Notable Nursing: Update November 2012

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Patient Experience Summit Instills Empathy and InnovationPatient Experience Summit Instills Empathy and Innovation: National Leaders Offer Expertise for Compassionate Care

What is relationship-based care and why is it important to the nursing profession? While these are not new questions in a culture focusing more on the patient experience, national leaders offered singular insights into the answers at the recent Third Annual Cleveland Clinic Empathy and Innovation Summit.

More than 840 attendees, from 34 states and 28 countries, representing hundreds of hospitals, healthcare systems and businesses, gathered at the Summit in May to enhance their ability to be compassionate and deliver excellent, patient-centered care. The three-day event covered a wide range of topics, with particularly valuable guidance provided in the “Translating the Language of Caring” kickoff session.

A Nation’s Call: Compassionate Care

“There is a call for a compassionate healthcare system, led by the Schwartz Center at the Massachusetts General Hospital and its medical director, Dr. Beth Lown, which requires the skills of involvement, including engagement, and attentiveness to patients’ concerns and changes in their clinical condition, that are essential to a nurse’s expertise,” says Patricia Benner, PhD, RN, FAAN, FRCN, Professor Emerita, University of California, San Francisco.

Compassionate healthcare is based on the recognition and validation of the needs, concerns and distresses of others, coupled with actions to alleviate them, according to Benner. “It is the role of nurses, as frontline problem solvers, to ensure that this positive engagement occurs throughout the patient’s care,” she says.

Compassionate care has many components, and its fundamentals begin to be instilled from the beginning of schooling. However, the primary wisdom for compassion requires engagement, attentiveness and experiential clinical learning as a nurse’s career evolves. “Time and interest in the patient’s concerns and clinical condition are essential to exercising astute clinical judgment,” says Benner.

“Dr. Benner delivered a powerful and informative talk about the need to empower nurses to use empathy and compassion in their communication with patients,” says Mary Linda Rivera, RN, ND, Executive Director, Office of Patient Experience at Cleveland Clinic. “The audience was engaged throughout her presentation, as this topic is becoming a point of focus at hospitals across the country. It generated significant interest.”

Nurses should focus more on the interpersonal relationship, rather than on the application of technology, according to Joyce J. Fitzpatrick, PhD, MBA, FAAN, Elizabeth Brooks Ford Professor of Nursing, Case Western Reserve University, Cleveland.

“While technology is important, we often get caught up in the application of these tools,” says Fitzpatrick. “There needs to be a re-awakening of the interpersonal connection. I believe that measurement of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores is actually helping nurses reconnect with the basic understanding of their role with patients. Transformational change happens one relationship at a time.”

Relationship-based care is the primary driver behind the guidance Fitzpatrick offers her students. “One of the exercises we teach is spending five uninterrupted minutes with every patient,” she explains. “Sitting down face-to-face with the patient, asking questions to understand their illness and asking what we can do to help them — all of this can make a huge difference. There’s no replacement for that direct contact.”

“The expertise Dr. Fitzpatrick brought forward regarding interpersonal relationships fit perfectly with our theme, which conveyed the importance of focusing on improving the patient experience by giving caregivers the necessary tools, training and confidence to succeed,” adds Rivera.

Mindful Consistency

In order to blend clinical reasoning with compassionate care, “situated coaching” should be applied, according to Benner. “While ‘managerialism’ is a good thing for controlling essential aspects of day-to-day care, it’s situated coaching from frontline leaders that supports compassionate care. There’s no checklist that guides the nurse in a caring practice,” she says.

Thinking in action, relational responses to patients and families, recognizing changes in the patient, and developing a sense of salience are primary components that require situated coaching for new staff. A stable nursing staff is fundamental to coaching new nurses and ensuring institutional learning and cumulative knowledge development, Benner explains.

“When there is a lower turnover rate of nursing staff, nurses are much better prepared to be active participants in compassionate interpersonal care, and to be attuned to early warnings of changes in a patient’s condition, due to the stability their team has built,” says Benner. “It’s this stability that leads to a positive patient experience and overall compassionate care environment.”

“Anecdotal evidence indicates that relationship-based care is at the core of what we all want when we’re patients,” Fitzpatrick says. “Any relationship you have is built on the interpersonal connection. Measuring these outcomes, either through HCAHPS or research, will help nurses see the impact of their work.”

Ohio APNs Add Schedule II Drugs to ProtocolOhio APNs Add Schedule II Drugs to Protocol

Advanced practice nurses (APNs) in the state of Ohio are poised to fill a growing gap of needed care with the passage of Am. Substitute Senate Bill 83. The new legislation, which allows APNs to write prescriptions for schedule II controlled substances, such as fentanyl, oxycodone and methylphenidate, represents a victory for APNs resulting from five years of consensus-building across healthcare specialties. Cleveland Clinic APNs are now preparing for what they say opens a door to broaden the scope of their practice.

“For our nurses that work in pain management, not being able to prescribe opioids has been a challenge,” says Meredith Lahl, MSN, PCNS-BC, PNP-BC, Senior Director of Advanced Practice Nurses at Cleveland Clinic. “Physicians rely heavily on the APN to fill in the medication piece, and this legislation allows the nurse to coordinate the patient’s whole care.”

“Physicians are extremely busy, and when a patient’s pain is leaping out of control, this legislation allows us to offer more timely care by being able to implement the step of prescribing and managing their pain medications,” adds Esther Bernhofer, BSN, PhD(c), RN-BC, a Nursing Education Specialist on Cleveland Clinic’s main campus, who specializes in pain management. “This is not only a marvelous step for the mid-level nurse, but for the bedside nurse who will benefit from the APNs assistance.”

The bill, which was signed into law by Governor Kasich on March 9, 2012, took effect June 8, 2012. APNs with a certificate to prescribe (CTP) and certificate to prescribe externship (CTP-E) may prescribe in accordance with Sub. SB 83 and the revised Ohio Board of Nursing Formulary, which specifies the schedule II prescribing parameters, to be posted on the Board’s website. The Board will adopt a new rule to specify continuing education (CE) requirements, with an anticipated effective date of no later than October 31, 2012.

Requiring Expanded Education

Currently, APNs with a CTP and CTP-E are not required to complete the state- required six-hour CE course prior to prescribing schedule II drugs. The CE rule effective date is planned for no later than October 31, 2012, to provide ample time for CTP and CTP-E holders to complete the CE requirement by August 31, 2013, according to the Ohio Board of Nursing.

Yet employers and institutions that grant APNs practice privileges in Ohio may establish their own policies – a directive Cleveland Clinic’s Zielony Nursing Institute is taking seriously.

“Opioid abuse is a major problem in the United States,” explains Bernhofer. “With increased responsibilities, APNs must be thoroughly educated on the whole picture of pain management when prescribing schedule II drugs. The current bill requires minimal education, but there is so much more to managing pain than just prescribing drugs.”

Cleveland Clinic will have more stringent rules than the state, according to Anne Vanderbilt, MSN, CNS, CNP, Clinical Nurse Specialist, Center for Geriatric Medicine, at Cleveland Clinic’s main campus. “We will not be allowing APNs to prescribe schedule II drugs until they complete our expanded education program,” she says.

To enhance the bill’s requirements, Cleveland Clinic is developing an advanced schedule II drug education program to take place this fall. The day-long CE event for APNs will include multiple short presentations from pharmacists, physicians and experts in pain management. The required course will also review the use of the Ohio Automated Rx Reporting System (OARRS), a tool established in 2006 to assist healthcare professionals in providing improved and safer treatment for patients.

“Any prescriber is required to be registered and sign in to OARRS,” says Vanderbilt. “It’s a valuable tool to assure that a patient is getting the appropriate drug therapy and is taking their medication as prescribed, and it will help alert us to signs of possible misuse or diversion of controlled substances.”

“Our expanded education will help prepare APNs by detailing all points related to prescribing schedule II drugs,” she adds. “Through high-quality speakers and a care-based approach to learning, we plan to make the most of the opportunities the new law will bring to our APNs and their patients.”

Early Mobility Research in the Neuro ICUEarly Mobility Research in the Neuro ICU: Phase 1 Results Provide a Nursing Call-to-Action

The detrimental effects of immobility on patients in intensive care units (ICUs) are clear, but what remains vague is the impact of an early mobility protocol and what resources are needed (beds with mobility features and a portable lift) for the neurological ICU population. Malissa Mulkey, MSN, CCRN, CCNS, and a team of 60 nurses in the neuro ICU at Cleveland Clinic’s main campus have taken steps towards getting answers.

Neuro ICU patients were historically excluded from studies of early mobilization. When they were included, sample sizes were very small and data was not analyzed by type of ICU population. Since available data was minimal, Mulkey developed an early ambulation protocol specifically for this patient group. Before implementing the ambulation protocol and encouraging nurses to use available mobility resources, Mulkey needed to assess the current state of mobility in the neuro ICU (phase 1). Data was collected between July and November 2011, and the mobility protocol was implemented in February 2012.

Phase 1 results of Mulkey’s study were recently shared at Cleveland Clinic’s Eighth Annual Nursing Research Symposium Conference. They reinforced that there is considerable need for increased nursing actions to mobilize patients. Among patients treated in two Cleveland Clinic neuro ICUs (22 beds total), almost 40 percent never progressed in ambulation beyond movement in bed (turning/positioning, range-of-motion exercises and raising the head of the bed); and less than 10 percent were standing/bearing weight and walking.

“We believe our phase 1 findings were consistent with other neuro ICUs across the country. Our results provide baseline data and rationale for increasing early mobility,” says Mulkey, a clinical nurse specialist whose role includes caring for patients in the neuro ICU. “The highest baseline level of mobility most patients achieved did not vary based on most patient characteristics and comorbid conditions. These phase 1 results gave us greater confidence that patients could benefit from an early mobility program without having safety issues.”

Results were shared with the neuro ICU staff, who were also educated about mobility expectations once an order is written. Education included a discussion of equipment and use of the early mobility protocol, including criteria for continuing/advancing progressive mobility, exclusion criteria and when to discontinue the protocol. “The protocol and change in practice expectations are beginning to make a difference, Mulkey states. “We noticed that we are calling a lift team to assist nursing staff in getting patients out of bed, and using physical therapists to provide a holistic hands-on approach.”

“When we compared our results to other reports in the literature, we learned that neurological ICU patients were less likely to get out of bed or have early mobility activities to the same degree that those who were in other ICUs did,” explained Nancy M. Albert, PhD, CCNS, CHFN, CCRN, NE-BC, Senior Director of Nursing Research and Innovation, and Mulkey’s mentor for the study. “Our baseline results will provide us with specific details of growth during the early mobility protocol’s post-implementation period. We plan to compare post-implementation to pre-implementation results. Further, we will reassess neuro ICU activities six months after the end of the post-implementation data collection period to learn if the early mobility protocol and changes in nursing actions become hard-wired once research study expectations are no longer being monitored by a study nurse.”

Overcoming Misperceptions

One important finding from the phase 1 results was that mobility was not based on patient acuity, even though there was a trend toward less mobility in higher-acuity patients. Results also showed that ventilator use was detrimental to early mobility. However, many ventilator dependent patients in non-neuro ICU settings were engaged in early mobility protocols, providing the research team a rationale for using the protocol in patients on a ventilator. “We know from the literature that having a ventilator should not prevent people in an ICU setting from getting out of bed,” Albert says.

Mulkey’s research is novel in that she is evaluating patients’ psychological profiles before neuro ICU discharge, according to Albert.

“Depression and anxiety levels were, in general, higher than levels in non-hospitalized adult subjects,” Mulkey says. ”"Interestingly, hostility levels were lower than in non-hospitalized adults in phase 1.”

“We will not know if an early mobility protocol has any effect on psychological profile status until we complete the post-implementation data collection phase of the study, but we hypothesized that greater mobility while in the neuro ICU may give hope to extremely ill patients and that they may have less depression, anxiety and hostility about their current medical condition,” Albert says.

Further of these efforts to move the mobility protocol forward comes from a small prospective research report recently published in the Journal of Neurosurgery. The study’s authors evaluated patients admitted to the neuro ICU of a tertiary care center. When comparing patients treated in the ICU during two-week periods, before and after implementation f a mobility protocol, they found a 300 percent increase in mobility following the protocol’s introduction. When comparing data during the entire pre- and post-intervention periods, the authors found significant differences in length of stay, hospital-acquired infection rates, urinary catheter days, days in restraints and ventilator-associated pneumonia rates, all favoring patients who received the mobility protocol. The mobility protocol did not lead to an increase in falls or inadvertent line disconnections.

“The results of this report are hypothesis-generating but have some limitations. The authors only analyzed mobility data during two-week periods pre- and post-intervention. Also, the long pre-intervention time frame of 10 months may have led to internal validity issues due to maturation, especially since most ICUs have instituted bundled interventions to decrease infections and length of stay over time.”

The results of Cleveland Clinic’s study on early mobility in neuro ICU patients are pending completion of post-implementation data collection. Both Mulkey and Albert believe the study’s impact will be far-reaching.

“The support from the entire neuro ICU team has brought the paper protocol on early mobility to life,” says Mulkey, who was honored in May 2012 with Cleveland Clinic’s “Nurse Researcher Excellence Award” for her work on phase 1 of this study. “It’s through our combined efforts that we can address the total needs of patients in the neuro ICU, from increasing mobility to addressing mental needs.”