Notable Nursing: Spring 2012
Professional Development Gets Personal: Nurses Share How and Why They’re Advancing Their Education
The challenges are substantial:
Increase the share of nurses with a baccalaureate degree to 80 percent by 2020, and double the number of nurses with a doctorate by that same year. These recommended goals from the 2010 Institute of Medicine (IOM) report, The Future of Nursing, are ones that Cleveland Clinic takes seriously. Meeting these goals calls for commitment at the institutional level as well as vision and determination from individual nurses. This special report profiles four Cleveland Clinic nurses who are advancing their education amid everyday career and life challenges — often with some help from fellow nurses.
can’t believe I’m doing this.” That’s what Donna Rittenberger, RN, CGRN, first thought as she entered her BSN program early in 2011. After all, she had been a nurse since earning an ADN in 1983, became certified in her specialty in 1994 and assumed increasing responsibility throughout her career, rising to her current position as Nurse Manager, Digestive Health, at Hillcrest Hospital in 2000.
"A part of me felt, ‘After almost 30 years of practice, what could I gain from this?’” Rittenberger says.
After a short while in the program, however, she was wishing she had gone back to school many years earlier. “It’s been really good for me,” Rittenberger explains. “I’ve found a lot of pleasure in learning things I hadn’t expected to. For example, my courses in business communication and finance have been very helpful in my role as a nursing leader.”
She’s found it so fulfilling that she plans to continue on in an MSN program after she earns her BSN, which she’s on track to complete later this year.
Rittenberger’s experiences are exactly what Cleveland Clinic aims to foster in the wake of the 2010 IOM report. “We’re making it a goal to get 80 percent of nurses to the BSN level going forward,” says Sarah Sinclair, MBA, BSN, RN, FACHE, Executive Chief Nursing Officer and Chair of the Stanley Shalom Zielony Institute for Nursing Excellence. “We’ll do it in a reasonable time frame to give an opportunity to everybody who is committed to earning that degree.”
In Rittenberger’s case, the impetus for advancing her education was an upcoming Magnet Recognition Program® requirement for all nurse managers to have a degree in nursing at the baccalaureate level or higher.
For other nurses, the initial motivation to pursue further education came from within or from colleagues and mentors. “I knew I wanted to advance my degree in a way that would use my strengths and interests,” says Esther Bernhofer, BSN, PhD(c), RN-BC, a Nursing Education Specialist on Cleveland Clinic’s main campus who is near completion of a five-year BSN-to-PhD program. She initially looked into MSN programs, but when she expressed an interest in ultimately completing research and teaching in her specialty, pain management, she was told she would benefit from a PhD.
“I thought, ‘I can’t do that — a PhD is beyond me,’” Bernhofer says. But a doctoral-prepared senior nurse researcher colleague convinced her otherwise and encouraged her to apply. “The message I received from my colleagues and managers here was, ‘You can do it — go for it. What can we do to help?’ That was very encouraging.”
For Chad Hollis, BSN, RN, who is pursuing an MSN to become a nurse practitioner (NP), it was the NPs and physician assistants who work with him on the vascular surgery floor at Cleveland Clinic’s main campus who spurred him on. “They told me about NP programs and always helpfully challenged me on the floors about how to handle different clinical situations rather than just telling me what to do,” he says. That broadened his perspective on patient care and lit the spark to pursue training to take on greater clinical responsibility.
Common challenges, differing solutions
Despite the many motivations, taking on a multiyear school commitment while holding down a demanding clinical job is not easy. Time management is the overriding challenge.
“Balancing priorities can become incredibly hectic,” says Jennifer Van Dyk, MSN, RN, Nurse Manager, Orthopaedics, Lakewood Hospital, who is halfway through a doctor of nursing practice (DNP) program.
That’s especially the case for nurses with big family commitments. Van Dyk, the mother of a newborn, says the time demands have simply forced her to quickly develop strict organizational skills. “I’ve also become better at accepting help — at home, work, wherever,” she explains. “Getting to know myself and being honest about what I can and cannot do has been important.”
Others have overcome the time demands of work and school in more concrete ways. For Rittenberger, the flexibility of her online BSN program has made all the difference. “The availability of online degree programs changes the equation for a lot of people, especially those with family commitments,” she says.
Hollis finds the availability of on-site courses to be key. Thanks to a collaborative effort between Cleveland Clinic and Kent State University in Kent, Ohio, he is able to attend his weevly classes on Cleveland Clinic’s main campus. “That makes the program really convenient,” he says. “I only have to travel to Kent, Ohio, a handful of times.”
A clear role for institutional support
All nurses profiled here mentioned Cleveland Clinic’s generous tuition support as an important factor in their decision to further their schooling. “It’s a huge help,” says Van Dyk. “I couldn’t be doing this without it.” Even those who say they’d probably be pursuing their degree anyway add that the tuition support is helping them earn it much faster.
Institutional support manifests in other ways as well. “The Nursing Institute has put a lot of importance on professional development and furthering our education,” observes Van Dyk. “There’s a general aura of support.” Rittenberger says she has “complete support” from her leadership: “They are very connected with my goal and want to see me succeed.” Hollis says his floor is flexible about solving scheduling challenges that come up for him around final exams. ”That makes it less of a struggle,” he notes.
For Bernhofer, who started at Cleveland Clinic in 2005 after decades working in home care and community hospitals, institutional support came in less tangible ways. “When I arrived and saw all that was happening at Cleveland Clinic — the complexity of the cases, the way everyone worked, all the resources here — it opened my eyes to professional possibilities I didn’t even know I had before,” she says. “That’s a lot of what motivated me and what supports me today.”
Mentoring is another common form of institutional support, but more notable is how quickly nurse scholars become mentors to their fellow caregivers who may be considering advanced nursing education.
“My going back to school has had an impact on some nurses who report to me,” says Rittenberger, explaining that one has since begun further nursing education and two others are seriously considering it. “I’ve played a role in showing them that learning is fun and that if I can still do it at my age, they certainly can too.”
Van Dyk has seen similar trends among some LPNs and RNs who report to her. She also reports a community of “peer mentors” among the 10 or so Cleveland Clinic nurses who are currently enrolled in the same DNP program that she is. “We spend a lot of time supporting each other, providing resources to each other and networking. All of us are very focused on becoming mentors to future DNPs down the road.”
Words of advice
There are recurring themes in the advice these nurses have for others considering following their path: Take it one step at a time. Seek out available resources. Keep your eye on the goal. “Just start talking to people in the educational programs you’re thinking of,” Bernhofer counsels. “Let them know your story, your interests and your needs. The nursing educators out there are really interested in helping you make your dreams come true.”
“Be aware that many options are now available to meet your schedule and lifestyle,” advises Rittenberger. “There are online programs, on-site courses and classes for night-shift workers.”
“Start with one class, one semester — everybody can take one class,” Van Dyk says. “And use the resources available to you, be they tuition support, manager encouragement or assistance from co-workers and family. Don’t be afraid to ask for help.”
Shared Governance: Model for Inclusive Decision-Making Expands in Reach and Impact
Since shared governance was implemented by nurses at Cleveland Clinic’s main campus 11 years ago, it has grown to include all regional hospitals within the health system. Now best practices that were fostered by the model are increasingly having an impact throughout Cleveland Clinic and beyond.
Shared governance is an organizational model for health systems that empowers nurses to have a voice in decisionmaking on policies and standards surrounding quality of care and their professional practice. It is based on a number of core principles:
- Partnership among healthcare providers and between providers and patients
- Equal focus on services, patients and staff
- Accountability and willingness to invest in decision-making
- Ownership of contributions to healthcare decision-making
The biggest impact shared governance has had at Cleveland Clinic is in giving staff nurses the opportunity to get involved in projects to improve quality measures and patient satisfaction, according to Meredith Lahl, MSN, PCNS-BC, PNP-BC, CPON, Senior Director of Advanced Practice Nursing. All nurses are contributing to those two overall goals, she says.
Lahl chaired the Shared Governance Coordinating Council from 2006 through 2011. The Coordinating Council is the main body in the shared governance structure on Cleveland Clinic’s main campus and oversees and links all the individual councils from across main campus. It also has begun to integrate councils from the regional hospitals in Cleveland Clinic health system.
“Shared governance allows front-line staff to get involved in decision-making,” Lahl says. “It is a part of their practice they can control. They have valuable input to give related to processes, systems and structures that affect patient care as well as teamwork and coordination of care.”
A tool kit to spread best practices
As the shared governance model has grown and spread across the health system, a tool kit available on the intranet site of the Cleveland Clinic Zielony Nursing Institute has facilitated standardization of shared governance processes and procedures used on Cleveland Clinic’s main campus. The tool kit simplifies the process for nurses to start up a council or get involved in an existing one. It provides information on what shared governance is, how to start a council, how to recruit members, and the nuts and bolts of setting up a meeting.
The site is also a place where nurses can share information about projects they are working on to improve quality and patient satisfaction. “Through the site, one unit can see what another unit is doing, which makes it easy to pilot or replicate programs in different areas,” Lahl says. Some successful shared governance projects have been extended across a hospital or the entire health system. For instance, Cleveland Clinic’s Hillcrest Hospital submitted a poster in 2011 on a best practice for timely symptom recognition and evidencebased one-hour benchmark antibiotic administration to patients presenting with febrile neutropenia. The practice is currently being implemented systemwide.
Shared Governance Day: A showcase for successes
Shared Governance Day is a key annual event that began in 2007 as a venue for promoting nursing professional practice and shared governance within Cleveland Clinic. Through its design using professional poster presentations, unit- and hospital-specific successes and best practices are highlighted and discussed among attendees. The fifth annual Shared Governance Day was held in November 2011 at Cleveland Clinic’s main campus, Euclid Hospital and Lakewood Hospital. It was the second time the event included the entire health system, and its focus was on quality improvement. Eighty-five posters were presented.
“The posters are a good way for front-line staff to be recognized,” Lahl says. “Staff are proud of quality improvement or other accomplishments and the positive effect their outcomes may have on patient care.” The posters are available all day for review and evaluation and are later uploaded to the Zielony Nursing Institute’s intranet site. Poster evaluation consists of rating each poster on five criteria for a total of 20 points. Teams completing highly rated work are recognized formally and their work is shared widely.
Lahl and Monica Weber, MSN, RN, CNS-BC, CIC, Patient Safety Officer/Magnet Program Manager, gave a joint presentation at the American Nurses Credentialing Center (ANCC) National Magnet Conference in October 2011 on using Shared Governance Day to highlight quality improvement across a multihospital health system. Many participants asked them to share some of the tools they presented, with the most-requested tool being the scoring matrix used to judge poster presentations for Shared Governance Day.
Enduring and broadening impact
Lahl notes that the influence of Shared Governance Day posters is extending beyond the Zielony Nursing Institute to other areas within Cleveland Clinic. For example, the Quality & Patient Safety Institute and the Office of Patient Experience have each displayed nurses’ posters at their own conferences. Moreover, some nurses have begun submitting their posters to national, regional and state conferences and to the American Nurses Association’s National Database of Nursing Quality Indicators.
Shared Governance Day in 2011 included participation by Cleveland Clinic Florida, whose nurses submitted eight posters. In fact, one of the posters from the Florida hospital, on a program that resulted in a significant reduction in pressure ulcer rates in the ICU, won an award. “Our staff was quite happy to participate, and our chief nursing officer was very supportive,” says Raquel Bryan, MHA, MPH, BSN, RN, CVN, Nursing Quality Coordinator, who traveled to Ohio to represent the Florida hospital. She adds that Cleveland Clinic Florida plans to participate again in 2012 and hopes to host the event in Florida someday.
Deb Solomon, MSN, RN, ACNS, BC, current Chair of the Shared Governance Coordinating Council, says Shared Governance Day “really energizes” nurses. “Nurses are embracing the event and look forward to actively participating,” she adds. Solomon, who is charged with coordinating Shared Governance Day in November 2012, says she already has quite a few hospitals in the system volunteering to host it. Nursing support testifies to the systemwide interest in the event and the opportunity it affords to highlight quality improvement projects that focus on outcomes of nurse decision-making using the shared governance management model.
Commonalities with Magnet criteria
Cleveland Clinic’s main campus achieved Magnet recognition in 2003 and was redesignated a Magnet hospital in 2008; Cleveland Clinic’s Fairview Hospital was granted Magnet recognition in 2009. Weber says that while the ANCC’s Magnet Recognition Program® does not specifically require that shared governance be in place, a healthcare facility would most likely have difficulty achieving Magnet recognition without full integration of the concept of shared governance.
The Magnet application manual, Weber says, defines shared leadership/participative decisionmaking as “a model in which nurses are formally organized to make decisions about clinical practice standards, quality improvement, staff and professional development, and research.” As part of applying or reapplying for Magnet recognition, healthcare facilities must demonstrate that they reflect and embody that model.
Beyond Recruitment: Evolving Strategies to Engage and Retain Nurses
An optimal patient experience requires an engaged nursing staff. With a national nursing shortage and a high rate of nurse turnover within hospitals (12.7 percent in Ohio), achieving the ideal level of engagement can be daunting. Leaders in Cleveland Clinic’s Stanley Shalom Zielony Institute for Nursing Excellence have risen to the challenge of engaging quality nursing staff by embarking on a long-term initiative focused on recruitment and retention.
The retention portion of the initiative, which kicked off in January 2012, aims to facilitate open communication between Nursing Leadership and new Zielony Nursing Institute employees, with the goal of maintaining a strong nursing staff that will enjoy productive and successful careers at Cleveland Clinic.
To support this effort, Sarah Sinclair, MBA, BSN, RN, FACHE, Executive Chief Nursing Officer and Chair of the Zielony Nursing Institute, has assembled a 45-person multidisciplinary committee that includes nurse managers, chief nursing officers (CNOs), associate chief nursing officers (ACNOs) and representatives from finance, human resources and marketing communications. As part of the initiative, committee members are personally spending time with new nursing hires throughout the health system. The informal, casual meetings are designed “to give the committee members the opportunity to learn about each person’s new hire experience, inquire about any needs or questions they may have and further help welcome them to their new roles,” Sinclair explains. Team members ask new hires if they have any suggestions for the orientation process and how they feel they have been able to acclimate themselves to their jobs. Also, Sinclair is encouraging individual hospitals in Cleveland Clinic health system to begin or continue their own recruitment and retention initiatives under the direction of their CNOs.
Casual conversations benefit new hires and leaders alike
Two of those CNOs — Kerry Major, MSN, RN, of Cleveland Clinic Florida, and Kelly Hancock, MSN, RN, NE-BC, of Cleveland Clinic’s main campus — offer new staff regular opportunities to meet with them personally and talk casually and candidly about their experiences as new employees.
Major meets with new employees 90 days after their hire in an informal gathering each quarter dubbed “Koffee with Kerry.” Between 50 and 75 percent of nursing employees hired in the previous quarter typically attend these events, in which Major and a human resources representative sit down and have coffee and conversation with the new hires. In addition to nurses, all new personnel additions to the nursing staff, including administrative employees, are invited.
Major began hosting her coffee events more than a year ago and says they help to “break down the barrier” between herself as CNO and her employees because the events give them the opportunity to get to know each other. “My employees are not afraid to approach me or give me feedback later because I met them early on in an informal setting,” she says. “When you break that barrier, your employees are much more amenable to talking to you. You’re no longer a faceless executive tucked away in an office somewhere.”
Among the issues discussed is the effectiveness of the onboarding process and orientation programs. Major makes an effort to find out if these programs were meaningful to the new hires by asking open-ended questions. She makes notes and gives feedback to the appropriate people, who may be directors, human resource managers or staff development personnel. As a result of comments from the conversations thus far, Major and her staff have made adjustments to the department-specific orientation program and improved the individual nurse coaching program. “This is really the best way to enhance your programs and get valuable feedback,” she says. “It’s a nice way to open the lines of communication.”
Hancock agrees. She has been holding regular lunches with her nursing staff since she became CNO of Cleveland Clinic’s main campus in July 2011. Her program, called “Chief Conversations,” is an informal way for her to recognize her staff’s accomplishments and for them to tell her what’s on their minds. “This has been a great opportunity for me in my new role,” Hancock says. “I’ve learned a lot, and it has really helped to guide my strategy for new initiatives and changes in current processes and programs.”
She speaks to her new hires as a group during their orientation and then reconnects with them at the Chief Conversations lunches, which are offered to all nursing employees. The lunches, which are held on main campus, are limited to 15 to 20 staff members in order to “accommodate a meaningful dialogue.” Hancock says some “great conversations” have taken place at the meetings and some ideas have been implemented as a result. One suggestion regarding peer interviewing was passed on to the directors and has been implemented for all nurses on main campus. Hancock says she has received much positive feedback on the Chief Conversations program and plans to continue it.
The first two weeks on the job are a key time to engage nurses, according to Deb Small, MSN, RN, NE-BC, who is CNO of Cleveland Clinic’s Fairview Hospital. Within that time frame, new nurses generally undergo a Performance Based Development System test to assess their on-the-job skills and critical thinking. That test, Small says, can be very intimidating, and nurses may need extra support to help them through this potentially tough time.
“In the first few weeks, along with getting nurses oriented clinically, alleviating fears and intimidation is really important,” Small says. “We spend that time getting new nurses adjusted to the culture here, getting their questions answered and doing what it takes to create a good job environment for them.” Each new hire is given a coach to whom his or her schedule is matched, and the two work together to help the new hire hone skills on a structured skill set list. The new hire also goes through an orientation process designed specifically for him or her.
At 45 and 90 days, the nurse manager and the coach meet with the new hires to find out how they are doing and what they need help with. Depending on which unit they work for, new hires may also spend a day with members of case management, pharmacy, phlebotomy or other areas, as part of the orientation process. Small says Fairview Hospital may eventually offer new hires a morning coffee program in which they can get together with other new hires to exchange ideas and information and gain support.
Retention efforts will continue to unfold
Under the leadership of CNO Dawn Bailey, BSN, RN, MAOM, Cleveland Clinic’s Euclid Hospital recently began implementing a plan to more closely address new nurse retention and turnover. One part of Bailey’s plan was an enhancement of her weekly staff rounding processes. Bailey holds informal meetings with all nursing new hires in the hospital at their 30-day mark. She asks them a short list of key questions to ensure that she’s aware of the main elements of their satisfaction with their onboarding experience, orientation, relationship with their coach, and overall reception in the workplace.
“We believe our nurses need to see and feel support from nursing administration,” Bailey says. “Nursing Leadership needs to be sure they are meeting expectations of our newly hired staff. To that end, my team of nursing directors will be helping me to keep in contact with these new employees at 60, 90 and 120 days.”
Another major focus for Bailey’s team is retention of older nurses. Euclid Hospital has highly tenured nursing and support staff, Bailey says, with a large number of RNs and LPNs poised to retire within five years. “We need to be creative and proactive in developing alternative shifts and roles that are less physically taxing on our older nurses. Alternative shifts will allow us to retain experienced nurses’ vast knowledge base and expertise in the practice environment,” she says, adding that she’s begun preliminary discussions with human resources on initiatives in this area.
Ultimately, a bundled approach with attention to ongoing twoway communication, collaboration between leadership and new nurses, and a focus that includes meeting individual needs may be the best approach for engaging and retaining nurses.
Taussig’s Responsiveness Project: Tapping Teamwork and Accountability to Improve Patient Experience
Providing world-class cancer care can be demanding. With more than 46,000 inpatients treated at Cleveland Clinic’s Taussig Cancer Institute in 2010 alone, Cancer Institute nurses understand this all too well. Despite competing demands and priorities of patient care, nurse leaders and staff throughout the Cancer Institute foster a supportive culture. They are aware of patients’ individual needs and believe that caregiver teamwork enhances their ability to be optimally responsive to patients.
The Cancer Institute’s efforts along these lines, dubbed Taussig’s Responsiveness Project, were initiated with the purpose of meeting inpatients’ needs quickly and effectively. The project was implemented in July 2011 and uses a systematic patient-centered improvement approach (see box for themes related to 17 improvements that target people, processes and technology). The project has measurable targets and expectations aimed at the primary project goal of delivering outstanding call-light responsiveness and improving patient satisfaction.
“Our focus is multifaceted and includes setting the expectations and creating a culture of teamwork, leadership and accountability, as well as establishing targets for responding to patients’ needs and leveraging our technology,” says Julie Fetto, MBA, BSN, RN, CHPN, OCN, Nursing Director, Taussig Cancer Institute. “The comprehensive approach, which includes sustaining our improvements through audits of the metrics and continuous feedback to the team, has been fundamental to our success.”
Fueling success through teamwork
Creating a plan to elevate overall responsiveness to patients’ needs across the Cancer Institute’s 103 beds in four units required a holistic, comprehensive approach involving all caregivers, including nurse managers, staff nurses and nursing assistants.
“Based on the breadth of factors that touch responsiveness, we had to evaluate the current state across all aspects of the institute, not just individual pieces,” explains Henry Buccella, Senior Director of Continuous Improvement for the Cancer Institute. “For 10 weeks after implementation, Julie Fetto and I rounded for an hour every week with a process scorecard to engage and involve all employees. We found that tapping into the capabilities of the health unit coordinators (HUCs) in regard to communications, accountability and urgency was a huge component of the project, in addition to better utilizing technology within our patient call-light communication system.”
A Responsiveness Project team worked closely with the HUCs to ensure they understood how important their roles were to quality patient care and patient satisfaction, define standard work expectations and priorities, and develop their role as champions of customer service. Ongoing support of the new initiative was achieved by identifying staff that had the most impact on process expectations and engaging them in developing solutions, according to Patti Akins, BSN, RN, OCN, Nurse Manager of the Bone Marrow Transplant and Leukemia Units. “It all goes back to everyone being here for the patient and ultimately how we can make the hospital experience better for them,” Akins says.
To do this, the project team reviewed the HUCs’ job description. “We recognized that they played a huge role in overall responsiveness to patient needs and nurse-patient communication to meet those needs,” says Anne Fitz, RN, MBA, CHPN, Nurse Manager, Harry R. Horvitz Center for Palliative Medicine at the Cancer Institute. “By making HUCs ambassadors of each unit, we empowered them to be in charge of navigating the patients’ call lights and requests to the front desks. Support from nursing leadership ensured that HUCs had a direct voice with nurses regarding patients’ requests.”
Support included a kickoff retreat. Nursing management used survey and focus group feedback from all HUCs to develop and strategize the best implementation plan. Once an implementation plan was drafted, the management team involved the HUCs in a retreat in addition to communicating the process, priorities and standard work improvement protocol. HUCs took the lead in accelerating the culture shift by promoting customer service, communication, teamwork, urgency and accountability. Leadership supported enhanced HUC visibility by recognizing good performance and offering coaching as needed.
“There is real-time accountability for the HUCs to answer patient calls within one minute and pass the request on to someone to meet the patient’s needs as quickly as possible,” says Kathy Day, BSN, RN, OCN, Nurse Manager, Medical Oncology.
Turnaround in patient satisfaction
Before the Responsiveness Project was implemented, the Cancer Institute’s Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient satisfaction scores were below the target range. Following implementation, the institute attained four months of sustained performance above 70 percent (73 percent represents the 90th percentile).
“The Cancer Institute’s patient satisfaction scores were in the middle of the pack comparatively across the system,” says Buccella. “We wanted to focus this pilot project on the institute and hit the ball out of the park. Our scores show that we’re doing it.”
The Role of rounding
Day credits purposeful hourly rounding, an initiative launched by Cleveland Clinic’s Stanley Shalom Zielony Institute for Nursing Excellence in 2010, as a primary component of the project’s success. Nurse managers systemwide were trained on key hourly rounding behaviors, including introduction (telling the patient your name and role); addressing the “four P’s” (pain, position, potty [toilet needs] and possessions/personal items); explaining the purpose of rounding and when you or others will return; and documenting the rounding. The goal is for nurses to make rounding “purposeful” every time. Nurses engage in a connecting moment with the patient at the end of each hourly visit to ensure that all needs are met.
Each day’s rounding activity is tracked as nurses sign a 24-hour log at the patient’s bedside. Real-time information is also reviewed through the call-light system, which Day reviews weekly to address any gaps in care. “Review of our 2011 data shows purposeful hourly rounding decreased the number of call lights by 50 percent,” she says.
The Responsiveness Project’s comprehensive focus is a win-win for patients and all caregivers involved. By readily meeting patients’ needs, the project reduces stress on the floor for the nursing staff. Further, reduced stress raises job satisfaction and fosters camaraderie, according to Fitz. “Although we’re not perfect and we continue to work each day on improvements, the movement to improve patient satisfaction is in place,” Fitz says. “We know that sustaining this is a daily effort, yet I feel it’s becoming ingrained in the culture. It’s still a huge amount of work, but it’s not as hard as it used to be because everyone knows that they are being supported.”
Seven Improvement Targets of Taussig’s Responsiveness Project
The Taussig Cancer Institute team implemented improvements in 17 areas targeting people, processes and technology. Examples include:
- Improved patient communication regarding responsiveness expectations and commitment, including health unit coordinator introductions and postdischarge letters from nurse managers
- Increased problem-solving frequency and effectiveness through problem-solving huddles for daily “abnormalities” (tracked via newly created process scorecards)
- Reduced risk through development and implementation of backup procedures for when a health unit coordinator is not available
- Increased urgency by defining/implementing an escalation process for over-target call times
- Better use of technology by changing critical call-light communication system settings to support best practices
- Better support of caregivers through creation of a support responsibility matrix for hardware, software, settings problems and needed reports
- More consistent visibility of RN/PCNA location and availability through tracking proper locator use and recommunication as needed
Letter from Interim Executive Chief Nursing Officer
Nurses are the largest sector of healthcare providers in the United States, with RNs alone accounting for more than 2.6 million healthcare jobs, according to the federal Bureau of Labor Statistics.1 With nurses’ influence poised to increase upon fuller implementation of the Affordable Care Act in 2014, we are looking ahead toward attention to primary care, prevention, career training and expanded nurse education. Changes in how care is provided — and by whom — are progressing rapidly. The challenge to nurses will be how fast they can acclimate and thrive in this evolving environment. There are many calls for action, and nurses are facing the future with a unified spirit dedicated to making a difference.
Nurses have been central to Cleveland Clinic from its beginnings over 90 years ago. Today, nurses at Cleveland Clinic reflect a united vision for the future of healthcare. Our nurses — more than 11,000 strong — are establishing themselves as equal partners and collaborators in comprehensive healthcare. Their growth is demonstrated by involvement in leadership and pursuit of additional certifications and advanced degrees. Nursing growth promotes career opportunities that were not available previously. Today, nurses can choose among a diversity of roles — acute or ambulatory care providers, educators, quality experts, managers and advanced practice nursing providers, to name just a few — across many specialties. Broadening nursing opportunities under the Affordable Care Act will make our world-class organization both stronger and more nimble.
In this issue of Notable Nursing, we share some ways in which our nurses support, encourage and empower one another to enhance care while furthering their profession. We include stories on promoting the advancement of nurse education, heightening bedside practice and decision-making, facilitating open communication between nurses and leadership, and providing systemwide initiatives that improve quality measures and patient satisfaction. Nurses at Cleveland Clinic are a strong voice that speaks to tomorrow’s healthcare reality.
The Zielony Nursing Institute is proud of our collaborative spirit and dedication to excellence. Our exceptional programming and innovations that support the broad scope of our nurses’ lives are examples of our commitment to deliver on the promise of world-class care. I hope you enjoy reading about the advances we make each day in nursing.
Becoming Baby-Friendly: How Lakewood Hospital Earned a Coveted Designation for Newborn Care
Cleveland Clinic’s Lakewood Hospital was designated a Baby-Friendly Hospital in March 2012. The hospital worked for more than five years toward gaining the designation from Baby-Friendly USA as part of the Baby-Friendly Hospital Initiative (BFHI), a global program sponsored by the World Health Organization and the United Nations Children’s Fund (UNICEF).
The BFHI encourages and recognizes hospitals and birthing centers that offer an optimal level of care for infant feeding. Since its launch in 1991, the BFHI has assisted hospitals in giving mothers the information, confidence and skills needed to successfully start and continue breastfeeding their babies (or to feed them formula safely) and has provided special recognition to hospitals that do so. Baby- Friendly USA is the nonprofit national authority for the BFHI in the United States.
UNICEF states that a hospital can be designated Baby-Friendly “when it does not accept free or low-cost breast milk substitutes, feeding bottles or [artificial nipples], and has implemented 10 specific steps to support successful breastfeeding.” These 10 steps are provided on the UNICEF website at unicef.org/programme/breastfeeding/baby.
“There is strong evidence to support breastfeeding as a best practice,” says Joyce Arand, MS, CNS, RNC, NEA-BC, Director of Nursing for Women and Children, Lakewood Hospital and Fairview Hospital. Compliance with the BFHI is endorsed by many professional health organizations, including the Association of Women’s Health, Obstetric and Neonatal Nurses; the American Congress of Obstetricians and Gynecologists; and the American Academy of Pediatrics. It is also endorsed by the Centers for Disease Control and Prevention, the National Institutes of Health and the U.S. Surgeon General.
Of the more than 15,000 hospitals and maternity facilities around the world that have been granted Baby-Friendly designation, 135 are in the United States (as of press time). Of these, Lakewood Hospital is only the fourth in Ohio and the first in Northeast Ohio.
A team effort
“It took a real team effort to make this happen,” says Lynn Barabach (photo above), MSN, RNC, Nurse Manager, Birthing Center and Teen Health Center, Lakewood Hospital. “We worked as a system to make evidence-based maternity care practice changes across the Cleveland Clinic birthing centers. We changed policies and educated our nurses and providers. We also educated our support staff so they would understand if a patient were to ask them about something related to breastfeeding.”
Lakewood Hospital adopted The Joint Commission’s Perinatal Care Core Measure on Exclusive Breast Milk Feeding in 2010, according to Coe Bell, BSN, RN, IBCLC, Manager for Perinatal Education. “This quality measure helps us assess the percentage of babies we deliver who leave our hospital having been exclusively breastfed,” Bell says. “Exclusive breastfeeding is important because babies who receive only breast milk in their first days of life are more likely to be breastfed longer.” She adds that the American Academy of Pediatrics recommends exclusive breastfeeding through the first six months of life, and breastfeeding along with complementary foods through the first year.
Many changes, one goal
To promote and support exclusive breastfeeding, the hospital has instituted the following:
Skin-to-skin care immediately after birth, if possible. The mother (or father, in some cases) is given the naked baby immediately after birth. She holds the baby “skin-to-skin” on her bare chest for an hour or more. Traditional weighing and measuring of the baby by nursing staff is delayed until after the initial feeding is completed. Immediate skin-toskin care has been shown to cause the mother’s temperature to rise to warm the baby, and it also helps regulate the baby’s heart rate and breathing, which better enables the baby to self-latch for breastfeeding.
Rooming-in. Lakewood Hospital’s birthing center has private rooms in which a mother labors, delivers and recovers in the same space. After delivery, the baby stays in the room with the mother and family, and the time that the baby is out of the room is kept to a minimum. This arrangement promotes family bonding, helps parents learn to care for their infant while expert care is close by and helps facilitate breastfeeding on demand.
Breastfeeding education and support. Classes led by international board-certified lactation consultants (IBCLCs) are available to pregnant women for teaching the basics and importance of breastfeeding. Hands-on support and education are available to new mothers while they are in the birthing center, and outpatient lactation support groups and help lines are available to mothers once they are discharged from the hospital.
Removal of items that do not support breastfeeding. Although the hospital is prepared with formula for mothers who make an informed decision to formula feed, it is not automatically offered. Also, the gift shop does not carry any bottles or items with nipples, such as pacifiers. “We try to remove as many barriers to breastfeeding as possible,” Barabach says. “It is still the mother’s choice whether to breastfeed, but we want to make sure it is an informed choice.” She notes that about 75 to 80 percent of new mothers leave Lakewood Hospital exclusively breastfeeding their babies.
Other System Hospitals Are on Baby-Friendly Path
In addition to Lakewood Hospital, several other hospitals in Cleveland Clinic health system — Fairview, Hillcrest and Medina — offer birthing services and have been preparing to meet the requirements for Baby-Friendly designation.
Fairview Hospital adopted The Joint Commission’s Perinatal Care Core Measure on Exclusive Breast Milk Feeding in April 2010 and has been working toward Baby- Friendly designation for the past five years. At press time, the hospital was scheduled to have an April 2012 on-site assessment by Baby-Friendly USA, one of the final steps in the process to obtain designation.
Hillcrest Hospital has been fulfilling requirements to become designated Baby-Friendly and has an on-site assessment scheduled for May 2012.
Medina Hospital has begun the process to pursue Baby-Friendly designation. Its goal is to have an on-site assessment planned by the fourth quarter of 2012 or the first quarter of 2013.
Changing Vascular Access Culture Through Knowledge and Empowerment
For many nurses, knowledge and experience gained through systematic training in vascular access is nonexistent or limited throughout their education and career. Yet more than 7 million central venous access devices and 160 million peripheral intravenous catheters are placed each year in the United States.1 This sheer volume presents many challenges for care, particularly in the area of central lineassociated bloodstream infection (CLABSI) prevention. Nurses at Cleveland Clinic are embracing the challenges of healthcareacquired infections through a unique program aimed at increasing knowledge of best practices in vascular access.
Vascular Access Resource Nurse Program
The Vascular Access Resource Nurse (VARN) program is a systemwide effort led by a multidisciplinary team composed of a vascular access specialist, a CLABSI prevention educator, an infection control preventionist, nurse managers and other nurse educators from four of Cleveland Clinic’s regional hospitals. The intensive eight-hour education program begins with a four-hour didactic section focused on nurse empowerment and broad vascular access evidencebased knowledge. Following the didactic section are five 30-minute hands-on, one-on-one workshops that focus on practical application of instruction related to central line dressing change, port access, central line removal, central line blood draws, occlusion treatments and assessment and treatment of extravasation.
“Our program allows participants to ask questions and apply evidence-based knowledge through hands-on competency stations,” says Nichole Kelsey, BSN, RN, Clinical Instructor, Nursing Education. “After completing the VARN program, participants leave with a comprehensive body of knowledge of vascular access nursing that empowers their everyday abilities.”
Knowledge is power
The VARN education program empowers bedside nurses by giving them the authority, knowledge and skills to facilitate best practice in vascular access, according to Chris Thomas, MSN, CNP, VA-BC, Manager, Vascular Access Services, Fairview Hospital. “Most of our participants were not taught any of this knowledge in nursing school, yet they are the most liable for vascular access complications,” explains Thomas, who has been teaching the VARN program since its first class in November 2010. “There are hundreds of programs that speak to educating nurses on vascular access, but we have something special that is raising the attention of vascular access specialists nationwide. We thought our approach would encourage nurses to take the lead in managing vascular access care needs, but we had no idea it would be this successful, to the point that physicians are asking for VARNs specifically.”
As experts of vascular access, Kelsey and Thomas are committed to spreading the message of the VARN program. Increasing local attention to the VARN program has been paralleled by increases in the number of nurses desiring to take the course. Over 500 nurses throughout Cleveland Clinic health system have completed the program, with 120- seat sessions filling in less than a week. And the training is making an impact.
“Due to the VARN educational program, we have 65 nurses who are championing this cause,” notes Alina Zakrocki, BSN, RN, Infection Preventionist, Lakewood Hospital. “I see how empowered they feel discussing central lines with physicians — they have the knowledge to collaborate with them about removing a femoral vein line quickly or discussing why it should not be placed at all. The program promotes team communication and collaboration, and we saw a reduction in CLABSIs in 2011.”
A focus on detail informed by big-picture thinking
As use of central catheters and intravenous lines increases due to high acuity, focus on the care surrounding their use needs to remain a high priority. Emphasis on details such as scrubbing for 30 seconds with chlorhexidine prior to line placement provides course participants with basic care details and expands their base of knowledge so they can offer better options for patients, says Zakrocki.
Karen Theodore, RN, Clinical Instructor, Medina Hospital, agrees. “As nurses, we perform many tasks routinely, but do we really think about why we do them?” she asks. “When completing vascular access audits each month, we ask ourselves if we are doing all we can to prevent CLABSIs. The VARN program causes a lot of excitement. Nurses have new knowledge and incorporate it into practice.”
As the program expands, its fundamental message remains clear: Education and practical training on best practices in vascular access are not just for new nurses or nurse managers — they are for everyone involved in the daily care of patients requiring a central line. “Administrative support for nurses to become a VARN is given at every level of leadership,” says Thomas. “Each day we ask how we can change the culture in a way that encourages our colleagues to share their knowledge and assertively apply their knowledge and skills to improve patient outcomes. The VARN program helps nurses make the Zielony Nursing Institute’s vision and mission a reality.”
1. Richardson DK. Vascular access nursing — practice, standards of care, and strategies to prevent infection: a review of flushing solutions and injection caps (part 3 of a 3-part series). J Assoc Vasc Access. 2007;12:74-84.
Using Core Measures to “Be Remarkable”
It’s been 25 years since The Joint Commission (formerly Joint Commission on Accreditation of Healthcare Organizations) announced its intentions to standardize core performance measures into its accreditation process. Core measures, which are always evolving, are now often regarded only for their ties to reimbursement and not their original intent of implementing evidence-based practice to improve patient care, according to Nancy DeWalt, RN, Nurse Manager, Progressive Care Unit, Cleveland Clinic’s Hillcrest Hospital.
DeWalt is the driving force behind Hillcrest’s “Be Remarkable” program, an initiative created to elevate clinical care. The program uses a core measure flow sheet to gauge the application and assessment of quality discharge measures for five medical conditions or areas (congestive heart failure, acute myocardial infarction, pneumonia, stroke and surgical care safety) and to instill the importance of improving patient satisfaction.
“For each of my 50 staff on the heart unit to ‘be remarkable,’they must apply all measures to every patient throughout each shift, regardless of the diagnosis,” explains DeWalt. “By using a flow sheet, we take a comprehensive approach to tracking congestive heart failure, acute myocardial infarction, pneumonia, stroke and surgical care improvement. To meet our priority of taking care of each patient the best way possible, we are inclusive of all potential needs. Currently, we are ahead of the curve on including Joint Commission-required measurement changes and additions, such as the pneumonia measures that were added in January 2012.
The impetus for the Be Remarkable program, implemented in June 2011, is to instill pride in the delivery of care. Organized through a unit practice council, the program is guided by a group of charge nurses who are champions for the cause. Through presentations, ongoing education and patient education fliers, staff reinforce the key principles of core measures and the importance of overall patient satisfaction that results from their attention to care.
“Regardless of core measures and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores, nurses should all want to be remarkable,” says DeWalt. “As a unit, we evaluate ourselves on how well we meet the needs of our patients and we strive to leave a positive lasting memory with each patient and family member. By utilizing our program’s flow sheet and patient education tools as a guide, we are reminded that each of us is the first line of patient satisfaction.”
The program is making a difference across the hospital, with nursing assistants and health unit coordinators being trained to use the Be Remarkable approach. “We have gone 374 days without a catheter-associated urinary tract infection and have not had any core measures below expectations in more than five months,” DeWalt says. “Also, our patient satisfaction scores have doubled and are still climbing.”
How to Write the Perfect Abstract
Writing an abstract is a craft that nurses are wise to master if they aim to be influential clinicians, researchers, administrators or educators. As with any craft, practice — guided by sound principles — is the key to mastery.
The abstract is a concise synopsis or representation of a research or clinical project, and is often required as part of a manuscript or presentation submission. “The successful abstract provides an overview of your work and offers enough detail to demonstrate the work’s importance,” says Nancy M. Albert, PhD, CCNS, CHFN, CCRN, NE-BC, Senior Director of Nursing Research and Innovation at Cleveland Clinic.
Abstracts of manuscripts should provide enough detail (together with article keywords) to help readers and database searchers determine if the full manuscript will meet their knowledge needs, Albert notes. For a presentation, an abstract is the basis on which meeting organizers decide whether to accept the abstract’s author as an oral or poster presenter.
Structured or unstructured?
Abstracts may be structured (with section headings) or unstructured (without headings), depending on the requirements of the targeted journal or requesting organization.
Most structured abstracts typically have five section headings (see sidebar), but the number and heading names may vary according to the criteria of a specific journal or requesting organization, the type of work being presented (quality improvement, innovation or research) and whether the intent is for an article or a presentation. For instance, standard section headings are more applicable to research studies and systematic reviews than to case studies or reports of quality improvement initiatives or innovative projects.
Typical Anatomy of a Structured Abstract
Background or Introduction.
This section tells readers why they should care about your work. It should be short (a single sentence, if possible) and identify a specific gap in knowledge about your topic. The aim is to hook readers and persuade them to read on.
Objectives or Purpose.
This is a statement of how your work will address the problem or gap in knowledge identified in the previous section. Once this purpose is set forth, the remaining sections should stay on topic and align with it.
This portion should be detailed enough to let readers understand how your project was carried out and gauge its rigor. For research projects, it typically touches on the setting, sample, research design, measurement/instrumentation, and data collection and analysis. Even for reports of different types of projects, such as a quality improvement initiative or a systematic literature review, the focus should be on how the project was designed and measured to fulfill its purpose, not on the process of how you made the project happen.
This section reports specific results for the major end points mentioned in the Methods section. This section is often the longest, and it needs to be structured to provide key points about the project’s aim, question or purpose. For research abstracts, report p values when significant and when space allows. Also, a table or figure, if easy to read, can trump text, so use one of these visual methods to show some results when allowed.
This is a summary of results. It should be focused specifically on addressing the project’s purpose or objectives. If the word count allows, it may also touch on implications of your findings or future research needs.
Breaking New Ground: Nurse Introduces Mobility Protocol to Neuro ICU
Protocol empowers nurses to help uniquely challenged patients return to mobility more quickly.
When Malissa Mulkey, MSN, CCRN, CCNS, started working in the neurological ICU at Cleveland Clinic’s main campus more than two years ago, she wanted to get her patients moving. “I thought we weren’t doing enough to promote early movement,” says Mulkey, a clinical nurse specialist who also cares for patients in the neurological step-down unit.
Early mobility is important in neurological ICU patients for the same reasons it is in other populations: to reduce the risk of hospital-acquired conditions such as pressure ulcers, to avoid prolonged length of stay due to weakness and deconditioning, and to lessen patients’ rehabilitation needs after discharge. These benefits fueled Mulkey’s interest in mobility, yet when she searched for early mobility protocols in the literature, she found none that were amenable to patients treated in the neurological ICU.
Mulkey found that neurological ICU patients were excluded from studies of early mobilization. “Nurses may be less comfortable getting these patients out of bed, given their medical diagnoses and unique needs and challenges, including confusion,” she observes.
Undaunted, Mulkey decided to adapt early mobility protocols from the literature to accommodate patients in a neurological ICU environment. After gaining support from ICU leaders and other ICU clinical nurse specialists, she authored an early mobility protocol specifically for patients treated in the neurological ICU. It was implemented in the neurological ICU on Cleveland Clinic’s main campus in late February 2012.
Once the physician writes an “activity as tolerated” order for a patient, nurses are charged with facilitating early mobility. The protocol leads nurses to advance patients through increasing degrees of mobility. It begins with steps like elevating the head of the bed by 30 degrees, turning and repositioning, and range-of-motion exercises, and it continues through steps such as weight bearing and standing or walking in the hallway. Criteria guide nurses on when to initiate and when to proceed to the next step; exclusion criteria are also included. Nurses use their clinical judgment and the patient’s response to mobility to advance through the protocol. Thus, patients can make progress without needing to wait for a new order before moving to the next step.
A designated nurse representative is temporarily assigned to a unit for several hours a day to encourage progression of patients through the protocol, to help with documentation and to provide assistance with the physical aspects of mobility promotion.
“The traditional thinking has been, ‘We can’t move these patients — they’re too sick,’” says Victoria Rhoades, BSN, RN, CCRN, Nurse Manager, Neurological ICU. “The mobility protocol aims to start these patients’ recovery as soon as possible because that will improve their outcomes. We look for even small increments of movement early on, and then help patients progress as far as they can before they go to the regular floor.”
Mulkey’s ultimate goal reaches even beyond that point. “Most of our patients have been going from the hospital to some type of rehabilitation center, not directly home,” she says. “I want to see if we can change that.”
More Moves Toward Mobility
The protocol has been complemented by a number of other recent mobility promoting changes to the neurological ICU. More physical and occupational therapists have been added, with some dedicated solely to the unit. Specially designed chairs with fold-down arms have been introduced. Portable lifts are available with disposable slings, and bed features make it easier to get patients out of bed regardless of their weight or physical handicaps. Unit nurses have been trained by physical and occupational therapists to use the chairs and new bed features and were offered additional instruction in body mechanics.
Detecting Delirium in the Neuro ICU
Nurses champion efforts to monitor for delirium in a setting where it has largely been neglected — and where it can prove particularly damaging.
Despite being a neurological condition, delirium has not traditionally been monitored for in neurological ICUs across the nation even though it is widely assessed in other critical care settings. That’s because its symptoms closely resemble those of many potentially lethal neurological conditions, including vasospasm, cerebral edema, meningitis and encephalopathy, according to Kate Klein, MS, ACNP-BC, RN, CCRN. “The fear is that if we call these symptoms delirium early on, we might miss — or mistreat — a life-threatening condition,” explains Klein, who works as a nurse practitioner in neurological ICUs at Cleveland Clinic’s main campus.
Nevertheless, early identification and treatment of delirium in neurological ICU patients matters. The longer these patients remain in a state of delirium, the harder it is for them to emerge from it, and the worse their long-term outcomes are. “If we can detect delirium early, we can use pharmacologic and nonpharmacologic interventions to help resolve this transient neurologic derangement and help patients recover faster,” Klein says. “It’s about not looking at patients solely in the short term, which used to be the prime focus in critical care, but doing more to prevent morbidity in the longer term — getting patients home, back to work, back to their daily activities.”
Delirium also matters because it affects 30 to 80 percent of ICU patients and is a major driver of ICU costs, Klein notes. These and other factors spurred a growing interest in assessing for delirium in critically ill patients with primary neurological injuries. The need for assessment generated the desire to validate a tool for use in the neurological ICU. Interest has focused on two instruments that are wellvalidated in other ICU settings:
The Confusion Assessment Method for the ICU (CAMICU),designed from the DSM-IV criteria for delirium, assesses for fluctuations in mental status, inattention, level of consciousness and disorganized thinking. It can be administered in approximately five minutes by the bedside nurse.
The Intensive Care Delirium Screening Checklist, an eightitem checklist of delirium characteristics based on DSM-IV criteria for delirium. It is completed by the bedside nurse as part of daily charting over the course of at least an eighthour period.
Klein and other nursing colleagues are currently investigating whether either of these tools or the neurointensivist’s subjective impression can be validated for use in the neurological ICU.
Until an instrument is validated in this setting, Klein and her colleagues focus on what they can do at the bedside to mitigate suspected delirium in their patients. “The goal is to help patients recover from their injury and provide necessary treatment, which often involves simply normalizing their day,” she says. This is done by frequent orientation to surroundings, date and time. Also, getting patients moving as early as possible, having them sit in a chair so they can better interact during family visits, and facing them toward the window so they can see if it is day or night can be highly beneficial in promoting clear, organized thinking.
Reassurance also is key. “We tell patients that delirium is common in this setting and that delusional thoughts are not unexpected,” she adds. Klein is hopeful about prospects for identifying the best monitoring tool and ultimately the most effective treatments. “People are using the word ‘delirium’ in this setting now. That’s a recent development. There’s a growing appreciation of how damaging delirium can be in patients with critical illness and how changes in the early phases of care can improve these patients’ longterm outcomes.”
Assessing Education Needs of Asthma and COPD Patients in the ED
The volume of patients who present to emergency departments (EDs) with asthma or chronic obstructive pulmonary disease (COPD) is high. Cleveland Clinic ED nurses were prompted to wonder if they could better target educational efforts to patients’ information needs to reduce future ED use for these chronic, manageable conditions.
“We weren’t sure whether patients were coming to the ED for asthma/COPD because they lacked knowledge about managing their condition or because of other factors,” says Robbie Dixon, RN, an ED nurse at Cleveland Clinic’s main campus.
Although numerous tools are available in the literature for assessing patients’ educational needs about asthma and COPD, Dixon and her colleagues found no studies that used available tools in the ED setting.
So they developed and conducted a cross-sectional, correlational study using survey methods to assess the information needs of patients treated in the ED for asthma or COPD and to determine if patient characteristics were associated with information needs about these conditions.
Dixon and colleagues modified the Lung Information Needs Questionnaire (LINQ), a validated tool designed to measure patients’ need for information about their respiratory disease. They used the LINQ’s 16 questions that gauge patient knowledge across six domains:
- Disease knowledge
The questionnaire includes four demographic questions; however, to determine which factors might be associated with patients’ levels of information needs, the researchers added eight additional patient characteristic questions.
They administered the questionnaire to patients aged 13 to 90 years who resented with asthma or COPD exacerbations at two EDs in Cleveland Clinic health system (a tertiary care urban ED and a suburban community ED) from mid-2009 to mid-2011. Patients who participated were sufficiently alert and aware, and had at least one other ED visit for asthma or COPD in the prior year.
Low to moderate information needs revealed
More than 150 patients completed the questionnaire. “The total LINQ scores showed that patients had low to moderate information needs based on the domains studied and in the overall score, reflecting some gaps in information needed to provide optimal self-care,” explains Dixon.
Patients’ needs were greatest for information on diet and disease knowledge. Information needs levels were lower for exercise, smoking, medications and selfmanagement, but information need gaps were present for all domains.
In analysis of patient characteristics, only two factors were associated with total LINQ scores: patients who had a primary care provider (PCP) had lower overall information needs, as did patients with higher incomes.
When results were analyzed by individual knowledge domains, information needs were significantly associated with at least one patient characteristic for all domains but one — exercise. The two characteristics most frequently associated with level of information needs in specific domains were whether patients lived alone and whether patients had a PCP. Living alone correlated with greater information needs regarding medications, self-management and smoking. Not having a PCP correlated with greater information needs about medications and smoking.
“In light of these findings, we need to do a better job getting patients to schedule an appointment with a PCP before they leave the ED, since having a PCP correlates with better overall information levels,” says co-investigator Nancy M. Albert, PhD, CCNS, CHFN, CCRN, NE-BC, Senior Director of Nursing Research and Innovation. “Income level and living alone are nonmodifiable characteristics that have important effects on information needs. Although we cannot alter patient income or their status of living alone, we can create processes and systems that encourage patients to seek care from a PCP and have their knowledge needs met outside the ED setting.”
Study Gauges Consistency in CLABSI Classification
Increased focus on central line-associated bloodstream infections (CLABSI) led Cleveland Clinic infection prevention nurses to study consistency in applying the CLABSI definition.
Reducing CLABSI has become a growing priority for infection prevention. It is important for infection prevention teams to reliably and consistently classify CLABSI so that nursing units are aware of their true rates of occurrence and can better promote patient safety interventions.
“CLABSI are considered preventable, so they are starting to be factored into healthcare quality indicators and reimbursement,” says Megan DiGiorgio, MSN, RN, CIC, of the Department of Infection Prevention at Cleveland Clinic’s main campus. “As bedside caregivers are asked to review infections to determine how they could have been prevented, we need to ensure consistency in applying the definition of CLABSI.”
The challenge of classification
That is not always an easy task. While her department follows the Centers for Disease Control and Prevention (CDC) definition for CLABSI, DiGiorgio says the definition does not always reflect clinical presentation of the patient. That’s particularly the case in special populations, such as hematology-oncology patients, since the CLABSI definition was developed primarily with medical or surgical patients in mind.
To examine their department’s consistency in defining CLABSI, DiGiorgio and her fellow infection preventionists conducted a descriptive, correlational, cross-sectional study in which they randomly selected two blood cultures each day from all positive cultures drawn from hospitalized patients at Cleveland Clinic’s main campus. Each blood culture was evaluated for CLABSI separately by two infection prevention nurses randomly selected from an overall team of eight infection prevention nurses who participated in the study. The aim was to determine the inter-rater reliability of CLABSI classification for each specimen. Blood cultures were evaluated each day for nearly four months to achieve the 165 cultures needed for adequate statistical power.
Promising levels of reliability
DiGiorgio and her colleagues are pleased with the results of their study, which they are preparing for publication. “The level of inter-rater reliability that we found is higher than the levels reported in many studies of inter-rater reliability of different infections in other clinical settings,” DiGiorgio explains. She adds, however, that few existing studies of inter-rater reliability of CLABSI classification based on current CDC definitions were available for comparison.
The findings highlight the challenge of applying the CLABSI definition in a complex clinical setting, DiGiorgio says.
In this study, DiGiorgio and her research team also collected data on some characteristics of infection prevention nurses to examine factors associated with CLABSI inter-rater reliability. Nurse characteristics (for example, length of time as an RN, length of time in current job, certification in infection prevention and other factors) were not associated with consistency in classifying CLABSI between two raters. These results indicate that orientation and ongoing team communication about issues affecting optimal CLABSI classification are being addressed in a way that promotes consistency in carrying out classification procedures.
DiGiorgio hopes this study may spur other hospitals to consider similar investigations. “It provided an opportunity to examine a facet of our daily work,” she notes. “We hope to encourage others to explore research opportunities in their work. That’s what we did, and it served as a valuable learning tool for our department.”
Nurses of Note
Kathy Burns, MSN, RN, ACNS-BC, CEN, has a number of “firsts” to be proud of. She recently became the first — and only — clinical nurse specialist at Cleveland Clinic’s Medina Hospital, where she has worked for the past 17 years.
She also led the hospital on its journey to becoming the first and only hospital in its county to be certified as a Primary Stroke Center by The Joint Commission. The certification, which came in December 2011 as a result of Burns’ leadership over the previous year and a half, is a “huge benefit to the community,” she says. Burns coordinated the stroke program and led the team that educated hospital staff on the signs of stroke, treatment options, risk factors and care of stroke patients in preparation for The Joint Commission survey. As Stroke Coordinator for Medina Hospital, Burns continues to provide education on stroke not only to her colleagues but also to patients and the surrounding community.
Burns’ successes also include chairing the Central Line- Associated Bloodstream Infection Team at Medina Hospital. Under her leadership, the team worked to decrease the incidence of central line infections in patients in the ICU. Medina Hospital won national recognition for this initiative from the U.S. Department of Health and Human Services in May 2011.
Burns, her husband and their two sons have been actively involved in Boy Scouts of America for the past 12 years. In 2005, Burns volunteered as a nurse for the National Boy Scout Jamboree in Virginia, an event that draws about 40,000 Boy Scouts every four years for 10 days of physical challenges. In 2009, she was asked to serve as the first Chief Nurse/Deputy Chief Medical Officer for Nursing for the Jamboree. In that role, Burns developed educational programs, supervised staffing for 20 medical facilities and worked on logistics and disaster planning for Jamboree Medical Services. She and her staff also were responsible for teaching the medical team to use the electronic medical record.
Burns has been asked to repeat her service in that role for the 2013 National Jamboree. She also was appointed to serve on the National Health and Safety Council for the Boy Scouts of America — another first, as no nurse had previously been named to serve on this national committee.
During the 2009 National Jamboree, Burns led a research study to determine if there was a relationship between weight and the severity of injury in adolescent males participating in the Jamboree. Results of this research helped guide participant requirements for the 2013 Jamboree and were published in Journal of Pediatric Nursing in November 2011.
Mary Noonen, BSN, RN, BC, is a clinical instructor in the Nursing Education Department and certified in nursing professional development. She is a firm believer in continuing to challenge oneself throughout one’s nursing career.
“Nursing is continual growth,” she says. “You can become an expert in an area, but there is always room to grow.” She practices what she preaches by getting involved in nursing projects and activities that allow her to stretch beyond her clinical instructor role.
For example, last year Noonen was asked by nursing leadership to represent Cleveland Clinic’s South Pointe Hospital on the systemwide nursing research council. She embraced the opportunity and is really enjoying it. “I am a novice researcher,” she notes. “But you have to grow to become an effective instructor and presenter. It was a wonderful opportunity to be asked to join this council.”
As a result of her appointment to the council, Noonen helped coordinate various educational opportunities with regard to conducting nursing research for internal Nursing Education Department staff as well as hospitalwide staff. She reports information she gleans from the research council at each staff meeting and regularly reminds her colleagues to consider research and evidence-based practices whenever possible.
As a clinical instructor, Noonen is based at South Pointe Hospital, but she travels throughout Cleveland Clinic health system to teach. She has helped roll out several “just-in-time” educational in-services for various nursing units. These include the development of online modules and floor instruction on topics including malignant hyperthermia, an agitation sedation scale and dofetilide protocols. Noonen also teaches basic and advanced life support as well as pediatric advanced life support classes and serves on the orientation team charged with nurse onboarding.
Noonen received the 2011 Excellence in Nursing Education– East Region Award as part of Cleveland Clinic’s annual Nursing Excellence Awards. Her award was based on nominations she received from peers recognizing her excellence and expertise related to education of nursing staff. Numerous staff members from across the health system nominated Noonen for her many contributions.
“This is an extraordinary honor,” she says. “I am blessed to work with phenomenal co-workers. Everyone wants to deliver a high-quality product, which keeps the bar high for everyone.”
Noonen, who is pursuing her MSN degree, has worked at Cleveland Clinic since 1993. When a back injury forced her to give up bedside nursing, she was naturally drawn to the Nursing Education Department. “I’m very happy being a clinical instructor,” Noonen says. “The beauty of this job is the variety of things I can be involved in.”
She adds that she has been fortunate to have had very good mentors who have “ignited my love of nursing.” She encourages new nurses to seek out good mentors as well. “You can’t quit learning,” Noonen says. “You have to keep asking questions.”
Anne Vanderbilt, MSN, CNS, CNP, is passionate about the geriatric patients she works with on a daily basis. She has spent the past 11 years at Cleveland Clinic’s main campus caring for them, educating them and her colleagues, and conducting research on issues affecting this “especially vulnerable group.” “These patients need and deserve dedicated and highly trained skilled providers,” she says.
Vanderbilt believes that most nurses who specialize in geriatrics do so because of a personal experience. And she is no different. Her inspiration was her grandmother, to whom she was very close. She was involved in her grandmother’s care and saw her through a serious illness. Vanderbilt’s mother was a nurse as well who cared for patients in a nursing home.
Vanderbilt’s current work at Cleveland Clinic involves spending half of her time in the Nursing Education and Professional Practice Development Department, where she develops educational programs for her fellow nurses and other healthcare professionals and conducts research. She spends the other half of her time working with outpatient geriatric patients.
“I like the balance of research, education and clinical practice,” she says. “It’s exciting to impact patients and the profession of nursing on many different levels.”
In late 2011, Vanderbilt partnered with a physical therapist to address a chief issue in older adults — falls. Together they developed a specialty falls clinic in which they work with older adults in the community who are at risk for falls. Through the clinic, which is offered a few times a month, Vanderbilt and her partner provide an interdisciplinary evaluation of each person, which includes a review of their medications and an assessment of their strength and physical abilities. Based on this information, they offer recommendations on how each person can minimize his or her fall risk.
Vanderbilt also works to educate her colleagues by coordinating and teaching the Geriatric Resource Nurse Program — a model of care for hospitalized older adults that is recognized as a best practice by the Nurses Improving Care for Healthsystem Elders (NICHE) program, of which Cleveland Clinic is a member.
Through NICHE, Cleveland Clinic was invited to participate in a federally funded investigation along with 11 other hospitals to study catheter-associated urinary tract infections (CAUTIs) and practices surrounding catheter use. Vanderbilt was chosen to be the principal investigator for Cleveland Clinic in the 18-month study, which began in 2010. Because CAUTIs are now considered a quality measure, there is “now much more awareness of appropriate catheter use and duration,” Vanderbilt says. “Urinary catheters used to be thought of as benign devices of convenience but now are viewed more as an intervention with benefits and risks.”
Vanderbilt was the principal investigator on a study Cleveland Clinic main campus nurses conducted independently in 2005 on urinary catheters. She is also involved in a research study of known risk factors for delirium in patients undergoing elective orthopaedic surgery.
Maryann Yavor, MSN, RN, is known at Cleveland Clinic’s Hillcrest Hospital for her motto: “It’s all about the babies.” As Nurse Manager of the Neonatal Intensive Care Unit (NICU) there, Yavor says that she and her staff of 95 all naturally feel this way.
“No matter what decision is made, every decision hinges on what’s best for the babies,” she says.
This is tangibly evident in the newly renovated NICU at Hillcrest. The new unit, which opened in November 2010, features 24 private rooms and a host of amenities that facilitate the family-centered care that Yavor and her team believe is so important.
While plans were being made for the renovation of the unit, Yavor made sure that her team had the opportunity to contribute their ideas and suggestions.
“Through shared governance, all nurses had the opportunity to focus on what they thought was most important,” she says. “They all came together and contributed ideas. I respected their opinions and listened to all of them.”
She led the team in giving opinions and feedback on what the new NICU should be. Spearheading this process is one of the things she is most proud of in her 30-plus years on the unit. She has been the nurse manager for six years.
“I truly believe in lateral leadership — the sharing of ideas,” Yavor says.
Her team is very close despite more than doubling in staff size to accommodate expansion of the unit. She says the focus was on hiring nurses with experience to staff the unit, but she also hired new graduates who shared her team’s passion.
With the renovation of the unit, Hillcrest’s NICU also transitioned from a Level II to a Level III facility — a big jump in critical care that presented a positive professional challenge to her staff. The change to a private room setting also required flexibility from her staff, as they were used to seeing each other and communicating in one main NICU room. But with the constant use of personal hands-free communications technology, her nurses are able to communicate with each other just as quickly and are now comfortable in the private room setting, which is ultimately advantageous to the babies.
Yavor encourages her staff to attend national conferences and supports them in developing and attending local neonatal nursing education days to promote advancement of knowledge in the neonatal nursing specialty.
Under Yavor’s leadership, daily rounding on the unit has grown to include individual teams that involve pharmacists, social workers, physicians, nurses, and occupational, physical and respiratory therapists.
“We are successful because we are a multidisciplinary team,” she says. “We believe that neonatology is a team sport. Everyone, including the parents, has input on the baby’s care for the day.”