The Four Habits model, used to improve patient-physician communication, can also prepare nurses to deliver relationship-centered care more effectively, study data shows.
When it comes to patient care, there's a technical side and an emotional side. The best nurses are masters of both, and according to a new study, a set of commonly used physician communication skills that aim to improve on the care provider's soft skills can be effectively applied to nursing training, too.
"I really believe relationship-centered care is really what it's about," the study's first author Mark J. Fisher, Ph.D., RN, an assistant professor in the College of Nursing at the University of Oklahoma Health Sciences Center, told me in an interview.
"Simply communicating using technical skills and focusing purely on information can provide a level of care, but I'm not sure it's the highest level or the most effective level."
The study found that a nurse training program based on the Four Habits Model "improves newly licensed nurses' self-perception of their preparation for emotion-focused conversations with parents" of pediatric patients.
The Four Habits are commonly used in physician training programs to help improve patient-physician communication, says Fisher, who tweaked the model slightly to study its effectiveness for pediatric nurses.
"My experience in the pediatric hospital setting and interactions with nursing students revealed many newly licensed nurses and most nursing students were quite anxious about talking with parents of children in the hospital setting," Fisher told me by email after our phone conversation.
The Four Habits are:
Invest in the beginning, which includes making introductions, asking questions about the patient/parent concerns, and planning visits
Elicit the patient's perspective (adapted for pediatrics as "elicit parents' perspective,") which includes things such as asking the patient about how their health issue affects their lives and what their goals are for treatment
Demonstrate empathy, which includes being open to the patient's emotions and conveying empathy, either with statements ("you seem worried") or with body language
Invest in the end, which includes delivering and explaining diagnostic information and talking about the patient's understanding of and willingness to engage in follow-up care
The Four Habits model respects and integrates the patient's and family's perspective into the care in a real and meaningful way, "which I think it vital," Fisher said. "It's caring 'with' instead of caring 'for.'"
Caring "with" allows clinicians to have a richer knowledge base to apply to the patient. For instance, the parents of a 14-year old might not have any medical background, but they certainly know their child better than anyone.
"They have 14 years of experience that we need to incorporate into care," Fisher said. "If we don't elicit that information, that's 14 years of information that we're missing."
Eliciting and understanding such information requires empathy. Nurses are often simply assumed to be empathetic, but as an assistant professor of nursing, Fisher believes that real empathy training is lacking in much nursing training. Such training wouldn't teach nurses how to feel empathy, but how to manage it and apply it to patient care.
"We teach a lot of communication skills and technical skills," he said. "What can we do about these emotions?"
Because the Four Habits outline a way to manage and apply emotion, Fisher wanted to teach those techniques to nurses and find out whether such training was beneficial. The study's intervention group participated in a one-hour, three-part education simulation session that involved participating in role-playing scenarios, whereas the control group simply observed a one-hour video.
According to the published study results:
Compared with the controls, the intervention group improved significantly in four of five areas: preparation, communication skills, relationships, and confidence. [Fisher told me that the study's key outcome variables were preparation, communication skills, relationships, confidence, anxiety, and total preparation.] Experience level had minimal effect. Over half of the nurses in the intervention group reported using one or more of the Four Habits in clinical practice.
Fisher says nurse leaders who want to incorporate this type of training for their own nurses can accomplish it through similar role-playing workshops or in-service days, perhaps by recruiting parents of former patients to come in and work with nurses in simulated scenarios. It's something that his own nursing students appreciate and benefit from, he adds.
"It's not me teaching them. It's parents who have lived through the experience," he says. "It's real for them."
I asked Fisher whether being so in tune with patient and family emotions could exacerbate compassion fatigue.
"I think that's absolutely something that needs to be looked at and considered," he said. But he also pointed out that there's a difference between empathy and sympathy.
"We're more interested in the empathy," he added. "I think empathy is something we see in nursing a lot, but I don't know how much training there is around it."
Who knows? Perhaps a formal understanding and application of empathy through training could actually help alleviate compassion fatigue.
"I'm not talking about having the patients and the parents be our best friends," Fisher says. Instead, he believes nurses should simply slow down and take the time to hear and understand their perspective.
"We pause and take a moment to hear what is going on for that parent," he says. "It's not about us giving information, it's us receiving information."
It had a lean staffing model—so lean, in fact, that the hospital was relying more and more heavily on an outside nurse staffing pool called Noll Pool that's meant to fill emergency, same-day absences at the hospitals in the Omaha-based Alegent Creighton Health system.
When Denise McNitt, MS, RN, NEA-BC, started as chief nurse at Mercy in January 2012, the hospital's nurse staffing problem was about to hit its tipping point.
"We really hit an unsustainable number of contract hours," says McNitt, who is now vice president of patient care services. Although Mercy Hospital isn't the largest hospital in the Alegent Creighton Health system, it was using a much bigger percentage of Noll resources than other hospitals.
And because Mercy Hospital was dipping into the emergency pool so much, it was getting harder to staff the rest of the system, too. "My problem at Mercy was starting to affect all the other hospitals," McNitt says.
Mercy Hospital was also experiencing a significant amount of turnover among its core nursing staff. McNitt says the hospital was itself continually taking people off of some shifts to cover others, and directors were competing with each other for core staff, in addition to being overreliant on the Noll Pool.
"We were in a reactive mode," she says. "We were robbing Peter to pay Paul."
Analytics showed that the units were actually overstaffed, but the hospital's own, in-house float pool was down to just six people; in other words, nearly nonexistent. Managers were staffing their own units, and there was no central person responsible for overseeing hospital-wide staffing (a "quarterback," as McNitt calls it).
"It got worse and worse as the summer months went by," McNitt says. "We knew we had to do something."
So she pulled together her team of directors; ran staffing analytics with Avantas; and conducted surveys at the unit and house levels to find out what staff believed to be the No. 1 issues for the hospital.
The surveys showed that the lack of an in-house float pool was a huge problem, as was the very high incidence floating that staff nurses did outside of their own units. This was all exacerbated by the lack of a "quarterback." In addition, there wasn't 24/7 team lead coverage.
"We were setting [ourselves] up for competition among our own units," McNitt says. "We put together a plan to work on each of those gaps."
The Solution The first step, she says, was to hire a daytime house supervisor to take the staffing pressure off of the unit directors. They also hired round-the-clock team lead positions, increasing the number from one per floor to three or four per department.
Next, they realigned the leadership of the units so the critical care and post-critical care units were under one director and the medical-surgical and orthopedic medical-surgical units were under another. These units were made partner units.
"The goal was to align the competencies of the nurses," McNitt says.
Realigning the units also helped realign staff. No one wanted to "float." Instead, nurses were cross-trained for both of the partner units. In addition, all new hires come onboard with the understanding that they'll be trained for and work on both partner units.
"[It is] expected that they will go equally to both units," McNitt says, which eliminates the "floating" mentality.
Another way that the floating mentality has been changed is through the name itself. Mercy Hospital not only substantially beefed up its float pool—from six to 60 nurses—but has also renamed it the "resource team." The hospital recruits to fill the resource team specifically, and has even hired some nurses from within the hospital's core staff.
"I've really gotten away from using the word 'float' because it has such a negative connotation," McNitt says. "It really isn't a float pool; it's a resource team."
Now the mentality of being part of the resource team has truly changed.
"They're not floating. That's just what they were hired to do," she says. "We were very intentional about who we hired, we were very picky about who we hired."
So far, the changes have yielded positive results. According to McNitt, the hospital has reduced floating among its core staff from 4.6 FTE-equivalent per pay period in FY2012 down to 1.5 FTE-equivalent per pay period as of the second quarter of FY 2014.
Float Reduction
FY2014
FY2012
1.5 FTE-equivalent
4.6 FTE-equivalent
In addition, the turnover rate fell from 15.3% in FY 2012, to about 10% in FY 2014. The hospital also saved $600,000 between FYs 2012 and 2013.
Turnover Rates
FY2014
FY2013
FY2012
10%
12%
15.3%
Nurses are happy with the changes, too.
"There's been a lot of very positive feedback from the nurses," McNitt says. "It's rare that I hear anyone complain about staffing."
In fact, there's been a complete reversal from January 2012. McNitt believes that Mercy Hospital's contract usage is now among the lowest in their healthcare system. And now that staffing isn't an issue anymore, the directors can put more of their energy toward patient care.
"They've got other things to worry about on a daily basis," McNitt says. "But staffing's not one of them."
For the first time, the White House has honored innovative nurses who invent, hack, or "make," devices and workarounds that fix healthcare problems and improve patient care.
Roxana Reyna, BSN, RNC-NIC, WCC, was at the Lincoln Memorial on her cell phone when she took a break from her sightseeing to talk with me about the "making" she does as a Skin and Wound Care Prevention Specialist at Driscoll Children's Hospital in Corpus Christi, TX. She was in Washington, DC, as a special invited guest of the White House, and the excitement in her voice was obvious.
"I was invited as an honored maker to the first-ever Maker Faire that was held at the White House," she told me. "When the Washington people heard about MakerNurse, they were excited that such making was going on at the bedside."
MakerNurse, as you might remember, is an initiative of the Little Devices Lab at MIT that's supported by the Robert Wood Johnson Foundation. It has collected stories from nurses who invent, hack, or "make," innovative, new devices and workarounds that fix healthcare problems and improve patient care.
Reyna's work involves wound care and prevention for babies and kids.
"I tell the mom, 'You know MacGyver? I'm MacGyver,'" she says.
She measures, cuts, experiments, figures what works and what doesn't, and works with materials that are often manufactured with adults in mind.
"My daily making consists of skin and wound care prevention, such as cutting up foam to protect against pressure under drains and tubes, crusting with advanced products to create barriers, and teaching other nurses how to make in order to provide continuity of care," she told me by email after our phone interview.
Reyna adds that she has "the support and collaboration of my surgeons and physicians that I work with that allows me to design, create, and make."
Although she has that kind of ongoing support and collaboration at her hospital, much of the making nurses do every day in hospitals across the country goes unnoticed and unheralded. For many nurses, figuring out solutions to patient care problems in this "MacGyver" kind of way is just part of how they do their job.
"It's having to troubleshoot and come up with a solution for the problem," says Reyna. "It's just like the nursing process."
For nurses who are doing quiet—and not-so-quiet—making, MakerNurse has provided a forum for them to share and celebrate their achievements. Since its launch last fall, MakerNurse has featured nurse-made fabrications such as a pediatric nebulizer that doubled as a pacifier; a reusable, soft-padded tracheostomy collar; and an IV shield.
Now, MakerNurse says it has launched an online community dedicated to empowering and encouraging nurses who engage in this kind of innovative making.
And later this summer, MakerNurse will release a series of tools and resources to empower nurses to make and innovate at the bedside, improving patient care and health. According to MakerNurse, the new tools will include step-by-step instructions on how to make a variety of health-related tools.
Hospitals can encourage nurse making and innovation by taking a page out of Driscoll Children's Hospital's book.
"The thing I love about it there is they give me the chance to grow, to be creative, to do things I need to do to help the patient, to see help them survive, to help them get home," Reyna says. It involves daring, risk taking, empowering nurses at the bedside, collaboration, and allowing ideas to flow from nurses, not from administration, she says.
One of the things she's proudest of is a dressing she helped create for babies born with omphalocele, a birth defect in which the intestines protrude out of the body and are covered only by a thin layer of tissue. Surgery will eventually repair the defect, but until then, it's at risk of opening and infection, and needs protection.
"We apply a Hydrofiber dressing that is made of an antimicrobial," Reyna says. "We've been able to take the properties of a dressing…shape it, form it, and be able help the patient."
It's an innovation that pays off.
"We've been able to see no mortality with what we do, no infections with what we do," she says. "We've had kids go home as soon as 11 days."
Hopefully with the new tools coming from MakerNurse, more nurses will have the help and encouragement to take making to the bedside, too.
A book written by two RNs details strategies for understanding and interacting with patients as individuals, and suggests nurse leaders can help by "giving nurses space" to do so.
It's early evening, and it's time to take Mrs. Smith's vitals. The nurse knocks on the door, just as a formality, and doesn't pause before entering the room. The patient is talking with her daughter, but the nurse goes about his business anyway, interrupting the conversation, quickly taking the vitals, and leaving. He's got a job to do, and other patients to see.
But Mary K. Walton, MSN, MBE, RN, director for Patient and Family Centered Care at the Hospital of the University of Pennsylvania, as well as a nurse ethicist, says a nurse's job isn't only about tending to a patient's physical needs, nor is it only about clinical responsibilities.
"It's not about the tasks," she says. "The tasks are important, the clinical skills are important, but it's [about] understanding the patient's needs."
Walton, along with Jane Barnsteiner, PhD, RN, FAAN, and Joanne Disch, PhD, RN, FAAN, is the co-author of a new book, Person- and Family-Centered Care, published by the Honor Society of Nursing, Sigma Theta Tau International. The book aims to help nurses move away from the idea of caring for a "patient" and instead toward caring for a person.
Understanding the patient as a person means making a conscious effort to discover the individual who's being cared for, his or her unique needs, fears, vulnerabilities, values, and families.
"There's a different kind of vulnerability when you're admitted to the hospital," Walton says. "When you take your underwear off and put on a gown and a nametag it really changes who you are."
With that in mind, a patient's values should help to guide healthcare decision making, and it's up to clinicians to forge a partnership with patients and families to understand what those values are. Although good nurses certainly know the ropes of clinical care, patients are the experts on themselves, Walton says. And family members can be experts on their loved ones, too.
"On the clinician's side, it's important to learn how to elicit an individual's values and preferences," she says. "If you're going to honor them, you have to know what they are."
Toward Better Outcomes Sometimes nurses and other clinicians think family members are the way, but having family members present and engaged in care just might improve outcomes.
For instance, when a nurse is explaining to a sick person how to change a wound dressing or take their medications, he or she might also ask who could sit with them to hear the instructions, too, just to make sure that they understand.
Or maybe talking with a patient about what makes them feel nervous or unsure would reveal that they "feel really scared lying in this bed at night and I feel good to have my brother with me," Walton says.
Nurses might make little tweaks to their rounding by knocking on a patient's door and waiting for the patient to tell them to come in. Or they could ask the patient whether it's a good time for them to come in, and let them know that it's OK for them to ask the nurse to come back in ten minutes. If the nurse doesn't come back in ten minutes he or she should offer an apology.
A nurse should also consider whether a patient with a bad attitude might be acting out of fear, rather than anger. Instead of backing away from the situation, a nurse might say, "I can tell you're concerned about something. I want to understand," Walton says.
"That skill is not something that people know intuitively for the most part… sometimes listening is a very effective therapeutic strategy."
How Nurse Leaders Can Help Walton says nurse leaders can help with the culture shift toward patient- and family-centered care by modeling these behaviors and letting nurses know they're not alone. Leaders might do things such as rounding with the nurses and showing them how to ask questions that elicit a patient's values.
For instance, if a patient says that everything is fine, a nurse leader might ask, "Tell me what fine looks like," Walton says.
And nurse leaders should honor how their staff feels, too, by "giving space for nurses to say, 'I'm having a really hard time with this," Walton says. Debriefings between nurses and leaders after dealing with challenging situations are helpful, too.
All of these strategies can be implemented with an eye toward providing better patient care and ultimately, achieving better outcomes.
"It's not about the patient is always right," Walton says. "It's about helping people improve their communication skills."
For every 15 healthcare providers who receive the influenza vaccination, one fewer person in the community will contract an influenza-like illness, research shows.
There's been an ongoing debate about whether healthcare workers should be required to get flu vaccines. Often the focus of that debate has been the rights and responsibilities of nurses.
But a new study suggests that when healthcare workers do get vaccinated, the consequences go beyond the hospital and reach into the larger community.
The study, presented over the weekend at the Association for Professionals in Infection Control and Epidemiology's (APIC) 41st Annual Conference, shows that for every 15 healthcare providers who receive the influenza vaccination, one fewer person in the community will contract an influenza-like illness.
"Healthcare personnel vaccination extends beyond the walls of the hospital," the study author, James Marx, PhD, RN, CIC, infection preventionist consultant at Broad Street Solutions in San Diego, told me via email.
Marx analyzed archival data from the California Department of Public Health from between 2009-2012 for the study. A correlation design study determined the relationship between vaccination of hospital healthcare personnel and influenza-like illness in the community; hospitalization due to respiratory infection; and death from pneumonia or influenza. 1 in 3
According to the abstract, "There was an inverse relationship between vaccination rates of health care personnel and influenza morbidity as measured by influenza-like illness when three consecutive years of data were combined and analyzed."
Little seems to raise the ire of this column's readers than the topic of mandatory vaccines for healthcare workers. They take to the comments section (scroll down the page) to debate the ethics of such policies and the efficacy of the vaccines themselves.
According to the CDC, the efficacy of the influenza vaccine varies from season to season, but it does cite numerous studies showing its overall effectiveness. For instance, one study showed that flu vaccination reduced children's risk of flu-related pediatric intensive care unit admission by 74% during flu seasons from 2010–2012.
Another showed that flu vaccination was associated with a 71% reduction in flu-related hospitalizations among adults of all ages and a 77% reduction among adults 50 years of age and older during the 2011-2012 flu season.
The CDC and other organizations are also urging healthcare workers to get vaccinated against the flu. The coverage rate for healthcare workers was estimated at 72% for the 2012–13 season, representing an increase from 66.9% in the 2011–12 season and 63.5% in the 2010–11 season, the CDC reports.
However, voluntary flu vaccination doesn't seem to raise the rates enough, and many healthcare organizations have been reluctant to make getting flu vaccines a condition of employment. Some have taken that step, though, including University of North Carolina Health Care and Johns Hopkins.
One of the first to implement such as mandate was Loyola University Medical Center. A four-year study of the mandatory flu vaccination program there found that it did not lead to excessive voluntary termination.
It reports that "in the first year of the mandatory policy (2009–2010 season), 99.2% of employees received the vaccine, 0.7% were exempted for religious/medical reasons, and 0.1% refused vaccination and chose to terminate employment.
The results have been sustained: In 2012, 98.7% were vaccinated, 1.2% were exempted and 0.06% refused vaccination… Over the course of four years, fewer than 15 staff members (including volunteers) out of approximately 8,000 total chose termination over vaccination."
Whether or not a healthcare organization chooses to mandate the flu vaccine, Marx says it's still up to a hospital and its leadership to increase vaccination rates among employees.
"Vaccination rates vary widely based on leadership commitment," he says. Therefore, nurse and other leaders should role model annual influenza vaccination, and healthcare organizations should provide free vaccines and convenient access to them; doing so will make flu vaccination a "cultural expectation."
Marx also adds that hospitals should publicize vaccination campaigns with senior leadership, and "include the patient. They need to know what the hospital does to keep them safe."
A program that offers scholarships to students making a career switch to nursing opens up a world of opportunity not only for the students, but for the profession.
Nursing has traditionally been dominated by white women, but since 2008, a scholarship program from the Robert Wood Johnson Foundation and the American Association of Colleges of Nursing has been working to increase diversity in the workforce.
Now, as the New Careers in Nursing Scholarship Program enters its final year, it is yielding lessons for all nurse leaders about the kinds of nursing grads who make the profession more diverse and well-rounded.
"The reason this is important, of course, is because the population of nursing does not really reflect the population at large," says Polly Bednash, PhD, RN, FAAN, CEO of the American Association of Colleges of Nursing and program director of the NCIN. "We are now working very aggressively to have the number of people entering the profession look more like the population of the United States."
According to the U.S. Census Bureau, individuals from ethnic and racial minority groups accounted for 37% of the population in 2012, the AACN reports in a fact sheet about nursing diversity. But people from minority backgrounds represent just 19% of the RN workforce, according to a 2013 survey cited in the fact sheet conducted by the National Council of State Boards of Nursing (NCSBN) and The Forum of State Nursing Workforce Centers. Men are also significantly underrepresented in nursing.
"We need to have a nursing population that represents that same diversity," Bednash says. "That's how you get people the best care."
For instance, the AACN fact sheet cites an April 2000 report prepared by the National Advisory Council on Nurse Education and Practice, which found that "a culturally diverse nursing workforce is essential to meeting the health care needs of the nation and reducing the health disparities that exist among minority populations."
Since 2008, the NCIN program has distributed 3,517 scholarships to students at 130 different schools of nursing. The schools receive grants to support traditionally underrepresented students who are also making a career switch to nursing through an accelerated baccalaureate or master's degree program.
Each NCIN scholarship recipient has already earned a bachelor's degree in another field, and is making a transition to nursing through an accelerated nursing degree program, which prepares students to assume the role of registered nurse in as little as 12-18 months. In addition to the scholarship, the program also provides support to the students throughout their studies.
By targeting underrepresented students who already have bachelor's degrees enter accelerated baccalaureate or graduate nursing programs, the scholarship program not only increases nursing diversity, but also helps to advance the IOM's goal of having 80% of nurses hold a bachelor's degree by 2020. It also introduces into the workforce nurses who are focused, driven, and carry with them the experiences of past careers.
"The individuals who enter these kinds of programs are not just older. They have some life experience [and] have made a very conscience and purposeful career choice… which then commits them in a very different way to the profession," Bednash says.
These "new grads" also know what it's like to have a job and be accountable at work, she says. "We hear from employers that they like these graduates very much."
Bednash says these students make the switch to nursing from a wide variety of other professions, such as literature, biology, art, and psychology. One student owned a car dealership, and another was a ballet dancer.
"It's an enormously diverse group of people," she says.
Moreover, these students are taught and display leadership qualities, something that employers also appreciate, doing things like forming their own alumni group that helps its members with leadership development, Bednash says.
According to Bednash, most also have plans to earn advanced-practice degrees. She says that 20%-25% of the students enter the accelerated graduate program, and 75% of those in the baccalaureate program say they eventually plan to get a graduate degree.
A Senate bill calls for unit-by-unit staffing plans and publicly reporting those staffing plans, but stops short of dictating mandated nurse-patient ratios.
Federal requirements for unit-by-unit staffing plans and publicly reporting those staffing plans are at the heart of the newly introduced Registered Nurse Safe Staffing Act of 2014 (S. 2353), which stops short of dictating across-the-board, mandated, nurse-patient ratios.
Jerome Mayer, associate director, Department of Government Affairs at the ANA, tells me that the ANA isn't "directly opposed" to the kind of mandated nurse-patient ratios that California has in place and that some nurses in Massachusetts are fighting for (and against).
"But we think we have a more pragmatic approach," which is outlined in the new legislation, Mayer says.
That approach does include staffing ratios, but they would be set by the nurses themselves and would vary by unit and even by shift.
The bill would require hospitals to establish committees that would create unit-by-unit nurse staffing plans based factors such as the number of patients on the unit, severity of the patients' conditions, experience and skill level of the RNs, availability of support staff, and technological resources.
One crucial part of the bill is that those committees would be required to that it consist of at least 55% direct care nurses. The rest of the committee can be made up of anyone else the hospital wants to appoint, from nursing administrators to physicians, and other stakeholders.
"If you don't give a simple majority to direct care nurses nothing's really going to change," Mayer says. "If you don't have some power behind the staff nurses…chances are it's not going to really work very well."
The committee would go unit by unit, and shift by shift, to determine the minimum number of nurses for each, and that ratio would be upwardly adjustable. The ANA would develop guidelines to help the committees set their staffing plans.
"There is a ratio but the committee sets it," Mayer says. "If you need to bump a couple more nurses on the unit you can do that."
Mayer says this legislation is driven by ANA-members who want better staffing, but avoids the "hard-line approach" of one-size-fits-all ratios because when it comes to nursing, one size does not fit all.
"What works in a rural hospital in my hometown [in North Dakota] may not be the same thing in an urban trauma center," Mayer says. "It allows flexibility and it also allows buy-in."
Although it might be possible for a committee to create an inadequate, slapdash staffing plan simply to comply with the rules, another critical aspect of the legislation is the requirement to publicly report the staffing plans.
"We as consumers of healthcare are getting smarter about the delivery of care," Mayer says. "If you're able to compare the staffing levels… you're probably going to go to the one that has a better ratio of nurses to patients."
If passed, the federal law wouldn't supersede any existing state legislation that's stronger, but would require other states and hospitals to come up to snuff.
Mayer admits that passing this or any legislation is a marathon, not a sprint. The bill was read twice on May 15th and referred to the Committee on Finance. No vote has yet been scheduled.
"It's a long process. Sometimes it takes a decade or more to get real movement," he says. "After the Affordable Care Act, I think healthcare has taken a backseat federally… there's not a lot of appetite for it."
But even though the legislation might not pass soon, doesn't mean that it's unimportant. Mayer says ANA's members always say that their top concern is adequate staffing.
"Just because it's a long uphill fight doesn't mean it's not one worth fighting," he says.
Moreover, there's no reason for hospitals to wait for a federal or state mandate to create the kind of committee and staffing plan that the legislation calls for. They can do it now.
"We encourage them to do something similar," Mayer says. "It's just not getting done."
Researchers hope to learn whether small sensors attached to patients can help identify those at risk for falls.
Up to 1 million people in the United States fall in hospitals every year, says Agency for Healthcare Research and Quality, and when they do, the effects can be far-reaching. Patient falls are not only a safety issue, but a financial one as well.
According to the American Nurse Today, "The average hospital stay for patients who fall is 12.3 days longer, and injuries from falls lead to a 61% increase in patient-care costs."
In addition, if patients injure themselves after falling and their hospital stay is longer, hospitals run the risk of not being reimbursed, says Cindy Rishel, RN, PhD, OCN, administrator of nursing research and practice for the University of Arizona Medical Center-University Campus.
Despite using a falls risk model to identify which patients were at risk for falls, Rishel says her organization's falls rate—considered to be a nursing-sensitive indicator—was all over the map.
"I'm continually looking at the quality data for the entire organization," she says. "Our falls rate was not where we wanted it to be… we [couldn't] seem to get consistent improvement."
Other things they'd tried hadn't worked much either, such as bed alarms, which the hospital currently uses. In fact, University of Florida research from November 2012 showed that using bed alarms doesn't decrease patient falls and related injuries.
"When the bed alarm goes off, the patient's already out of the bed," Rishel says. Other ways of monitoring the patient—such as via video camera—were deemed too invasive, disrupting what little privacy hospital patients have, she says.
Rishel knew something more had to be done. That's why the hospital is now piloting something that she believes is a first: Whether small sensors attached to patients can help identify who is at risk for falls.
The small, wearable Zephyr BioModule sensors continuously track patients' skin temperature, physical activity, heart rate, respirations, and echocardiogram readings. More than 2 gigabytes of patient data is collected daily per sensor, and that data is then plotted against an algorithm that estimates fall risk.
"What it's measuring is motion in the patient, and it can tell us when the patient's at rest [or] when the patient is staring to move," Rishel says, adding that the sensors are very lightweight, attach to the patient with a regular electrocardiogram electrode attachment, and can be worn in the shower.
"The only thing the nurse has to do is… change it every 24 hours," she says.
The pilot began in September 2013, and will continue through September of this year. So far, 43 patients in the hematology/oncology unit have worn a sensor, and the researchers hope to get 100 patients to wear it by the time the pilot ends.
Rishel is one of the study's principle investigators, along with Bijan Najafi, PhD, M.Sc., University of Arizona associate professor of surgery, medicine and engineering, and director of the interdisciplinary Consortium on Advanced Motion Performance, or iCAMP. The manufacturer, Zephyr Technology loaned the hospital the sensors and other technology needed for the study, and other costs and staff are being provided by iCAMP.
Although the pilot is still underway, Rishel says early the data show promise.
"Early indications are in the few that have fallen you do see a pattern change," she says. "You see it on the data grab. You can see a change in the position of the patient from a supine to a prone position," for instance.
Although this part of the study is just for collecting data that might correlate patient activity with falls, Rishel says they hope to eventually expand the pilot to start alerting nurses when a fall seems about to happen.
"If we see this correlation in the data and the falls, we can link [the devices] to the phones that the nurses carry," she says. "We think it's going to prove that it's worth expanding this out."
The hospital might also expand risk assessments to include other factors that might indicate an increased falls risk, and make other changes based on the pilot data.
Rishel says that the pilot not only holds potential for the hospital and patients, but for nursing care, too.
"The nurses on the unit have been very supportive," she says. "They're very excited by the possibilities."
Nursing leaders at a Florida hospital finally found an infection control method that helped arrest a stubborn problem with hospital-acquired infections. It took them 20 years.
But a bundle of infection control interventions including hand-hygiene initiatives, multidisciplinary taskforce meetings, and isolation and cohorting "didn't really make much of a dent in the situation," Elizabeth Davidson, R.N. M.S.N., nurse manager of the surgical intensive care unit at JMH.
But after 20 years of trying different things, something unexpected finally worked: Weekly emails to the C-suite.
Between January 14, 2011, and March 30, 2012, Luisa S. Munoz-Price, MD, Jackson Memorial's medical director of infection control, sent weekly emails to the hospital leadership, including the C-suite of the hospital, the Quality and Patient Safety Division, and the nursing and medical directors of inpatient units, according to the study published in the American Journal of Infection Control.
"She was looking for a different way to attack the problem and get upper-level management involved," Davidson says. "She was trying to get a multidisciplinary approach in which there was accountability. That's why we had to reach out to the upper-level management."
The emails described and interpreted the findings of the preceding week's bundle of interventions; relayed the number and location of new carbapenem-resistant A. baumannii acquisitions; and described environmental findings, including culture results and ultraviolet markers (as indicators of cleaning).
The emails also included maps of the units showing the location of carbapenem-resistant A. baumannii-positive patients and objects, as well as weekly action plans, according to the study.
"They would give us a roadmap of how the bacteria was moving through our unit," Davidson says. "It was more specific. Instead of just talking about infection in your unit in general, we would pin it down to specific patients."
'We Were the Culprit' Davidson says the data and action plans would trickle down from the leadership, adding that charge nurses had print-outs of the emails in their hands at all times, and used them every day to pre-plan things such as patient placement within the unit.
They also shared the email contents with the staff. For instance, the maps and culture results showed not only how the infection was spreading but who was spreading it. Although representatives from hospital wouldn't tell me whether anyone was fired for failing to clean properly, they did say that individuals were spoken to about their performance and appropriately disciplined, when needed.
"You could definitely make the connection that we were the culprit," Davidson says.
Starting with the C-suite made everyone more accountable, and sharing the infection information with staff helped them see how they personally were helping to prevent infections by performing certain interventions, such as completely wiping down surfaces. The environmental workers took the information especially seriously, Davidson says.
"We shared everything with them and they saw the rates drop… that momentum went a long, long way to convince people," she says. "If they believe that, that's true, if they believe that those interventions are making a difference, they're much more likely to carry them on."
Nurses and others did see the infection rates drop. According to the study, as of December 2013, the number of new acquisitions of carbapenem-resistant A. baumannii was down to one per month hospital wide, even after the weekly emails stopped.
Researchers examined data from an infection control electronic database from before, during, and after the study period (representing a total of 42 months) and found that there were 198 new infections during the 13-month period before the emails started, 168 in during the 14-month that the emails were being sent, and 72 in the 15-month period after the emails stopped.
'A Striking Decrease' in Infection Rates According to the study, the emails stopped because "there were only scattered weekly acquisitions to report."
Other data, such as readmissions and money savings weren't addressed in the published study data.
"Weekly electronic communications were associated with a striking decrease in the rate of new acquisitions of A. baumannii at our institution probably because of a combination of education, communication, feedback, and peer pressure," the study says. "As brought up by one of the reviewers of this paper, this article is more management than science and entails organizational culture change."
The culture change aspect of the study results has been evident among nurses. For instance, having the weekly emails and directives from the hospital leadership helped nurses on the unit speak up if they saw someone doing something dangerous for infection control, such as failing to wash their hands or not cleaning the patient rooms properly.
"The nurses became very, very territorial about their patients," Davidson says. "They would really have zero tolerance for a physician, perhaps, that would violate any kind of infection-control practice. They also got much pickier about their rooms being cleaned."
It became acceptable and even expected for nurses to call their managers and request that someone from environmental services to re-clean a room that wasn't up to snuff. They weren't afraid to tell physicians to take off their lab coats or wash their hands before examining a patient, says Laura Harris, RN, BSN MS, Director of Critical Care at Jackson Memorial Hospital.
"It's almost like it became OK to say something out loud to someone, to hold someone accountable. That's not easy to do," Harris says. "It became easier the more people that did it."
Harris adds that Davidson was very vocal herself and set the example for staff nurses to have these kinds of conversations, too.
See how Cleveland Clinic, Johns Hopkins Hospital and other top hospitals are recognizing nurses this week.
National Nurses Week (May 6-12) is upon us, and hospitals across the country are taking a few days to recognize their biggest—and arguably most important—team of caregivers. I reached out to some of the country's top academic and community hospitals to find out how they were celebrating and recognizing their nurses this week. Here's a look:
Cleveland Clinic, Cleveland, OH Cleveland Clinic's Executive Chief Nursing Officer K. Kelly Hancock, MSN, RN, NE-BC, says via email, "We are proud to honor our 12,000 Cleveland Clinic nurses for making a difference in our patients' lives and helping us deliver on our mission of patients first."
Among the Cleveland Clinic's scheduled events:
Town Halls held throughout the enterprise by all CNOs, including Hancock at the main campus
Discounted tickets to the May 6 Cleveland Indians vs. Minnesota Twins game, with a Cleveland Clinic RN throwing out the first pitch
Awards ceremonies, including the announcement of the 2014 Nursing Excellence Award Winners
Blessing of the Hands throughout Cleveland Clinic hospitals
Appreciation breakfasts, luncheons, dinners, and desserts delivered to units on all shifts
$5 gift cards from Panera Bread to all Cleveland Clinic nurses
External and internal text-to-win campaigns. Participants can text "Nursesrock" to 28748 for a chance to win an iPad mini and automatically be opted in to receive regular text updates from Cleveland Clinic Nursing.
Reflexology, aromatherapy, and reiki sessions
A media campaign using digital billboards, advertorials, and radio commercials to thank nurses
The Johns Hopkins Hospital, Baltimore, MD
"For Nurses Week, we are having fun at three different events," Karen Haller, PhD, RN, vice president for Nursing and Patient Care Services at The Johns Hopkins Hospital, says via email. Johns Hopkins Hospital will:
Provide tickets and bus transportation on May 7 and 8 for nurses to attend a film premiere of The American Nurse: Healing America, which features Naomi Cross, one of the hospital's own nurses
Host 1,500 for a bullpen party and ballgame at Orioles Park on Friday
Host the Tenth Annual Hopkins Nursing Charity Golf Outing at Hayfields Country Club on Monday, May 12
Massachusetts General Hospital, Boston, MA
"Each year, Massachusetts General Hospital has a week-long program of offerings for our nurses and nursing students," according to MGH's special projects manager, Georgia W. Peirce.
This year, the events include research posters on display all week, a special interactive research poster session during Research Day, and the presentation of nursing research awards. There's also a series of lectures, a staff nurse breakfast, and a high tea.
MGH will also unveil a new portrait of Linda Richards, America's first trained nurse.
"She was the third superintendent of the Boston Training School at MGH, one of the first three nursing schools established in the US that followed the Nightingale system," Peirce says.
Memorial Sloan Kettering Cancer Center, New York, NY
"Each year, Memorial Sloan Kettering Cancer Centerrecognizes nursing excellence at the Samuel and May Rudin Awards ceremony held during National Nurses Week," media associate Andrea Baird, says via email. "The awards are sponsored by the Rudin Family Foundation and honor excellence in nursing practice, leadership, education, research and patient care." Other events include:
Celebratory breakfasts and lunches held throughout the week in all MSK locations throughout NYC and at our regional sites.
A guest speaker, Mark Lazenby, PhD, RN, AOCN of Yale University, will deliver a special presentation on spirituality in palliative and cancer nursing on May 9
A remembrance service paying tribute to MSK nurses past and present on May 6
Mayo Clinic, Rochester, MN
"Mayo Clinic is celebrating nurses week is by giving all of our nurses a free copy of the new book "The Nurses of Mayo Clinic: Caring Healers" by Arlene Keeling, PhD, RN, FAAN," says spokesperson Alyson M. Gonzalez. "The book covers the past, present and future of nursing at Mayo Clinic…The author is also visiting our campus next week to give presentations to our nurses on the book and its contents."