Nurses can handle much of the strain that healthcare reform will place on doctors and should be given both the education and the authority to take on more medical duties, the U.S. Institute of Medicine said on Tuesday.
A report from the institute calls for an overhaul in the responsibility and training of nurses and says doing so is key to improving the fragmented and expensive U.S. healthcare system -- President Barack Obama's signature political initiative.
With an ordinary webcam like the ones that people use today to keep in touch with loved ones, parents may one day monitor their babies' vital signs, and doctors may do a quick blood pressure check.
Technology being developed at the Massachusetts Institute of Technology turns a low-cost camera into a kind of remote stethoscope that never has to touch a patient's body. In work published in May in the journal Optics Express, a team led by Ming-Zher Poh, a graduate student in the Harvard-MIT Health Sciences and Technology program, demonstrated a way to monitor a person's pulse by tracking minute changes in the way light reflects off their face as blood flows beneath the skin.
A nurse manager comes into your office and says, "Mary Lou just doesn't seem to get it. She makes mistakes and when I talk to her about it she gets really defensive. You need to provide some education for her." Is Mary Lou's performance issue really about lack of skills or knowledge? Or could it be something else entirely?
Staff development specialists (SDS) are often asked to provide education when nurse managers identify individuals or groups of employees who are not meeting performance expectations. Although lack of skill or knowledge can be the cause of under-performance, there are other causes that should be considered.
Because SDS' are neither staff nor management, they can engender trust among the staff and are in a unique position to investigate the root cause of performance gaps. This article provides SDS' with tools to:
Diagnose common causes of performance gaps
Formulate a plan to address specific performance problems
Identify metrics to evaluate the effectiveness of interventions
Don't all nurses want to do a great job? Of course! So, if they are not doing a great job they must need more education, right? Not necessarily, although education is often the "go to" tool in management's tool box. And when performance does not improve, SDS' are just asked to provide more education. This cycle can continue indefinitely if we don't step back and really look at the cause of the performance gap.
The Human Performance Technology model
Human Performance Technology (HPT) is "a systematic approach to improving productivity and competence, through a process of analysis, intervention selection and design, development, implementation, and evaluation designed to influence human behavior and accomplishment" (International Society for Performance Improvement, 2000). The goal is to identify and develop a set of interventions that solve or mitigate barriers to performance. HPT grew out of the instructional design field and is a valuable tool for SDS' in analyzing performance gaps and developing appropriate interventions.
Performance gaps
A performance gap is the difference between what someone is actually doing (or not doing) and what they should be doing. The first step in correcting a performance gap is to understand what the difference is between the behavior being exhibited and what the expectations are. The importance of the gap should be considered next. What will happen if corrective action is not taken? If you do decide to intervene, can a worthwhile result be expected? If inaction will result in patient harm, then of course performance must improve. However, in some cases, the payoff for intervening is negligible and therefore not worth the effort.
Cause analysis
Once it is determined a significant performance gap exists, SDS' can assist nurse managers in determining the cause of that gap to develop the most appropriate intervention. The first step in analyzing the cause of performance gaps is gathering information through interviews of key stakeholders (see the list of questions at the end of this article). There are three primary causes of performance gaps:
Lack of knowledge or skills
Lack of motivation, and
Organizational or system barriers
If nurses have never performed the skill or task expected of them, then formal training is an appropriate intervention. When a knowledge deficit exists, instructor-led classroom training, computer?based programs, or a blended learning approach can be used. If manual skills are required, then use of skills labs or simulators may be effective.
If nurses have been provided the knowledge and performed the skill before, but the opportunity to perform is presented infrequently, a different type of education is required. This may take the form of "just in time" tools such as posters or guidelines outlining the critical steps in performing the skill. Brief in-services, videos, or DVDs available on the unit may also be effective in providing on the spot refreshers. Electronic media, such as PDAs and online resources, are also becoming popular means of ensuring up to date information is available at the bedside.
If nurses possess adequate knowledge and skill, then motivation to perform must be considered. Do nurses perceive some kind of punishment for a job well done? For example, highly skilled and organized nurses may always be asked to take extra admissions or the most acutely ill patients on the unit, leaving the impression that they are working harder than others. The solution in this case is to distribute assignments equally among all staff. A lack of positive feedback for their extra efforts can also lead to a lack of motivation to continue doing a good job.
Acknowledgement of their performance with a simple thank you may be all that is required.
In some cases, non-performance is inadvertently rewarded. For example, nurses who lack organizational skills may not be asked to take extra admissions or be expected to provide assistance to team members. Nurses may get personal satisfaction from their poor performance, perceiving that they don't have to work as hard as others. When it is perceived that non-performance results in a positive or desired outcome, this perception must be removed. Consistent standards of performance must be expected of all staff. When non-performing nurses adhere to expectations, then their behavior must be reinforced with positive consequences.
When we permit poor performance, we promote its continuance. Therefore, positive consequences should increase when nurses meet performance expectations. Conversely, appropriate consequences for non-performance must be consistently enforced.
The third common cause of performance gaps are system-related issues. First, do nurses know what is expected of them? Ensuring that performance standards exist, are clear and complete, and that they are readily available to staff is essential. Of course, nurses must have read the standards and understand them.
Lack of available resources may also result in suboptimal performance. It is difficult for nurses to meet performance standards if the tools they need are not available. Ensuring that staff, in adequate numbers, with the appropriate skill mix are available to meet the acuity needs of patients is essential. Inadequate supplies may also present an obstacle to good performance. Checking par levels and ordering procedures will ensure availability of adequate supplies to get the job done correctly. Equipment that is in proper working order and conveniently located on the unit will also enhance desired performance.
Selecting the appropriate intervention
Before implementing an intervention, it is important to consider other factors such as quality or regulatory standards, time, and finances. SDS' can work with nurse managers to develop criteria based on these factors and select the intervention that best fit those criteria and the goal of improving performance. It will be important to gain commitment from all key stakeholders—nurse managers, staff, and other ancillary departments involved—prior to implementing interventions.
Measuring success
Measures of success must be determined prior to implementing any performance improvement interventions. The change in behavior must be clearly stated and understood by both managers and staff nurses. Deadlines for improvement must be identified and adhered to. Other key metrics may include a reduction in errors or injuries and increased satisfaction scores from patients, staff, and physicians.
If performance does not improve, other factors may be involved. For example, nurses may be in the wrong role, e.g., they are just not cut out for critical care. Perhaps the nurse is in the wrong area of specialty and transfer to another unit can be considered. E.g., labor and delivery may be a better fit for the nurse's skills in communication and compassion. It's also worth asking whether the nurse's professional goals are congruent with the goals of the organization, Perhaps another organization or setting would better meet his or her professional needs.
Summary
There are many reasons that nurses do not perform as expected. The Human Performance Technology model can be a useful tool for SDS' in leveraging their role in the identification of performance gaps and appropriate interventions. The unique position of SDS' as neither staff nor management engenders trust between them and staff nurses. By strengthening relationships with nurse managers, they can play an integral role in improvement of staff performance.
Questions to ask a staff member:
Can you explain what is expected of you?
Have you been given a job description?
How do you find out what is expected of you?
How do you know when you are meeting job expectations?
Do you get feedback? How often? From whom?
Do you have all the equipment or supplies you need to do your work?
Have you requested material and supplies that you have not received?
What happens if you do an outstanding job on a particular day?
Does the structure or culture of the organization help or hinder your work?
How effectively are the goals and strategies of the organization communicated to you?
What about changes in practice? Tools?
Are you getting enough help and guidance?
Do you know how to do _________? Was this covered in your orientation?
Has the employee received adequate training to perform this task?
Questions to ask a manager:
Has the employee ever performed this task satisfactorily?
How often is the task performed?
Does the employee experience something undesirable when he or she performs this task?
Is there something about performing the task that is perceived to be punishment?
Does the employee get some sort of pay-off for not doing what is expected?
Does the employee get prestige, status, or other self-gratification for poor performance?
Are written standards available?
Are written standards complete?
Are written standards clear?
Have the standards been read?
Are the working conditions suboptimal?
Does the organizational culture support the desired behavior?
Are supplies adequate?
Do the given tools fit the job?
References
Human Performance Technology Central. (n.d.) Available from www.humanperformancetechnology.org/hptmodels.html.
Wilmoth, F., Prigmore, P., & Bray, M. (2002). "HPT models: An overview of the major models in the field." Available from www.humanperformancetechnology.org/Models%20hpt1.pdf.
Stolovitch, H. D., Keeps, E. J., & Finnegan, G. (2000). Handbook of Human Performance Technology: Improving Individual and Oganizational Performance Worldwide (second edition). Hoboken, NY: Wiley Periodicals, Inc.
Fournies, F. (1999). Why Employees Don't Do What They Supposed to Do and What to Do About It. New York: McGraw-Hill.
Barbara Mayer, RN-BC, MS, PhD(c), is director of professional nursing practice at St. Vincent Medical Center in Los Angeles.
In April 2008, Baystate Medical Center (BMC), a 653-bed teaching hospital in Springfield, MA, began implementation of its Bar Code Point of Care technology to positively impact medication administration in reducing errors.
In the early pilot programs, BMC reported a 50% bedside scanning rate for all medications and a medication error rate of 1.2 errors per 1,000 patient days.
Following the implementation of an organization-wide bar code scanning process in September 2008, BMC improved its medication scanning rates to 87%—90%. The medication error rate also decreased to 0.3 errors per 1,000 patient days, a 75% reduction.
Implementation and pilot programs
Planning and implementing a bar code scanning system at the bedside was a major undertaking for BMC because the patient safety-focused process is designed to significantly reduce medication administration errors.
"What is so impactful about the whole process is that all departments—with the exception of some emergency departments—are fully bar coded," says Gary Kerr, MBA, PharmD, director of pharmacy services at BMC. "The central pharmacy has been re-engineered to support the outputs necessary to drive and sustain medication bar codes."
BMC started small, with a six-month pilot program that involved three nursing units. It was during this six-month pilot program that Kerr and Mark Heelon, PharmD, medical-surgical director at BMC, committed themselves to learning everything about the bar coding process.
It became clear early on that there were numerous obstacles when scanning a patient every time he or she received a medication, from packaging to process. Examples of identified scanning challenges included large-volume IVs, medications without bar codes, medications with reflective packaging (e.g., suppositories), and computerized physician order entry (CPOE) mismatching products or administration times of medications.
One specific example of a CPOE scanning issue occurred in the pediatric ICU, where continuous Albuterol updrafts needed to be scanned on an hourly basis, resulting in suboptimal scan rates for the unit. To help resolve the issue, interdisciplinary collaboration among nursing, informatics, and pharmacy focused on educating staff about how to correctly enter continuous Albuterol orders.
This process was accomplished by developing a medication care set to guide the provider in selecting the appropriate products that ultimately influenced scan rates. This intervention also reduced the number of times the respiratory therapist needed to scan the medication. "There was really no reason to have the respiratory therapist repetitively scanning on the hour for Albuterol," says Heelon. "Or for any nurse, for that matter."
The process was changed from needing to scan constantly to the staff member or nurse scanning the medication only when the Albuterol updraft was replaced.
"The foundation of the success of this project was the open line of communication between pharmacy and nursing," says WendySue Woods, RN, MSHA, CSHA, senior consultant at The Greeley Company, a division of HCPro, Inc., in Marblehead, MA, and senior advisor to BMC.
BMC felt comfortable implementing this process organization-wide after trialing it for six months and receiving feedback from the nurses on the unit.
Current bar coding success
On each unit, BMC nurses have ready access to bar code scanners. With the scanner in hand, the nurse is able to enter the patient's room with the patient's medication and scan the label on the medication.
This process augments the five rights of medication administration at the patient's bedside to ensure that the correct patient receives the correct medication.
"In the past, a medication error that might have reached the patient could have been backtracked to a pharmacy technician placing a wrong medication or strength in the automated dispensing cabinet," says Heelon. "With the new processes and scanners at the patient bedside, we have seen a dramatic decrease in medication errors reaching our patients."
In addition to adding the bar code and scanning process, BMC was able to reevaluate the package system it was using for its medications. Prior to the new process, BMC was purchasing some bulk drugs. Internal repackaging was necessary to create unit doses and assign a bar code to the drug.
"We reevaluated and shifted some purchases to companies where we paid a slight premium for the drug but the medication already comes as a unit dose with a bar code," says Kerr.
Even though this had a slight negative impact at the ingredient cost level, it has proven to be cost-effective at the system level. The FDA is moving toward requiring bar codes on all drugs.
Reaching 100%
Despite these challenges, as of April, BMC has been able to maintain an 87%-90% scanning rate of medications at the bedside.
Kerr admits that the leadership team interacts with him frequently regarding BMC reaching the elusive 100% medication scan rate.
"With respect to that last 12%, we are diligently addressing package and process challenges, while acknowledging there are areas that will never make the 87%-90% rates," says Kerr.
For instance, the post-anesthesia care unit struggles with reaching high medication scan rates. In this particular area, patients who are coming out of surgeries often receive titrated drugs every 10-15 minutes for pain. To drive appropriate throughput and patient flow, the nurse is constantly trying to stabilize the patient in order to move him or her through the system and get ready for the next patient.
"Because of the nature of the unit, the nurses would be scanning the drugs much more frequently than a conventional inpatient unit," says Kerr.
Management buy-in
The role of senior management and the commitment of multidisciplinary nursing-informatics-pharmacy teams have added to the success of the program.
"This organization can enjoy this success as they have remained true to the focus on patient safety," says Woods.
Kerr echoes that sentiment, saying that leadership involvement has been key. "BMC is committed to be the best and lead the way in technology and automation processes in support of patient safety," he says. "Leadership identified the opportunities, supported funding of the project, embraced key process improvement concepts, and drove the change."
________________________________________________________________________ This article was adapted from one that originally appeared in the October 2010 issue of Briefings on The Joint Commission, an HCPro publication.
A report released Tuesday may give nurses with advanced degrees a potent weapon in their perennial battle to get the authority to practice without a doctor's oversight.
The report, released by the Institute of Medicine and sponsored by the Robert Wood Johnson Foundation, says nurses should take on a larger and more independent role in providing health care in America, something many doctors have repeatedly opposed, citing potential safety concerns. It calls for states and the federal government to remove barriers that restrict what care advanced practice nurses - those with a master's degree - provide.
Home chemotherapy (HC) represents an opportunity to transition care for a subset of chemotherapy patients from the outpatient infusion center to their home. Not only do patients report feeling more comfortable receiving treatments in familiar surroundings, hospitals that provide HC may differentiate themselves from their competitors, potentially attracting new patients.
Until the 1980s, infusion therapy was administered almost exclusively in the hospital. However, over the past 3 decades, there has been a dramatic shift to the outpatient setting driven by pharmaceutical advancements, lower overall costs in outpatient clinics and increased convenience for patients. The emergence of HC is a natural continuation of this shift on a smaller scale, with the further potential to improve patient satisfaction and free up chair space and nursing resources for programs that are facing current or anticipated capacity or staff constraints.