Listen to RNs if You Want Them to Accept Change

After a change project centered on an electronic plan of care fell flat, Albany Medical Center's clinical informatics specialist took nurse end-users' feedback seriously and embarked on a mission to improve their perception of the plan of care.

If it's true that beauty is in the eye of the beholder, then just a few years back Albany (NY) Medical Center's nursing staff's electronic plan of care would have been seen as "Dogs Playing Poker" rather than the "Mona Lisa."

In the summer of 2013, the organization had finally taken the plunge and moved from a paper plan of care to an electronic one, says Susan Dillon, RN, MS, CNML, a clinical informatics specialist at the medical center.

"Since electronic health records have come along, these plans of care have been converted to an electronic form," she says. "The idea is that nurses would be able to access this information, enter individualized patient problems, and have interventions associated with them [at their fingertips]"
By making the change from paper to pixels, the organization hoped to give its nurses another tool to improve patient outcomes and to help move patients along the care continuum efficiently.

"The electronic plan of care [helps] identify problems. It actually gives suggestions to nurses on the goals we want to obtain," says Margie Lee, RN, MS, assistant nurse manager in the vascular unit at the medical center.

"So when you put a certain problem in there, like fall risk for one example, the system will automatically divert you to the goal that there's no falls. It also suggests some interventions that will help the nurses obtain the goal. The suggested interventions are actually based on evidence-based information."

A survey in 2014 survey to assess nurses' perceptions of the electronic plan of care, however, showed clearly that they were not impressed. But instead of shrugging off the results, Dillon chose to use the nurses' input to improve their perception of the plan of care as well as the plan of care itself.

And it worked.

A Call to Action
Dillon was a not involved in the initial planning and launch of the electronic plan of care—she was a nurse manager at the time—but when she moved into the clinical informatics department, managing the plan of care was going to be her project.

"I was hearing a lot of dissatisfaction from the nurses," Dillon says. "I wanted to use the survey as a starting point to say, 'Where am I, what's my baseline, and what are all of these nurses thinking about the plan of care?'"

And the results?

"The results were not wonderful," she says. "But not completely unexpected for me. Some of the things I kind of anticipated."

For example, 68% of the nurses agreed that the electronic plan of care added to their workload.

"We never told the nurses this was going to be a slam dunk and it's not going to add work," Dillon says, "so that wasn't a big surprise that 68% of nurses completely agreed with that. They were right, it did add to the workload. I felt that I could handle that one."

But some of the other results, like the nurses' perception of how the plan of care was impacting quality of patient care, were more surprising and worrisome to Dillon.

"When [I saw that] only 33% felt use of the plan of care improved their patient outcomes—that was unacceptable to me. That was a call to action. I knew I had to do something," she says.

The Action Plan
Dillon's first step was to talk with the plan of care steering committee about adjusting some of the interventions the system suggested.

"A lot of the interventions around the problems were based around education issues," she ­says. "One of the things that I brought to the team was that we needed things that were going actually to drive patient care and help the nurses in making better decisions that are ultimately going to improve the outcomes."

This lead to a revamp of the pressure ulcer plan of care with assistance from the wound, ostomy, and continence nurses.

"We built a distinct pressure ulcer problem. If a nurse says it is a [stage] 2, they can now go into our plan of care and pull up [that problem]. They can click on that electronically and it brings up all of the interventions, some that are required and some that are optional," she says.

Dillon also addressed the nurses' concern that when there was a problem with the plan of care they weren't getting help to resolve it. This concern was brought back to the units' clinical nurse specialists.

"We did do a blitz with the clinical nurse specialists. [We told them] 'you do need to be the resource. You need to go back and let your nurses know that you are the person they should go to for immediate problems.'"

She also did some reeducation with the nurses on how to use the feedback section of the plan of care. "We realized they didn't really know how to put proper feedback in about things they would like to see in the plan of care or things that should be changed to make it a more workable document," she says. "So we did a big blitz to show them there is a form where they can write anything and when they write in it, if it says anything about plan of care, it comes directly to me. Then my job is to respond to the person, to kind of work through what they're talking about as far as an improvement."

Hard Work Pays Off
As surprising as the results of Dillon's original survey were, the results of a follow-up survey were just as unexpected. "On the survey that I gathered, it actually gave me a good numbers of improvement from the previous survey. It actually surprised me," Lee says.

For example, when asked on the 2015 study if they preferred the electronic plan of care rather than the previous way of doing things, 85% of the nurses reported the preferred the electronic plan of care. In 2014, only 65% preferred the electronic plan of care.

"[Their perception of] the accuracy of the plan of care went from 48% to 71.2%. It's a big improvement," Lee says. "They actually believe in the plan of care and can depend on the plan of care. It serves as their backup on rendering quality care to their patients. It guides them on what to do and it gives a lot of information to be able to meet the goals that we're expected to meet."

From this experience, Lee gathered some wisdom that anyone making changes in a healthcare organization would be wise to keep in mind.

"It made me aware that being sensitive to their thoughts and their perceptions, being valued as part of a team, being heard for their feedback and suggestions are factors that are needed to gain participation in any organizational project or implementation" she says.

"You can't just make a change in an organization without following up on it [to see] if it's working. If it's not working you have to address it, you have to pay attention to it."