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Essentials of Advanced Nursing Practice Field Experience

Info: 4782 words (19 pages) Essay
Published: 8th Feb 2020 in Nursing

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Purpose

 As healthcare providers we are held accountable in our provision of care by

multiple groups of people with the most important being the community we serve. 

The purpose of this paper is to identify an opportunity within my organization to improve

patient care outcomes.  As a consultant I will be conducting a nurse leader interview,

analyze current data (HCAHPS scores, community needs, evaluate the community

standard) and devise a plan for implementation that will change current practice

ultimately improving patient care.

Overview

 The chairperson of the Unit Based Council for the B4 Telemetry Step Down unit

was interviewed about her role within the organization, the shared governance process

and its direct impact on quality improvement activities to improve quality outcomes. A

face-to-face interview was conducted over two hours. Highlights of the interview

included the hierarchy involved in driving change within our organization, the

community we serve, and the challenges of meeting the community needs as well as the

effect on patient care outcomes. The metrics evaluated during the interview included

HCAHPS scores, benchmarking at the state and national level as well as comparing

assessments of the facilities within the east bay area. Based on the interview there are

areas in the HCAHPS survey that have not meet our organizational goal and have been

declining in the past quarter. It is evident that a new strategy will need to be developed to

improve nursing communication. The approach will be multifaceted with changes being

made in the hospital policy to support performance expectations (mandatory nursing

bedside report), education for the nurses to improve communication (bedside report) as

well as developing a tracking tool to keep all stakeholders aware of real time data. The

plan will include evaluating the current HCAHPS survey results to develop interventions

that will support an environment where patients feel they are always listened to and

participate in their plan of care. The goal will focus on improving the HCAHPS score in

the category  “How often did nurses communicate well with patients?” more specifically

to question 3 in the survey, “How often did nurses explain things in a way you could

understand?” I will evaluate the effectiveness of implementing bedside report by having

frontline leaders conduct unannounced rounds to monitor compliance with the bedside

report process, evaluate current HCAHPS results and display both results in the staff

break room for all stakeholders to view.

Description of Organization

  John Muir Health has been the premier provider of health care services in Contra

Costa County (East Bay Area), California since 1920. John Muir Health is a non-profit

organization that has combined four campuses into one health system through it

transformation efforts. The health systems origin began in 1930 as Mount Diablo

Hospital (now John Muir Health- Concord Campus). Mount Diablo Hospital was founded

by a nurse who operated in a four-bedroom house across the street from the hospitals

current location with a focus of community health for the city of Concord. In 1940, John

Muir Health Walnut Creek was founded by a group of physicians whose focus was on the

community in Walnut Creek. To put this into perspective, Concord and Walnut Creek are

sister cities with both hospitals being 5 miles from one another. In the past 10 years the

health system combined both campuses to remain financially viable and to increase the

communities access to care close to home. Most recent were the additions of the

Behavioral Health Center and San Ramon Regional Medical Center to the John Muir

Health System. In its current state of healthcare delivery, John Muir Health serves the

entire community of Contra Costa County extending into Alameda and Solano counties.

 John Muir Health’s motto “We listen, We explain, We work together as a

team” extends to their 9000 employees across their 554 bed medical facility in Walnut

Creek, 245 bed medical facility, 73 bed psychiatric facility and more than 30 outpatient

offices. John Muir Health specializes in a myriad of categories including cardiac surgery,

orthopedics, robotic surgery, weight-loss surgery, neurology, cancer care, and high-risk

obstetrics. The Walnut Creek Campus is the sole trauma center for Contra Costa County

and the Concord Campus is the destination for all cardiac care. Both campuses are

accredited by the Joint Commission with a gold seal of approval, have received Magnet

recognition for Nursing and were the only non-academic centers in Northern California to

consistently be ranked as two of the nation’s top hospitals by U.S. News and World

Report. Additionally, the health system has received gold performance by the American

Heart Association / American Stroke Association, Chest Pain Center Accreditation,

Commission on Accreditation of Rehabilitation Facilities, Leaders in LGBT Healthcare

Equality and are centers of excellence for knee and hip replacement.  I was unable to

identify the number of patient encounters for the year however I was able to identify that

our emergency room at the Concord Campus evaluates on average 250 patients a day

with 75% of the patients being admitted to the Concord campus hospital. The

Organizational chart is as follows: The Board of Directors is comprised of community

members whose sole purpose is to ensure that the mission of the organization is being

served to the community with oversight in quality metrics, approval of proposed

initiatives and financial viability. The executive team includes the CEO, Executive

President of the Health system, CAO of the John Muir Physician Network, Chief

Transformation Officer, Chief Nursing Executive, Assistant Chief Nursing Officers,

Nursing Directors, Nursing Managers, Charge Nurses and Nursing staff.

Primary Needs of Population

 

 John Muir Health serves 1.2 million people across 715 square miles throughout

Contra Costa County. The county has two other hospitals, Kaiser and Contra Costa

Regional (county hospital) with John Muir Health being the largest Health System in the

county.  58% of the population is 18 to 65 years old with the median age being 41 years.

15% is older than 65 and 27% being under the age of 18.  Contra Costa county is

primarily Caucasian (65%), with 26% Hispanic, 17% Asian and 9.5% black/African

American.  34% of the population’s primary language is not English with homelessness

affecting 25,000 people. (Contra Costa n.d)

 Being a non-profit organization John Muir Health conducts a community needs

assessment every three years to be in compliance with the Patient Protection and

Affordable Care Act. The goal of a community needs assessment is to identify the assets

of a community and determine potential concerns it faces. (Sharma 2000). The last

assessment by John Muir Health was completed in 2016. The assessment identified the

needs of the community in the following order:

 1.Obesity, Diabetes, Healthy Eating and Active Living

            2. Economic Security

 3. Healthcare Access & Delivery, including Primary & Specialty Care

 4. Oral/ Dental Health

            5. Mental Health

 6. Substance Abuse, including Alcohol, Tobacco and Other drugs

 7. Unintentional Injuries

 8. Violence and Injury Prevention (2016 Community Assessment 2016).

 John Muir Health is addressing the health needs of the community through

various approaches. The first approach is community outreach and support. John Muir

Health is an active participant at the local farmers market where they educate the

community about obesity prevention, maintaining a healthy diet and increasing their

amount of daily physical activity. Additionally, John Muir Health sponsors multiple no

cost classes that rotate through the health system (hospitals, urgent care centers, primary

care centers) that support the communities needs in the prevention of obesity, nutrition,

physical activity and diabetes management/support. By educating the community on

obesity prevention we can hope to avoid unnecessary hospitalizations to manage their

disease process. John Muir Health has been steadily working on improving the

community’s access to health care by opening their own primary care centers within the

county as well as partnering with specialists at Stanford and the University of San

Francisco. The next approach John Muir Health has taken is through its transformation

efforts to decrease the cost of their insurance product. This has supported the community

with the lowering the cost of care and battling the current high cost of care (insurance,

co-payments, deductibles). John Muir Health’s position is that health care should be

affordable and close to home to increase compliance with healthcare and improve the

quality of life of the community. That being said John Muir Health has a robust charity

care program where they have partnered with community clinics to provide subsidized

care to underserved community members.  Lastly, John Muir Health is developing a

public service campaign focusing on the use of their primary care, the emergency room

and hospital services. It is important to educate the community about the use of each level

of care to help the community understand where they should go to seek appropriate care.

This will have a dramatic impact on the volume of patients our emergency room cares

for, appropriate the care in the most cost effective manner and decrease the cost burden to

our community. Case in point: sore throats can be evaluated in the primary care office

and the emergency room can treat legitimate emergencies. By taking all of the

aforementioned steps John Muir Health is addressing the community needs and

supporting their health.

Nurse Leader’s Role

 I interviewed Holly who is the Unit Based Council Chairperson for her unit. She

described her role as a frontline leader who attends the UBC leadership meetings,

supports the unit in performance improvement initiatives and improves morale on the

unit. She identified the key concern for our unit and hospital has been improving

communication amongst nurses and the patients we care for. She explained that through

the shared governance process the UBC leadership group was able to highlight the

nursing communication issue and make it a priority amongst the executive nursing

leadership team. In addition to her role in performance improvement she clarified that the

role is not solely rooted in performance improvement and that nursing morale in our

department as well as hospital wide has been a challenge with the change in the structure

of our executive leadership. She described her approach to support her team as intuitive

caring. She has implemented a cheerful check-in process to support team members

throughout their shift where no one sits down until they have checked in with their

colleagues to evaluate if they need assistance in completing tasks. She has taken this

approach to the next level, by independently and confidentially reaching out to colleagues

who have personal crisis’ that could affect their performance in the workplace. In her

opinion, the whole person needs to be addressed in order to support the current quality

improvement initiatives, which align with the high quality care provided to our patients.

 As the Unit Based Council chairperson she has informal and formal influence

amongst her unit based team as well as hospital wide team. The American Association of

Colleges of Nursing has identified nine roles that are essential for the MSN prepared

nurse. The nine roles are:  I. Background for Practice from Sciences and Humanities, II.

Organizational and Systems Leadership, III. Quality Improvement and Safety, IV.

Translating and Integrating Scholarship into Practice, V. Informatics and Healthcare

Technologies, VI. Health Policy and Advocacy, VII. Interprofessional Collaboration for

Improving Patient and Population Health Outcomes, VIII. Clinical Prevention and

Population Health for Improving Health and IX. Master’s-Level Nursing Practice

(Denisco & Barker, 2016). It was apparent during our interview that Holly’s role as the

Unit Based Council Chairperson strongly aligned with essentials II, III, and IV.  Essential

role II (Organizational and Systems Leadership) provides safe high quality patient care

by effectively communicating with staff, patients and families The nurse leader

demonstrates communication techniques that are respectful with teams and teamwork,

including team leadership, building effective teams and nurturing teams (Denisco &

Barker 2016). Holly shined in this role. Despite her personal objections in the

prioritization of hospital wide performance initiatives, she was able to illustrate her

position in focusing on nursing communication at the leadership level while supporting

her unit-based team. Essential role III (Quality Improvement and Safety) is the

cornerstone of Holly’s role as the Unit Based Council Leader. Being comfortable with

analyzing quality measures and correlating them to patient safety is a top priority for a

nursing leader. Without the ability to do so would disable the leader in improving

patient care as they would be unable to identify the successes and/or opportunities for

improvement for their health system. The unit based council chair persons position within

the organization aligns with this essential role because they are able to readily correlate

safety concerns with unit based activities as well as hospital wide activities. For example,

Holly mentioned that the fall rate had increased within our unit however it had remained

stagnant or decreased in the other units of the hospital. When she assessed the previous

quarters data she was able to identify the trend that affected the patients who fell. Which

was that the hospital supervisor had oversaturated our unit with a challenging patient

population and we had a higher rate of external staff (registry nurses) working in our

department. The combination proved to be catastrophic for our patients. Holly discussed

with her colleagues what they thought could have been done differently to support our

patients. She took those recommendations to the Unit Based Council leadership group

who developed a plan with the support of nursing leadership to not oversaturate a nursing

unit with one patient population and to disburse registry personnel amongst the units with

assigned buddy’s to verify they are complaint with the hospitals policies.  Holly was able

to promote quality care by using high reliability techniques whilst analyzing errors to

improve patient care ( Denisco & Barker 2016). Lastly, Essential IV (Translating and

Integrating Scholarship into Practice) I believe is the most important for the nurse leader.

As it is the ability to integrate theory, evidence and clinical judgment to collaborate with

teams to improve care outcomes and support policy changes. The policy changes are

generated by knowledge dissemination, planning and evaluating knowledge

implementation ( Denisco & Barker 2016). As the unit based chairperson Holly was able

to utilize evidence based practice and translate it into the implementation of purposeful

hourly rounding to increase our patient satisfaction scores.

Characteristics of Organization

 

 John Muir Health like all organizations has strengths and weaknesses. The

strengths I identified were the support provided to the UBC chairperson to implement

changes in practice to improve the delivery of patient care. The support was team focused

with a common goal of caring for our patients. The unit-based team embraced their UBC

leaders recommendations and was successful as a result of executive leadership support.

This was in alignment with the hospitals motto “ We listen, We explain, We work

together as a team”.  A weakness I identified during the interview was the lack of

communication amongst the care team when providing care to their patients. Patients

raised concerns that they were not being listened to about their symptoms, physicians

were not explaining the plan of care to the patients or nurses, and nurses were spending a

large portion of time chasing down the physician to discuss the a patient’s status and

were dissatisfied with the lack of collaboration with the plan of care. If the physicians had

reached out to the nursing team prior to rounding on the patient the nurse would have an

opportunity to discuss the patient’s symptoms, responses to treatments and suggest

amendments in the plan of care. Once the physician and nurse completed their dialogue it

would be a priority to ask the patient how they felt about their plan of care and make

adjustments with the interventions and goals in the plan of care. Through this

collaboration the care team would able to provide a consistent plan of care to the patient.

To support patient centeredness by engaging the patient in their plan of care nurses could

implement the evidence-based practice of bedside reporting. By doing so they would be

able to increase the patients involvement in their care and improve patient satisfaction

(Reitz 2017). It was apparent that the lack of communication amongst the health care

team translated to the patient not being involved in their plan of care and the low

HCAPHS scores in the nurse communication category.

 John Muir Health has a healthy evidence based practice program with strong

quality improvement projects. I observed the following evidence based practices: Hand

Hygiene, Nurse Driven Foley Catheter Protocol and Patient Mobility. In the staff huddle

room the unit had quality boards that demonstrated the past quarter and current quarters

data related to fall, Catheter Associated Urinary Tract Infections, Hospital Acquired

Infections, and DVT prophylaxis. There were posters on the walls that walked the health

care provider through each quality improvement initiative with the assessment,

interventions and goals. All of the information posted in the huddle room provided an

avenue for the staff to evaluate data and observe how their compliance with the quality

initiatives improved their patient’s quality of life.

 

Recommendation for Organizational Change

 My recommendation for organizational change is to implement the use of nursing

bedside report. Bedside report has supported patient safety with a proven decrease in

medication error and fall rates (Sand-Jecklin 2014) with a focused approach to at the

bedside. While conducting bedside report nurses are able to dually check that fall risk,

associated interventions, medication infusions and call lights are appropriate for the

patient as well as eliminate miscommunication that could occur if report was not

conducted at the bedside. Furthermore, beside report increases patient involvement in

their plan of care with resultant improvement in patient satisfaction (Reitz 2017). 

Involving the patient in their plan of care supports patient centeredness by individualizing

the plan according to the patient’s wishes and goals with their hospitalization. Good

communication increases satisfaction of patients and their family members and decreases

errors, ensuring safe passage for patients (Rogers, 2017).

Rationale for Recommended Change

 Numerous studies have demonstrated that with the use of bedside report patient’s

involvement in care increases, errors are identified or avoided entirely and the patient’s

satisfaction increases (Reitz 2017).   That being said to improve the communication

amongst the care team and support John Muir Health’s motto “We listen, We Explain,

We work together as a team” bedside report must be implemented to decrease the

hospitals weakness in communication. By using a standardized nursing report approach

the patient is able to participate in their plan of care as well as the nurses are able to

decrease the risk for harm to the patient during their hospitalization with safety checks

during the report process. Additionally, bedside report enables the nurse to develop a

therapeutic relationship necessary to exchange information in front of the patient (Vines

2014). By establishing the therapeutic relationship the patient will feel supported in

verbalizing their needs even if they may be contrary to what the physician has prescribed.

Through this process patient satisfaction will increase and will have a positive impact on

the nurse communication scores in the HCAHPS survey.

Measures to Evaluate

 

 To evaluate the effectiveness of bedside report implementation on patient care

and patient satisfaction the nurse leader would identify nursing communication in the

HCAHPS survey as the national benchmark for performance. The hospital provides the

HCAHPS survey results to the staff on a monthly and quarterly basis. The areas focused

on would be in the nursing communication category. This includes: How often did nurses

communicate well with patients? and , “How often did nurses explain things in a way you

could understand?” (Measuring and Benchmarking Clinical Performance 2013). The

nurses would be required to comply with the bedside report expectation with compliance

being randomly audited by leaders on the unit on a weekly basis until it is hardwired into

practice. From that standpoint, compliance would be monitored on a monthly basis.

 The nurse leader would then collect all data and post the results on the unit for all

team members to view on a monthly basis. After implementing bedside report there

should be an increase in patient and nurse communication and an increase in

reimbursement for having patients who are always satisfied with their care.

References

 

  • 2016 Community Assessment. (2016). Retrieved December 9, 2018, from https://www.johnmuirhealth.com/content/dam/jmh/documents/community/2016_commun_health_needs_assessement.pdf
  • Contra Costa County. (n.d.). Retrieved December 11, 2018, from https://www.census.gov/quickfacts/contracostacountycalifornia
  • Denisco, S. M. & Barker, A. M. (2016). Advanced practice nursing: Essential knowledge for the profession. (3rd ed.). Burlington, MA: Jones & Bartlett. ISBN13:97812284072570
  • Measuring & Benchmarking Clinical Performance. (2013, May). Retrieved December 5,               2018, from http://www.ahrq.gov/profesionals/preventions-chronic-care/improve/system/pdfhandbook/mod7.html
  • Reitz, O.E., Scheidenhelm. S (2017). Hardwiring Shift Report. Journal of Nursing Administration, 47 (3), 147-153. doi:10.197/NNA.0000000000000457
  • Rogers, J. (2017) Can We Talk?  The Bedside Report Project. Critical Care Nurse,37(2) , 104-107. doi: 10.4037/ccn2017369
  • Sand-Jecklin, K. , Sherman, J. (2014). A quantitative assessment of patient and nurse outcomes of bedside nursing report implementation. Journal of Clinical Nursing, 23, 2854-2863. doi: 10.1111/jocn.12575
  • Sharma, A., Lanum, M., & Suarez-Balcazar, Y. (2000, September). A community needs assessment guide. Retrieved December 7, 2018, from https://cyfar.org/sites/default/files/sharma 2000.pdf
  • Vines, M.M. (2014, August). Improving Client and Nurse Satisfaction Through the Utilization of Bedside Report.  Journal for Nurses in Professional Development, 30 (4), 166-173. Retrieved from http://www.nursingcenter.com/CEArticle?an=01709760-201407000-00002

 

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