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Notable Nursing: Fall 2012

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Professional Practice Model Sets Foundation for Exemplary Care

On a busy evening in the emergency department at Cleveland Clinic’s Hillcrest Hospital, someone visiting a family member suddenly experienced stroke-like symptoms. “Without notice, ED nurses responded immediately and began to care for this patient in an organized, efficient manner,” recalls Melissa Richardson, BSN, RN, the hospital’s Primary Stroke Center Program Manager. “They demonstrated clinical expertise while also supporting the emotional needs of the patient and family.”

A framework for ideal practice

Those ED nurses exemplify the Zielony Nursing Institute’s Professional Practice Model, which was designed to resonate with the 11,000-plus nursing professionals at Cleveland Clinic. It’s a meaningful model for everyone from ambulatory to critical care nurses. “Nursing is a complex profession that deals with the physical, mental, emotional and spiritual aspects of each person served,” says Cynthia Candow, BSN, RN, CMSRN, Clinical Instructor for Regional Hospitals. “The Professional Practice Model framework unites nurses so all of us are caring for people specifically and intentionally.”

The model, titled “Nursing Practice Model: Colleagues in Care,” is an amalgam of theories, with the greatest emphasis on the following concepts:

  • Relationship-based care, as championed by Marie Manthey, MNA, FRCN, FAAN, PhD (hon)
  • Thinking in action, as advanced by Patricia Benner, PhD, RN, FAAN, FRCN
  • Systems thinking and serving leadership, as advocated by Peter Senge, PhD, and Ken Jennings, PhD

At the center of both the model and its schematic depiction (see above) is Cleveland Clinic’s guiding principle: Patients First. The outer rim, representing the theories listed above, provides the unifying frame for practice, and the four inner quadrants describe the practice elements:

  • Quality and patient safety
  • Healing environment
  • Research and evidence-based practice
  • Professional development and education
Strategies for Spreading the Model

Cleveland Clinic’s Zielony Nursing Institute has adopted several methods to make sure nursing professionals understand the Professional Practice Model. One of the most effective is a two-hour interactive workshop taught by Cindy Willis, MSN, MBA, RN, Senior Director of Nursing Education, and Cynthia Candow, BSN, RN, CMSRN, Clinical Instructor for Regional Hospitals. So far, nearly 300 people from a variety of units at six Cleveland Clinic hospitals have participated.

The workshop begins with an introduction to the theorists behind the Professional Practice Model and an explanation of its history. Then participants work in small groups, answering questions about why they entered nursing and whether they are living out their dream. “The simple act of examining why nurses are in the nursing profession ignites a light,” says Candow. Nurses discuss the attributes they bring to nursing and how those attributes — and their related actions — coincide with the four quadrants of the Professional Practice Model. The final activity features a case study with a poor outcome. Nurses identify the breakdown, aspects of the model that were affected and how the breakdown influenced patient outcomes.

Willis, who has been a nurse for 33 years, sees the benefit of the workshop for participants as well as herself. “I have a renewed sense that we are all here for the right reasons,” she says. “I’ve become energized listening to staff nurses say they are living the dream.”

Other didactic tools associated with the Professional Practice Model include:

The Colleagues in Care toolkit, which comprises several pieces to help implement the model using the health system’s staffing model. Included are an overview brochure, leadership discussion guide and role summaries for everyone from chief nursing officers to case managers.

Cleveland Clinic Learning Center educational modules (“What is a Professional Practice Model, and How is it Different from a Care Delivery System?” and “Nursing Practice Model: Colleagues in Care”) that detail the model’s principles. Nursing professionals can access these on Cleveland Clinic’s Intranet.

The Professional Practice Model video series, featuring six videos, including four devoted to the practice elements of each of the model’s four quadrants (see main text).

Theorist learning tools (for four theorists) with examples of how the individual theory fits into the Professional Practice Model. Units display a poster board and representatives educate nurses, as needed.

Modeling relationship-based care

James Middleton, MSN, MBA, RN, was part of a team of nurses who defined the foundational principles for the Professional Practice Model early after its development. As Nursing Director for Cleveland Clinic’s Respiratory Institute and Head & Neck Institute, he views the model as the guiding force for nursing practice. “I see it as a picture frame that surrounds everything we do,” Middleton says, “and our nurses are inside the painting, creating the artwork itself.”

He cites a recent initiative in the medical intensive care unit (MICU) on Cleveland Clinic’s main campus. The MICU nurses implemented 6 a.m. and 6 p.m. phone calls, at the end of nursing shifts, to MICU patients’ family members to update them on how their loved one was faring. The aim was to build relationships with families and provide communication on a predictable basis in recognition of how exhausted family members often become. “At first, nurses were hesitant about what they could and couldn’t say on the calls,” Middleton says, “but they really developed autonomy and their own communication styles with families. It has truly cemented the relationship between nurse and family members. Families fully embraced and appreciated the phone calls. It’s a clear example of relationship-based care steering practice, and it is now being considered for application as a best practice across the health system.”

Similarly, relationship-based care is at the heart of an initiative called “Take 5” implemented by nurses in the pediatric unit at Cleveland Clinic’s Fairview Hospital. Nurses are urged to take five minutes early in their shift to sit down with each of their patients’ families to discuss, face to face, their goals for the day. In one of those sessions a mother said, “I’d like my baby to be able to sleep and rest well today.” In response, the nurses rearranged the schedule for measuring the baby’s vital signs so that it took place after the baby breastfed. The baby was able to rest peacefully, and the mother was very grateful. “Sitting down with the patient or family sends an important message that they and their goals are important to us,” says Nancy Dorenkott, BSN, RN, CPN, who works on the unit.

Exemplifying other key concepts

In addition to relationship-based care, two other main theories behind the model — serving leadership and thinking in action — are on display daily across Cleveland Clinic. As Senior Director of Nursing Education, Cindy Willis, MSN, MBA, RN, facilitates many educational programs. “I see the cream of the crop among our nurses, and I realize that they have honed their skills through our education department,” she says. “We plant the seeds that allow nurses to practice at different levels.” Willis and other educators act as serving leaders through professional development.

In turn, ongoing education helps nurses think in action. “Critical thinking is at the center of the nursing process, which is the foundation of our practice,” says Middleton. “But we are always continuing to develop and fine-tune our critical-thinking abilities, and that’s especially important for novice nurses.”

When Amy Galassi, BSN, RN, was approached about becoming a summer science intern mentor and co-investigator on a research project, the perioperative services nurse at Hillcrest Hospital was hesitant. “I didn’t know anything about research!” says Galassi. “But I seized a great opportunity to grow professionally.” She attended an evidencebased practice workshop and Cleveland Clinic’s annual Nursing Research Conference. “Now I am eager to help co-workers understand and use research to discover the evidence behind our nursing practices,” says Galassi.

As the Professional Practice Model is implemented across Cleveland Clinic, witnessing the framework in action may be the best way to demonstrate its significance to nurses. In addition, Cleveland Clinic uses diverse tactics to ensure that nurses understand the model (see sidebar). “We strive to get nurses to realize that the model is a shared vision of how nurses put patients first,” says Candow.

Helping nurses shine

As part of Hillcrest Hospital’s push to foster familiarity with the Professional Practice Model, nurse leaders asked nursing staff to share stories related to its implementation. “We’re trying to get our nurses to understand the model, look at the elements of all four quadrants and recognize what they do in their areas that fits,” says Sue Sturges, MSN, RN, Senior Nursing Director for Hillcrest Hospital.

Bev Kus, RN, shared an experience from the antepartum wing of the hospital’s family maternity center. One longterm patient seemed increasingly glum, so Kus arranged a mini-makeover to lift her spirits. “It was wonderful to see her smile after the beauty spa day,” says Kus. “It brought back how we need to see the entire patient — mind, body and spirit.”

Sue Sturges, MSN, RN

Sue Sturges, MSN, RN

Hillcrest Hospital is rolling out another idea to help nurses connect with the model. Each unit will display a trifold poster with the model in the center and its four practice elements listed on either side. Blank cards with headings from each practice element domain will be placed next to the poster. Nurses will be encouraged to write down examples of how they applied new research knowledge or highestlevel evidence from the literature, ensured patient safety or quality care, facilitated a healing environment, or received education or professional development. The cards will be attached to the poster for the rest of the unit to see.

“We want nurses to share their stories through the framework of the Professional Practice Model — to recognize that it represents the things they do every day,” says Sturges. “In most cases, there’s a nurse that shines.”

Immersion Program Helps New Nurses Recognize Patients’ Urgent Needs

Cleveland Clinic has created an intensive weeklong training program for recentgraduate nurses who need help making the transition from school to the bedside. As part of its new-hire orientation program, Cleveland Clinic uses the Performance Based Development System (PBDS) to assess all nurses. With PBDS, nurses view simulated video vignettes. They are then presented with a variety of clinical situations and asked to identify the best action to take in each situation.

‘Knowledge-rich but application-poor’

Since August 2011, nurses with PBDS scores that place them in a “Does Not Meet Expectations” category have been assigned to spend a one-week period in Cleveland Clinic’s immersion program. The program is held every three weeks, usually with 10 to 36 new nurses participating each time. “PBDS results have increased our awareness that nurses may need further assistance in recognizing signs and symptoms of disease presentations and, in some cases, signs and symptoms of urgent clinical situations,” explains Christine Szweda, MS, BSN, RN, Senior Director of Operations, Nursing Education.

Krause, BSN, RN

About 45 percent of recent-graduate nurses are sent through the immersion program. Although a few new nurses initially take exception at being asked to participate in the program, almost all quickly embrace the opportunity to bridge the gap between what they learned in school and the knowledge and skills they need to be successful at the bedside, says Julia Gorecki, MBA, BSN, RN, Director of Nursing Education – Competency and Assessment. “We provide nurses a 40- hour learning opportunity to demonstrate improvement in their ability to recognize patient problems and identify urgent situations,” Gorecki says.

“New nurses may arrive knowledge-rich but applicationpoor and need to learn to put it all together,” says Szweda. “A number of new nurses try to collect so much information from a patient that they cannot identify what is truly relevant. The program’s emphasis is solely on problem identification, not management.” For example, she says participants are taught to differentiate shortness of breath with a fever from shortness of breath with wheezing so they can identify the relevant symptoms to present to the physician. “We get a lot of positive feedback at the end of the program,” she adds. “We really see nurses begin to apply the knowledge they acquired in the program, and many participants are very appreciative.”

The program: Immersion in three key questions

The immersion program is highly standardized to deliver a consistent message and was developed in conjunction with the human resources department. Feedback given to nurses is documented extensively.

On the first day (Monday), nurses watch eight videos simulating patient scenarios. They participate in small groups of up to five nurses per clinical instructor.

Participants are asked three questions about each case:

  • What signs and symptoms do you see?
  • What problem do you think the patient is experiencing?
  • Does anything need to be done urgently for this patient?

Participants are then asked for the rationale for their answers. “We want to make sure they are not just making a guess but have thought through their response,” Szweda explains.

Cynthia Candow, BSN, RN, CMSRN, Clinical Instructor for Regionals Hospitals, facilitates this first day. She says the patients in each video have just one problem, and all signs point to it. Once nurses offer their theories, each group puts their answers on a flip chart and discusses them. “We let new nurses see how their diagnosis matches the history and signs and symptoms,” she explains. “This also gives the clinical instructor a perspective on where each nurse is and how to help them better assess their patients.” Candow adds that this first day is pivotal: “Nurses start to recognize that they need to be in the immersion program and that their clinical instructors very much want them to succeed.”

On Tuesday and Thursday, nurses spend time on medical/ surgical units reviewing patient reports and considering what should be their focus when they are in each room at the patient’s bedside, asking the same three questions that were part of the situations explored by video on Monday. After each patient visit, the group debriefs with the instructor.

Wednesday is spent in a low-fidelity simulation lab. Nurses examine six mannequins with clinical problems and again must answer the same three questions from the other days. “These same questions are asked over and over,” Szweda says. “It’s truly an immersion concept.”

Raising the Bar
The results

On Friday, for the final assessment, new nurses view 10 patient videos. Most are presentations of problems seen earlier in the week. “We expect nurses to answer at least seven of the 10 patient scenarios correctly,” explains Gorecki. “The hope is that our new nurses demonstrate that they’ve improved during the week. Our minimum expectation is that they recognize patient needs and determine whether they are urgent.”

Ninety-five percent of the approximately 350 nurses who have completed the program have been able to clearly demonstrate improvement during the week. Prior to the immersion program, 17 percent of nurses who scored poorly on the first PBDS assessment were still unable to recognize patient problems when they were reassessed toward the end of orientation. Since the immersion program has been introduced, less than 1 percent of nurses reassess this way.

Raising the bar

Nurse educators who run the program have been trying to determine if they can anticipate which new nurses will have problems with orientation. So far, there has not been a correlation between new nurses’ success in their jobs and attendance at a particular nursing school, attainment of a bachelor’s degree vs. an associate degree, grade point average or nurse gender. Hospital nursing educators have shared PBDS assessment findings with local nursing schools to help academic educators improve their nursing curricula.

Candow says nurses must be willing to reach for their untapped potential and that she loves helping them fulfill that potential. “We get a great picture of new nurse capabilities during the immersion program week,” she says. “Many nurses love coming and learning.” She adds that the program has raised the bar for nursing. “It’s not enough anymore to just fill out an application,” Candow explains. “This is one of the programs Cleveland Clinic is using to attract and keep the finest nurses available. Everyone benefits from it.”

Curbing Nonessential Use of Patient Restraints in the ICU

Sandy Maag and Myra Cook

When data on restraint use in Cleveland Clinic’s intensive care units (ICUs) showed that many units had prevalence above the National Database of Nursing Quality Indicators® (NDNQI) benchmark for hospitals with 500 beds or more, Sandy Maag, BSN, RN, and her team began developing a plan for improvement.

“Patients have the right to be free from restraints,” says Maag, Nurse Manager for Nursing Quality. “Restraints prolong patient stays and impact the patient’s dignity. We don’t want to use them unless they are needed for safety.” She notes that restraints can actually increase agitation and delirium, which ironically are two conditions that restraints are often used to manage. Restraint use is also associated with physical weakness (deconditioning) and an increase in the risk of pressure ulcer development.

At the end of 2010, Cleveland Clinic project managers trained in FasTrac™, a team-based, collaborative problemsolving process, initiated a 12-week project to develop a plan to improve restraint use scores. A committee of staff nurses, nursing management and clinical nurse specialists was enlisted, and the team received support from Stephen Davis, MD, Chair of the Department of Pediatric Critical Care and Director of ICU Operations, and Kelly Hancock, MSN, RN, NE-BC, Executive Chief Nursing Officer (who was Clinical Director of the Heart & Vascular Institute and Senior Director for the ICUs at Cleveland Clinic’s main campus at the time).

The committee began by contacting similar healthcare organizations to learn how they managed restraint use. Results were inconclusive; the committee was unable to identify significant best practices, as all large tertiary teaching organizations they contacted were struggling with the same issue. Following the FasTrac methodology, the group then outlined its “most wanted improvements” and focused on the items most important to their goal of reducing restraint use: family education through printed materials and clinical education through algorithms for ventilator liberation and restraint minimization.

Educating family

Two nurses — Kelly Clement, BSN, RN, in the pediatric ICU, and Laura Schenck, BSN, RN, CCRN, in the cardiovascular ICU — were charged with creating a brochure to educate patients’ families, as well as patients themselves, on restraint use. The brochure, which is given out in the ICUs, outlines what restraints are, why they are used and when they are removed. It also lists possible alternatives. The brochure includes tips on how family members can help ease the patient’s anxiety while he or she is receiving ICU care.

Educating clinicians: Restraint minimization algorithm

To make more informed decisions regarding optimal restraint use, nurses needed a tool to assess patients. Renee McHugh, MSN, RN, CCNS, and Malissa Mulkey, MSN, APRN, CCRN, CCNS, both members of the FasTrac team, developed an algorithm for just that purpose. Drawing on McHugh’s experience in the medical ICU and Mulkey’s experience in the neurological ICU (where there was a high level of restraint use), as well as on a literature review, they created a restraint minimization algorithm that focuses on determining the underlying causes of agitated patient behavior. Restraints are recommended within the overall treatment plan as a last resort.

“We wanted to focus on eliminating the behavior that causes the need for restraints,” Mulkey explains. “It is usually pain, delirium or anxiety. We knew we could work with nurses to assess and address these three factors.”

For each of the three factors, valid and reliable assessment tools were incorporated into the algorithm. Pain and anxiety assessment tools were already available to Cleveland Clinic nurses: the Nonverbal Pain Assessment Tool or visual (verbal) analog scale for pain, and the Motor Activity Assessment Scale for anxiety. After assessment, the algorithm guides nurses to administer pain medication as necessary and appropriate, consulting with pain management clinicians if needed. Nurses are also encouraged to consider complementary and alternative methods of relieving pain, such as imagery and massage. For anxiety, they are advised to determine if patients have chronic anxiety and need to be medicated or if they were on an anxiolytic agent at/before admission to the ICU. If patients are not being treated for chronic anxiety, nurses may consider an anxiolytic agent or use nonpharmacologic means to comfort and reassure patients, whether through music therapy, pastoral care or visits from loved ones.

The third assessment tool, the Confusion Assessment Method for the ICU (CAM-ICU), has been implemented in most ICUs to assess the presence of delirium. “Because patients can develop delirium from their environment (in addition to medications), nurses are encouraged to maintain patients’ circadian rhythms by keeping lights on during the day, making it dark at night and keeping clocks and calendars visible in rooms,” McHugh says. Soft music and minimal environmental stimuli also are recommended. Additionally, psychiatry consults and medication reviews may be undertaken, as appropriate.

Liberating patients from ventilators

One leading reason patients are restrained in the ICU is for their protection while intubated. Patients may try to remove their endotracheal tube or other catheters in close proximity once they become aware of them. To address the issue of self-extubation and promote earlier planned extubation, thereby minimizing restraint use, Myra Cook, MSN, RN, ACNS-BC, CCRN, and Sarah Kus, BSN, RN, FCCS, developed a ventilator liberation algorithm. The processes are driven by nurses and respiratory therapists, and stem from current research evidence reported in the literature, Cook explains.

The algorithm involves a “sedation vacation,” or spontaneous awakening trial (SAT) followed by a spontaneous breathing trial (SBT). During the SAT period, nurses turn sedation off to see if patients remain calm. For patients who pass the trial, an SBT can be performed to determine readiness for extubation. SAT and SBT trials can be performed on a daily basis until extubation is appropriate.

Cook says the ventilator liberation algorithm was rolled out as a template. The process was similar to what was already being practiced by ICU nurses, but the steps were not previously in writing. Formalizing steps into an algorithm made the process more structured and increased awareness of the trials and nurses’ roles in routine assessment. “A collaborative approach helped move the extubation process along more quickly,” Cook explains. “Nurses and respiratory therapists began to take a more active role.”

Restraint use down

In the wake of the overall project’s implementation, total restraint use in Cleveland Clinic’s ICUs declined by 38 percent from the fourth quarter of 2010 through the third quarter of 2011. “The numbers have gone down and stayed down,” Maag says. “Our restraint use in the ICUs has remained below the NDNQI benchmark. We have accomplished our goal and are working hard to sustain it. The assessment tools and algorithms are visible reminders of the need for ongoing processes.” Maag says her team expects to maintain the lower prevalence of restraint use by keeping awareness levels up.

The successes achieved with this project to reduce nonessential restraint use in ICUs at Cleveland Clinic’s main campus have led to its subsequent implementation in ICUs across the entire health system.

Nursing Clinical Ladder: Updates and Expansions Push Participation Up

A working group of nursing representatives from across the Cleveland Clinic health system spent nearly all of 2011 updating, standardizing and expanding Cleveland Clinic’s nursing clinical ladder, which has been in place since 2008.

The clinical ladder program recognizes the experience, knowledge and clinical expertise of nurses by bestowing professional titles and financial rewards in the form of lumpsum bonuses. Clinical ladders were being used in several different forms among individual hospitals in the Cleveland Clinic health system. The working group standardized the ladder for RNs and LPNs across the system.

Enhancements aligned with overall vision

The basic concept of the ladder remains the same, says Ann Dugan, MSN, MBA, RN, CNS, a nursing educator who helped facilitate revisions to the clinical ladder program, but it has been enhanced to better encompass the vision and values of the Cleveland Clinic Zielony Nursing Institute. Its objectives are to:

  • Promote excellence in practice to ensure quality patient care
  • Develop and recognize excellence in leadership
  • Maintain expert nurses at the bedside
  • Encourage ongoing personal and professional development
  • Facilitate career advancement
  • Support recognition and retention

The ladder has five levels of advancement for RNs and three levels for LPNs. For both RNs and LPNs, the ladder has four categories — clinical, education, community and leadership — in which nurses can earn points for qualifying activities and achievements. Modifications were made to the qualifying activities and achievements in each category, allowing nurses to have greater flexibility and options in qualifying activities in appropriate categories based on individual job descriptions.

One notable new requirement is that nurses must complete activities or achieve an outcome within each of the four categories to advance to the next level of the ladder. Previously, a nurse could achieve a higher level on the clinical ladder based on accumulated (overall) points and specific requirements for each level. “We want to encourage and acknowledge those who are well-rounded in their career,” explains Dugan. “We also want to recognize how nurses promote and advance the nursing profession through activities they are involved in, both at work and in the community.”

Participation climbing

The 2011-2012 clinical ladder participants were the first to use the new standardized ladder. Since the ladder program began in 2008, the number of nurses applying and being accepted into the program has steadily increased, with 430 RNs participating in 2011 and 922 in 2012. Even with the recent growth, Dugan says the working group continues to meet to make improvements to the program as necessary. For example, in 2012, the Nursing Institute placed greater emphasis on “nursing innovation and research” as part of its strategic initiatives. When revisions were made, the leadership category was reassessed to ensure that attention was placed on rewarding nurses for innovations.

Ann Dugan

Extending the ladder to care partners

One of the improvements made in the 2011 revisions was the decision to expand the ladder’s reach. Initially developed for just RNs and LPNs, the ladder has now been introduced in modified versions for patient care nursing assistants (PCNAs), health unit coordinators (HUCs), medical assistants and nursing informatics specialists.

Extending the clinical ladder program to nursing’s clinical and supportive/nonclinical care partners was a logical progression — “the natural next thing to do,” according to Nancy Kaser, MSN, RN, ACNS-BC, Senior Director, Nursing Education and Professional Practice. Kaser facilitated the creation of the clinical ladder program for HUCs in the fall of 2011.

“We were thrilled to be able to put this together,” Kaser says of the committee she oversaw. “HUCs are the gears that keep communication flowing and keep units running smoothly. The clinical ladder program provides welldeserved recognition for the contributions HUCs make.” She adds that it’s important that the program engage all levels of staff and promote interdisciplinary professional growth and development.

One in three HUCs applies

The clinical ladder program for HUCs was rolled out in the first quarter of 2012. About 100 of the nearly 300 HUCs across the health system submitted letters of intent to express interest in becoming eligible for the program. They had until the end of September to assemble portfolios for review. The portfolios contain information on college degrees, associations and activities that translate into points that then dictate where each HUC falls on the ladder’s four steps.

The HUC ladder mirrors the RN/LPN ladder, with tweaks to individualize it for HUCs’ distinct role. The same is true of the ladders for PCNAs, medical assistants and nursing informatics specialists, all of which were rolled out this year as well.

Useful for specialty-team RNs too

Karen Goda, ND, RN, a clinical information systems analyst in the Department of Nursing Informatics, says her department of about 20 employees, mostly nurses, began using the clinical ladder in 2010. At that time, informatics specialists took the clinical ladder used by RNs and “reframed it to more closely match our responsibilities, education and experience,” she explains. While nursing informatics RNs do not provide bedside care, they support the integration of data, information and technology into nursing practice. Based on feedback from the first-year recipients, Goda and her group recently revised their version of the ladder.

They use the same point system as clinical nurses but include some different categories based on their unique responsibilities. For example, nurses who receive certification training on the Epic electronic medical record system receive points, as do informatics nurses who serve as project managers for the department.

Goda says she and her department view the clinical ladder as a retention tool. Three department members qualified for the program the first year. Because of positive feedback from first-year participants, more applied the second year, and nine department members qualified. In light of the informatics team’s continued interest, Goda personally hopes the clinical ladder will soon be extended to additional nursing specialists, such as the Department of Nursing Informatics’ nurse liaisons at Cleveland Clinic Regional Hospitals.

Growth in APN Numbers Tracks Growing Roles and Satisfaction

Cleveland Clinic has dramatically expanded the use of advanced practice nurses (APNs) across its health system in the last few years. The organization’s approximately 150 APNs in 2004 have proliferated to more than 900 today, and they work in a wide range of settings, including inpatient and intensive care units, family health centers, surgical services, emergency services and critical care transport.

Nursing Growth Chart

Growth in advanced practice nurses (APNs) on Cleveland Clinic’s main campus. See text for acronym expansions.

“We are using APNs across all areas,” says Meredith Lahl, MSN, PCNS-BC, PNP-BC, CPON, Senior Director of Advanced Practice Nursing. The largest group is certified nurse practitioners (CNPs or CRNPs), who represent about two-thirds of APNs at Cleveland Clinic, followed (in order) by certified registered nurse anesthetists (CRNAs), clinical nurse specialists (CNSs) and certified nurse midwives (CNMs).

Lahl attributes the growth in APN numbers to several factors. One is that Cleveland Clinic offers many opportunities for APN students to complete clinical practicums with its healthcare providers. The number of APN students has ballooned from about 60 in 2009 to about 400 in the first half of 2012. “The more opportunities we have to hire APNs in various clinical areas, the more graduate nursing students we can provide training to, which we hope will lead to hiring those we have trained,” she says. She adds that Cleveland Clinic increased its tuition assistance program, which makes advanced schooling and certification affordable for more nurses.

‘Growing our own’

Also, more nurses may be encouraged to pursue APN roles as a result of greater institutional recognition of the value of APNs. Nurses’ job satisfaction is much higher when APNs can work to the full scope of their training and licensure, Lahl says. “These two factors have really helped us ‘grow our own.’ By encouraging our RNs to take on more responsibility, advance their career and earn more money, we make it more likely they will receive an advanced degree and maintain employment in our health system.” She notes that these messages regarding APN roles are consistent with the recommendation from the Institute of Medicine’s 2010 Future of Nursing report that nurses practice to the full extent of their education and training.

Payoffs in revenue, access, satisfaction

Lahl points out that many of Cleveland Clinic’s APNs are direct revenue generators, especially in outpatient care settings. They also help Cleveland Clinic meet growing patient demand for access. “Our APNs see patients independently and function very autonomously, but they are always part of a team and have access to a physician anytime,” she says. Lahl adds that the work of APNs consistently boosts patient satisfaction and quality of care — a claim supported by diverse examples from across the health system.

APNs in Action
Carmela Lemcke

NEONATAL CARE: Developing expertise at the front lines

Carmela Lemcke, CNP, who works in the neonatal intensive care units (NICUs) on Cleveland Clinic’s main campus and at its suburban Fairview and Hillcrest hospitals, describes her role as “the front line” of care for fragile newborns. “[APNs] are often the first ones to see infants in the delivery room and NICU,” she says. “We are acutely involved in their stabilization and admission. As a result, we developed excellent procedural skills.” Examples of the procedures performed include resuscitation at delivery, intubation, lumbar punctures, placement of chest tubes and insertion of vascular or other nonsurgical central lines. Lemcke and her APN colleagues perform daily assessments and collaborate with neonatologists to develop treatment plans. They also prescribe medications, order tests, confer with specialists and offer family counseling. “We have a significant amount of hands-on time with each baby and foster a very familycentered approach,” she says.

Lemcke adds that APNs greatly appreciate being able to use their procedural and decision-making skills to the maximum. “Nursing training is so rigorous today, and being allowed to make more decisions and apply our expertise really improves our job satisfaction,” she says.

Cathy Dobrowski

HEADACHE CLINIC: Autonomy yields appreciative patients

Cathy Dobrowski, MSN, ANP-BC, an adult nurse practitioner who works in the Headache and Facial Pain Clinic on main campus, says the ability to make independent decisions is what attracted her to work at Cleveland Clinic. “There is very strong support of APNs,” she says. “I love being able to practice independently. I initiate treatment plans, manage patients and do my own procedures,” such as trigger point injections and botulinum toxin therapy.

When Dobrowski started in the headache clinic five years ago, she was the only APN. Today, she is joined by another nurse practitioner and two physician assistants. “We have a great team. The seven physicians we work with are very supportive of us,” she says.

Dobrowski enjoys taking on added challenges. For example, she recently traveled to the state capital to testify in support of the addition of botulinum toxin to the list of drugs nurse practitioners are authorized to prescribe in Ohio, an initiative that has since been approved. And she hopes to soon be able to see new patients, not just established ones. “Because our schedules are more flexible [than physicians’ schedules], we are able to see patients more quickly — often the same day — which patients really appreciate.”

Maureen King

FROM CARDIOLOGY TO VACCINATIONS: versatility breeds satisfaction

Maureen King, CNP, elicits histories and performs physical exams on patients admitted with chest pain who are in observation status at Fairview Hospital. After reaching consensus with the cardiologists she practices with, King developed a cardiac care documentation tool that serves as the note placed in the patient’s chart. Ordering routine diagnostic cardiac tests early in the day allows the cardiologist to review findings and determine if the patient needs further diagnostic testing or if testing may be completed on an outpatient basis. The physician is able to spend quality time reviewing the results with the patient, and this can reduce the patient’s length of stay.

King has also formed a team to increase vaccination rates among adult inpatients. “We use the Epic electronic medical record to identify patients who qualify for vaccines, such as those for pneumococcal pneumonia or influenza, and help nurses on the floors administer those vaccines,” King says. She adds that in addition to reducing morbidity, mortality and healthcare costs, immunization of appropriate individuals is a recently added core measure expected by the Centers for Medicare & Medicaid Services. King says the diversity of what she does makes her job rewarding. “I am able to pursue so many avenues,” she explains. “I am a clinical instructor for four local nursing schools, I conduct research and I am a direct patient care clinician, helping two distinct patient populations. It is so multifaceted. I really enjoy it.”

System-wide Program Creates a Culture of Employee Recognition — Caregivers Celebrating Caregivers

“Thanks for a job well done.” That’s the message Cleveland Clinic caregivers have sent to one another more than 245,000 times since the health system rolled out a comprehensive, enterprise-wide rewards and recognition program in June 2010. And these messages of recognition are making a difference on the organizational level as well as for individual caregivers and teams — including many nurses.

The program, known as Caregiver Celebrations, was designed to meet the need for a consistent, system-wide approach to recognize standout employee achievement, explains Matthew Majernik, Executive Director, Total Rewards, in Cleveland Clinic’s human resources department. “The best organizations to work for recognize their employees,” he says. “And while there were many good departmental programs for caregiver recognition throughout our health system, there was no enterprise-wide program.”

So, in 2010, Majernik led an effort to create Caregiver Celebrations by drawing on successful programs from within the system and best practices from other organizations. Objectives for the program included building a culture of recognition and employee well-being; attracting, engaging, motivating and retaining caregivers; and creating a competitive advantage over other healthcare organizations. The result was a program that allows any employee to recognize any other employee (or team) for going above and beyond, for handling a tough situation effectively or simply for being a reliably capable colleague day in and day out. Employees can be recognized through four different tiers of awards (see sidebar); recognition at the three highest tiers is given by managers only and carries varying levels of monetary awards. Employees and managers use a simple password-protected website to submit recognitions and award nominations.


TIER 1 Appreciation Award

168,298 given in first two years

  • Nonmonetary recognition
  • Any employee can give (peer to peer/manager/physician)
  • Each month, 50 awardees at this tier randomly selected to receive $25 gift certificate

TIER 2 Honor s Award

72,322 given in first two years

  • Monetary award given by managers ($10, $25, $50 or $100 amounts)
  • Annual budget of $25 per direct report (award dollars are “grossed up” to cover the tax burden)
  • Usually given to direct reports, but can be given to any employee in the health system

TIER 3 Excellence Award

1,651 given in first two years (to 4,027 recipients*)

  • Recognizes outstanding achievements
  • Quarterly awards given at institute and division level
  • 1 percent of institute employees recognized per quarter
  • $250 gift certificate or monetary award plus desktop award

TIER 4 Caregiver Award

108 given in first two years (to 401 recipients*)

  • Recognizes the best of the best
  • Given annually at enterprise level (50 awards chosen from among 200 nominations)
  • $2,000 monetary award, desktop award and attendance at annual banquet with CEO

CEO Award

4 given in first 2 years (18 recipients*)

  • $10,000 monetary award given annually to one individual and one team

*Awards at these levels can be given to teams, hence the excess of recipients compared with awards.

Enthusiastic adoption two years out

Majernik has been gratified by the utilization of Caregiver Celebrations to date. “We had more than 245,000 award recipients in the program’s first two years,” he notes. “Three recognitions per employee is considered world-class according to market best practices, and we are already there with a brand-new program.” He adds that the program appears to have helped improve scores on a key question from Cleveland Clinic’s annual employee engagement survey: “In the last seven days, I have received recognition or praise for doing good work.” The mean response to this question (on a scale from 1 to 5, with 5 indicating strong agreement) has risen from 3.26 in 2009 (the year before Caregiver Celebrations was launched) to 3.47 in 2010 and to 3.67 in 2011, its highest level to date.

Leaders from the Zielony Nursing Institute and throughout Cleveland Clinic say there is good reason the program is so widely used. “Caregiver Celebrations gives leaders a consistent, reliable way to recognize employees,” says Sandy Maag, BSN, RN, Nurse Manager for Nursing Quality. “Because the program is easy to use, I find myself recognizing employees more often.” Maag adds that the ability for employees at any level of the organization to recognize each other is particularly valuable. “Receiving recognition from colleagues makes it more meaningful,” she says.

“The program formalizes the ‘thank you’ process and makes recognition special,” says Dana Wade, MSN, RN, CNS-BC, CPHQ, Senior Director of Clinical Education, Nursing Faculty and Student Onboarding. “Receiving an award notice is almost like receiving a written letter in the mail, which is so rare these days. Sending an award provides managers with an opportunity to engage, thank and recognize their employees and others, which is important in retaining staff.”

Giving employees “the feeling that someone is actually paying attention to their actions” is one of the program’s assets in the eyes of William Bryant, MBA, BSN, RN, CNOR, Director of Surgical Services at Hillcrest Hospital. “Spotlighting the work of someone who normally would not go above and beyond is even more gratifying to me,” he says. “This serves as a reminder that consistency in approach by leadership to address interpersonal interaction does pay off in the long run.”

Award recipients offer positive feedback as well. “It’s very rewarding to know you are appreciated,” says Teresa A. Daniels, MSN, RN, a clinical analyst in the Department of Nursing Informatics who has received awards at the tier 1 and 2 levels. “Many times words are spoken, but the award certificate is a nice addition to the spoken words.”

“The program reaffirms and validates what you’re doing,” says Margaret “Peggy” Marquard, LPN, who received a tier 3 award for her work on the orthopaedics unit at Lakewood Hospital. “It just makes you feel good.” She adds that “it means a lot that it comes from a fellow employee. It makes for great work relationships — you feel more like family than co-workers.”

Crossing departmental boundaries

Jeff Disrud, Director of Facilities at Fairview Hospital, recently recognized two of the hospital’s nurses with tier 3 awards. He appreciates that Caregiver Celebrations allows leaders to recognize employees from any department. “Being able to recognize each other without any barriers is important because it solidifies the feeling that we work as a team,” he says.

Doreen Ukovic, a financial analyst who received a tier 2 award from a Nursing Institute leader for her support in providing administrative data, concurs. “The award made me feel appreciated and helped me realize that even though the finance group has no direct patient contact, information we provide can still affect the experience and outcomes of our patients,” she says.

Sue Andrella, Director of Media Production, was recently recognized through the program by a Nursing Institute leader for her work on a tribute video honoring Cleveland Clinic nurses. “Our team’s job is to inform and inspire through video — to tell the amazing stories that happen here,” Andrella says. “The stories of our nurses are ones we absolutely love to produce. Even though we are in a nonclinical field, we strongly believe we are tied to the Cleveland Clinic experience, and receiving the award was a powerful confirmation of our role in putting patients and caregivers first.”

As a manager, Andrella has considerable perspective on both sides of the awards equation. “Taking time to thank those we work with, whether directly or across departmental lines, can be difficult,” she says. “We mean well — we may even add it to our to-do lists — but everyone is busy and sometimes it just doesn’t happen. Caregiver Celebrations gives everyone the ability to recognize others in a meaningful and lasting way. It’s fast and easy to use, and it even alerts the employee’s supervisor of the recognition and a job well done. How wonderful is that?”

The next frontier: Recognition from patients

Majernik says he’s aware of no other U.S. health system with a rewards and recognition program as robust and comprehensively integrated as Caregiver Celebrations. “With our tier 3 awards alone, we are recognizing and rewarding the top 1 percent of our employee population every quarter,” he notes. In the case of the Nursing Institute, which has 5,700 employees on Cleveland Clinic’s main campus alone, that means 57 nurses at the main campus location have the opportunity to be recognized significantly each quarter.

Buzz about the program has prompted other healthcare organizations to inquire about it, says Marilyn Collings, Director, Total Rewards, who oversees Caregiver Celebrations. “We get a lot of calls from hospitals that want to learn more about the type of platform we have for our enterprise-wide recognition program and other details about the program,” Collings says.

Cleveland Clinic is looking to build on the success of Caregiver Celebrations with a new program that allows patients and visitors to recognize caregivers in a manner similar to the one used by employees. The program, which allows recognitions to be submitted online or via paper cards, was piloted in five clinical areas earlier this year and yielded more than 1,500 recognitions in its first month. The program was rolled out system-wide in September. “The number of awards from patients and visitors may well surpass those from employees,” says Collings, “particularly for the clinical nursing staff.”

Peer Evaluations for Clinical Nurse Specialists: A ‘Leap of Trust’ Can Pay Off in Improved Practice

Cleveland Clinic’s Zielony Nursing Institute recently tasked two of its clinical nurse specialists (CNSs) — one a seasoned veteran and the other a newcomer to CNS practice — with the challenge of creating a peer evaluation process for their fellow CNSs.

The request came in the wake of 2009 mandates from The Joint Commission and the National Committee for Quality Assurance (NCQA) that advanced practice nurses (APNs) undergo peer review as part of their professional evaluations. The mandates reflect the reality that APNs are credentialed and privileged in the same manner as medical staff.

CNC Peer Evaluation Process

Amanda Corniello, MSN, RN, ACNS-BC, PCCN

The task fell to Kathleen Hill, MSN, RN, CCNS, and Amanda Corniello, MSN, RN, ACNS-BC, PCCN. Hill is an experienced CNS who serves on the APN privileging committee that vets all 900 APNs who work in the Cleveland Clinic health system. Corniello, who became a CNS more recently, was invited to bring a fresh perspective to the effort.

Addressing the unique CNS role

The CNS evaluation is different from the evaluation of other APNs because of the nature of CNS responsibilities, which include:

  • Maintaining clinical expertise and facilitating evidence-based nursing practices in a specific patient population or role
  • Supporting clinical nurses
  • Serving as a liaison between bedside nurses and physicians
  • Serving as a sounding board and consultant for nurse managers
  • Troubleshooting nursing processes
Sample questions from the CNS peer evaluation

Have you contacted this CNS with a clinical question related to his/her specialty? If yes, was the individual able to appropriately and adequately answer or assist you?

Does this CNS reveal his/her skills and experience during meetings or committee work? Please explain.

In collaborating within a group or on a project, does this CNS carry out his/her commitments and/or assignments? Please explain.

Has this CNS asked you for assistance with a clinical situation or project? If yes, was the need for assistance proportional to his/her skill level and/or expertise level? Please explain.

Is this CNS a good role model for professionalism? Specifically, does he/she display the appropriate comportment, professional appearance and code of conduct?

If I had one suggestion to make to this CNS for improvement or growth, it would be...

“CNSs are different in function from other APNs because we are experts in nursing care,” Hill explains. “Other APNs work collaboratively with physicians, so physicians, who would be involved in their peer review, can easily observe or review their work. CNSs are an extension of nursing practice and focus on establishing benchmarks for quality and translating best practices to the bedside. Our clinical work and outcomes are not as obvious to physicians and administrators.”

Guidance from the literature and internal vetting

Initially, Hill and Corniello conducted a literature review to obtain more information on peer evaluations for CNSs and APNs in general. Their search turned up three articles that helped guide them in developing the evaluation process and 12 questions they deemed appropriate for peer evaluation. Those 12 questions (see sidebar for examples) were presented to a larger group of CNSs for validation and input. From there, guidelines were developed to facilitate the process:

  • The peer evaluation is confidential. The only person who views responses to the evaluation is the CNS who is being reviewed.
  • Responses are anonymous unless the CNS being evaluated requests to speak with one or more of the people who reviewed him or her.
  • Three CNS peers evaluate each CNS. Two are chosen by the CNS and are usually colleagues with whom the CNS works on a regular basis; the third is chosen by the CNS’s supervisor. If a CNS has prescriptive authority, an additional evaluation is required from a physician.
  • Peer evaluation is not tied to performance reviews or salary increases, although it’s hoped that each CNS will use the feedback to improve his or her practice.
Lessons from the rollout

Peer evaluations for CNSs were completed for the first time in the fall of 2011 as a pilot project involving 23 CNSs in the Department of Nursing Education and Professional Practice Development on Cleveland Clinic’s main campus. Hill and Corniello say the process worked well despite what they call a few “bumps in the road,” such as underestimating the time needed to blind more than 75 reviews, collate them and send them to each CNS. “An objective, neutral third party is essential to maintain the confidentiality and integrity of the process,” Hill observes. They are using participant feedback to improve the second round of evaluations, which will take place in the fall of 2012.

“Overall, the peer review process was enlightening for most CNSs, and our colleagues really appreciated the feedback,” Corniello says. Many CNSs opted to share the comments they received with their supervisors, she adds. “The reviews were full of specific, actionable suggestions for improvement, and reviewers offered valuable reflections on their colleagues’ contributions and skills.”

CNC Peer Evaluation Process

Kathleen Hill, MSN, RN, CCNS

Hill says she believes it is a “leap of trust to have someone evaluate your practice” but that honest appraisals can definitely help to improve CNS practice.

Hill and Corniello presented their experience in developing the evaluation process at the annual meeting of the National Association of Clinical Nurse Specialists in March 2012. They plan to submit their work to other professional organizations and have a manuscript in the works.

“We believe CNS peer evaluations have great potential for adoption by other hospitals and healthcare organizations that employ APNs,” Hill says.

Innovating to Achieve Magnet:Programs That Help Achieve Designation Invariably Improve Patient Care

Innovating to Achieve Magnet

Requirements to achieve designation or redesignation under the Magnet Recognition Program® have changed in recent years. Although it is easy to get lost in the details of the changes, Cleveland Clinic finds that strategies that are best for patient care — proactive practices that promote continuous improvement of nursing quality and patient outcomes — are also the keys to success under the revised Magnet requirements.

All about outcomes

Until recently, applying for Magnet designation required describing how a healthcare organization was meeting 14 “forces of magnetism,” concepts that contribute to excellence in nursing care. But since 2008, the American Nurses Credentialing Center, which runs the Magnet program, has asked organizations to actually demonstrate — not just describe — their success in achieving exemplary practice in each of Magnet’s five outcomes-based components.

For example, to address patient fall rates under the revised requirements, a hospital needs to provide data that show its fall rates are lower than national averages and describe how frontline staff nurses have been involved in innovative action-planning processes to achieve targeted outcomes.

“The focus is on measuring what we are doing and how we know it is making a difference, whether in patient outcomes, nurse satisfaction or creating a better hospital environment,” explains Monica Weber, MSN, RN, CNS-BC, CIC, Magnet Program Manager and Patient Safety Officer at Cleveland Clinic’s main campus.

Weber describes the focus on demonstrating outcomes as a maturational process. Although it requires more work for hospitals and health systems, she believes it is worth it. “A certain level of resources needs to be devoted to keeping up with Magnet status, but in the end, it leads to a strong professional practice environment and provides external validation that the structures are in place for excellence in nursing care,” she says. Outcomes-focused programs also support recruitment and retention, she adds, because nurses seek to work in an enriching environment.

Ongoing monitoring is key

Cleveland Clinic constantly monitors its internal nursing benchmarks to ensure it is meeting them. These internal goals are tighter than those required for Magnet designation, Weber says. The health system has developed “dashboards,” trending reports on patient care that make it easy to visually compare quality indicators to benchmarks. Nurse managers can log on and share valuable information with their staff in an easily digestible format.

Funding career development and encouraging research One important aspect of nursing excellence is helping nurses develop professionally. Cleveland Clinic maintained its tuition-reimbursement programs for the entire health system, despite the recent weak economy. “Many hospitals have done away with tuition and travel reimbursement,” Weber says. Additionally, reimbursement has been maintained for qualifying memberships in professional nursing organizations and for initial specialty certification and certification maintenance. Nurse leaders also helped create a unique cohort for nurses to pursue doctorates at Case Western Reserve University in Cleveland. “Many nurses use these benefits to grow their careers,” Weber notes.

Another way of promoting professional growth is to encourage nurses to find answers to practice-related questions. Throughout Cleveland Clinic, senior nurse researchers are available to coach nurses who want to perform research. Coaches help nurses develop stronger projects and master the process of writing and editing at a level that warrants journal acceptance. Writing-for-publication seminars for nurses are offered throughout the year as well.

Magnet Standards
Maintaining the Magnet momentum

Cleveland Clinic’s Fairview Hospital, on Cleveland’s western edge, is currently preparing its application for Magnet redesignation, which is due in early 2013. Maintaining the momentum after a hospital’s initial Magnet designation can be a challenge, says Deb Small, MSN, RN, NE-BC, Chief Nursing Officer for the hospital. “You have to keep building on it,” she explains. “We set the bar higher, we’ve been reviewing our strategic plan yearly, and we reset our goals to keep excellent empirical outcomes in the forefront.”

Indeed, setting a vision for excellence is key to achieving Magnet designation, according to Aniko Kukla, MSN, RN, CPNP, Fairview Hospital’s Magnet and Nursing Quality Manager. She notes that strategic initiatives and gap analyses that focus on outcomes, evidence-based practices and research are essential to making this happen. One way to promote excellence, Kukla explains, is to identify talented nurses who can lead the way. “If you focus on ongoing professional development of nurses, quality care will follow,” she says.

The hospital uses many other methods of keeping Magnet and related quality issues in front of the staff:

  • “Magnet Monday” emails focusing on Magnet issues or excellence in care are sent to nurse managers to share with their teams.
  • “Scavenger hunts” related to Magnet designation urge nurses to compete to answer questions by visiting websites related to excellence in patient care.
  • An essay contest was held in which nurses were encouraged to write about what Magnet means to them; winners won a trip to a Magnet conference in Los Angeles.
  • Quality, evidence-based practice and other issues pertinent to Magnet recognition are always on the agenda at service team meetings.
  • A monthly newsletter highlights accomplishments toward Magnet, as do regular town hall meetings with the hospital’s chief nursing officer.
  • Magnet champions from each unit or area meet monthly to share achievements and plan activities that promote principles associated with Magnet recognition.
Double-Checking Insulin Preparation Not Perceived by Nurses as Significant Burden

Insulin ranks among a handful of “high-alert” medications identified by the Institute for Safe Medication Practices (ISMP) as potentially requiring special safeguards to reduce error risk.

Both the ISMP and The Joint Commission recommend that nurses regularly double-check each other’s preparation of insulin doses. This recommendation led Cleveland Clinic nurses to conduct a two-arm study on double-checking of insulin to assess (1) actual error prevention and (2) nurses’ perceptions of the burden of the task.

In September 2010, clinical nurse specialist (CNS) Mary Beth Modic, MSN, RN, CNS, CDE, joined with other CNS colleagues to enlist three medical units and two surgical units on Cleveland Clinic’s main campus to participate in the research. Two units were designated as intervention units. Nurses were required to double-check each other’s insulin preparation for every patient during the four-week study period. In the remaining three units, which served as the usual-care group, standard insulin preparation practices were continued (i.e., no double-checking).

Mary Beth Modic

Mary Beth Modic, MSN, RN, CNS, CDE

Further, Fairview Hospital has added new positions that advance principles central to Magnet, including a nursing quality manager, and strives to hire more advanced practice nurses to facilitate more evidence-based practices, Kukla says.

Perspectives from a first-time applicant

Cleveland Clinic’s Hillcrest Hospital, in Cleveland’s eastern suburbs, has been working toward Magnet recognition and hopes to submit written documentation early in 2014. Molly Loney, MSN, RN, AOCN, Clinical Nurse Specialist for Special Projects and Magnet Coordinator, emphasizes that Magnet should be viewed as a journey, not a destination. “There is no endpoint,” she says. “You are always striving to find ways to involve and develop staff, and help them discover ways to own their practice.”

“Day to day, we are creating a culture where nurses can pursue a spirit of inquiry about patient care practices,” Loney explains. “We want them to ask, What is the evidence behind what we do? and How can we improve our practices? Magnet standards offer a road map for helping nurses practice based on the strongest level and quality of evidence available.”

The hospital created a supportive infrastructure to help empower nursing and support staff and connect their practice with nurse-sensitive quality indicators. “We now have shared governance as a philosophy as well as a structure and a process,” says Sue Collier, MSN, RN, NEABC, Chief Nursing Officer and Vice President of Nursing at Hillcrest Hospital. “It is integral to everything that happens with staff and manager relationships. It has opened the eyes of council members and the recipients of changes to see that they have influence.” As an example, she cites the work of the hospital’s nursing assistants council, which proposed and helped develop a program within Cleveland Clinic’s career ladder initiative geared specifically to nonlicensed nursing support staff.

Loney adds that working toward Magnet recognition has helped solidify interhospital collaboration that already existed at Cleveland Clinic. She notes that a special consortium was created among Magnet team leaders at each hospital to share resources and lessons learned in achieving best practices that promote Magnet recognition.

Bottom line: Be proactive

Weber points out that it is crucial for any organization hoping to achieve Magnet recognition to be proactive. For instance, she notes, frontline staff need to be involved in performance improvement, and unit-based shared governance groups need to suggest ways to improve performance data.

To that end, Cleveland Clinic’s annual Shared Governance Day event is an opportunity for teams from all hospitals in the health system to share their work on nurse-sensitive indicators. “When nurses know they will present their work, it really focuses them on their goal,” Weber says. “Every year, the quality of the projects shows maturity and greater understanding of how to demonstrate outcomes,” she adds.

Being proactive figures into Weber’s final advice: Plan feasible, actionable outcome metrics before starting any initiative. “You have to know from the get-go how you will recognize success,” she says.

Predicting Pressure Ulcer Risk in vascular Surgery Patients: Study Raises Promise of a More Robust Tool

Cleveland Clinic nurses set out to identify factors associated with pressure ulcer development in a particular inpatient population — vascular surgery patients — and came away with a surprising finding: In this population, the Braden Scale tool for assessing risk of pressure ulcer development is much less predictive of ulcers than are a number of other risk factors.

Factors associated with risk of hospital-acquired pressure ulcer in the vascular surgery unit*
  • Higher blood urea nitrogen
  • Higher body mass index
  • Primary diagnosis of atherosclerosis
  • Nonwhite and non-Hispanic race/ethnicity
  • Lower right ankle brachial index measurement
  • Low (< ~10) or high (> 45) hematocrit values
  • Intensive care unit stay during admission
  • Braden Scale score in “high” or “severe” risk category
  • Female gender

* Listed from strongest association (top) to weakest association

The finding is from a retrospective medical records review of all patients admitted to the 25-bed vascular surgery step-down unit on Cleveland Clinic’s main campus from November 2008 through December 2009. “We suspected our vascular surgery population had a higher rate of pressure ulcer than other non–intensive care surgical patient populations,” says principal investigator Amanda L. Corniello, MSN, RN, ACNS-BC, PCCN. The suspicion stemmed from high rates of patients with poor circulation associated with peripheral vascular disease and the multiple comorbidities that these patients often have.

Yet Corniello and her colleagues could not find research literature reports that assessed pressure ulcer prevalence and risk factors specifically in patients with peripheral vascular disease. “In fact, some studies even excluded vascular populations,” says Corniello, a clinical nurse specialist in the Heart & Vascular Institute. So a team that included staff nurses and assistant nurse managers undertook a research study to determine risk factors for pressure ulcer development in patients on the vascular surgery unit. They systematically reviewed data from an administrative database and electronic medical records to extract a wide range of patient characteristics. They then analyzed the frequency and association of characteristics among patients on the unit according to whether or not patients developed a pressure ulcer during their stay (hospital-acquired pressure ulcer [HAPU]).

Nine risk factors identified

Among 849 admissions to the unit during the study period, the incidence of HAPU was 11.8 percent. Regression analyses revealed nine factors that were significantly associated with the risk of HAPU; these factors are listed in the table (left) from strongest to weakest association.

“We were surprised to find that the Braden score was not as predictive of risk in this population as many other factors were,” says Corniello. “It doesn’t appear to be as important in our vascular surgery population as in other populations.” She adds that other surprises included the absence of current or past smoking and incontinence as significant risk factors for pressure ulcer development in this population.

Next steps: validation of a risk score, clinical interventions

Corniello and her colleagues are now collecting more data in a new cohort of patients to validate the predictive values and nomogram-based risk score they developed using the nine identified risk factors. If the nine factors are validated, the team will work to make the risk score tool as user-friendly and efficient as possible for clinical use. The risk score promises to be easy to implement into practice, as data for six of the nine risk factors can be collected at admission and only three risk factors (blood urea nitrogen, hematocrit and Braden score) require ongoing monitoring.

“If the true predictive value of the nine identified variables is powerful, we will have a more accurate assessment tool that will identify vascular surgery patients at risk for developing pressure ulcers,” says co-investigator Jacqueline Bates, BSN, RN, CMSRN, an assistant nurse manager who works on the unit. That, in turn, would be followed by development of clinical interventions to lower the risk of HAPU in this specific population. “We want to be more proactive about identifying vascular surgery patients who may be at risk for HAPU. Our primary goal is to initiate preventive measures and interventions earlier on,” Bates explains.