Although The Joint Commission's National Patient Safety Goals force many organizations to focus primarily on MRSA, central line-associated bloodstream infections, and surgical site infections, ventilator-associated pneumonia (VAP) is a high priority for anyone in the hospital setting.
Mortality rates alone force hospitals to take a critical look at prevention processes. VAP is the leading cause of death among hospital-acquired infections, according to the Institute for Healthcare Improvement (IHI). Hospital mortality of patients already ventilated who develop VAP is 46%, compared to 32% for those who are ventilated and do not develop VAP.
Just as most facilities have implemented central line and surgical site bundles, the IHI has published a ventilator bundle with four evidence-based practices:
Elevation of the head of the bed
Daily "sedation vacations" and assessment of readiness to extubate
Peptic ulcer disease prophylaxis
Deep venous thrombosis prophylaxis
A study published in the October 2009 American Journal of Infection Control focused on prevention of VAP in the intensive care setting. The study implemented interventions in three different phases to reduce the incidence of VAP in the ICU.
In the study's first phase, from March 2001 to December 2002, researchers evaluated the effectiveness of Centers for Disease Control and Prevention (CDC)-recommended evidence-based practices, including no routine changing of humidified ventilator circuits, periodically draining and discarding condensation collecting in the ventilator tubing, and changing the heat and moisture exchangers when they malfunctioned mechanically or became visibly soiled.
From January 2003 to December 2006, researchers intervened in the processes while performance monitoring was occurring at the bedside.
Finally, from January 2007 to September 2008, the researchers continued interventions and implemented the IHI bundle in addition to oral decontamination with chlorhexidine and the use of continuous aspiration of subglottic secretions (CASS) endotracheal tubes, says Alexandre R. Marra, PhD, lead author of the study and infectious disease physician for the ICU and medical practice division at Hospital Israelita Albert Einstein in São Paulo, Brazil.
The incidence density of VAP in the ICU per 1,000 days was reduced from 16.4 in phase one to 15.0 in phase two to 10.4 in phase three. The study noted that achieving a rate of zero VAP was possible only in phase three, when all interventions exceeded 95% compliance. In November 2009, the hospital celebrated one year without VAP.
"Our main reason for doing the study was to show that VAP prevention using the majority of evidence-based measures for controlling this hospital-acquired infection in the ICU is a difficult process that involves the accountability of many healthcare workers who care for ventilated patients," Marra says.
The initial results
The first phase of CDC evidence-based practices yielded disappointing results, particularly regarding compliance rates, Marra says.
"It was necessary to have a lot of discussions and changing ideas with the ICU team to make a better performance in our compliance rates," he says. The ICU team was composed of doctors, nurses, and respiratory therapists.
In early 2007, the hospital's CEO declared zero tolerance for VAP. Intervention measures continued, but with more intensity and urgency, Marra says. At that point, phase three was also initiated as an added measure.
Implementing all three phases at once
Although Marra's study gradually implemented each phase over the course of more than seven years, implementation of all three phases yields optimum results.
"Our recommendation is to begin using all the sources at the same time: VAP bundle, oral decontamination with chlorhexidine, and CASS endotracheal tubes," says Marra. "It is important to mention that VAP bundle is not a checklist, but a process that is necessary to intervene for improving compliance with these processes at the same time that performance monitoring is occurring at the bedside."
The intervention portion of the study was particularly beneficial. It's not enough to simply hand staff members a checklist. Working with ICU team members to ensure consistent and correct compliance is the only way to see improvements, Marra says.
"Our experience shows that it is not enough to control [head of the bed] or only to implement the IHI ventilator bundle, as some centers have advocated," says Marra. "We believe that by getting the involvement of all members of the ICU team, we ultimately had success in applying all these process measures over several years. We have an ICU nurse taking care of these processes every day and also a respiratory therapist giving support to us."
Although the ICU team at Hospital Israelita Albert Einstein has been able to sustain zero VAP rates for a full year, Marra recognizes the goal is ensuring continued compliance to achieve that rate.
"We are completely aware that we may not be able to sustain zero VAP rates indefinitely, but our goal is to sustain nearly perfect compliance with the ventilator bundle and maintain ICU team motivation for VAP prevention," Marra says.
Oral care: The most important phase
Evidence is mounting that in addition to the Institute for Healthcare Improvement's ventilator bundle, oral care is an important infection prevention process, according to a study published in the October 2009 American Journal of Infection Control.
Alexandre R. Marra, PhD, lead author of the study and infectious disease physician for the ICU and medical practice division at Hospital Israelita Albert Einstein in São Paulo, Brazil, says the last phase was the most important in significantly reducing VAP rates.
"I strongly believe, and I have no doubt, that the last phase was the most important," Marra says. "We got a decrease of more than 70% in our VAP rate in the ICU."
A study published in the September 2009 American Journal of Infection Control focuses on oral care to prevent VAP. Mercy Medical Center in Springfield, MA, initiated the following measures every four hours for mechanically ventilated patients:
Brushing patients' teeth with cetylpyridinium chloride (changed to chlorhexidine gluconate in 2007) using a suction toothbrush
Cleaning the oral cavity with suction swabs treated with hydrogen peroxide
Applying mouth moisturizer
Performing deep oropharyngeal suctioning
Controlling secretions with suction catheters
Kathleen Hutchins, RN, MSN, lead author of the latter study, began research in 2004. By 2007, oral care intervention, coupled with the ventilator bundle, led to an 89.7% reduction in the VAP rate at Mercy.
This article was adapted from one that originally appeared in the January 2010 issue ofBriefings on Infection Control, an HCPro publication.
It takes a special person to be a mentor, as being one requires time, energy, and commitment to the task.
"I became a mentor from a desire to see other people grow and develop and to assist them to do just that," says Barbara Brunt, MA, MN, RN-BC, NE-BC, director of nursing education and staff development at the Summa Health System in Akron, OH.
Brunt has been recognized nationally for her ability to mentor others. She is a recipient of the National Nursing Staff Development Organization's Outstanding Mentor Award, which was presented to her at the organization's annual conference in July 2009 in Philadelphia.
Her organization's mentor program is called Mentoring Aspiring Professionals (MAP). Before we discuss the components of MAP, it will be helpful to differentiate between a preceptor program and a mentor program. Some organizations use the terms interchangeably, which can become a real problem for the organization and employees.
Preceptor and mentor differences
There are some similarities between preceptors and mentors: Both must have a sincere desire to help their colleagues succeed, have a strong commitment to their organization and their colleagues, and have some training and education to be successful in these roles. However, the types of training and education required differ.
Preceptors need job expertise because their role is to accomplish specific, measurable tasks in a certain amount of time. The objective is usually to facilitate the successful orientation of people to their new job and role responsibilities. To do this, preceptors must comprehend and implement the principles of adult learning, evaluate orientees' job performance, and offer and receive constructive criticism.
The objective of a mentoring relationship is to facilitate professional growth and development. Mentors must also be leaders who are willing to help others advance in their chosen career path. Mentors must be knowledgeable about resources for such advancement and be able to act as objective sounding boards.
The preceptor relationship has a definite, fixed beginning and end, whereas the mentor relationship is more fluid. It is of indefinite length and has no clearly expected conclusion.
Authority is another important difference. Preceptors are authority figures who have input into the success or failure of orientees. Mentors function as facilitators who have no formal authority over those who are being mentored. Mentors work to help people realize their career potential. This type of relationship can be invaluable to an organization that wants to groom leaders who will contribute to organizational success. Such organizations establish a mentor program for the specific purpose of identifying employees who possess leadership potential and helping them to develop this potential.
Identifying future leaders
Summa Health System's MAP program is a "leadership development program for employees who possess leadership potential and want to prepare themselves to compete for management positions within the organization," says Brunt.
The program is open to employees from all departments, not just clinical areas. Those who want to be mentored (referred to as protégés) must make a formal application for acceptance into MAP. They must have been an employee for at least three consecutive years working full time or on a regular part-time basis. Applicants must possess a bachelor's degree or be enrolled in a bachelor's degree program. They must not have on file any disciplinary actions for the six months prior to application, and must not have received a rating of "needs improvement" or "does not meet some expectations" on their most recent performance evaluations.
Brunt explains that MAP was born as the result of senior management's belief that there was a need to identify persons within the organization who have leadership potential and offer such employees opportunities to enhance their leadership potential.
Setting goals
Selected protégés must commit to one year of mentorship. Applicants may request a specific mentor or be assigned to a mentor who best complements the protégé's goals as identified on the application. It is expected that the mentor and protégé have at least monthly meetings at times and places convenient to both. They jointly determine goals and experiences that will help the protégé achieve those goals.
Summa offers quarterly educational lunch meetings. Education topics are selected based on protégé and mentor input. Examples of classes include panel discussions with senior management staff and discussions pertaining to quality improvement. Protégés also have the opportunity to attend the organization's leadership institute classes.
At the conclusion of the 12-month mentorship process, there is a graduation ceremony with formal acknowledgment of the work accomplished by both mentors and protégés. Although the formal mentorship process concludes with the graduation ceremony, mentors and protégés may choose to continue with the mentorship process.
Professional growth
Brunt mentored a nurse who was in the process of exploring various career options and roles, and who was currently working as an obstetrics case manager. As part of their mentorship process, she and Brunt worked on writing an article about their organization's case management program.
Brunt is pleased to note that the article has been accepted for publication in a professional journal. "These kinds of successes, where you can actually see that mentoring made a difference, is one of the true rewards of participating in the mentoring process," she says.
Mentor and preceptor programs, while different, both have the potential to enhance individual professional growth and development as well as organizational success. It is important to differentiate between the two.
Some mentorships occur naturally and informally. Others, such as those initiated by Summa Health System's MAP program, are more formally planned and implemented, with a definite purpose and even a proposed (although not required) conclusion.
The important point is that mentorships can and should be rewarding for mentors and those who are being mentored. The outcomes can be professionally exciting for not only the mentor and protégé but for an entire organization as well. If your organization is looking for ways to facilitate professional growth and development with a desired outcome of improved organizational outcomes, consider developing and implementing your own mentor program.
This article was adapted from one that originally appeared in the January issue of The Staff Educator, an HCPro publication.
Amid a looming shortage of nurses nationwide, Indiana nursing programs rejected about 2,500 qualified applicants because the schools didn't have the full-time faculty needed to teach them, a survey found. The 2008 survey by the Indiana Nursing Workforce Development Coalition said faculty shortages prevent nursing programs from maintaining a supply of qualified applicants. About half of Indiana's nursing faculty work part time as adjunct faculty while they maintain jobs as nurses, but the schools need more nurses who are able to teach full time, the survey found.
Nursing services company The Ensign Group Inc. announced it acquired two skilled nursing facilities in Idaho and one in Utah for an undisclosed price. Ensign said it bought the Emmett Care & Rehabilitation Center, located in Emmett, ID, and the Park View Rehabilitation and Care Center, which is based in Burley, ID. It also acquired the Paramount Health & Rehabilitation Center of Salt Lake City, which it had leased about a year ago.
Orientation is an overwhelming time for new nursing employees, who are faced with learning many systems, processes, and people as quickly as possible. The situation is even more difficult for new graduate nurses, who must overcome the transition from school to practice.
New grads have a tricky balancing act to perform involving learning new skills, committing policies and procedures to memory, prioritizing patients' needs, and even remembering where the supply closet is. Wouldn't it be nice if they had a safe environment in which to practice those skills before being thrust onto the unit and dealing with real patients?
That's the idea behind Phoenix-based Banner Health System's new simulation center. The organization is hoping that simulation holds the key to successfully onboarding new nurses and helping them transition swiftly to become competent, confident nurses.
Waste not, want not
Banner Health opened its first simulation center in 2006 at Banner Good Samaritan Medical Center in Phoenix. The facility proved so popular with the nine Banner facilities in the state that it soon became too small.
Around this time, Banner's Mesa Hospital was moving into a new facility, leaving the organization wondering what to do with an empty medical center. It decided to turn the building into a state-of-the-art simulation training center to be used by all of Banner's facilities in Arizona.
The center was extensively renovated to house the largest simulation center in the country, which passes for a real-life hospital. It includes a 20-bed ED, an 18-bed med-surg unit, a 14-bed ICU, and two ORs. It is filled with a variety of high- and low-fidelity simulation modalities and offers some virtual training. It also hopes to develop virtual avatars to facilitate behavioral health training.
Standardizing training
Carol Cheney, MS, director of simulation and innovation at Banner Health, says the organization decided to create a standardized onboarding program for all nursing staff in the Arizona region, which would involve time at the new simulated medical center.
Previously, each facility had its own orientation and precepting structures. "We did an audit and [found that] all units trained in different ways," says Cheney. "We wondered, who produces the better nurse? And no one had an answer."
Cheney spearheaded a project to create a standardized orientation for all new nursing employees and ushered everyone through the program at the simulated medical center.
She brought teams together to examine what needed to be part of orientation, what was required by regulation, as well as problem areas that could be identified as common across Banner facilities.
"We created a comprehensive curricula surrounding these topics," says Cheney. "We double-checked all policies and procedure guidelines against [Agency for Healthcare Research and Policy and Institute for Healthcare Improvement], so we could bring forward the best evidence-based practice standards."
Skills and scenario-based training
All new hires, whether experienced nurses or new graduates, first go to their own facilities to receive facility-specific orientation. Afterward, they go to the simulation medical center, where they participate in skills training and scenario-based training.
The experienced nurses are guided through short scenarios, but the new nurses must experience four-hour scenarios that are set in the department in which they will work. For example, if they will be working in the ICU, new nurses have a one-to-two patient ratio just like they will have in reality.
The four-hour scenarios involve all aspects of unit life that new nurses will experience. For example, they:
Learn how to perform patient handoffs
Practice patient assessments
Distribute medications
Contact physicians or ancillary services for items their patients need or for patient orders
Enter their documentation in the electronic medical record
"We have a facilitator on the floor to help them," says Cheney. "The real goal is to immerse them in that environment, on a somewhat simplistic level—we're not trying to scare them—to show them the reality of the unit they will be on." After the scenario is complete, the new nurses are debriefed and encouraged to talk through the scenario and what happened. Because the facilitators know exactly what occurred, they can provide coaching and guidance specific to each nurse.
"We do it in a nonpunitive way," notes Cheney. "We don't say, 'Susie, you didn't do this.' What we'll do is talk about the patients and what was happening with the patients."
In essence, the scenarios allow new nurses to practice patient care, critical-thinking skills, documentation, and all of their new responsibilities in a safe environment. "And the beauty is that their [fictional] patients are essentially plastic," laughs Cheney.
Measuring outcomes
Before the program began, Banner surveyed preceptors to identify common problems they were seeing among new graduates. The facility turned these common issues into scenarios for new grads to practice at the simulation center.
Cheney says Banner doesn't want new nurses' time with preceptors to be spent on learning tasks such as how to hook up an IV pump, which can be done in the simulation lab.
Banner wants time spent with the preceptor to be an opportunity for new nurses to develop critical thinking and focus on learning clinically advanced knowledge. The new simulation training center also allows Banner to create a report on each new graduate and his or her particular skills and competence.
"Orientation used to be really arbitrary," Cheney says. "Now we're saying, 'Let's not look at time; let's look at competence.' "
Report summaries based on a series of measurements help identify new nurses' competence level. The reports are provided to each learner and his or her manager, preceptor, and educators, which allows units to individualize training.
The simulation medical center identifies new nurses who are ready to take on a greater patient load, as well as those who struggled with suctioning or tracheotomy care so the unit can help them in that area.
Cheney is also collecting data to refine the training for the long term. "We're able to see, where do people make their errors? Are they procedural errors or are they decision-making errors?" she says.
Cheney plans to examine the data Banner is collecting to identify what really needs attention and what does not. This will allow the organization to refine the program over time and continually work to ensure that new nurses receive the best orientation possible.
Editor's note: This is the second article in a two-part series about nurse residency programs. Part one, which discussed the benefits provided by residency programs, appeared in the November 17 edition of the NurseLeaders weekly e-newsletter.
Benner (1984) told us that upon becoming a nurse, individuals develop in stages based on gaining experience. It is important to note that Benner describes experience not as longevity with the passage of time, but rather as the refinement of knowledge through encounters with many practical situations. Nurses are typically exposed to a variety of patients and care situations along the path to becoming competent. A well-structured nurse residency program can guide the new graduate nurse through exposure to many circumstances, thereby increasing experience, which in turn supports quicker development of competence.
Structuring a program
A nurse residency must be more than an extended orientation. New graduate nurses are not just transitioning to a new job environment, they are transitioning to a new role. This role development includes not only developing clinical skills, but learning to apply critical thinking and becoming acquainted with leadership skills. Residents are no longer nursing students; the focus of a nurse residency should be guidance for application of their knowledge.
Most organizations accept nurse resident applicants as a cohort, which helps manage the program efficiently. Participants also gain an informal support system in their resident peers.
Many programs struggle with how to integrate a didactic component into a nurse residency. Keeping didactics within the cohort can be beneficial, but as residents are working in various clinical specialties, topics must have a general focus. Although clinical exposure is the foundation of a nurse residency, didactics that enhance the experience of the specialty need to be incorporated. In addition, leadership skills should be touched upon during a nurse residency.
The desired outcome of a nurse residency is new graduate nurses who quickly develop into competent, efficient, and confident staff members. Offering flexibility within the clinical structure to consider the nuances of various nursing specialties is crucial to the success of a program.
A successful program also requires preceptors and mentors who are committed to facilitating the growth of nurse residents.
Strong preceptors support the clinical component and guide residents gradually from shadowing to independent practice while ensuring exposure to different situations that lead to competence. Strong mentors support the didactic component by posing various challenges to residents that facilitate their assimilation of knowledge and clinical exposure into competent nursing practice.
Sometimes, the roles of preceptor and mentor may be fulfilled by the same individual. Other times, depending on the scheduling needs for residents or the unit, multiple preceptors may be used. Communication among all those involved with residents is crucial to monitor progress and must extend to the unit's nursing leadership and the nurse residency program coordinator. This can be a formal or informal process but should be defined as part of the program.
Benefits of a nurse residency group
In developing or updating a nurse residency program, the initial considerations should look at activities to support the cohort. A nursing core orientation usually offers an in-depth overview to organizational nursing practice for newly hired nurses. Offering a separate core orientation for the resident cohort may better meet the new nurse graduates' needs.
Bringing the cohort together at defined intervals for education provides the opportunity not only to review various topics relevant across the practice spectrum, but also allows the individuals to build stronger relationships with other nurse residents.
Socialization is an important consideration in job satisfaction, and each nurse resident will integrate with his or her unit's team. But the shared experience of entering the nursing profession together makes the residents true peers who can support each others' development as nurses. And as the cohort successfully completes its journey through the residency, a recognition celebration for the group is in order.
Curriculum and activities
Developing unit-based activities for the nurse residency requires flexibility in guiding the structure of the program. Flexibility allows for program adaptation at the unit level, ensuring that it meets the needs of residents and the unit. Nurse residents typically should not “count in the staffing numbers” for an extended period, so a variety of learning opportunities can fit into scheduled shifts. By having residents and preceptors teamed for patient assignments, there is flexibility for residents to be guided for clinical opportunities or be relieved for didactic components.
Consideration should be given to developing tools or strategies that will help assess and monitor progress. A tracking tool that notes residents' exposure to skills and processes can offer insight. Creating a unit-specific tool can outline various assessment skills, equipment, procedures, specific medications, or documentation standards needed within the unit's specialty. It could be formatted for daily or ongoing use and it can note opportunities to observe or perform. Whatever tools are developed should be simple to use and have the purpose of guiding the resident-preceptor teams in structuring the clinical experience for variety and challenge.
The didactic component of a nurse residency should guide and support residents as adult learners and be addressed at the unit level and for the cohort. Mentors can facilitate residents' incorporation of clinical experiences and knowledge. It is this incorporation that leads to competency and efficiency and gives new nurses confidence in their practice.
Routine meeting time between residents and mentors away from the clinical setting can be used for discussion and review. This time may include going over new clinical experiences, knowledge that is important to the specialty area, or case studies, all avenues to reinforce learning.
Additional education can be accomplished through granting self-study or guided time. Residents can complete assignments that will benefit integrating specifics into their practice. This might include review of unit-based competencies or unit-based policies and procedures or specific classes such as ACLS. Residents may be assigned to visit alternative sites that give insight into the continuum of care for the patient. For example, a resident on a cardiac care unit might visit the cath lab, or a resident on a postsurgical unit might visit the operating room.
Residents should also have exposure to understanding nursing leadership. Mentors should take responsibility for introducing residents to issues such as resource utilization, peer review, and quality improvement. Shadowing a nurse leader at the organizational or unit level can give residents perspective on the demanding challenges of a nurse leader.
Length
Organizations offer various timelines for their programs, but be flexible with the prescribed program length to accommodate the needs of each specialty practice. Whatever the required length of time, participant evaluation is needed to monitor progress. Input for the evaluation should come from the preceptors, mentors, and unit nurse leaders and be shared with the resident program coordinator. Self-evaluation should be offered to residents, and peer evaluations from other nurses could be considered. In addition, nurse residents should have the opportunity to evaluate their preceptors and mentors.
When developing or updating a nurse resident program, start by setting objectives for participants to accomplish. There may be objectives for the cohort, with additional objectives for the resident's unit. The program's main goal is always competent nurses, regardless of the outlined objectives. By combining the structure of a nurse resident cohort with flexibility at the unit level, this goal will be accomplished.
Reference
Benner, P. (1984) From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Menlo Park, CA: Addison-Wesley.
Vicky Goeddeke, RN, MS, CEN, CPEN, is the ANCC Magnet Recognition Program® and nursing excellence manager at Northwest Community Hospital in Arlington Heights, IL.For information on how you can contribute to HealthLeaders Media online, please read our Editorial Guidelines.