Post on 27-Jul-2020
Learn It, Lead It, Live It: Strategies to Refocus on the Fundamentals of
Nursing CareKathleen Vollman MSN, RN, CCNS, FCCM, FCNS, FAAN
Clinical Nurse Specialist, Educator, ConsultantADVANCING NURSING LLC, Northville MI
kvollman@comcast.net
©ADVANCING NURISNG LLC 2019
Disclosures for Kathleen Vollman
• Consultant-Michigan Hospital Association Keystone Center
• Subject matter expert for CAUTI and CLABSI, HAPI, C-Diff and Sepsis for CMS/HIIN
• Consultant and speaker bureau:– Sage Products now a business
unit of Stryker– Eloquest Healthcare– Urology division of Medline
Industries– Baxter Healthcare Advisory
Board
Objectives• Describe the forces within the current health care
environment that are driving the need resuscitate the basics with evidence to create a safer patient environment
• Compare and contrast the different tools and techniques to create a culture driven by the evidence where nurses feel empowered to engage & own their own practice
• Discuss measurable outcomes to determine a successful culture change & an early adopter environment of new information
Patient Safety in the EU: Harm Facts
• WHO states patient harm 14 leading cause of global disease burden
• 1 in 10 patients are harmed at one point during their treatment• Variation in level of surveillance of patient safety issues by
country• If EU reduced AE’s through safety initiatives
• 750,000 less harm events• 3.2 million fewer hospital days• 95,000 fewer deaths
• ½ the patients in Europe think they could be harmed by hospital care
• US has saved 28 billion between 2010-2015 thru safety prevention
.OECD, The Economics of Patient Safety, March 2017 https://www.oecd.org/els/health-systems/Theeconomics-of-patient-safety-March-2017.pdf Eurobarometer, Special Eurobarometer on Patient Safety and Quality Care, 411/2014OECD, The Economics of Patient Safety: Strengthening a value-based approach to reducing patient harm at national level, March 2017
Understanding The Journey
NursingOrganizations
• How many nurses went into the profession with the belief they could help people and be able to make a difference?
• How many nurses graduated from nursing school with a somewhat clear understanding of the skills and interventions used by the profession to achieve quality nurse patient outcomes?
• How many nurses still feel the ability to make a difference and understand what nursing uniquely contributes to quality patient outcomes?
That’s not the way we do it here!!!
What is a Culture?
Represents a set of shared attitudes, values, goals, practice & behaviors that makes one unit distinct from the next
Pronovost, PJ et al. Clin Chest Med, 2009;30:169-179
Driving Components in a Work Culture
Reasons for Confusion & Disillusionment in Nursing
A narrow definition of health How we define autonomy Nursing’s unique contribution Absence of recognition for basic nursing care
activities
Vollman KM, Stewart KH. AACN Clin Issues. 1996;7(2):315-323.
A
Narrow
Definition
of
Health
Medicine’s Health Definition
The absence of disease and measured in terms of morbidity and mortality
Nightingale’s Health Definition
Health is not only to be well but to be able to use what ever power we have.
Wellness & IllnessWellness & Illness
Wellness is comfortable somatic sensations accompanied by optimal functional ability whether we have a disease or not
Illness is uncomfortable somatic sensations or a decreased functional ability whether we have a disease or not
Autonomy
Means the self-directed diagnosis & treatment or it is a self determined and controlled action that does not require authorization from another
Confusing Autonomous Scope of Practice
Setting Judgments
AutonomousNursingScope of Practice
MedicalNursingScope of Practice
Florence Nightingale …
An expert in nursing’s autonomous scope of practice
Surveillance & monitoring of patient conditions for early detection of problems
Preventing complications
“I use the word nursing for want of a better. It has been limited to signify little more than the administration of medicines and the application of poultices. It ought to signify the proper use of fresh air, light, warmth, cleanliness, quiet, and the proper selection and administration of diet—all of these at the least expense of vital power to the patient”
Notes on Nursing (1860/1969 p. 8)
Florence Nightingale on:
The distinction between disease and illness
“… so deep-rooted and universal is the conviction that to give medicine is to be doing something or RATHER EVERYTHING; to give air, warmth, cleanliness, etc., is to do nothing.”
(emphasis added) Notes on Nursing, (1860/1969, pg. 9)
Self Directed Treatment Categories for Nursing
Hygiene-related activities Nutrition-related activities Elimination-related
activities Comfort-related activities Movement-related
activities Rest/activity relate
activities Learning and
development-related activities
Safety-related activities
Sense of normalcy-related activities
Interaction-related activities
Coping-related activities Physical environment-
related activities Alteration in ADL-related
activities
Recognition & Reprimand Structures within Acute Care Settings
• Recognition• Physiologic assessment • Completing medical treatments in a timely
fashion• Assisting physicians with activities
• Reprimand• Medication administration• Questioning content of medical orders
Behavior that is recognized and reinforced continues
Behavior that is ignored or not reinforced does not continue
Missed Nursing Care
• Any aspect of required patient care that is omitted (either in part or whole) or significantly delayed.
• A predictor of patient outcomes• Measures the process of nursing care
Kalish, R. et al. (2012) Am Jour Med Quality, 26(4), 291-299.
Hospital Variation in Missed Nursing Care
Kalish, R. et al. (2012) Am Jour Med Quality, 26(4), 291-299.
Outcomes of Missed Nursing Care: A Systematic Review
• 14 studies connecting missed nursing care with at least 1 patient outcome• Patient Satisfaction ↓ • Lower quality of care reported by nurses with greater missed care • Clinical Outcomes
• Medication errors• CLA-BSI’s• Pneumonia• UTI’s• Pressure Injuries• Falls• Failure to rescue
Recio-Saucedo A, et al. J of Clin Nurs. 2018;27:2248-2259
5 nurse sensitive adverse events in 22 med-surg units added
1300 additional hospital days for 166 patients &
$ 600,000 in excess costs
Tchouaket E. JAN. 2017;73:1696
Reasons for Missed Nursing Care
Kalisch, BJ, et al. American Journal of Medical Quality. 2011; 26(4), 291–299Ball JE, et al. BMJ Quality and Safety 2014 Feb;23(2):116-25.
9.4% variance in missed nursing care
Qualitative Review• Interruptions/multitasking/task
switching• Fatigue & physical exhaustion• Cognitive biases• Lack of patient & family
engagement• Lack of physician resources• Leadership issues• Moral distress & compassion fatigue• Documentation load• Large proportion of new nurses on
unit• ComplacencyPractice environment correlates to missed nursing care
Rationing Care-How we Prioritize
• Highest priority activities for nurses• Those which are likely to have an immediate negative
impact• Administering meds• Medical directed treatments• Procedures-wound dressings, labs
• Lower priority activities for nurses• Those which show no immediate negative harm
• Ambulation• Oral hygiene• Emotional support• Teaching
Bail K, et al. International Journal of Nursing Studies. 2016;63:146-161
Rationing contributes to functional and cognitive decline
Bail K, et al. International Journal of Nursing Studies. 2016;63:146-161
Fundamentals of Care Framework
The Fundamentals of Care Framework. Reprinted from Conroy, Feo, Alderman, and Kitson (2016)
• Fundamental care involves actions on the part of the nurse that respect and focus on a persons essential needs to ensure their physical & psychosocial wellbeing.
• These needs are met by developing a positive & trusting relationship with the person being care for as well as their families/carers
Feo R, et al. J of Clin Nurs. 2018;27:2285-2299
Patient Perceptions of Missed Nursing Care
Kalisch, B et al. (2012). TJC Jour Qual Patient Safety,38(4), 161-167.
Reconnect With Our Professional Purpose
“It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm.”
Florence NightingaleNotes on Hospitals: 1859
Advocacy = Safety
Protect The Patient From Bad Things
Happening on Your Watch
Interventional Patient Hygiene
• Hygiene…the science and practice of the establishment and maintenance of health
• Interventional Patient Hygiene….nursing action plan directly focused on fortifying the patients host defense through proactive use of evidence based hygiene care strategies
Incontinence Associated Dermatitis Prevention
Program
INTERVENTIONAL PATIENT HYGIENE(IPH)
Oral Care/ Mobility
VAP/HAP
Catheter Care
CA-UTI CLA-BSI
Skin Care/ Bathing/Mobility
HASISSI
Patient
Vollman KM. Intensive Crit Care Nurs, 2013;22(4): 152-154
Falls
PATIENT
CLEAN GLOVES
CLEAN GLOVES
HAND HYGIENE
HAND HYGIENE
INTERVENTIONAL PATIENT
HYGIENE(IPH):The Physical
Fundamentals of CareOral Care/
Mobility/Comfort
VAP/HAP
Medication Management
CA-UTI CLA-BSI
Skin Care/NutritionBathing/Mobility
SSI
Patient
Vollman KM. Intensive Crit Care Nurs, 2013;22(4): 152-154
PATIENT
CLEAN GLOVES
CLEAN GLOVES
HAND HYGIENE
HAND HYGIENE
VTECatheter Care
Falls
HASI
SSI
Adverse Drug Events/
Medication Errors
Norway’s National Patient Safety Campaign 2014-2018
• Aims were to: 1) reduce patient harm, 2) build sustainable structures for patient safety and 3) improve patient safety culture. • Falls• Urinary tract infections• Central line infections• Pressure injuries• Safe surgery/postoperative infections• Stroke treatment, • Prevent overdose and suicide• Medication reconciliations, drug review in home care and in
nursing homes
Lund J. 9th European Public Health Conference: Parallel Sessions in 2017
• Reduce incidents of harm by 25% from 2012 until 2019
• Increase 30-days survival after hip fracture by 2%
• At least 80% of respondents from health units will report a ripe patient safety climate.
Lund J. 9th European Public Health Conference: Parallel Sessions in 2017
Attitude &
Accountability
Factors Impacting theability to Achieve QualityNursing Outcomesat the Point of Care
Achieving the Use of the Evidence
ValueVollman KM. Intensive & Critical Care Nursing, 2013 Oct; 29(5): 250-5
Patient Advocacy/Safety Related to Clinical Practice
• Nurses knowledge of the Evidence based care• Ability to deliver the care to the right patient at the right time,
every time it is needed• The ability to communicate patient concerns in a concise,
data driven manner and take appropriate action• Understanding the chain of command when faced with
resistance and that we are the patients voice
Communication Strategies
• Tools to help structure communication• SBAR for communication with Doctors: Situation,
Background, Assessment and Recommendation• CUS Words: I am Concerned, I am
Uncomfortable, This is not Safe
Use CUS words when assertion of your communication fails…things go wrong…concern expressed but mutual decision not reached or proposed action doesn’t happen in time frame agreed upon
What Supports Our Ability to Advocate & Use the Evidence?
• Leadership support• Evidence-based knowledge• Experience• Effective communication• Respectful communication and being respected
• Goes both ways• If we as nurse don’t know or believe something different than
the doctors order what should we do?• Understanding that it’s worth it!!!!!
Understanding The Journey
Nursing Organizations
Culture Assessment is Critical
Assessment of Safety & Work Culture-Organization & Unit
• SAQ (Safety Attitudes Questionnaire)• Teamwork• Safety• Working conditions• Job satisfaction• Stress recognition• Perception of upper management• Perception of unit management
Strive for 80%, if < 60% SAQ scores correlates to decreases in clinical outcomes
AACN Healthy Work Environment Assessment tool-Unit Level
• Skilled communication• True collaboration• Effective decision making• Appropriate staffing• Meaningful recognition• Authentic leadership
Health Care QualityDonabedian Framework
STRUCTURE PROCESS OUTCOME
Having the right things in place
Doing the right things
Having the right things happen
Quality of care is represented by an entire systemic integration from structure to process and to outcome,
but not by one or the other independently
Organizational & Unit Structures that Supported the Empowerment
Shared Governance Model
Continuous Quality Improvement Model
Professional Practice Model/Clinical Ladder
Unit Based Leadership Model
Educational Support
Foundational Principles to Maximize Staff Empowerment
• Share Governance = Shared Leadership of Practice/Ownership
• Shared governance is a structural model that frames the professional practice within health care settings (Porter-O'Grady, 2012).
• Shared governance empowers nurses to participate in decision making, nursing practice, and development of nursing policies (Bednarski, 2009).
Foundational Principles to Maximize Staff Empowerment
• The Unit is the center of a shared governance model..the locus of control is at the point of service
• Staff need mentoring and leadership coaching• Shared leadership means the clinical and administrative
lead of the unit are part of the unit practice/governance council
• Defined accountability of all members• Sufficient time in meetings to formulate ideas and plan
work (unit meeting 4hrs)
One of the reasons people don’t achieve their dreams is that they desire to change
their results without changing their thinking
John C. Maxwell
Structure:Collaborative Practice Teams
CPT: Collaborative Practice Teams have responsibility for the different performance measures, P4P, VBP
Example Structure:Unit Based Accountability Teams
• Every patient care unit in hospital or group practice• Composition: Medical Director, Nurse manager, Clinical
Nurse Specialist, System Performance Improvement Leader
• Responsibilities:• Establish clinical/quality goals for unit• Responsible for unit outcomes---unit dashboard
• Clinical and operation measures• Quality• Patient Safety and safety culture• Patient satisfaction• Employee satisfaction
Helpful Hints to an Empowered Practice
• Encourage staff to be a part of unit governance council or on projects or task forces to solve clinical issues with the evidence
• Start up a journal club or participate…help them learn to read evidence
• Strategies to impact value of practice
Strategies to Impact Value Structure
• Patient Care Conferences
• Role Modeling
• Bedside Consultation
• Unit Process Improvement Projects
Patient Care Conferences
Medical FocusNursing Therapeutics
Nursing Rounds Format
1) Brief Medical History: Past history, reason for admission, stable/unstable
2) Pulmonary: Secretions/type and amount, single use or in-line catheter, ability to tolerate repositioning, assess need for continuous lateral rotation therapy and/or the prone position, assessment of functional readiness to wean
3) Psych/Coping: Assess for agitation/ Dx of anxiety, pain and/or delirium, safety issues, sleep/rest pattern, use of diversional activities, Dx of powerlessness
4) Family: Coping, support systems, discussion of code status, evaluation of home environment/discharge needs
5) Activity: Physical therapy needs, activity/exercise schedule, prevention of contractures
Purpose of the Rounds Format
Impact care practices that prolong LOS or create complications
Reinforce Ownership of nursing practice
As a Nursing practice reward structure
To enhance continuity of care
To build intellectual confidence
Strategies to Impact Value Structure
• Patient Care Conferences
• Role Modeling
• Bedside Consultation
• Unit Process Improvement Projects
Bedside Consultation:
Creating the
Ah-hah
Experience
Teaching Pathophysiology & Clinical Decision
Making Skills
bedside consultations self study
modules
Unit Process Improvement Projects
CNS/APRN guidance
Staff designed, implemented & evaluated
Develops sense of ownership, pride & accomplishment
Clinician and Financial Outcomes
It Takes a Village
Measurement is Key
Nurse Sensitive Care Indicators
• Death among surgical patients with treatable serious complication
• Pressure ulcer prevalence• Falls prevalence• Falls with injury• Restraint prevalence (vest
& limb only• UTI rate/ICU• Blood stream infections
(BSI) from invasive catheters (ICU and high risk nursery)
• Ventilator-associated pneumonia (VAP and high risk nursery)
• Smoking cessation for AMI
• Smoking cessation counseling for heart failure and pneumonia
• Skill mix• Nursing care hours per
day• Voluntary turnover• Nursing Environment
IndexNursing Quality Forum 2004
Additional Measures
• Non-ventilator hospital acquired pneumonia• Employee satisfaction• Retention of qualified experience staff• Staff Empowerment
• Culture and healthy work environment tools• Participation in process improvement & committees• Presentations-posters and podiums• Actively engaged in problem solving
DO NO HARM
Advocacy Starts with Us