populations Through a Leadership Development Program," detailed how Jennifer M. Grenier, RN-BC, MSN, nurse director, telemetry at not-for-profit Rush Oak Park (IL) Hospital, was able to provide 10, 238 meals to an area food pantry over the course of four months by repackaging leftover food the hospital was going to throw out.
Not only was she able to address the needs of those in the community facing food insecurity, but she was also able to provide healthcare screenings at the food pantry on donation days with help from RNs on The Surplus Project team.
While significantly different than reading cardiac rhythms and administering medications, she still used her nursing skills of critical thinking and assessment to identify a community health issue and to develop a solution that affected the health of a patient population.
The Nurse Leader's Role in Care Coordination and Transition Management
Navigating the healthcare system can be tricky for patients, especially those with co-morbid conditions and multiple providers. Gaps in care, such as medication errors or missed follow-up appointments, can occur when patients' care plans aren't well communicated. As a result, patients may end-up experiencing avoidable complications and costly hospital readmissions.
Improving care coordination and transitions isn't just the domain of RNs with designated care coordination roles, says Mary Beth Kingston, RN, MSN, NEA-BC, executive vice president and system chief nursing officer at for-profit Aurora Healthcare in Milwaukee, WI.
"Many times we think of care coordination as specific RN coordination roles, and there are many of them, and they've proven to be very effective in terms of managing health and improving outcomes," she says. "But focusing on inpatient nurses is equally important because it's recognizing the fact that all nurses have care coordination roles."
Outlined in the statement and discussed during the session are six principles nurse leaders can follow to help create a care coordination process that "includes all staff, key stakeholders and nurse leaders across the continuum of care:"
Know how care is coordinated in your setting
Know who is providing care
Establish relationships with multiple entities and individuals who can work together to improve care coordination and transition management systems
Know the value of technology, its impact on workflow, and the roles of care coordination team members
Engage the patient and family
Engage all team members in care coordination
As Kingston points out, nurse leaders play a vital role in creating the scaffolding that supports care coordination at an organization.
"I'm not a care coordination expert," she says, "but what I do know is, that as a nurse leader, I really need to understand what's happening in my organization because I'm often in the role of advocating, of translating, of integrating, and of decision-making regarding care coordination technology."
The BSN-Prepared Nurse Navigator in the Ambulatory Setting
Through years of research, University of Pennsylvania nurse researcher Linda Aiken, RN, PhD, FAAN, FRCN, has found that hospitals with more BSN-prepared nurses have lower mortality rates and fewer adverse patient outcomes compared to those with less BSN-prepared nurses.
At Bon Secours Health System, a not-for-profit Catholic system headquartered in Marriottsville, MD, nurse leaders are seeing the value of BSN-prepared nurses in the ambulatory setting as well.
"When allowing our baccalaureate-prepared, professional nurses in the ambulatory setting to work to the fullest extent of their education and training, we have achieved a significant clinical and financial return on investment," says Liana Orsolini, RN, PhD, ANEF, FAAN, care delivery and advanced practice system consultant at Bon Secours Health System.
Angel Daniels, RN, MSN, CCN, clinical manager, clinical operations and medical home department at the health system explains that by using BSN-prepared nurse navigators, Bon Secours has been able to generate revenue to the tune of $1 million annually in the areas of complex case management, annual wellness visits, and transitions of care.
"By allowing the nurse navigator to complete the annual wellness visits, that generates revenue because it allows the providers to increase capacity and open their schedules to see more patients, "she says.
Nurse navigators have also contributed to cost reduction by maintaining a 1-2% readmission rate for the system.
The most important factors related to job satisfaction among new nurse managers are not the same as they are for novice staff nurses or even more experienced managers.
When it comes to improving care quality and outcomes, reining in healthcare costs, and providing value-based care, nursing is where the rubber of an organization’s strategic plan meets the road. And, according to Maja Djukic, PhD, RN, assistant professor in College of Nursing at New York University, frontline nurse managers are essential players in achieving these goals.
“Nurses are there around-the-clock to care for their patients and have this unique opportunity to improve individual patient care because we are with patients constantly,” she says. “Unit-level managers are in a similar position, in terms of affecting outcomes for the entire population of patients on their particular unit, because they usually have 24-hour responsibility for patient outcomes on that unit.”
Frontline managers also affect the retention of staff nurses, says Djukic, a co-investigator for the RN Work Project, a decade-long, national study on new nurses’ careers funded by the Robert Wood Johnson Foundation and launched in 2006 by principal investigators Christine T. Kovner, RN, PhD, FAAN of NYU’s College of Nursing and Carol S. Brewer, RN, PhD, FAAN of the University at Buffalo (New York) School of Nursing.
“I had been working with Dr. Kovner as a doctoral student and was really interested in jobs satisfaction and turnover of nurses,” she says. “As I developed that line of work, I realized my key audience was really managers because one of the top reasons new nurses were leaving their jobs was poor management. So I became more interested in the nurse manager workforce.”
As the study participants gained career experience, some began taking on roles as nurse managers, and Djukic is now collecting data on new nurse managers—those with less than two years of experience as frontline nurse managers.
“As our sample of new nurses matured, more of them were going into management positions, so I had more data on these new nurses who then transitioned into manager roles and were new in their role of the manager.”
So what influences new nurse managers job satisfaction rates? The two most important factors, says Djukic, are personality and procedural justice.
Personality
I once worked with someone who always had something to complain about. It didn’t matter if she was working on the frontline or working as a manager, nothing was ever right. Eventually, I concluded that even if she worked at the grocery store deli counter, she’d still find fault with something. She had what Djukic describes as a “negative affect” or a tendency to see things through a pessimistic lens.
It probably shouldn’t come as a surprise that new nurse managers who rated themselves as having a negative affect (strongly identifying with statements like, “Minor setbacks sometimes irritate me too much.”) reported lower rates of job satisfaction.
Changing someone’s personality is difficult so it’s best to consider this factor before filling a manager position. “There’s an opportunity to be more mindful in terms of selection [of managers] into these roles and to pay attention to people’s personalities,” says Djukic.
Senior managers have much greater control over the second factor, procedural justice.
Organizational Involvement
“What that means is, for novice managers, it’s really important for them to feel involved in organizational decision making,” she says. “They want to senior leaders to be transparent about how decisions that involve or affect these novice mangers are being made.”
New nurse managers also want to be able to have input into decisions that affect nurses.
“The factor that had the greatest influence in job satisfaction was this idea of organizational involvement and asking managers what they think, and also asking them to contribute to changes that will affect them in the future,” she says.
Additionally, Djukic found that novice nurse managers desired a high-degree of autonomy and variety in their positions as well as having opportunities for mentoring and creating and building collegial relationships their peers and with physicians. The presence of organization constraints, like barriers to the resources necessary to do their jobs, also played a role in satisfaction rates.
“The most important factors related to novice nurse manager satisfaction are not exactly the same as they are for novice staff nurses or even more experienced managers,” she says. “This group has a unique set of needs, and so the programs to improve their job satisfaction should really be customized. In order to retain them, be mindful about the specific needs this particular group.”
CNOs rank evidence-based practice low on their priority lists even though its use is necessary to achieve their top goals of improving quality and safety. OSU's CNO shares specifics on how nurse execs can build EBP-friendly cultures.
When I saw the results from a recent study on nurse executives’ prioritization of evidence-based practice, I was shocked. Only 3% of the CNOs surveyed ranked evidence-based practice as a top priority. How was that possible?
EBP has become such a buzzword in the nursing profession that I assumed it would be at, or at least near, the top of every CNO’s priority list. Plus, its implementation is part of the criteria for achieving the American Nurses Credentialing Center’s much coveted Magnet Designation.
Mary Nash, RN, PhD, FAAN, FACHE, chief nurse executive at The Ohio State University Health System and assistant dean at The Ohio State University College of Nursing in Columbus, had a similar reaction to the findings. “I’ve been a nurse exec for 32 years,” she told me. “I was really surprised.”
But perhaps the results shouldn’t have been such a surprise to either of us.
As I mentioned in last week’s column, many nurses went to school before EBP was part of the curriculum and therefore, have not been steeped in its concepts and processes for their entire careers.
Not being an “EBP-native,” however, isn’t an excuse for not getting up to speed on EBP.
“We have got to educate the chief nurses, the nursing directors, and the nurse managers [in EBP],” says the study’s author Bernadette, Melynk, RN, PhD, CPNP/PMHNP, FAAN, FANP, associate vice president for health promotion, university chief wellness officer, and dean of the College of Nursing at The Ohio State University.
“We’ve got to equip them with skills in EBP so they can build a culture and an environment that makes EBP the easy choice for people to make at the bedside.”
A Common Thread
The first step in developing a culture that embraces EBP is to set clear priorities. Nash recommends using the strategic planning process to identify about four areas on which to focus.
“We have an annual strategic planning process and a five-year strategic plan,” she says. “We look at four major areas:
Quality and safety
Nurse engagement
Patient experience and
Cost-effective care delivery
Once these areas have been defined, it’s time to bring EBP into the picture. “Rather than thinking about [EBP] as a separate component, we think about it as woven into all of our four priorities,” Nash says. “It’s a thread that’s woven across all those dimensions.”
Take the health system’s top priority of quality and safety, for example. Preventing and reducing central-line acquired bloodstream infections is a common quality and safety goal across the U.S. healthcare system. Evidence on ways to achieve this goal (Nash specifically mentions the use of disinfecting port protector caps) should be assessed and implemented.
“You think about each one of those quadrants,” she says. “You think about what’s wrong, where the evidence is, and what you can do that may be a best practice for improving.”
To garner support for EBP among his or her C-Suite colleagues, a CNO must produce data regarding an intervention’s outcomes. Back to the previous example, Nash says using reports to show that CLABSI rates declined after using an \ evidence-based protocol, and tying that decrease to cost savings from shorter length of stay or lower complication rates, would be vital in getting other executives to support the culture change.
“They don’t want to hear stuff. They want to see reality,” she says. “When you take a look at trends and they’re all going in the right direction, it’s pretty compelling. Then you can say, ‘We really need to do this and here’s what the ROI is.’”
Investing in Infrastructure
While it’s necessary to achieve an organization’s goals and outcomes, creating a culture that values EBP is not instantaneous. It can, in fact, takes years of hard work.
“You think, ‘That’s great I’ll just weave it into my strategic plan and that will be that,’” Nash says. “But it doesn’t come overnight. We made a decision about four-and-a-half years ago that we were going to have an infrastructure that supported EBP.”
That meant creating a full-time position for a director of evidence-based practice to ensure that policies and procedures at all of OSU’s five hospitals were evidence-based.
“After four-and-a-half years of having this role and having an EBP council, the staff now talk in terms of EBP,” says Nash of the investment. “She’ll be on the unit and they’ll say, ‘Well, the latest evidence says…” It really is enculturated where people feel compelled to make sure the patient gets the very latest and best care.”
Sending staff through an EBP immersion program has also helped promote use of EBP among nurses. Nash says that when nurses recognize a problem or see an opportunity to improve care, they look for evidence to help develop a solution.
She told me about a nurse on the heart failure unit who recognized patients were falling at consistent times during the day. It turned out the falls were tied to the times patients received their Lasix dosages. The nurse took the initiative to independently create an EBP poster to share with her peers.
“When there’s a problem on the unit, [the nurses] do a lit search, and they come up with a solution,” Nash proudly says. “It’s really neat to see. In all my years, I have not seen as much of a culture for EBP as we have here.”
Nurse leaders may believe in the power of evidence-based practices, but more than 50% say EBP is practiced at their organizations "not at all" or "somewhat." The way forward is to quantitatively demonstrate value, says one advocate.
What do Santa Claus and evidence-based practice have in common? Believing in them doesn't mean they exist. If you're scratching your head over this riddle's answer, let me explain. I'll even use evidence on EBP to help make my point.
In 2012, a study published in the Journal of Nursing Administration reported that nurses ranked resistance from nurse leaders and nurse managers as one of the top five barriers to implementing EBP. Now a new study published in Worldviews on Evidence-Based Nursing has found that, while chief nurse executives say they strongly believe EBP results in high-quality care, only 3% of the 276 CNOs and CNEs ranked EBP as a top priority. And 74% reported that they allocated zero to 10% of their annual operating budgets to build and sustain EBP in their organizations.
More than 50% said EBP is practiced at their organizations "not at all" or "somewhat."
"These chief nurses believe in EBP. Their top two priorities are quality and safety," says the author of both studies, Bernadette Melnyk, RN, PhD, CPNP/PMHNP, FAAN, FANP, associate vice president for health promotion, university chief wellness officer, and dean of the College of Nursing at The Ohio State University in Columbus.
"But there's a major disconnect because they don't see evidence-based practice as a direct pathway to get their organizations to high quality and safety. So that's a big problem."
A big problem indeed. Especially when you look at one of Melnyk's other findings—chief nurses reported that more than one-third of their hospitals were not meeting benchmarks for NDNQI measures.
So what is contributing to this disconnect that threatens the quality of patient care? And how can nurse leaders overcome it?
Melnyk and her colleague Mary Nash, RN, PhD, FAAN, FACHE, chief nurse executive, OSU Health System and assistant dean, OSU College of Nursing, spoke with me about the causes and solutions to this EBP paradox.
Getting to Know EBP
When I went to nursing school in the mid-to-late 1990s, EBP wasn't quite yet a "thing." Interest in EBP began to pick-up steam when, in 2003, the IOM set a goal that 90% of healthcare decisions would be evidence-based by 2020.
With 55 being the average age of the chief nurses in Melnyk's study, it's safe to assume that they, like me, weren't exposed to EBP from the beginning of their nursing careers and instead had a course on nursing research.
Even when nurses go back for their master's or doctorate degrees, it's likely they are still being taught how to conduct nursing research versus implementing EBP, Melnyk told me.
"There's so many academic programs throughout the country that are still teaching bachelor's and master's degree students the rigorous process of how to do research instead of teaching them how to do EBP," she says. "The reason for that is because, think about it, the DNP is a relatively new degree. So you've got PhD researchers who are still teaching research all throughout the country who have really never learned EBP."
Melnyk says though almost 70% of the chief nurses in the study had master's degrees, more than 50% said they were not sure how to measure outcomes of the healthcare services they were delivering. Plus, more than half of the study's respondents reported they had not accessed databases for evidence-based guidelines "in the past eight weeks."
This led me to ask Melnyk a question I had originally crossed off my list because I thought it was too basic. What is the difference between EBP and research?
"EBP is a problem-solving approach to the way we deliver healthcare that integrates the best evidence from research studies with a clinician's expertise and a patient's values and preferences. So you're using the evidence that's generated. Research is a scientific process through which you generate new knowledge and new evidence to be used by clinicians," she told me.
"One is the generation of research, new findings, new knowledge— that's research. The other (EBP) is translating the evidence that's generated from research into practice to improve the quality of care in patient outcomes."
Beyond Belief
After uncovering these findings, Melnyk went on to practice—evidence-based practice, if you will—what she preaches. She contacted Pamela Thompson, CEO at the American Organization of Nurse Executives and the two organized a summit of 160 nurse leaders who were members of AONE. The goal was to find out how they could support this group in implementing EBP.
"Do you know what they told us?" Melnyk asks. "'Help us to show CEOs and CFOs in our organizations the return on investment with EBP.' That's what they wanted. You see, in nursing, we traditionally haven't been good at ROI."
Nash says relationships with other C-suite members play an important role in creating a culture that supports EBP.
"I think a barrier is when the chief nurse is not positioned to be a voice in the organization, and the reason I say that is that's where you build the relationships and relationships build trust," she says. "We need to be at the table, and people need to look at nurses as scientists and individuals that have a lot of knowledge about quality and safety rather than just nice to have."
Demonstrating Value
Data and reports that prove EBP is working is another way to show EBP's worth. Showing colleagues numbers that illustrate there has been a decrease in CAUTIs, CLABSIs, or length of stay since an EBP intervention has been implemented, strengthens the argument for EBP.
"You've got to be quantitative. They don't want to hear stuff. They want to see reality," Nash says. "When you take a look at trends and they're all going in the right direction, it's pretty compelling to say that EBP is effective."
And when a chief nurse shows how EBP has moved the organization toward its goals and proven its ROI, it's fair to ask CEOs and CFOs to make a concrete commitment to supporting EBP.
"Take it back to your CEO [and] your CFO and say 'We've saved $500,000 by changing this practice. We want half of that to come back to nursing so we can further fuel our efforts to get everybody up to speed on EBP,'" Melnyk says.
A University of Missouri project is reducing avoidable hospitalizations by shifting the culture, processes, and systems at 16 unique facilities. It's benefitting hospitals and health systems as well as nursing facilities.
Forrest Gump was right when he said, "Life is like a box of chocolates. You never know what you're gonna get."
That was certainly my experience during my brief foray into hospice nursing. I'm not referring to the types of patients or their individual situations, but rather, the way care was delivered in different settings and organizations.
I could walk into one nursing home and it would be outfitted with electronic medical records. Two hours later, I'd be at different facility that was still using paper charts and a Kardex for medication scheduling.
In hospitals, the types of EMRs varied from facility to facility as did workflows and chains of command.
Who to page, how-to-page them, where to put the progress note, all differed. Processes and systems, at both acute and post-acute care facilities, varied so widely it was overwhelming.
This experience played through my mind as I talked with University of Missouri researchers Colleen Galambos, PhD, ACSW, LCSW, LCSWC, professor in the College of Human Environmental Sciences' School of Social Work and Gregory L. Alexander, RN, PhD, FAAN, professor in the Sinclair School of Nursing about a project they are involved with called the Missouri Quality Initiative for Nursing Homes.
MOQI, which was launched in 2012 under the leadership of the university's Marilyn Rantz, RN, PhD, FAAN, curators' professor emerita, is a partnership among MU, the Centers for Medicare & Medicaid Services, and state Medicaid programs to improve care at 16 nursing facilities in St. Louis.
As one can imagine, this no small project. Shifting the culture, processes, and systems at one facility can be a challenge. But 16 unique facilities?
"Everybody's starting in a different place," Galambos told me. "We have 16 different facilities with 16 various capabilities, and 16 cultures."
Factor in all the other stakeholders involved in nursing home resident's care—hospitals that admit and transfer residents, primary care providers, labs, hospice—and it truly becomes an enormous undertaking. But it's one that seems to be working.
Decreasing Avoidable Hospitalizations
Don't be fooled by the name of the program, the project doesn't just benefit nursing homes. It addresses issues of importance to hospitals and health systems as well.
The four main goals of MOQI, which is a four-year project slated to wrap up in September 2016, are to:
Reduce potentially avoidable hospital transfers
Decrease polypharmacy and antipsychotic medication use among nursing home residents
Increase discussions on goals of care and completion of advance directives
Introduce secure communications for electronic transfer of health information among healthcare providers, nursing homes, and hospitals
Thus far, the project appears to be on track to meet these goals. Data released in January 2016 in CMS's year three report on the project shows that compared to 2012 there has been a 21% decrease in nursing home residents' all-cause hospitalizations, a 34.5% decrease in potentially avoidable hospitalizations, and a 27% decrease in all-cause ED visits.
"Essentially what we've done is we've saved a lot of Medicare dollars by taking care of people in the nursing home versus transferring them back and forth," Alexander says. "That's been a good thing for the residents and it's a good thing for the facilities because they get to keep better continuity of care for the residents."
Raising the Bar Through Feedback
Though the project is finding success, that doesn't mean that the intervention is simple. There's not one magic bullet that providers can implement to ensure improvement.
Rather, MOQI is built upon four major components:
An APRN in each nursing home to provide direct services to residents and to mentor and educate nursing staff about early symptom and illness recognition, assessment, and management of conditions commonly to nursing home residents
Early recognition, assessment, and management of residents' conditions. Positive, collaborative relationships with SNF residents' primary care providers
Proactive discussions about end-of-life decision making. Development and implementation of end-of-life decision making and communication systems
Improvement of hospital transitions and communication, and reduction of polypharmacy
"What the people we had working for us in the field did was identify those [stakeholders] and then bring them together into the stakeholder group to be able to communicate and talk about the way they did things," Alexander says. "It created this sort of understanding about how each worked, and how we could bring that together to be more seamless."
The 16 APRNs, who work full-time in each SNF, round on the residents and provide direct care, are also supported by other MOQI team members, Galambos points out. This includes a health information technology coordinator, social work care transitions coach, database Coordinator, INTERACT coach, and project supervisor.
Feedback is also an essential part of the project.
"We've provided lots of different feedback mechanisms and reports that enable them to see the progress that they're making," Alexander says. "If there are issues, then we can address those issues immediately and do the root cause analysis about what the systems problems are with readmissions. Then we send teams to those facilities that have the most problems to problem solve and troubleshoot the issues."
While there are many moving many moving parts, Alexander says the complexity of the project is worth it if it means improving quality of care.
"We're putting it at the forefront of their work so they are starting to recognize things early, and getting something done for these residents up front so we can avoid the hospital readmission in the long run," he says.
"We're introducing new measures—some very valid measures and reliable measures—but we also have some that are a little less studied in nursing homes. But that's okay because we're raising the bar."
After a new care model positively affected outcomes related to HF patients, Holy Name Medical Center in New Jersey expanded the use of advanced practice nurses inside and outside the medical center.
If you were given carte blanche to create a nursing care model, what would it look like?
Judith Kutzleb, RN, DNP, CCRN, CCA, APN-C, vice president of advanced practice professionals at Holy Name Medical Center, in Teaneck, NJ, had to answer that question when the organization 's CEO handed her the opportunity a few years ago.
She easily could have forged ahead alone, but instead Kutzleb sought the input of others to develop the model.
"I don 't really like to do anything alone, " she told me. "My leadership style is one that enhances others to grow, so I designed a subcommittee of nurse practitioners and clinical nurse specialists in order to come up with a model that would be able to be implemented in the organization. "
Judith Kutzleb, RN, DNP, CCRN, CCA, APN-C
The group 's brainstorming sessions led to the creation ofThe NP Care Model, a patient-centered, collaborative-care approach intended to decrease readmissions and costs of care, and improve patient outcomes. The model 's details and outcomes were recently published in Nursing Economic$ .
"The model became the patient-centered model because the whole point is, if we 're meeting healthcare challenges, we need a collaborative team, " she says, "which means we 're not taking the place of anything. The model is not taking the place of anything. It 's going to enhance that which already being delivered. "
And enhance care it has.
A Win-Win Scenario Evidenceshows that APNs provide equal or better outcomes when compared to physicians, yet there is often still resistance to allowing APNs to function at the top of their licenses.
In 2013, theNew England Journal of Medicinepublished a studythat reported "the Council of Medical Specialty Societies and the American Academy of Family Physicians strongly opposed broadening the scope of practice of nurse practitioners. "
But as Kutzleb points out, one provider doesn 't have to trump another.
"I don 't look at my place as a doctorally prepared nurse practitioner as taking a physician 's place, " she explains. "I look at it as a partnership. In a partnership, if I bring my best to the table, and the physician brings his best to the table, ultimately the patient 's going to win. "
As the results of the model show, when healthcare disciplines work collaboratively and APNs are given responsibilities that allow them use their administrative and clinical expertise, there can be big payoffs for patients, physicians, and the organization.
"The nurse practitioner is the conduit throughout the disciplines in order to make the patient experience and outcomes the very best, " Kutzleb says.
The program, which originally focused on heart failure patients, was implemented in January 2012.
Over a 12-month period, 30-day readmission rates dropped to 8% from 26%. Healthcare costs for the group of 312 patients receiving care via the NP Care Model was $311, 818 during 30-days after discharge. Prior to the model 's implementation, cost of care for this patient population during the 30-days post-discharge was $1,019,405.
Spreading Success
Together with the multidisciplinary team, the NP identified HF patients to be admitted to the program.
"We looked at those that we could catch early in the disease, " Kutzleb says. "By having patient engagement, they 're going to learn how to self-manage, and they 're going to have a better longevity with a chronic disease. "
The NP then met the patient and family, introduced herself and her role, and provided basic patient education in the hospital. They made post-discharge follow-up appointments with the patient for more intensive education sessions, as well as confirming the patient had follow-up appointments with the necessary physicians.
The NP worked with the physician on the care plan, made sure all diagnostic tests and reports were completed, medications were stable, and that the discharge plan was put into action.
After the patient was discharged, the NP connected with the patient by phone within 24 to 48 hours.
During the first NP follow-up visit, the patient received a full physical assessment and a full educational session with along with a family member or support person. The NP reviewed diet, daily weights, and set the patients up with a medication management tool that allows the NP to optimally schedule the patient 's medications.
"By planning the medications throughout the day, they didn 't take all the medications all at once and then felt too tired to do anything else, " Kutzleb says. "It became a routine and then became inherent in their daily schedule. We gave them a printout and we were able to update that printout at any given time. It was successful, we had a tremendous drop in recidivism. "
The drop in recidivism went beyond the initial 30-day discharge period. The 60-day and 90-day readmission rates for the group receiving care through the model were 4% and 3% compared to 27% and 29% in a group receiving typical care.
Because of these significant results, advanced practice providers are being added to more of the medical center 's service lines including cardiology, chronic care management, oncology, and genetics.
The model 's success also helped Kutzleb make the case to deliver APRN provided care beyond the hospital walls.
"I was successful in writing a business plan and got approval from the physician oversight committee and opened the first fully run nurse practitioner primary care practice in Bergen county, " Kutzleb says.
With the old fee-for-service model transitioning to one focused on value-based care, Kutzleb says healthcare delivery will need to evolve as well.
"Healthcare is changing and for all its pluses and minuses, it needs to change. It wasn 't really ever meeting the needs of the patient. "
Hoping to counter stress and compassion fatigue, one hospital has created private spaces for its nurses to process their emotions before returning to their patients, refocused. At least one study links better nursing environments to better patient outcomes.
Crying at work is traditionally frowned upon, but I'm going to put myself out on a limb and admit I've done it. And, if you're being completely honest, you've done it, too.
After a code, a patient's death, a scolding from a physician, or a day when nothing seems to go right, many of us have sought solace in the nearest linen closet, locker room, or bathroom stall and let the tears flow.
In fact, just last week, this photo of an ED physician grieving the loss of a patient, popped-up in my Facebook feed, courtesy of an ED nurse friend. When someone who isn't a healthcare professional commented that it's unreasonable to expect healthcare workers to jump back into their shifts after a patient's death as if nothing happened, my friend replied, "We do it every day."
But, this 'rub some dirt on it and get back into the game' mentality might not be serving our profession well.
A study published in 2011 found that in a sample of 182 oncology nurses, one-third demonstrated emotional exhaustion and reported low rates of personal accomplishment, one-quarter reported depersonalization, and a 50% reported levels of emotional distress.
"Compassion fatigue is a huge issue for us all in bedside nursing, and we as leaders need to look into and address that," says Jacklynn Lesniak, RN, MS, BSN, senior vice president of patient care services and chief nursing officer at Cancer Treatment Centers of America at Midwestern Regional Medical Center in Zion, IL.
Jacklynn Lesniak, RN
One way CTCA Midwestern is tackling this issue is by giving RNs the time, tools, and space to process their feelings in the comfort of nurse-designed renewal rooms.
Disconnect to Reconnect
Jillianne Shriver, RN, BSN, HN-BC, team lead for the inpatient medical oncology unit at CTCA Midwestern, was inspired to develop the concept for the organization's renewal rooms after learning various types of relaxation techniques, during a three-week training on holistic nursing.
Those techniques included aromatherapy, journaling, and meditation. Though many of these interventions don't take very long—Shriver says benefits can be seen in as little as five minutes—finding the time and place to practice them during a busy shift can be challenging.
"I decided that I really wanted somewhere for the nurses to take that time to renew, rejuvenate, and recharge," she says. "To step out of whatever situation they may be in, whether that be a stressful or busy day, and have five to 15 minutes to themselves to be able to focus, ground themselves, take a deep breath, and then step back into practice."
Shriver began the project in May 2013 by reclaiming a storage space in which to she established the first renewal room. In it she placed a massage chair and tools for aromatherapy, music therapy, and journaling. There is also a sand garden, small waterfall, inspirational books, a Tibetan singing bowl, and a yoga mat.
"The environment I wanted to create is a private space," Shriver says. "We ask that they go in by themselves."
Before entering, nurses must let their charge nurse know they need to use the room and must turn over their phones, pagers, or other communications devices. The door is locked to ensure no one can interrupt them during their five to 15 minutes away.
"That way there's not any distractions, and they can really take that moment to focus on themselves," Shriver says. "In nursing, we have a wide variety of emotions, and they're able to go in there and express those emotions in a quiet, safe place."
A Much Needed Intervention
Aware of the aforementioned study on oncology nurses' experiences of burnout, Shriver wanted to make sure the room was serving its purpose. So she asked nurses to rate their anxiety levels on a Likert scale before and after using the room. After three months, it became clear it was a much-needed intervention.
Jillianne Shriver, RN
"We logged that the room was utilized over 422 times in three months," she says. "After reviewing the surveys, 96% of the nurses reported that they had a decreased level of anxiety and they felt much better after they left the room."
In addition, Shriver says there was often a line of nurses waiting to use the room and the nurses shared some of their personal experiences using the room.
"I had a nurse say that after a patient crisis, her heart was racing and she shouldn't catch her breath," Shriver says. "So she went to the renewal room to cry it out. After that she was able to be present for all of her patients at that time."
She presented her findings to nursing leadership, which in turn supported the addition of renewal rooms in the construction plans for the organization's new inpatient tower that opened in November 2015.
"As the chief nursing officer, I was able to advocate for the staff through the building process and say to the board of directors, 'We really need this space in the new building.'"
Lesniak says there are now five renewal rooms in the organization—one on each unit in the inpatient tower, one in the surgical department, and one in the outpatient care area.
Benefits of a Holistic Environment
The renewal rooms are part of CTCA Midwestern's larger commitment to providing a holistic environment for both staff and patients, says Lesniak.
"One of our goals is to be a premier provider of nursing care and to establish that in an environment of healing and hope," she says. "Normally you look at an environment of healing and hope as being very patient-centric, which at CTCA is foundational to our model. But we took it a step further and [looked] at how it affects our nursing staff."
This includes supporting nurses in obtaining specialty certification in holistic nursing. Lesniak says there are currently 36 nurses who have achieved the holistic nursing specialty certification.
Developing a holistic work environment is more than something that is just nice to do for the nurses. Lesniak says helping nurses stay connected to their mind, body, emotions, and spirit, can benefit organizations and patients as well.
"As CNOs, something we're facing is the recruitment and retention of great talent," she says. "Holistic nursing and things like the renewal room and other methodologies of ensuring our bedside staff can take care of themselves are a huge strategy to help with recruitment and retention of our bedside nurses in the country."
New research by Linda H. Aiken, RN, PhD, FAAN, FRCN, at the University of Pennsylvania supports the idea that happy nurses equal happy (and healthy) patients. The study found patients who had surgery at hospitals with better nursing environments, including Magnet designation (which CTCA Midwestern has achieved), and above-average staffing levels, have better outcomes at the same or lower costs than other hospitals.
And in healthcare, no matter how you get there, better patient outcomes is what it's all about.
"We really want our nurses to empower themselves by realizing the importance of their practice of self-care," Shiver says, "because when nurses take care of themselves, they can better serve their patients, the patients' families, and their communities."
The CNIO of Carolinas HealthCare System talks about the benefits of clinical documentation optimization, the challenges of change management, and the importance of leveraging technology to raise job satisfaction among RNs.
As someone who did the bulk of her Christmas shopping online this year, there have definitely been times when technology has made my life easier. But as much as I love avoiding frenzied crowds, technology can also make life overwhelming.
It seems like I'm constantly wading through a barrage of emails, texts, instant messages, and social media updates in search of that diamond of vital information from my children's daycare provider buried amid the coal of 20% off coupons.
Becky Fox, RN, CNIO
I'm not alone in trying to keep my head above water in the sea of digital communication.
"Look at how much communication and information comes at us in our personal lives, whether that's social media, our personal phone, personal email, or personal texting," Becky Fox, RN, CNIO at Carolinas HealthCare System in Charlotte, NC, told me during a recent interview.
"There's a lot of information overload that's [coming to us] personally. And it's the same thing in our work lives." Fox and I talked about how to manage the growing volume of information so it may enhance both the nurse's role and patient care rather than detract from it. The transcript below has been lightly edited.
On Optimization:
"One of the big projects we're working on is what we're calling the clinical documentation optimization project. We've had our EMR in place for a number of years, and this is just an opportunity for us to go back and simplify, standardize, and optimize all of the things we had in place.
One big focus is to take the systems that already have great functionality and make them much more user-friendly and workflow-driven and just make things easier for the nurse.
We'll be turning on more functionality and bells and whistles but, at the same time, reorganizing the things that we have in place. It's kind of like if you walk into your pantry and things aren't organized in the best way and then you reorganize it and you can see all the labels, you can see exactly where the soup is, you can see the chips. It will make things easier when the nurse goes to document the daily assessment on the patient.
We're also trying to drive smart workflows as well as push information to the clinicians at right time. We're not going to alert them every day, we're just going to alert them at the appropriate time when there are key quality measures or aspects that need to put in place, whether that's a reminder to tell the nurse to flush the patient's central line, or to document something.
We're also going to be doing work around identification of patients with Clostridium difficile. For example, a patient may have a couple of symptoms, but if it's day four of their admission and I'm taking care of the patient for the first time, I might not have all the information in front of me.
In the computer system, we have a lot of that information. Instead of asking the nurse to go look that up, the system can do that through automation and alert the nurse that the patient is at risk for c. diff.
It's not that the nurses don't know how to recognize c. diff, it's just that the nurse has six or seven patients with various conditions. We can take these computer systems, make them smart, and make them do all the heavy lifting so that we're just pushing valuable information to the nurse."
On Change Management:
"Everyone recognizes that change is coming, but it's coming at people at such a fast pace that it's really hard for them to digest and to continuously make small, minute changes. We're leaning toward the stance that we need to pause and give the nurses a break to adjust to the changes and then make changes in bigger buckets and bigger sweeps, rather than stringing out different things.
For example, we have five different systems that we're going to either try to upgrade or put changes into this year, including the optimization project. Do we go live on something in March, April, May, June, and July?
That's five different times for education, five different supports at various levels, not to mention all the emails to all the nurses and all the paper that gets printed and posted on bulletin boards. Do you just couple that all in one? So that on Monday, this is how you did your work, which is how you've done it for the past year, but on Tuesday we're going to completely change how you do things, but we're going to give you good support at the elbow to make sure that you know exactly what you need to do.
We're leaning toward this approach because this is where our bedside nurses are—[they're saying], "Just give it to me at once."
It's still hard adjusting, I think, because everyone is somewhat overwhelmed in their personal lives with email and communication. Probably our biggest challenge is how to get the information to people without bombarding them with emails, notifications, and meetings."
On Staff Education:
"One of the other things we're trying to turn a little bit is how to we educate everyone. Historically, you would bring all of the nursing staff into the training room, which of course is offsite, and spend seven to eight hours training them. It was really hard.
People walked out and only remembered about 30% of what you told them. Then a week later it goes live, and now they really don't remember too much of anything or they're just challenged to remember it all in context.
We've recognized that when people get onboarded at an organization it's really overwhelming to take a new job. They're wondering, "Where do I park my car? What color do my scrubs need to be?" These are the kinds of questions people are consumed with when they're coming to orientation. They're trying to figure out the basic things so when we were injecting a lot of computer stuff at that stage, we'd find it wasn't sticking, and it didn't have context.
We're trying a new approach on our optimization project. We're going to do two hours of training on a web-based tutorial. Then we'll bring to them to a classroom, but the classroom is truly scenario-based. When someone walks in and says, "Hi, I'm an ICU nurse," we give them an ICU scenario packet and have them document a patient.
The scenarios they get are in the context of a workflow. Your patient is 67 years old with COPD, you've done a head-to-toe assessment, now let's go ahead and document a respiratory assessment. We walk them through the workflow of that. We're trying not to spend so much time on the front-end, but spend more time on the back-end. Then let's focus on the nuances of the unit and have some good reinforcement by their preceptors when they get to the unit."
On the CNIO role:
"As a CNIO, my job is to help make things better for the nursing staff and to have a positive impact on the patients we serve.
The nurses will feel better because they'll have a better user experience and will feel more confident in what they're documenting. We know nursing job satisfaction is a big issue. When you have happy nurses, it all makes a difference to patient care. We want to make sure that the nurses have a good work experience because we know that will ultimately impact our patients. And that's our goal."
Yale New Haven Hospital's nurse SWAT team goes beyond just responding to changes in patients' status. It uses predictive data to anticipate problems, and intervenes at the earliest signs of decompensation.
Go with your gut. How often have you heard that advice about relationship, career, or parenting concerns?
Some of us have more accurate gut instincts than others. We get that feeling that something is right, or wrong—like when we somehow "know" to avoid an intersection just moments before an accident occurs—but we're not sure why.
I used my gut instinct often when I worked on a neuroscience unit many years ago. Sometimes something just seemed off about a patient, even though their vital signs were stable, and they knew who they were, where they were, and what year it was.
In fact, one of my strongest memories of my time there was when I called the neurosurgery team near the end of a 12-hour shift because I felt that my patient—an elderly gentleman who had slipped on ice, fallen, had a sustained a small subdural hematoma a few days prior—wasn't quite himself.
He was a gregarious guy and was quite skilled in providing non-answers to my questions by turning his responses into jokes. He managed to convince the residents, the attending, and his family that he was fine. The medical team left in a huff, annoyed at my "overreaction."
Still, as I gave my report in preparation to go home, I advised my night shift relief to "keep an eye on him because something was up." And I was right. He ended up having a seizure in the middle of the night and became combative.
Had this happened today, rather than a decade and half ago, I might have had the ability to use predictive data to support my hunch and to persuade the neurosurgeons to take action before the patient deteriorated.
The nurses at Connecticut's Yale-New Haven Hospital have been doing just that through the use of a nursing SWAT team and predictive data.
Refining Rapid Response Teams
I'd describe the way YNHH is using the combination of a SWAT team and predictive data as two steps beyond the typical use of Rapid Response Teams.RTTs came into vogue around 2005 when the Institute for Healthcare Improvement included them as one of six recommended interventions to improve patient safety during its 100,000 Lives Campaign.
These multidisciplinary groups of clinicians intervene at the bedside when a patient shows signs of deterioration. The goal is to stabilize the patient to prevent a transfer to the intensive care unit, cardiopulmonary arrest, or death. It's now possible, however, to identify subtle clinical changes earlier than ever and to intervene proactively rather than reactively, thanks to early warning scoring systems.
Sheila Coonan, RN, MN, CNML
One of these methods is called the Modified Early Warning System,aphysiological score system based on five factors: systolic blood pressure, heart rate, respiratory rate, temperature, and level of consciousness.
Another, which YNHH uses, is the Rothman Index. In addition to physiologic trends, it factors in clinical assessment data and lab results which enable clinicians to know which patients are at risk for deterioration. Because the Index interfaces with the hospital's EMR, the SWAT team nurses, who have at least a minimum of two years ICU experience and basic certifications like ACLS, can monitor real-time Rothman Index scores remotely within the hospital.
"If someone's heart rate, blood pressure, or their SAT changes, they've already started to cascade in a negative fashion," says Sheila Coonan, RN, MN, CNML. She is the patient service manager, daily operations pool, SWAT team, IV team, and nursing resources at Yale New Haven Hospital.
"When [you pull] in those other data elements, which are really nursing assessments… the patient is going to stop responding normally before their vitals change. When that person doesn't feel like eating or is a little bit more lethargic in bed, those things are really hallmarks. They're showing you that they're trending in a different way."
Real Time Equals Real Results
Diane Vorio, RN, MSN, NEA-BC, vice president, patient services, and associate chief nursing officer at Yale New Haven Hospital, shared a recent SWAT success story with me. At the beginning of one of the SWAT nurses' shifts, she was remotely reviewing her assigned units when she saw that a patient had a concerning Rothman Index score.
"The patient was in the high-risk category, which carried a 24% higher mortality rate," says Vorio. "She immediately investigated and went up to the unit only to find the patient had been sent off floor unattended to the echo lab."
She rushed to the lab and brought the patient back to the unit.
"The patient had a systolic blood pressure of 80 and needed to get a unit of blood," Vorio recounts. If it had not been for surveillance by the SWAT team, "the patient would have crashed in echo" she says.
"We averted an escalation in care to the intensive care unit, and the patient was actually discharged the next day."
This is not just an anecdotal success story. In the September 2015 issue ofBMJ Quality and Safety, Coonan and her co-authors reported that they saw a 30% drop in mortality thanks to the SWAT team's monitoring of the index scores through the EMR.
Developing Clinical Confidence
Implementation of a SWAT team has other benefits as well, says Vorio, especially for new graduate nurses who, as I did, may feel their gut is telling them that something is wrong and that they need to articulate the problem to a physician.
Diane Vorio, RN, MSN, NEA-BC
"The nurse feels far more confident to back up her gut feeling with data—basically to call out the data," Vorio says. "Then if she's still not happy with the response, she can call the SWAT nurse."
Coonan points out that support from the SWAT team can help facilitate critical thinking skills and boost confidence and competence.
"Every time a newer nurse interacts with that SWAT nurse, I know for a fact that the next [time] they do two more steps independently, or have that two more thoughts that they're very confident on [it's] because they've been interacting with SWAT," she says. "They've learned from SWAT."
"It gives you that real level of security to be able to use data in a concrete way," Vorio says. "There's nothing worse than saying 'Boy, I should have but I didn't.'"
Adding an NP with a background in psychiatric nursing was just one tactic a Chicago nursing director used to dramatically improve care among unfunded behavioral health patients in the ED.
Ajimol Lukose, DNP
Around 2012, Ajimol Lukose, DNP, RN-BC, nursing director at Swedish Covenant Hospital in Chicago, noticed a trend—more patients with behavioral health issues were seeking treatment in the emergency department. This development came on the heels of the state cutting $113.7 million in general funds from its mental health budget, and Chicago closing of six of its 12 city-run mental health clinics.
"There was a reduction in mental health clinics, so the follow-up or outpatient programs were limited. That resulted in patients showing up in the emergency department," Lukose told me.
On any given day, there could be as many as six or seven behavioral health patients in the ED.
"Our emergency department was struggling with patients with mental health issues staying there for three and four days and waiting for state transfer, especially unfunded patients," she said.
At the same time, Lukose needed to implement a project for the doctorate of nursing practice degree she was working toward. She has a background in psychiatric nursing and thought she could help address some of the issues around caring for this patient population by developing a safe care delivery model to improve care quality and reduce length of stay in the ED.
Her results were even better than expected.
The Best-Laid Plan
Lukose developed a number of goals for the project. Short-term, she wanted the initial behavioral health assessment in the ED to occur within one hour of its order time and to have behavioral health interventions initiated within two hours of the consultation order time.
Long-term, she wanted to decrease behavioral health patients' ED length of stay, the use of sitters and behavioral restraints, elopement events, and labor costs.
Through a literature review, she identified three best practices to support these goals:
Place a psychiatric liaison in the ED
Designate a dedicated area in the ED for behavioral health patients, separate from the general patient population
Create guidelines, protocols, and policies to direct ED staff on how to care for behavioral health patients
Lukose hired a family nurse practitioner with a background in psychiatric nursing as the psychiatric liaison. The NP worked eight-hour shifts, Monday through Friday. She rounded on behavioral health patients in the ED, completed the psychiatric evaluation, initiated appropriate interventions, and coordinated discharge planning.
"The interesting thing that we found was many of them did not need to be in an inpatient psych unit," says Lukose. "Because the ED physicians were not comfortable, they would keep them" until the patients could be transferred to a psych unit.
The NP also facilitated a 30-day medication supply program for underinsured patients and established a "bridge" program for patients who needed temporary support until they connected with a behavioral health follow-up provider.
"If they get discharged from the ED, they don't always get an appointment for follow-up right away. It might take a month or three weeks," Lukose says. "She provided three follow-up visits while [a patient] was waiting for the post-discharge follow-up with the mental health provider. They could walk into her small program, which is a room in the ED."
Location, Location, Location
Creating a dedicated space in the ED for behavioral health patients may sound costly, but Lukose says it wasn't not the project highest ticket item. The largest expense in the entire project was hiring the NP.
"Doing the facility enhancement is not a costly program," she says. "We weren't buying equipment. We just removed items to make the room simple."
Working with the ED director, they were able to identify a section of the ED where five beds could be dedicated to behavioral health patients. The crisis department, which had previously been located outside the ED, was moved inside the department to help improve collaboration.
"There was a big disconnect between the crisis staff and the ED staff so we moved their office to this particular area so they are available constantly," she says.
Clustering the behavioral health beds in one area also facilitated a decrease in sitter use.
"We had them in the general ED, but here and there, we had to provide a sitter for each patient," Lukose says. "In reality, they don't always need one-to-one care. Because we have this one separate area, you can have one sitter for three patients."
Lukose and the ED director developed policies, procedures, and guidelines using the Four S Model, which calls for focus on "safety, support, structure, and symptom management." For example, giving behavioral health patients a different color gown so they can be easily identified if they are trying to elope, placing all patient belongings into a locked cabinet, and ensuring metal objects like soda cans or silverware are not brought into the room.
In addition to training to help boost the staff's comfort and compliance with the new polices, a checklist was created.
"If you give a nurse a three-page or four-page policy, they're not going to sit down and read the policy all the time," she says. "So we made a one-page checklist, which is a summary of the entire policy, so the nurse can make sure everything is done."
Impressive Outcomes
After these changes were implemented in April 2013, Lukose collected three months of post-implementation data in October, November, and December of 2013. The results of the project? Behavioral health consultations were completed an hour after being ordered 93% of the time and interventions were initiated two hours after the consultation was ordered 92% of the time. Sitter use decreased by 46% as did sitter costs. Labor costs decreased by 49%.
At first glance, it may seem like length of stay didn't budge much—average length of stay for all behavioral health patients in the ED was 12. 3 hours prior to the project and 8.8 hours after its implementation. But when Lukose looked at insured behavioral health patients' length of stay in the ED compared to uninsured behavioral health patients, there was a definitive improvement for the second group whose pre-project average length of stay was 24.1 hours and post-implementation average was of 16.3 hours.
Lukose took the analysis of length of stay a bit further after her DNP-project was completed. She found that in fiscal year 2014 the average length of stay for all behavioral health patients in the ED decreased to 12.5 hours from 17.9 in fiscal year 2013—a 30% reduction. For all uninsured behavioral health patients in the ED, the length of stay dropped to 29.1 hours in fiscal year 2014 from 48.5 hours in 2013—a 40% reduction.
And, for uninsured patients waiting to be transferred to a different facility, average length of stay was 36.2 hours in fiscal year 2014, down from 74.7 hours in fiscal year 2013.
"That was a great accomplishment for our hospital," she says. "I didn't want to start something and see that the project ended. It shows that the changes that were made have been sustainable and that the project was continuing."