When the University of Colorado Hospital (UCH) moved to a new facility in July 2007, it saw an opportunity to improve nurse satisfaction by upgrading the computer process nurses used at the bedside. The Aurora-based hospital first received ANCC Magnet Recognition Program® (MRP) designation in 2002 and was resdesignated in 2006.
In the old facility, nurses in med-surg areas had their own carts assigned to them, which they had to roll from patient room to patient room as they made their rounds so they could use the computer on the cart as they administered medication and documented at the bedside.
The carts were a huge frustration for nurses, according to Kathy Smith, MS, PMC, RN, supervisor, nursing informatics—and former MRP project director—for UCH. The carts were difficult to roll on the carpet in the hallways when moving from one patient room to another, and if the cart encountered a bump, it often logged nurses off the computer, so they had to start again when they reached the patient room. The computers also had batteries—which made the carts heavy to maneuver, and needed to be recharged all the time—and nurses found the batteries were always dying at the wrong moment.
Smith relates that many times the batteries needed to be replaced, which increased workload for the IT staff. In addition, UCH realized that having one cart per nurse wouldn't work with the new bar code medication administration it system was implementing.
"We could see right away that was not going to work," says Smith. "It would require that every time a nurse wanted to administer a medication, she would have to go find her cart, unplug it, move it into the room, then plug it back in, then boot it up, then administer the meds."
Smith relates that this was a fantastic example of the CNO advocating for nursing's needs. The hospital had already budgeted and expended money on the new bar code medication administration system, and then the CNO went back to the executive level and said that the nurses needed to have a computer in every room in the hospital. Despite the significant budget, the hospital invested in its nurses.
UCH chose another cart system, rather than a wall-mounted computer, because nurses wanted flexibility with moving the cart around to different parts of the room. Also, UCH had already planned the rooms in the new building, which weren't designed for wall-mounted computers.
To choose the best system, the hospital staged a "cart fair," at which nurses could examine the different types of carts on the market and determine the ones that would best meet their needs. They eventually chose mobile computing carts from Rubbermaid Medical Solutions.
"The new carts now stay put in every patient room," says Smith. "They are plugged into the wall, so nurses don't have to worry about the battery ever being run down." But still having the computer on a cart allows nurses the freedom to move around the room as they like and use the computer where it makes most sense for them and the patients.
The carts have a computer screen, the CPU in box, a big work space, a drawer, and a light. The light enables nurses to see medications and so forth during the night shift without turning on the lights in the room and greatly disturbing patients.
The new computers were crucial to the successful adoption of the bar code medication administration system, Smith says. "I think we would have had a revolt if we hadn't done it," she adds. "They would have been very dissatisfied. And it would probably have been a failure for our bar code medication administration project."
Smith says the carts contribute to nurse satisfaction. "The nurses love them," she says. "They made a big poster with a big thank you card and gave it to the CNO. It said 'Cow-a-bunga! ["Cow" is an abbreviation for "computer on wheels."] We love the new computers in patient rooms!'"
This article also appears in the December 2009 issue of HCPro's Advisor to the ANCC Magnet Recognition Program®, an HCPro publication.
Offering a nurse residency program is an important strategy for planning for the future in nursing, but many hospitals are finding these programs costly, considering the current economic conditions affecting many healthcare organizations. Despite the financial and personnel resources it takes to support a nurse residency program, there are sound reasons to continue or begin such a program in your organization.
Nurse orientations cost an estimated $20,000–$50,000 per nurse (Blanzola et al., 2004). In addition to orientation costs, turnover costs include marketing and recruitment expenses, salaries for overtime and/or external staffing resources to cover clinical staffing needs, and the potential effect on customer satisfaction scores. Nursing turnover has been estimated to cost 75%–125% of the average annual salary of an organization's nurses (Pine et al., 2007).
Organizations must weigh the cost of a nurse residency program against the cost avoidance of nurse turnover. A successful nurse residency program can lead to positive outcomes for organizations, such as lower turnover and the development of competent clinical practitioners. Anticipated future returns include improvements in staff satisfaction, clinical productivity, outcomes of care, patient safety, and, as a result, customer satisfaction (Keller et al., 2006). A successful nurse residency program helps nurses develop advanced nursing skills that contribute to these outcomes.
Challenges for new graduate nurses
Although 90% of academic nurse leaders feel new nurse graduates are fully prepared to practice, only 10% of hospital nurse leaders share this opinion (Berkow, 2009). The challenges of transitioning from nursing school to clinical practice for new nurse graduates leads to first-year turnover rates of 35%–60% (Blanzola).
New nurse graduates face a huge challenge as they transition from student to competent practitioner. New nurses must adjust to the clinical demands and environment of a new work arena, which have increasingly complex patients and specialties that are becoming more technology-focused.
In addition, new nurse graduates often work demanding alternate or rotating shifts that they were unaccustomed to as students.
For these reasons, new nurse graduates are attracted to organizations offering nurse residency programs that facilitate their transition to professional practice. Many have identified an interest in and desire to begin work in specialty areas that require strong clinical knowledge.
Cultural considerations that may lead to a new nurse graduate selecting an organization's nurse residency program include professional growth opportunities, coworker and physician relationships, nursing autonomy, scheduling, and recognition of nurses.
Orientation structure
Orientation programs are generally structured to introduce new hires to the new work environment and their new unit's scope of services. Programs typically provide information regarding the organization and the unit. Programs also assess new hires' knowledge and skill base and connect them to peer resources who can role-model expectations for nurses on that unit, as well as facilitate a sense of belonging to the team. The orientation period gives nurse leaders time to evaluate clinical competency, efficiency, communication skills, productivity, and customer service focus. Orientation programs are usually designed to guide nurses' transition to a different work arena, not a different role.
New nurse graduates have a different transition challenge—one from student to the role of a nurse—and a nurse residency program needs to be more than an extended orientation. There are a wide range of goals, program lengths, and outcomes reported for nurse resident programs (Keller et al., 2006).
New nurse graduates can become competent practitioners more quickly with the guidance of a nurse residency program. Programs should offer didactic and leadership components in addition to the standard clinical components offered in an orientation program. Incorporating didactic and leadership components supports the nurse resident's development beyond clinical skills, enhancing clinical judgment and critical thinking skills.
Residency design
Nurse residency is not a new concept—programs were first documented in 1980s literature (Altier & Krsek, 2006), and most are based on Benner's theory of novice to expert. Benner felt competence was typified by nurses who had been on the job in the same or similar situations and were consciously aware of connecting their actions to a long-range plan (Benner, 1984). Benner noted that competence was generally reached only after years of gaining experience as a practicing nurse. A nurse residency can facilitate new nurse graduates to advance more quickly from novices to competent nurses, lessening time as advanced beginners. A nurse residency, focused on developmental concepts, attracts new nurse graduates, and the organization enjoys the benefits of competent nurses and the bonus of low turnover.
Our experience at Northwest Community Hospital reflects these ideals. The initial nurse residency program was founded in 1995 and, based on Benner's theory, was originally a 24-month program. We discovered in the early nurse resident groups that through the mentorship of the residency program, nurses reached competence more quickly, and the program was reset first to 18 months and then to 12 months. These nurses come out of the program as competent practitioners. There remains some turnover among our nurse residents, but there is also longevity: 30% of the first nurse residents were still employed at our organization after 10 years. We have a culture of longevity at Northwest Community Hospital, but our nursing work force, like nursing in general, is aging. We are fortunate that our turnover rate is currently below the national and Greater Chicago–area averages. Because of our low nursing turnover, we enjoy a low nursing vacancy rate. But ours is a forward-thinking organization, so we continue to offer and support our nurse residency program. It's the smart thing to do.
References Altier, M., and Krsek, C. (2006). “Effects of a one-year residency program on job satisfaction and retention of new graduate nurses.” Journal for Nurses in Staff Development 22(2): 70–77.
Benner, P. (1984). From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Menlo Park, CA: Addison-Wesley.
Berkow, S., Virkstis, K., Stewart, J., and Conway, L. (2009). “Assessing new graduate nurse performance.” Nurse Educator 34(1): 17–22.
Pine, R., and Tart, K. (2007). “Return on investment: Benefits and challenges of a baccalaureate nurse residency program.” Nursing Economics 25(1): 13–18, 39.
Blanzola, C., Lindeman, R., and King, L. (2004). “Nurse internship pathway to clinical comfort, confidence, and competency.” Journal for Nurses in Staff Development 20(1): 27–37.
Keller, J., Meekins, K., and Summers, B. (2006). “Pearls and pitfalls of a new graduate academic residency program.” Journal of Nursing Administration 36(12): 589–598.
U.S. Department of Health and Human Services, Health Resources and Services Administration (2004). “What is behind HRSA's projected supply, demand, and shortage of registered nurses?”
Vicky Goeddeke, RN, MS, CEN, CPEN, is the ANCC Magnet Recognition Program® and nursing excellence manager at Northwest Community Hospital in Arlington Heights, IL.
Designation as a stroke center requires that all clinical and nonclinical hospital employees receive training on how to recognize a stroke and take appropriate actions. This was the challenge JFK Medical Center, a 500-bed acute care and rehab facility in Edison, NJ, undertook in 2007 when it pursued designation as a comprehensive stroke center by the New Jersey Health and Senior Services and a primary stroke center by The Joint Commission.
Why do nonclinical staff members need stroke education? A security officer, for example, might encounter a patient or family member exhibiting behaviors consistent with stroke. The officer must be able to recognize the signs and symptoms of stroke and how to promptly summon qualified patient care providers.<.P>
Direct patient care providers need more in-depth education, depending on their roles and the amount of care they provide to stroke patients.
Reaching far and wide
Educating an entire hospital is a daunting task. Donna Kozub, BSN, RN-BC, was assigned responsibility for educating non-licensed nursing department personnel, known as patient care technicians (PCT), in 2007. Kozub's target audience members were those who had the most contact with stroke patients. PCTs who had little or no direct contact with stroke patients (e.g., pediatric unit staff members) received basic education, but those who had more contact needed additional training, she explains. There were no specific mandates from accrediting bodies regarding the hours of education required, only that staff members must be educated. Length and content was to be determined by the educators.
Kozub began by searching the literature for education specific to non-licensed personnel. "I really relied heavily on the American Stroke Association's division of the American Heart Association's wonderful Web site. Part of it is designed for the community, which was a big help when writing at a level appropriate for our PCTs."
Kozub also relied on an interdisciplinary subcommittee of the Stroke Certification Team to help design the education. Members of the subcommittee included nurse managers, speech pathologists, and the neurovascular nurse clinician.
"We looked at it from not only a content perspective, but how to make the information meaningful for the PCTs so that they could apply it not only to their patients, but to their families and themselves as well," Kozub explains.
Nurse managers identified specific duties of PCTs so that education could be geared to helping them fulfill their responsibilities. The clinical director of speech pathology and audiology provided essential elements of curriculum related to communication with aphasic patients.
The senior speech pathologist gave input on topics related to dysphagia, and the neurovascular nurse clinician served as a clinical expert to evaluate completeness and accuracy of content.
Teaching strategies
All employees watched a one-hour stroke video. Kozub developed a three-hour stroke education program consisting of two one-and-a-half-hour modules for PCTs from the targeted patient units.
The first module was entitled "Care of the Stroke Patient," which Kozub offered frequently. "I tried to make it personal and fun," she says. "There were lively discussions about how stroke risk factors were affecting their own lives and the lives of their families."
The second module was entitled "Care of the Patient with Dysphagia" and was presented by the senior speech pathologist. During module two, learners could sample various diet consistencies and learned appropriate patient feeding techniques.
PowerPoint, lectures, discussions, handouts, and demonstrations were primary teaching strategies. Participants were evaluated with a written test after each module. Tests were graded at the end of each class and certificates presented to those who successfully completed the program.
"Most PCTs passed the written test without problems," says Kozub. "They were so proud, and I was proud of them."
Ongoing education
Although the classroom setting had many advantages, it also meant that program administrators had to offer modules frequently so everyone could attend, take time to grade tests, and keep manual records.
Since stroke education is required annually, changes had to be made to increase efficiency. In 2008, Kozub made the decision to move to a computer-based learning (CBL) strategy. "Although I love the energy of the classroom setting, it just wasn't practical to offer this type of education annually in the classroom," she says.
The advantages of CBL were easy access, around-the-clock training, and the ability to print test scores and confirmation of attendance. Disadvantages included the inability of participants to share experiences and practice hands-on feeding techniques and administrators not being able to perform demonstrations.
However, Kozub says the training worked just as well. Test scores with CBL were as good as when the content was presented in the classroom setting, and transfer of knowledge to the patient care setting remained high in both 2007 and 2008. Nurse managers expressed satisfaction with the CBL training since outcomes remained consistently high and scheduling was less of an issue.
Kozub hopes to develop an interactive education program that allows instant feedback when learners are asked to answer questions during the program. This technology could also allow learners to review specific slides and revisit challenging questions.
CBL training is now incorporated into orientation for PCTs hired for targeted units. The hospital also has used specific facets of the training to develop stroke competencies for PCTs. This initiative not only facilitated transfer of knowledge to the patient care setting, but enhanced the self-esteem and pride of the PCTs working with such a special patient population.
JFK Medical Center achieved stroke designation from The Joint Commission and the New Jersey Health and Senior Services. Education will continue to play a pivotal role in maintaining these designations.
This article was adapted from one that originally appeared in the November 2009 issue ofThe Staff Educator, an HCPro publication.
I am writing this from the perspective of a college professor who teaches mental health nursing, transcultural nursing, and pharmacology math. I also continue to practice as a nurse in the clinical setting, most recently in acute care on pulmonary step-down, adult psychiatry, and geropsychiatry units. It truly is a marvelous existence because I am fortunate enough to work with my former students while refreshing and maintaining the clinical skills I worked so hard to obtain all those years ago. My clinical practice often permits me to easily assess the effectiveness or, at least, retention of my teaching efforts and those of my peers as I observe our students' transitions from academia into beginning clinical practice.
We faculty consciously endeavor to instill a strong sense of professional pride and accountability along with the nursing knowledge. I'd even go so far as to admit nursing educators do indeed try to cultivate students who feel guilt or shame when their nursing performance fails to meet the quality thresholds fixed by our professional standards and practice guidelines.
My clinical role allows me to witness the interminable challenges my new professional peers daily confront. And I see a long-recognized disconnect arise: the one between what is taught and "real-world" pragmatism.
That incongruity, it seems to me, is even more conspicuous in these days due to an increased reconsideration of care delivery methods. Providers are reshaping delivery methods to be congruent with the Institute of Medicine's Six Aims of High-Quality Health Care (IOM, 2006). The Aims assert care should be:
Safe
Effective
Patient-centered
Timely
Efficient
Equitable
I would like to focus our present discussion on effective care. The IOM describes effectiveness in part as being evidence-based, meaning interventions for which there is objective empirical support. Effectiveness also includes avoiding continued use, or at least questioning the use, of interventions lacking scientific confirmation. Let's consider a clinical example.
For many years, nurses and respiratory therapists have instilled small amounts of sterile normal saline into tracheostomy or endotracheal tubes prior to suctioning. The purpose was to loosen thick secretions and aid airway clearance. It seemed a good idea at the time but research hadn't been done. The practice continues. In one descriptive comparative study (Sole, Byers, Ludy & Ostrow, 2002), 95 nurses and 37 respiratory therapists working in adult critical care units at four different sites were surveyed regarding their suctioning techniques. Thirty percent of all nurses and 78% of respiratory therapists reported routinely instilling saline prior to suctioning.
Is this practice supported by evidence? One very recent randomized clinical trial (Caruso, Denari, Ruiz, Demarzo, & Deheninzelin, 2009) using 264 subjects in a single surgical intensive care unit of an oncologic hospital found instilling saline before tracheal suctioning decreased the microbiology proven incidence of ventilator-associated pneumonia (VAP). In the results discussion, the investigators do wonder if the effect was in any way due to shallow sedation levels that permitted the saline to produce sputum clearing coughs (think "water-boarding" here). Also, the authors agree that there was no difference in suspected VAP rates between the intervention group patients who received saline instillation and the control patients who didn't. The researchers urge further studies before recommending saline instillation as a regular step in the suctioning procedure.
The preponderance of the evidence, however, suggests routine saline instillation can be harmful and ought to be avoided. Pedersen, Rosendahl-Nielson, Hjermind, and Egerod (2008) reviewed the available literature regarding endotracheal suctioning. The authors searched literature from 1962 through the present. A total of 77 papers were included in the final review, four studies describing patient personal experiences, 19 literature reviews, two meta-analyses, and 52 clinical trials. Their analysis findings include recommending nurses should suction only when necessary, use a catheter occluding less than half of the lumen of the endotracheal tube, use the lowest possible suction pressure, and avoid saline instillation.
At this point, envision one of my graduates being directed by a nurse mentor during orientation to squirt 5 or 10 mL of sterile normal saline into the tracheostomy tube before suctioning. The student recalls being taught differently and remembers the evidence, but often abjectly yields to confident assertions of the mentor: "I've been doing this for 26 years and it works." The outmoded, unsupported, and potentially harmful practices continue.
Saline instillation is merely an illustration of a more pervasive problem. There are similar current nursing practice versus evidence-based practice conflicts. So, here are some questions for us all. How can nursing educators in colleges and healthcare systems create an environment that fosters the introduction of evidence-based practice? How can we empower new graduates to feel confident and assertive about what they've learned while being respectful of their professional 'elders'? How can we convince, co-opt, or even coerce long-time nurses to quit unsafe and ineffective interventions? Any suggestions?
References
Caruso, P., Denari, S., Ruiz, S., Demarzo, S., & Deheinzelin, D. (2009). "Saline instillation before tracheal suctioning decreases incidence of ventilator-associated pneumonia." Critical Care Medicine 37(1): 32-38.
Institute of Medicine. (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press.
Pedersen, C., Rosendahl-Nielsen, M., Hjermind, J. & Egerod, I. (2008). "Endotracheal suctioning of the adult intubated patient—What is the evidence?" Intensive and Critical Care Nursing 25(1): 21-30.
Sole, M., Byers, J., Ludy, J. & Ostrow, L. (2002). "Suctioning techniques and airway management practices: Pilot study and instrument evaluation." American Journal of Critical Care 11(4): 363-368.
Richard Freedberg, RN, MSN, MPA, is professor of mental health nursing at Lansing Community College in Lansing, MI. He continues to practice in a clinical setting, and has experience that includes staff nursing and management roles in medical-surgical and mental health acute-care settings, home-care nursing, and medical intermediate care.
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The phrase "simulation modalities" may conjure up a variety of images. For example, some nursing staff development professionals think of a sophisticated training mannequin that produces computer-generated EKG printouts, responds to intubation efforts, and virtually behaves in ways similar to an actual patient. Others may think of an IV arm used solely for learning how to start IVs.
The point is, there is a wide range of simulation modalities, but many staff development specialists know of only a few, and still more are as of yet unaware of the vast potential for providing education via simulation.
Low-fidelity simulation modalities
Low-fidelity simulations are described as those that feel the least real to the learner (Holtschneider, 2009; Mt. Hood Community College, 2009). These simulations can be paper- or computer-based and are generally static models that allow for very little learner interaction within the simulation. Examples include computer- or paper-based tasks, mannequins that do not have the capability for providing feedback (e.g., a Resusci Anne that only offers computer printouts that evaluate the accuracy of breaths and compressions), or an IV arm that allows students to practice IV insertion techniques without feedback devices (Holtschneider, Mt. Hood Community College).
Low-fidelity simulation modalities are relatively easy to implement and transport and less expensive to implement than more sophisticated modalities. However, they are the least real of the modalities and therefore do not provide learners with the experience or the feeling of actually working in real-life settings.
High-fidelity simulation modalities
Also referred to as a high-fidelity human patient simulators (HPS), these are often the first thing people think about when we say simulation. When using an HPS, educators can implement a variety of scenarios that they can tape and play back for debriefing or guided reflection, as well as create blended simulations, incorporating actors assuming the role of patients with low-fidelity task trainers.
HPS is usually dependent on some type of computerized mannequin that allows the re-creation of the physical patient in a realistic physical clinical environment. Mannequin-based simulators have become increasingly common in areas such as the OR, emergency department, and critical care units, where life-threatening situations that require recognition and treatment often occur. Some simulators can even mimic the effects of various drugs, track the distribution of the drug in the body, and determine the exact effects that a specific amount of the drug will have on the human body.
The costs associated with these types of simulation generally increase with the level of sophistication of the simulator. Complex simulators may also be more of a challenge to set up and transport than more simple simulation techniques. However, the level of realism introduced by high-fidelity simulation modalities truly brings the learner into an interactive, genuine work environment.
Standardized patient educators
A tactic that adds to the high-fidelity simulation modalities is the use of standardized patient educators (SP). SPs are educators who are specially trained to portray patients, family members, and, at times, even members of the hospital staff.
Using SPs lets learners engage in mock conversations with patients, deal with family members who are frightened and questioning, and cope with colleagues who may not be acting professionally.
SPs are used in a variety of academic settings, such as medical and nursing schools. However, their use is now becoming more common in clinical environments because they add another dimension of reality. However, they also add to the cost. Organizations hiring these educators must screen them carefully and hire only those persons qualified to assume such roles.
Serious gaming
The term "serious gaming" involves the use of video game technology to add another dimension to the learning process. Learners function within specific rules and guidelines while playing interactive computer-based games. These games generally present a complex healthcare situation (e.g., multiple casualties from a terrorist attack arriving at an emergency department) that requires the learner to intervene appropriately.
Although the game format is viewed as a fun way to learn, the games offer deadly serious scenarios. Serious gaming is an increasingly popular training mechanism.
Video and computer games can be developed fairly quickly and can simulate functional entities in various clinical settings. However, they can be expensive to develop and learners must have appropriate training in their use. In addition, they require the availability of adequate equipment for learners.
Desktop simulations and virtual worlds
Desktop simulations and virtual worlds can be run on a desktop computer and only need a screen, mouse, and audio inputs and outputs. The learner can view data, see the patient via animation, perform diagnostic or treatment interventions, and interact with the patient by typing or, in some cases, actually speaking with the patient.
An advanced approach to this type of simulation allows several participants to participate in a virtual world simultaneously. Learners can interact with each other, the patient, and others in this world. A distinct advantage of this type of simulation is the ability to interact with various healthcare team members as well as the patient and family.
Virtual reality and visualization
Virtual reality is a computer-generated world that allows the learner or group of learners to experience various stimuli, often in a 3-D presentation. Learners typically wear head-mounted displays to receive visual and auditory cues. They can interact in the computer-generated world from various sites or be in a physical space in which they can interact with others.
Virtual reality is a rapidly developing field and gives a true sense of realism. However, the creation of a complex virtual patient and treatment setting can be time-consuming and expensive. It requires a complete computer model of the patient environment; a way to track visual, audio, and touch fields; adequate hardware for all sensory modalities; and hardware to compute all models, track inputs, and produce outputs in real time.
Mt. Hood Community College (2009). "Fidelity simulators." Retrieved October 1, 2009, from www.mhcc.edu/pages/493.asp.
National Nursing Staff Development Organization (2008). "Collaborative efforts across organizations: Building a simulation alliance." Journal for Nurses in Staff Development 24(6): 303–304.
This article was adapted from one that originally appeared in the November 2009 issue ofThe Staff Educator, an HCPro publication.
The nation's largest nurses' union and professional organization reached tentative agreement on a new contract with one of the biggest hospital systems in the country. The deal includes a collaborative effort to contain the spread of pandemics such as H1N1. The California Nurses Association/National Nurses Organizing Committee and Catholic Healthcare West agreed to establish a systemwide emergency task force of nurses and hospital representatives to monitor preparedness and set uniform standards that meet federal, state, and local government guidelines.