Notable Nursing: Fall 2013
Empathy: Finding the Connection that Makes Good Nursing Practice Great
Caregivers share how and why Cleveland Clinic makes empathy a priority.
“You can tell how much nurses care by how they enter and exit your room.” That’s what a patient who was blind from diabetic retinopathy told Cleveland Clinic nurse researchers earlier this year who were studying caring behaviors. “I’m very attuned to sounds,” explained the patient, who paid close attention to the footfall of nurses during his frequent hospitalizations for complications of diabetes. “Some nurses think they can sneak in and check on an IV line and leave without my knowing they were here. They’re so rushed, and it leaves you feeling neglected.”
During the patient’s current stay, however, he was moved by several nurses whose footfall was far more measured and who actively engaged him when checking his lines. “They allowed me time to interact,” he said. “They took my hand and said, ‘Mr. Smith, I’m so-and-so, and I’m going to be taking care of you. What’s the best way for me to care for you since you cannot see me?’ They would wait for a response and actually absorb it. When our exchange was over, I heard them walk slowly out of the room. I didn’t feel like they were just rushing off to the next patient.”
Patients look for empathy
Not every patient may be as acutely attuned as this man, but the point is clear: Patients notice nurses’ behaviors and demeanor, and patients are looking for — and are often in real need of — empathy from nurses and other caregivers.
Take the case of three patients interviewed for the same research study of caring behaviors. All were men with diabetes who suffered blood sugar lows while hospitalized. “Blood sugar lows are very unsettling for patients because they can be dangerous and leave patients feeling fatigued and ‘spent’ for the rest of the day,” explains Mary Beth Modic, DNP, RN, CNS, CDE, a clinical nurse specialist who interviewed the patients. “We quickly treat these patients with 4 ounces of juice and then wait 15 minutes to recheck their blood sugar. Nurses know that hypoglycemia is a risk associated with insulin, so there’s a potential for nurses to become desensitized to how distressing these episodes are for patients. All three men expressed how grateful they were that their nurses stayed to reassure them and monitor their response. That hadn’t always been the case during these patients’ past hospitalizations.”
New attention to a bedrock value
Empathy — the ability to put oneself in another’s shoes — has been a bedrock value of nursing since the profession’s earliest days, but it has drawn increased attention in recent years, due largely to a growing focus on patient experience. “Empathy is a core component of patient experience, and our nation has seen a surge of interest in patient experience,” says Donna Oliver, BSN, RN, MBA, Director of the Best Practice Department in Cleveland Clinic’s Office of Patient Experience.
As one of the first medical centers to hire a patient experience officer and create an Office of Patient Experience, Cleveland Clinic has helped lead that surge. “Our health system has made a mark by committing real resources to patient experience,” Oliver says, citing Cleveland Clinic’s Patient Experience Summit (subtitled “Empathy + Innovation”) as one example. The fourth offering of the annual three-day summit, which took place in May, drew more than 850 attendees from 34 states and 30 countries. “Ours is the only provider-organized summit on patient experience,” Oliver says. “Many attendees are newly assigned to the task of improving patient experience at their organizations, so they come looking for direction on where to begin. We also get calls from other hospitals about how to go about developing a patient experience program. Interest has certainly been raised.”
Oliver attributes that interest to increasingly educated patients who are defining what their experience should be. “High-quality care has become a standard expectation for many patients,” she says. “Increasingly, qualities that differentiate us and may be associated with patients’ choices of where to receive healthcare are in the nonmedical, non-healthcare-delivery-related aspects of ‘care’ that haven’t always gotten their due. Some examples are how empathic we are and how well we communicate with patients, listen to them and explain things so they understand. Patients now demand these experiential elements of care.”
Patient experience: Making the magic happen
To promote patient-experience elements of care at Cleveland Clinic, the Office of Patient Experience is charged with identifying and developing toolkits and resources to help caregivers provide a better patient experience. Although the office works with all caregivers, nursing is the primary focus. “The magic of patient experience usually happens at the bedside, and nurses are the caregivers at the bedside,” notes Lynn Woicehovich, BSN, RN, MPA, RRT, Director, Planning and Improvement, Best Practice Department, Office of Patient Experience. She says the office focuses on three areas to achieve the greatest impact:
- Engaging caregivers
- Building best practices around patient experience
- Engaging patients for their feedback
“For our patients to have a good experience, our caregivers need to be engaged and have an optimal experience as well,” Woicehovich explains. This includes making sure they have requisite competencies such as customer service skills and empathy skills.
The six patient experience managers and project managers in the Office of Patient Experience’s Best Practice Department devote much time to introducing or improving best practices such as purposeful hourly rounding, nurse leader rounding and bedside shift reports. “Our front-line staff do not have time to continually investigate the literature for advances in patient-experience best practices,” Woicehovich says. “We do that for them, by researching what others are doing, creating processes to standardize successful pilot projects, creating toolkits for best practices, gaining buy-in from stakeholders and instructing caregivers on implementing best practices.” The Best Practice Department team strives to incorporate new processes into what busy nurses are already doing rather than adding other tasks to their lists. “We’re looking to help nurses do what they’re already doing in a slightly different way, to ensure that opportunities for empathy and optimizing patient experience are taken advantage of.”
What Does Empathy Mean
6 Perspectives from Cleveland Clinic nurses or those touched
“Empathy is pretty much synonymous with communication. When it comes to patient experience, all roads lead to how we communicate with patients, and at the core of that communication is empathy.”
Lynn Woicehovich, BSN, RN, MPA, RRT
“Empathy is so important because everyone has a story. If you don’t make an effort to learn a patient’s story, you have no idea what they may be dealing with.”
Ione Freedman, MSN, RN
“Empathy is sojourning with someone so that you acknowledge their suffering or anxiety and you ease their burden in some way. We cannot always fix things, but we can let patients know we are there for them and will not let them feel alone.”
Mary Beth Modic, DNP, RN, CNS, CDE
The Golden Rule
“Empathy comes down to treating patients the way you’d want your child or parent to be treated, and extending that treatment to the patient’s family.”
Mike Wilson, father of two Cleveland Clinic patients and aspiring future nurse
“Empathy is a mode of understanding that involves emotional resonance with another person and making a connection with that person. It’s about relationship-based care and forging a relationship.”
Joan Kavanagh, MSN, RN
A Lived Experience
“Empathy is a lived experience. If I want to foster empathy in you, I’d better be living it with you. People who live and work in empathic communities will become empathic, for the most part.”
Kirste Carlson, DNP, RN, CNS
Can empathy be taught?
When asked if empathy can be taught, Oliver makes a distinction between empathy and empathy skills. “If someone doesn’t have a core desire to treat others with empathy, I don’t think we can impart that,” she says. “But there are caregivers with that desire who might not be fully equipped with the skills to always bring empathy into play effectively. That’s where we can make a difference.”
The tools Cleveland Clinic uses to that end include its foundational Communicate with H.E.A.R.T.SM model for excellence in customer service. The model is designed to promote Cleveland Clinic’s key expected service behaviors among caregivers when they interact with patients, visitors and co-workers. It includes interactive workshops and other activities as well as mnemonics for dealing with patients and their families. One example is the S.T.A.R.T. with Heart® tool, which recommends that caregivers always practice the following:
- Smile and greet warmly
- Tell your name, role and what to expect
- Active listening and assist
- Rapport and relationship building
- Thank the person
A similar mnemonic, Respond with H.E.A.R.T. ®, is tailored to situations when caregivers need to respond effectively to patient service complaints. “The Communicate with H.E.A.R.T. model helps prompt caregivers toward words and actions that demonstrate empathy to patients and families,” Oliver says.
Simulation opens eyes to empathy-building opportunities
Another tool for fostering empathy is the simulated patient care scenarios that new nurses participate in during orientation or residency. These simulations, which are recorded on video, present a great opportunity to give feedback on how nurses communicate with patients. “Nothing brings home to nurses their tone of voice, eye contact and nonverbal cues when interacting with patients as well as watching themselves on video,” says Joan Kavanagh, MSN, RN, Associate Chief Nursing Officer, Clinical Education and Professional Practice Development. “Our simulation lab allows caregivers to critique themselves and develop skills of empathy and emotional attunement. Nurses see themselves through a different lens.”
Simulation with video is used in similar ways to spur empathy-building behaviors during onboarding of unlicensed nursing personnel such as patient care nursing assistants (PCNAs). “For example, if a PCNA tends to just stand in the doorway when interacting with patients,” says Kavanagh, “video can help make the PCNA aware of the amount of distance separating them from patients and how their distance might create emotional distance as well.”
Empathy in all directions
The relationship-based care components of the Zielony Nursing Institute’s Professional Practice Model are another tool for promoting empathy among nurses. “Because making a connection and establishing a relationship with patients is crucial to empathy, our Professional Practice Model is foundational to empathic care,” Kavanagh says.
“We tend to think of relationships with patients when we think of empathy,” she adds, “but empathy for fellow caregivers is critical too, particularly among nursing leaders. The essence of empathy is imagining what another person’s situation feels like, so when nursing leaders’ decisions are informed by empathy, they are more likely to bring about changes that improve bedside nurses’ day-to-day work situations. Empathy facilitates trust, which is so important.”
Equally important is recognizing that practicing empathy requires having empathy for oneself, says Cleveland Clinic clinical nurse specialist Kirste Carlson, DNP, RN, CNS, who spoke on this topic at Cleveland Clinic’s 2013 Patient Experience Summit. “Empathy for oneself starts with taking deep breaths when you’re stressed, getting enough exercise, and eating less junk and more fruits and vegetables,” says Carlson, who is also a Gestalt therapist. “When we’re with patients, even if we say all the right words, if we don’t look and feel like we have the energy and presence to really care, patients aren’t going to believe we care.”
Carlson’s advice dovetails with wellness initiatives that are widespread at Cleveland Clinic and increasingly throughout U.S. culture. “Our organization is doing a great job weaving these expectations — and opportunities to fulfill them — into our daily lives,” she says, noting that it’s a development she’s seen accelerate over the past few years of her 30-year career here.
Modic, the aforementioned nurse who worked on the research study of caring behaviors, is another longtime Cleveland Clinic caregiver struck by the increasing priority given to empathy. “Although it was always important, it’s now gaining more prominence,” Modic says, citing initiatives like Cleveland Clinic’s award-winning viral Empathy video (see sidebar, p. 7) and a daylong course from the Office of Patient Experience on relationship-centered communication. “Devoting eight hours from a busy caregiver’s schedule to help them enhance their empathy skills speaks to this as an organizational priority.”
‘We are all caregivers’
Just as empathy is expected to inform caregivers’ interactions with everyone, it can make a profound difference no matter who it comes from. No story illustrates this better than the experience of Mike Wilson, father of two young children treated for a number of years at Cleveland Clinic for a rare mitochondrial disease that can cause various body systems to fail. Wilson’s children contend with seizures, muscle disorders, gastrointestinal problems requiring gastrostomy tube feeds, susceptibility to infections and a host of other complications from their condition. Caring for these children has dominated the daily lives of Wilson and his wife for years, requiring frequent hospitalizations and causing untold stress and anxiety.
Wilson is remarkable for his resilience and optimism despite the stress, but last fall one of his children was back in the hospital at Cleveland Clinic with potentially lifethreatening toxic megacolon. “I was incredibly down that day,” Wilson remembers. He went to a rooftop pavilion at the hospital to seek solace, where a food service worker was having her meal break. “This woman could tell from my face that something was wrong,” Wilson recounts. “She said, ‘You’re having a hard time, aren’t you? Tell me what’s the matter.’ So I told her what was going on. She totally stopped what she was doing, came up and gave me a long hug and said, ‘Hopefully it’s going to be all right. I’m praying for you.’ Although she had no special medical knowledge, she made an immeasurable difference to me. I was really upset, and she calmed me down and helped me recenter my focus. Even though she was on her own time, even though she didn’t know me, she reached out at the right time and showed she cared. And it really helped.”
Wilson says his years of interacting with the healthcare system for his children have spurred him to start making plans to go to school to become a nurse. He says acts of empathy like this have fueled his interest. “I’ve been struck by Cleveland Clinic’s philosophy that every employee is a caregiver, from those who clean the rooms to those at security desks. I’ve seen that philosophy at work here, and I aim to embody it myself by trying to engage folks I see in waiting rooms who look like they need to talk. Anybody can change a diaper, take a temperature and even give meds, but what really makes a difference is when you feel that somebody cares when they walk in the room. That’s the kind of caregiver I want to be.”
Out of the Office and Onto the Floors
Monthly rounding brings nursing leaders and other executives face to face with front-line staff and patients.
Associate Chief Nursing Officer for Quality and Practice
Dana Wade, MSN, RN, CNS-BS, CPHQ (center),
gets input from Jessica Christmyer, BSN, RN,
Katie Lehtinen, BSN, RN, and Eric Watson, BSN, RN,
during executive leadership rounding.
During monthly executive leadership rounding at Cleveland Clinic’s main campus last year, front-line nurses on a medical-surgical unit mentioned that they didn’t always have access to IV pumps for medication delivery. Hospital leaders heard the complaint and worked with the Department of Clinical Engineering to resolve the problem. If an IV pump is unavailable, staff now call a five-digit number — 24 hours a day, seven days a week — and receive a clean, packaged pump within 30 minutes.
“To this day, nurses still sing the praises of this change in practice,” says Kelly Hancock, MSN, RN, NE-BC, Executive Chief Nursing Officer. “We were able to improve their work environment and impact patients. That’s powerful.”
Cleveland Clinic instituted executive leadership rounding at its main campus two years ago and at its eight Northeast Ohio community hospitals (and one affiliate hospital) in December 2012. Each month, the executive team, their direct reports, institute administration, and physician, nursing and other nonphysician leadership break into teams of three and round at assigned inpatient and outpatient locations. They listen to issues and suggestions from front-line staff and use that feedback to enhance the patient and caregiver experience at Cleveland Clinic.
“All of us are caregivers, no matter what our role,” says Hancock. “Executive leadership rounding embodies that concept. It helps us further our guiding principle of putting patients first.”
Five Changes at a Community Hospital
Lutheran Hospital is a 204-bed community hospital on Cleveland’s west side. Each month, Chief Nursing Officer Denise Minor, DNP, RN, CNS, NEA-BC, participates in executive leadership rounding with Lutheran Hospital President Donald A. Malone Jr., MD, and Vice President of Operations Kris Bennett. The hospital has made dozens of changes based on input from front-line staff. “Staff have raised awesome ideas that we would not have known about otherwise,” says Minor.
Staff appreciate executive leadership rounding. “Having nurse managers and other executives visit the floor really helps build a more cohesive unit,” says Rich Szalkiewicz, RN, who works on a medical unit at the hospital.
Here are five issues raised by bedside nurses during executive leadership rounding at Lutheran Hospital and the solutions that followed:
Issue: Non-English-speaking patients could not read menus.
Solution: Menus are now available in Spanish.
Issue: Staff couldn’t find time to leave their units and get flu shots during flu season.
Solution: The hospital made flu shots available on each unit.
Issue: If one patient in a semiprivate room wanted to watch TV at night, it could interfere with the other patient’s ability to rest.
Solution: The hospital purchased headphones for TVs so patients can continue to watch after hours.
Issue: Staff wanted an on-site fitness center.
Solution: A former physician office was converted to a fitness room with treadmills and stationary bikes.
Issue: Nurses requested more workstations on wheels (WOWs) to complete electronic documentation.
Solution: The hospital ordered more WOWs for three nursing units.
Three components of leadership rounding
There are three key components to executive leadership rounding at Cleveland Clinic:
- An opening session
- The rounding experience
- A debriefing session
During the opening session, leaders receive instructions and celebrate exceptional caregivers (see sidebar). They also discuss the focus topic for that month’s rounding. For instance, one month the team discussed the significance of intermittent pneumatic compression devices for preventing venous thromboembolism. When leaders rounded, they talked to patients about the importance of wearing the devices.
Afterward, leaders break into assigned teams and round on designated areas for about 75 minutes. They document comments and observations on a form provided by the Office of Patient Experience, which oversees leadership rounding. During the first year, more than 200 multidisciplinary leaders rounded on 92 inpatient and outpatient units on Cleveland Clinic’s main campus alone.
The process ends with the debriefing session. Leaders collectively discuss the rounding and share patient and caregiver stories. Then the Office of Patient Experience collects the forms, enters all comments in a database, summarizes the results and sends summaries to each participant. Leaders are charged with making any necessary changes that fall under their purview.
The Office of Patient Experience tracks comments by placing them in 18 categories, ranging from hospital environment to pain management. “We’re looking for things we can fix,” says Rita Spirko, MSN, RN, Program Manager in the Office of Patient Experience. “We follow all issues from ‘open’ to ‘in progress’ to ‘closed.’” In 2012, more than 1,100 issues were identified and about 67 percent were closed or in resolution.
Executive leadership rounding achieves many goals: It helps improve patient care, caregiver engagement and environmental conditions. “As a bedside nurse, it makes me feel like my voice is heard,” says Brian Holbrook, RN, a nurse in the emergency department (ED) on main campus. “The leaders want to hear how things are going, what we need and what they can do to make things better.”
Holbrook recalls a rounding session when the director of environmental services visited the ED. Holbrook aired concerns about the time it took to get beds cleaned and curtains between beds changed. The delay led to longer patient waiting times. “We voiced our concerns, and now wait times to get beds cleaned are better than ever, especially in the ED,” he says.
Rounding is equally valuable for executive leaders. “It gives me an opportunity to engage with front-line staff and see how my job impacts what’s happening at the patient level,” says Dana Wade, MSN, RN, CNS-BS, CPHQ, Associate Chief Nursing Officer for Quality and Practice. “I’ve heard employees’ concerns, many of which can be corrected quickly.” For example, ED nurses on the main campus shared their apprehension about workplace safety when helping patients out of cars during emergent situations. Their comments prompted leaders from the ED and the Protective Services Administration to arrange for protective service officers to be regularly stationed in the ED area.
Executive leadership rounding also allows leaders to observe positive developments taking place on units, many of which can be replicated or used to shape best-practice strategies across the health system. Hancock witnessed a best practice on a cardiothoracic step-down floor. Two nurses were reporting off during a shift change. Rather than exchange information at the nurses’ station, they took a workstation on wheels and met in the patient’s room. “They included the patient, asking questions such as ‘Did the pain meds help you?’” says Hancock. Cleveland Clinic subsequently applied this shift-to-shift reporting strategy across the enterprise to improve the patient experience.
“I’m constantly surprised by the power of executive leadership rounding,” says Hancock. “It has influenced the engagement of our front-line staff, and our patients appreciate that we as leaders take time to make sure we’re meeting their needs.”
Information Technology Evaluation and Adoption: An ‘In the Trenches’ Approach Strengthens Value Proposition
The innovation and integration of new technologies to support nursing teams should not — and cannot — occur in a vacuum, according to Cleveland Clinic nursing staff charged with identifying and evaluating technology solutions to determine the right fit for value.
“As nurse liaisons, we are always rounding and talking with end users of the technology — bedside nurses,” says Katherine Sibila, BSN, RN, a nurse liaison for medicalsurgical adult inpatient units on Cleveland Clinic’s main campus. “We often observe something nurses are doing and think, ‘Maybe this piece of technology is the missing link that could help save time or improve patient care.’”
For example, in one of Cleveland Clinic’s short-stay units, nurses only documented on some, but not all, elements of a nursing progress record within the electronic medical record (EMR), and the process was cumbersome and timeconsuming. The solution was to reorganize documentation specific to this patient population and reduce redundancies. The new essential documentation elements contained only relevant information. “We streamlined the process and made it more efficient,” says Sibila, who is part of the Office of Nursing Informatics.
Input from bedside nurses at every step
Collaboration between bedside nursing teams and informatics staff is essential when identifying technology solutions that involve new work flows and processes, software, hardware and related equipment. Bedside nurses participate at every step: They suggest where a technology solution is needed, detail what would be most useful, test software or equipment in pilot programs, and help roll out new solutions. When evaluating technology-related equipment, “clinical nurse feedback is important,” says Karen Engell, BSN, RN, a clinical analyst in the Office of Nursing Informatics. “If nurses don’t like it or it doesn’t work well, we try something different.”
The challenges for nursing informatics teams are to balance the needs of nurses from many specialties against the regulatory and organizational standards for documentation and ensure that documentation remains meaningful and relevant to nursing care. Having nurses trained in technology solutions is the key to striking that balance.
Extensive research and analysis of software, hardware and related equipment take place even before projects reach pilot testing. For example, initial research may rule out equipment or software that is incompatible with the EMR system. When evaluating high-tech tools such as hardware, key questions include:
- Is it accurate and easy to use?
- Is it easy to store?
- Does it hold up well with persistent use?
- Is the vendor responsive?
“We can be like a Consumer Reports-type testing lab,” Engell says. When implementing bar-coding technology to comply with Centers for Medicare & Medicaid Services guidelines, she performed a head-to-head comparison of two scanners. Factors assessed included how well the devices scanned wristbands, medication bottles and IV bags; performance under low lighting; configuration options such as sound and light patterns; each device’s weight; and even how durable devices were when put through crash-test scenarios. “We want to know how equipment holds up under realworld use,” Engell explains.
By the pilot testing phase, bedside nurse feedback is essential to “work out bugs and kinks,” Engell says. Information is often compared before and after pilot testing to assess the impact of new technology, such as how well it holds up under real nursing unit conditions and the overall impact on nurses’ daily practice. “If bedside nurses are not satisfied as end users, or if the pilot does not improve patient care, we need to re-evaluate the product to see if it is worth implementing,” Sibila says. Ultimately, the best new technology solutions will integrate well with solutions already in place.
The best solutions may be homegrown
After a technology need is identified and current and upcoming solutions on the market are reviewed, sometimes the best option is to develop a custom solution. That was the case with a pilot project that allowed patient care nursing assistants (PCNAs) to record patients’ vital signs in real time at the bedside using an iPod Touch rather than writing down the information on paper and later entering it in the EMR. Project leaders looked at a product similar to what was needed, but it wasn’t yet ready for marketing, so a decision was made to invest effort into developing a custom solution.
To that end, Cleveland Clinic benefits from having an inhouse Clinical Systems Office with software development capabilities. Daniel Spencer, a software developer who worked on the iPod Touch project, says testing showed that a native app (i.e., one programmed to operate directly with the iPod Touch) worked more quickly and smoothly than a Web-based mobile app. “We obtained feedback from PCNAs on the units and quickly modified each iteration of the app,” Spencer says. “One of the huge advantages of being in-house is that we have direct access to nursing teams and are entrenched in the day-to-day process. A lot of software companies build off-the-shelf software based on assumptions or generalities, but we can add value since we are directly engaged with end users in healthcare.”
In pilot testing, the review team learned that the app created efficiencies by providing vital signs to nurses and physicians in real time and reducing opportunities for errors. “I use the app on a daily basis,” says PCNA Adam Sheaks, who participated in the pilot. “It’s much more convenient to enter vital signs right away than to try to find a computer that isn’t being used. I can enter data immediately and move on to my next task or next patient.”
Letting patient experience guide technology decisions
Patient experience is an important determinant of whether a new technology is the right fit for value. “We are guided by what patients tell us, and we try to be proactive,” says Greg Horvath, RN, Manager of Patient Experience in Cleveland Clinic’s Office of Patient Experience. “Patients let us know what we are doing right and not doing right, and they guide us about what direction to take when it comes to implementing new technologies.”
As technologies are rolled out, it’s important to communicate with patients about changes they might observe. For example, Engell says that with the iPod Touch project, PCNAs were instructed to explain what they were doing so patients wouldn’t think they were on their cell phones or sending personal texts.
Caregiver experiences and engagement are also inevitably affected by the introduction of new technologies that are designed to improve overall value. When staff nurses are involved in testing and implementing solutions that make their jobs easier and improve care delivery, their engagement soars.
Ultimately, informatics team members are advocates for both nurses and patients by aiming to deliver the right technology at the right time, according to Sibila. “We help nurses make their jobs easier by giving them the tools they need to provide better patient care,” she says. “We hope our solutions lead to greater efficiency in decision-making and effectiveness when evaluating care outcomes.”
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Getting Real: Simulation Center Brings a Team Approach to Training
Nurses, physicians and other providers train side by side in Cleveland Clinic’s new high-tech simulation center.
In June, nurses on a pediatric inpatient unit on Cleveland Clinic Children’s main campus location called the pediatric medical emergency team (PMET) to help a 2-year-old patient. The girl was covered in hives and crying out in pain. “The patient was stable, but we needed medication immediately,” says Jennifer Scavone, BSN, RN, a nurse on the unit. The PMET arrived quickly and worked in tandem with nurses to treat the patient.
Scavone says the situation went well thanks in part to monthly training her unit receives at Cleveland Clinic’s Multidisciplinary Simulation Center. Opened in spring 2012, the center offers nurses, physicians and allied health professionals hands-on training in realistic surroundings using prearranged medical scenarios. The inpatient pediatric unit often participates in mock emergency codes. “Because of the repetitious practice sessions in the center, when a real code happens on the floor it goes smoothly and we feel confident,” says Scavone.
Dedicated facility for high-tech instruction
Cleveland Clinic has offered simulated training for years, though not in a dedicated facility. “We’ve had pockets of simulation for teaching and assessment across the enterprise in surgical specialties and some medical specialties,” says J. Eric Jelovsek, MD, MMEd, medical director of the Multidisciplinary Simulation Center. “We realized there was value to consolidating it under one roof — pooling resources and personnel and raising the level of education.”
Any Cleveland Clinic unit or group can train at the Multidisciplinary Simulation Center for free. The center designs specialized orientation for groups, such as critical care nurses. It offers multidisciplinary training for entire units, such as a neurosurgical team.
The center is located in a more than 10,000-square-foot facility furnished with leading-edge equipment and a full range of medical supplies. It has advanced patient simulators that “cry,” “sweat,” “bleed” and “breathe.”
These sophisticated mannequins are available in adult, pediatric, neonatal and pregnant women models to facilitate training on hundreds of medical conditions. The center also includes a complete intensive care unit and fully functioning operating room (OR).
Fostering quick and appropriate responses
The goal is for trainees to learn how to respond quickly and appropriately in a safe setting. For example, a group of nurses re-enacted a scenario with a patient on a ventilator in respiratory distress. They had to troubleshoot the ventilator alarms, identify the patient’s problems and decide how to manage the situation. “With our full-mission scenarios and high-fidelity mannequins, we can replicate actual circumstances,” says Leslie Simko, MS, RN, administrator of the Multidisciplinary Simulation Center and director of nursing education. “So nurses really feel the consequences of their actions. They can take what they learn here and apply it to their work setting.”
All educational sessions are recorded, and participants view the training at a debriefing immediately afterward. The debriefing is invaluable, says perioperative educator Bridget Kerr, BSN, RN, CNOR, who helped facilitate training when the center opened.
Kerr created monthly mock emergency codes with various OR teams, from general surgery to colorectal, that challenged team members to consider tricky questions: Can you maintain a sterile field in case the surgery resumes? If a patient is prone, how do you access the chest to do compressions? Who runs the code in the OR? “Codes are seen infrequently in the OR, thank goodness, but we want caregivers to be knowledgeable and competent when they happen,” says Kerr.
Creating cohesion across disciplines
What sets the center apart from others is its commitment to a multidisciplinary approach. “The problem with most healthcare training is that each healthcare discipline completed it separately,” says Dr. Jelovsek. “Doctors go to medical school and nurses go to nursing school. We train in parallel systems, then come together at the bedside and are told, ‘OK, work together.’” Parallel training may lead to miscommunication and mistakes, he adds, whereas training together helps ensure that providers understand not only their role, but everyone else’s job too. The outcome is true teamwork.
The center fosters a multidisciplinary approach from the top down. “It starts with our organizational structure,” observes Dr. Jelovsek, who heads the center together with Simko. “We have nurse-physician leadership.” Additionally, the center’s simulation technicians include a paramedic and a computer scientist. “By melding various disciplines, we minimize barriers to best practice and the whole team works together,” notes Simko.
Both novices and veterans benefit
In 2012, more than 5,800 Cleveland Clinic nurses participated in simulation training, from new hires to veteran nurses. Each one benefited from the experience. “The last question we ask is, ‘What did you learn today that you will take back to your practice?’” says Simko. “All nurses were able to tell us something valuable.”
Ultimately, practices learned and reinforced through simulation training benefit patients. “The simulation center is an excellent way to bring people from multiple disciplines together and promote practices that standardize the Cleveland Clinic care model we strive to provide,” says Dr. Jelovsek.
Best Practice Snapshot: Standardized Stat Boards Put Delivery Room Supplies Within Quick Reach
Most newborns are vigorous, but approximately 10 percent require assistance to begin breathing, and 1 percent need extensive resuscitative measures to survive. To efficiently treat such newborns, the birthing center nursing staff at Cleveland Clinic’s Fairview Hospital created stat boards containing resuscitative supplies. In 2012, The Joint Commission cited the stat boards as a best practice in its report to Fairview Hospital.
“In the past and in most other birthing centers, resuscitative supplies were located in a cart or drawer and were not well organized,” says Joyce Arand, MS, RNC, CNS, NEA-BC, Director of Nursing for Women’s and Children’s Services at Fairview and Lakewood Hospitals, two Cleveland Clinic community hospitals. In an emergency, nurses would go there and search for what they needed. “Our nurses developed a board that hangs on the wall and has all necessary resuscitative supplies organized in one place.”
Standardization is key
Stat boards are located behind doors in the 17 operating and delivery rooms in Fairview Hospital’s birthing center. More than 20 items hang on each board, including stylets, endotracheal tubes, syringes, laryngoscopes with blades, medication transfer devices, suction tubing and suction catheters. “Each item is outlined on the board so staff know where items go, the way someone might organize tools in their garage,” explains Arand.
Fairview Hospital has used stat boards for years, but Heatherly Kilbane, BSN, RN, a staff nurse in the birthing center, took the idea a step further by implementing quality and safe practice measures for their use. Kilbane coordinated setup of the stat boards in each room to ensure they were identical, and she created a checklist for nurses on every shift to make sure all supplies were available. Outlines of items with expiration dates are highlighted in yellow so nurses can verify that no outdated items are used.
Having standardized stat boards simplifies the job of restocking supplies. Previously, nurses would add items based on personal preference. Kilbane and Ann Roach, MSN, RNC OB, RNC-MNN, ACNS-BC, a clinical nurse specialist in Women’s and Children’s Services at Fairview, reviewed the protocol for newborn resuscitation, made a list of nurses’ and physicians’ immediate needs during resuscitation, then selected inventory items for the stat boards. “Now we have consistent stat boards that are up to date with supplies based on need,” says Kilbane. Items that are used less frequently, but are necessary for extensive resuscitative measures, were moved to the birthing center’s code pink carts.
Saving time when it matters most
The stat boards improve patient care. “They save time in the moments after a baby’s birth,” says Roach. “We always anticipate the possibility of having to resuscitate a baby even when there is a great fetal heart rate tracing. Having everything available immediately makes all the difference in the world in initiating the steps of resuscitation.”
Fairview Hospital’s birthing center performs approximately 4,500 deliveries a year. In this busy labor and delivery setting, Kilbane says the stat boards are used almost daily. “They’ve become such a normal part of our everyday work that it’s remarkable we didn’t standardize them sooner,” she says. “There’s been a huge improvement in the time it takes to get those critical items into the hands of providers at the bedside.”
Nursing Informatics Leaders Find Strength in Numbers
An idea from a Cleveland Clinic nursing leader spawned ongoing statewide Epic user meetings — and continues to forge empowering connections.
Marianela (Nelita) Zytkowski, DNP, RN-BC, always enjoyed the national conferences hosted by Epic, the developer of Cleveland Clinic’s electronic medical record (EMR) software. The sessions provided new insights for nursing informatics professionals like her, and were always teeming with experienced EMR users from around the United States. But among attendees, it was hard to find others from her home state, Ohio.
“Each state has different regulations that affect how we can and should use EMRs,” says Zytkowski, Cleveland Clinic’s Associate Chief Nursing Officer for Nursing Informatics. “I started thinking it would be helpful to gather all of Ohio’s Epic users so we could network and work through common challenges together.”
Back in Cleveland, Zytkowski sent a survey to every Epic client in the state — 15 healthcare organizations — to gauge their interest in starting a statewide Epic users’ group. All 15 responded enthusiastically. And that was the beginning of today’s Ohio Nursing Informatics Organization (ONIO).
A day of networking and idea sharing…
Zytkowski chose a central location, The Ohio State Medical Center in Columbus, and asked a nursing informatics leader there if she would host the first meeting, knowing that Zytkowski and Cleveland Clinic would handle the rest of the planning and facilitating. Just weeks later, in November 2012, Epic users from around Ohio converged in Columbus for a one-day networking and idea-sharing event.
Some attendees were chief nursing officers and others were IT people who work with nursing; all were high-level leaders from an Epic-using healthcare organization in Ohio. Also attending was a nurse representative from Epic headquarters in Madison, Wis. “She was able to contribute to our discussions, answer questions and take our input back to the company,” Zytkowski notes.
ONIO’s first meeting included:
- A roundtable discussion about how nursing and technology are organized at each represented hospital
- Dialogue about the impact of the Affordable Care Act and “meaningful use” on nursing documentation
- Review of the reports that Epic can generate
- Presentation of new features in the next version of Epic technology
Most valuable, perhaps, was that attendees began sharing best practices about how EMRs were used in their organizations.
…Turns into quarterly meetings
The one-day seminar was such a success that attendees requested ongoing meetings. Since then, the group has met quarterly and has even welcomed three more Ohio hospitals that recently began using the Epic system.
Meetings continue to be held at The Ohio State Medical Center. Cleveland Clinic continues to initiate new members and house the group’s records. But each member organization takes turns facilitating meetings and setting agendas. Any member can submit agenda items and solicit advice at any time.
All about sharing — even across disciplines
“When Cleveland Clinic nurses were getting ready to start bar-coding patient medications at the bedside,” says Zytkowski, “we wanted to hear how other hospitals were doing it so we could learn from them. A couple of group members gave us excellent recommendations, such as which settings to select in the Epic system and how to silence the scanner so its beeping wouldn’t disturb sleeping patients.”
Everyone shares what they know, she notes. Often, members invite each other for in-person visits to see processes firsthand. The group now invites guest speakers to discuss healthcare trends and regulations across the state. At one meeting, the Ohio State Board of Pharmacy talked about rules and laws governing medication administration from an EMR and the impact of the Bar Code Medication Administration system on patient safety and quality outcomes. ONIO members invited their hospitals’ pharmacists to attend with them.
Spreading the success to other states
ONIO has been so successful that Epic has turned to the group for help with initiation and support of similar groups in other states. Epic has even given the group its own web portal where members can share documents and stay in touch between meetings.
“I think we all feel so much more empowered because of our networking and being able to take information back to our workplaces,” says Zytkowski. “There aren’t many informatics people at any one organization, so this group helps us all feel more connected.”
Research: Innovative Role-Tracking Tool Provides Window into CNSs’ Work and Contributions
Jennifer Colwill, MSN, RN, CCNS, PCCN,
discussing research results at a poster presentation.
When Jennifer Colwill, MSN, RN, CCNS, PCCN, made the leap from staff nurse to clinical nurse specialist (CNS) in 2008, she says her job at Cleveland Clinic suddenly went from very concrete to broad and somewhat ambiguous. “I would think back to the week before and ask, ‘What all did I do?’ It was hard to say in tangible terms,” explains Colwill, who says CNS colleagues told her they had the same dilemma. “Once you’re in a CNS role for a while, you know what you are doing, but there’s no way to concretely measure your work if you don’t track it. It’s like mist in the distance that can vaporize.”
Colwill looked into commercially available tools to track the work of advanced practice nurses, but she found nothing that fit her needs. So she created homegrown software using an Excel spreadsheet to generate a visual representation of her contributions. Colwill’s supervisor suggested that she consider expanding the concept into a tool that any CNS at Cleveland Clinic could use.
From personal tool to research initiative
Colwill ran with the idea, ultimately teaming with colleagues to study use of a refined version of the software, called the Role Tracker Tool, by 14 CNSs across Cleveland Clinic. The study purpose was to quantify CNS work roles over a five-month period and determine if roles were associated with personal characteristics, job goals and time spent in quality initiatives.
Participating CNSs worked in a variety of settings, including intensive care units (ICUs), medical-surgical units, telemetry-monitored step-down units and others. Colwill and colleagues tracked the time CNSs spent each day in six role categories:
- Professional development
The study achieved its primary goal by demonstrating that CNS work can, in fact, be measured. Other notable findings:
- Time spent in various work roles varied by specialty, years as a CNS, years at current employer and nurse comfort in her/his role, even after controlling for nurse characteristics.
- Despite perceptions that education is a primary CNS responsibility, education ranked fourth in terms of hours spent. Clinical, quality and consultant roles ranked higher, with research and professional (self) development ranking lower.
- CNSs in ICUs spent relatively more time serving in the clinical expert role, and CNSs in step-down units spent the most time in the quality role.
- Time spent on quality initiatives was not associated with changes in quality improvement outcomes.
Colwill says this may be due to a “ceiling effect” that reflects a steady state of optimal patient care quality. Colwill, who practices in a cardiovascular step-down unit, says the research study is important because CNS roles are broad and difficult to quantify, and data like these yield insight into the multiple foci of CNSs’ work and the impact CNSs can have. “When nurse administrators and other leaders have a better understanding of CNS work, they can better utilize CNSs to improve patient outcomes and employee engagement,” she explains.
Colwill has presented results of the study locally and at two national CNS conferences.1 Other health systems have expressed interest in participating in a multicenter study that would be led by Cleveland Clinic.
Meanwhile, commercialization of the Role Tracker Tool is being explored by Cleveland Clinic Innovations, the health system’s commercialization arm. Enhancements to the tool are also underway, including creation of a Web-based database interface with mobile app functionality.
Building better knowledge workers
Colwill says when she started researching the work CNSs do, she came across the term “knowledge worker,” coined by renowned management consultant Peter Drucker. “Attributes of the knowledge worker include being highly skilled, doing work that is highly individualized and difficult to capture, and having a real influence on others to get better outcomes,” she says. By that definition, she notes, the CNS is the epitome of a knowledge worker.
Colwill adds that the Role Tracker Tool benefits CNSs themselves as much as it helps nursing leaders. “We can use this information to ask ourselves, ‘How do I get better?’ It can help us determine where to focus our efforts for greatest impact since our work is so broad. That type of knowledge is power.”
Research: Helping Nurses Stay in the Rhythm of ECG Interpretation and Intervention
Study explores where skills reinforcement and support are warranted in the wake of initial ECG training.
Nurses at Cleveland Clinic are expected to have competency in electrocardiogram (ECG) interpretation and application. Newly hired nurses undergo ECG instruction that blends computer-based learning with instructor-led training. During new nurses’ third week of orientation, they must pass a test of basic ECG clinical competency. The blendedlearning course and test methods have been used for many years at Cleveland Clinic. Two nurse educators sought to learn the utility of the current ECG training approach in terms of:
- Nurses’ ability to interpret ECG rhythm strips many weeks later
- Nurses’ comfort level in determining clinical intervention in response to ECG abnormalities
- Factors that may predict long-term proficiency following ECG skills training
With little to go on in the literature, Carol Ann Brooks, BSN, RN, CCRN, and Nancy Kanyok, MSN, RN-BC, CNS, decided to lead an effort to find answers. They assessed and tracked 69 nurses at the time they started orientation training at Cleveland Clinic’s main campus. “Our primary aims were to determine if nurse retention was associated with ECG competency and if application of initial knowledge was retained after taking a course that combines computer and live training and passing a test,” says Kanyok, a nurse educator. “We wanted to learn the ECG clinical competency of nurses who were practicing in units with hardwire or telemetry monitoring, post-course completion.”
Findings: Proficiency ebbs in the weeks after training
To answer research questions, researchers asked nurses to interpret nine clinical ECG case studies eight weeks into their orientation — or five weeks after taking their initial test of basic ECG competency. Interpretation involved identifying the ECG waveform rhythm, providing measurements of ECG components (e.g., PR interval in milliseconds) and providing a list of therapeutic interventions to treat that rhythm. Of the nine ECG case studies, three were simple, normal rhythms; three were intermediate level; and three were less common, more advanced ECG dysrhythmias.
Nurses’ mean test score was 89 percent at week 3 and fell to 63 percent on the assessment at week 8. “Nurses were comfortable interpreting ECG waveforms at week 8, but they were less comfortable applying therapeutic interventions,” says Brooks, a clinical instructor and the study’s principal investigator.
After review of nurses’ perceptions about their ECG clinical skills and characteristics, the factor that correlated most closely with ECG competency was nurses’ perceived comfort with applying therapeutic interventions. No individual nurse characteristics emerged as significantly associated with ECG competency scores at week 8, although there was a nonsignificant trend for younger nurses to score higher.
Brooks says the nurses’ test scores at week 8 reflected “intermediate” ECG competency. “Nurses still needed guidance and support because they perceived themselves as not being fully confident regarding treatments, and scores on the assessment’s therapeutic interventions section were low, especially for more advanced dysrhythmias that are also life-threatening.”
Guidance for future training
“This is a beginning,” says Kanyok. “Results may drive changes to our training in the future. The results provide evidence that our unit educators and coaches need to work with nurses, continue to focus on strip interpretation and make sure nurses feel comfortable putting forth bestpractice interventions.”
In the meantime, new nurses will continue to undergo the current blend of computer-based and instructor-led ECG training during orientation. “And once they get on the floor,” adds Brooks, “they interpret their patients’ ECGs.” She says that although many ECG monitors at Cleveland Clinic automatically interpret rhythm strips, “we tell new nurses to document the ECG rhythm strips, calculate the measurements, check the waveforms and make sure the system interpreted the strips correctly.” Continual practice helps reinforce clinical competencies and supports confidence in undertaking interventions.
Although the retention outcome has not yet been analyzed, Brooks adds that a bonus outcome was that the study validated use of the ECG clinical competency test in measuring nurses’ skills in ECG waveform analysis and determining the clinical interventions needed. “When we started on this quest,” she explains, “we could not find a valid, reliable tool to assess clinical competency. Though scores were significantly lower at orientation week 8 than at week 3, nurses’ ECG skills were at an intermediate level, which assures us they are providing safe, high-quality care to patients. At week 8 of orientation, nurses are expected to be on a path toward independent practice and to use nurse coaches to add to their knowledge base and clinical decision skills.”
Replication is welcome
The researchers are planning a manuscript for journal submission. Strengths of the research were its prospective design and enrollment of nurses from multiple work settings, including medical-surgical, critical care and cardiac step-down units. Since the study was completed at a single center, generalizability beyond a large, quaternarycare hospital is unknown. “It would be great if other nurses would replicate this study in their settings, such as community and rural hospitals,” Kanyok notes.