Friday, July 25, 2014

New Guidance Shows Importance of Evidenced-Based Best Practices in Hygiene

A new guidance published in the August issue of Infection Control and Hospital Epidemiology emphasizes the importance of proper hand hygiene to prevent the spread of health care-associated infections, reports Health Canal. RWJF Health & Society Scholars program alumna Allison Aiello and her colleagues developed the guidance, which includes a series of evidenced-based best practices for optimal hand hygiene in health care settings. The guidance encourages increased availability and acceptability of certain soap and alcohol-based rubs and the development of a system to empower health care personnel to create a personalized hygiene system that gives them a way to track their progress.

The recommendations include developing a multidisciplinary team in which representatives from administrative and unit-level leadership work together to establish a hand hygiene program that best fits each institution. The program should include clear performance targets and an action plan for improving adherence, according to the guidelines.

An INQRI-funded study published last year in Critical Care Medicine found that a nurse-led intervention combining a “bundle” of evidence-based practices with a comprehensive safety program dramatically reduced the mean rate of health care-associated infections. The study was conducted by David Thompson and Jill Marsteller associate professors at Johns Hopkins University in the School of Medicine and Bloomberg School of Public Health, respectively, and by J. Bryan Sexton now at the Duke University Health System Patient Safety Center.

Friday, July 18, 2014

Nurses Lead Innovations in Geriatrics and Gerontology

This story originally appeared in the July 2014 issue of Sharing Nursing's Knowledge, a monthly email newsletter from the Robert Wood Johnson Foundation.

Nurse-led initiatives are intended to help the nation’s health care system prepare for a crush of elderly people with multiple chronic conditions.

Nurses have been leading health care innovations since the dawn of the profession. They have ushered in broad-scale changes in areas ranging from better hygiene practices for wounded soldiers to public health visits to overcrowded urban homes to reproductive health services for women.

In more recent decades, nurses have begun developing innovations in geriatric care to help meet the massive health care needs of an aging population. They are finding new ways to improve the quality of care for older adults and ensure that it takes family and community considerations into account; improve access to highly skilled health care providers with training in geriatrics; narrow disparities that disproportionately affect older minorities; avoid preventable hospital readmissions; and more.

Their work answers the call from a groundbreaking report on the future of nursing that was released in 2010 by the Institute of Medicine (IOM). It urges nurses to continue their long legacy of innovation “as the health care needs of the population change from acute and infectious disease to that of an aging population with chronic disease.”

The country is, indeed, undergoing dramatic demographic changes. As Baby Boomers age and immigration patterns change, America is becoming older and more diverse. By 2050, the number of Americans age 65 and older will hit 40 million, about 20 percent of the population, according to the U.S. Census Bureau. These changes will strain the health care system and the nursing profession, the largest segment of the health care workforce.

Experts say the nursing workforce is not adequately prepared for a crush of elderly patients who are living longer, and sicker, with more chronic and complex health conditions. To meet these growing health care demands and bridge gaps in services for older Americans, the IOM said nurses “must continue to develop innovative care models based on current successes” in rural aging and other areas.

Fortunately, many nurses are already leading efforts to meet current and future health care needs. “Nurses are beginning to home in on the chronicity and the larger number of older people coming down the pike,” said Jennie Chin Hansen, RN, MS, FAAN, CEO of the American Geriatrics Society and a member of the study committee supported by the Robert Wood Johnson Foundation (RWJF) that drafted the IOM’s nursing report.

She pointed to the Transitional Care Model, developed by Mary Naylor, RN, PhD, FAAN, national program director for RWJF’s Interdisciplinary Nursing Quality Research Initiative (INQRI). The model utilizes nurses to reduce hospital readmissions among elderly patients after they have been discharged from the hospital. As many as one-third of re-hospitalizations are considered preventable, so reducing readmissions not only improves patients’ quality of life, but reduces health care costs.

The Program for All-Inclusive Care for the Elderly (PACE) is an example of a nurse-driven innovation in geriatric care. A replication of a program spearheaded many years ago by Chin Hansen, PACE is a now a federally legislated program in which interdisciplinary teams of providers give frail elders coordinated health, medical, and social services support by a one-stop system, a process that enables many to live in their own homes for longer periods of time.

Another nurse-led innovation, Nurses Improving Care for Healthsystem Elders (NICHE), was developed to better meet the needs of older adults in a health care system that, in general, lacked access to gerontology-trained providers and to care coordination services. The NICHE program is helping hospitals and, increasingly, community health systems, provide older Americans with “sensitive and exemplary care.” Under the program, “nurses are empowered by knowledge to provide high-quality care for older adults and, in doing so, teach others about the uniqueness of caring for older adults,” said Tara Cortes, PhD, RN, FAAN, executive director of the Hartford Institute for Geriatric Nursing in New York and an alumna of the RWJF Executive Nurse Fellows program (1999-2002).

And that’s just the beginning:

Promoting cancer screening among older African American women

Nurses all over the country are studying ways to improve care for older Americans. In North Carolina, for example, Dee Baldwin, PhD, RN, FAAN, a nurse educator at the University of North Carolina-Charlotte and an RWJF Executive Nurse Fellows program alumna (2000-2003), has spent decades exploring ways to prevent cancer in older African American women, who are more likely to die from the disease than other groups.

In 1992, Baldwin launched Project Breast Health, a culturally sensitive educational program to encourage more African American women to take advantage of cancer screening services. She also led an effort to hire lay navigators to raise awareness about breast and cervical cancer among older women in African American communities and developed electronic computer messaging to target the population. “We tried to look at different ways to reach people.”

Improving the quality of care in assisted-living facilities

Anna Beeber, PhD, RN, an RWJF Nurse Faculty Scholar (2011-2014) also from North Carolina, is exploring ways to improve the quality of care in assisted-living facilities. She is conducting research that examines staffing, service delivery, and resident outcomes in order to help assisted-living communities better match services with resident needs. “We really don’t know in assisted-living communities what, if any, influence nurses have on quality of care,” she says. And that is a critical piece of information that has the potential to improve care for the roughly 1 million Americans who currently live in the country’s 22,000 assisted-living facilities.

Increasing the number of geriatrics-trained nurses

In North Dakota, Jane Strommen, PhD, project coordinator of the North Dakota Gerontology Consortium, an initiative supported by Partners Investing in Nursing’s Future (PIN), is working to ensure that older people have more access to geriatrics-trained nurses. She and her team are promoting gerontology nursing via marketing materials, nursing conferences, nursing-themed summer camps, and stipends for nurses and nurse educators who study gerontology and geriatric nursing. “We have a growing population of older adults in our state, and we know the need for nurses who have the skills and training to care for them is just going to increase,” she says.

Creating safer homes

And in Maryland, Sarah Szanton, PhD, ANP, an RWJF Nurse Faculty Scholar (2011-2014) and associate professor of nursing at Johns Hopkins University, has come up with an innovative program to use “handymen” to turn older people’s homes into safe environments. Her goal is to enable elderly people to continue living in their homes as long as they are willing and able—and to stay out of nursing homes, which create considerable taxpayer expense. Read more about Szanton’s work here.

These projects are among the many nurse-led efforts under way across the nation to improve care for older Americans—a natural outgrowth, Chin Hansen says, of nurses’ skills, abilities, and population focus. “One of the things that nurses have always done is advocate for the patient and the family,” she says. They will continue to do that as their patients get older, and they will likely have a greater ability to transform health care as more earn master’s and doctoral degrees and assume positions of leadership in health care and society. Says Chin Hansen: “More nurses are being sought out for their leadership and their ability to change the current culture of medical care towards health and health care in an aging America.”

Tuesday, July 15, 2014

Collaboration, Communication Needed Between Nursing, Pharmacy Staff

Medication management decisions must be made with clear communication and collaboration between the nursing and pharmacy departments to avoid errors and negative patient outcomes, according to a recent Advanced Healthcare Network for Nurses article written by Executive Nurse Consultants Robin Fowler and Kevon Garrison of Aesynt, a company providing pharmacy automation technology and systems. Additionally, each hospital must find a medication distribution model that fits with its workflow and nurse leaders should have a strong voice in its selection. They write:

“The use of pharmacy technology is important to strategically improving the medication management process, but if decisions are made without nursing input, there can be unforeseen consequences. ... When the pharmacy and nursing departments meet frequently and all stakeholders are focused on the same end-goal, the outcome is a medication management model that produces fewer errors, greater efficiency and better patient outcomes.”

An INQRI-funded study examined acute care hospitals to determine the relationships among characteristics of the nursing practice environment, nurse staffing levels, nurses’ error interception practices, and rates of nonintercepted medication errors. The study, “Nurses’ Practice Environments, Error Interception Practices, and Inpatient Medication Errors,” was published in the June 2012 issue of the Journal of Nursing Scholarship and found that nurses’ error interception practices are associated with lower rates of nonintercepted medication errors.

The INQRI study also found that a supportive practice environment—reflected in factors including teamwork and nurses’ opportunities to participate in hospital- and unit-level decisions—is associated with a higher quality of nursing care.

The study was conducted in a sample of 82 medical-surgical units recruited from 14 U.S. acute care hospitals in New Jersey, and included 686 registered nurses.Linda Flynn and Dong-Churl Suh led the research.

Wednesday, July 9, 2014

Finding Solutions for Stressed Out, Exhausted Nurses, and Potentially Depressed RNs

A new survey of more than 3,300 registered nurses (RNs) shows that a majority were extremely stressed out due to lack of sleep, long hours, and numerous other workplace issues.

These high levels of stress and fatigue could lead to medical errors, and negative patient outcomes, as well as an increase in nurse burnout, further aggravating the current nursing shortage, according to the study by the Vickie Milazzo Institute, a legal nurse consulting training institute.

Among the findings, 64 percent of respondents indicated that they rarely get seven to eight hours of sleep and 33 percent said they hardly ever get that amount. Twelve-hour shifts and on-call shifts after regular shifts and overnight shifts contribute to the fatigue problem, according to the study. Fatigue and irregular sleep patterns can also lead to health problems for nurses, including increased risk of depression and anxiety disorders.

An INQRI-funded study, published in the May/June 2012 issue of the journal Clinical Nurse Specialist, looked at how depression and musculoskeletal pain among nurses impacts workplace productivity and quality of patient care. Researchers found that nurses experience depressive symptoms at a rate twice as high—18 percent—as the general public. The team found that pain and depression were significantly associated with presenteeism, which was significantly associated with patient falls, medication errors, and the perceived quality of care. Additionally, depressed workers often exhibit low mood, have difficulty concentrating, and are accident-prone.

The researchers analyzed surveys from 1,171 hospital nurses in North Carolina and found that the productivity loss due to pain and/or depression was $14,339 per nurse and $876.9 million for the state of North Carolina. If these numbers were extrapolated to the nation, the productivity loss would be $22.7 billion.

Addressing the Problems

According to the Milazzo study, other factors contributing to high levels of stress for RNs are an unhealthy work/life balance, lack of authority, recognition, and fair pay in the workplace, and lack of effective management. To address these issues, the study recommends that hospitals:
  • Make work hours for RNs realistic and sane;
  • Provide access to nutritious food;
  • Allow experienced RNs to have the authority to do their jobs and provide RNs with management opportunities; and
  • Improve management style to recognize RN’s unique contributions and provide fair pay, adequate paid time off, and a positive work environment.
As the INQRI study points out, it is also imperative to devote more attention to depression screening and early treatment for nurses. Advanced practice nurses can educate staff RNs about the high prevalence of depression in nurses, who, like the general population, may be reluctant to get screening and treatment, due to the social stigma attached to mental illness. The study identified Web-based screening as a confidential and cost-effective means of reaching the nursing population.

Other strategies for assisting nurses with depression include increasing staff nurses and managers’ awareness of and sensitivity to depression, advocating policies that support good mental health and treatment for those with problems, and promoting supportive work environments, according to the study.

The Effects of Nurse Presenteeism on Quality of Care and Patient Safety was led by INQRI grantees Susan Letvak and Christopher J. Ruhm.

The Vickie Milazzo Institute survey results are available here.

Wednesday, July 2, 2014

Nursing Leaders, Finance Professionals Should Improve Collaboration, Understanding

Nurses and finance professionals can align to improve finances at hospitals and health systems through a better understanding of their respective roles, a key nursing leader told attendees at the Healthcare Financial Management Association annual 2014 conference.

Pamela Thompson, CEO of the American Organization of Nurse Executives (AONE), suggested that understanding the importance of patient safety, and the changing science behind it, is one of the key steps in achieving alignment, Healthcare Finance News reports.

Nurses and other frontline providers deliver value to hospitals, but finance professionals often do not have a complete understanding of what they do, Thompson said in her remarks, noting that “the value of nursing is beyond the individual task performed … [it is] in the health outcomes achieved per dollar of cost spent.”

Patient safety is one area in particular that offers an opportunity to improve finances, particularly as the science surrounding patient care is becoming increasingly sophisticated. However, creating a safety culture takes time and resources and it can mean facing up to fears that reporting errors will lead to repercussions and retaliation, Thompson said.

“We have to convey the message that every time we reduce harm, we reduce costs,” Thompson said. “But we still need to work together to better determine the cost of allowing harm to occur. How do we measure the total patient harm rate per discharge?”

Ultimately financing and nursing professionals need to work collaboratively on questions such as these for the benefit of hospitals and patients, Thompson said. “Our commitments are very similar, we just articulate them differently. We have to align our goals, understand the interfaces and realize where coordination is essential.”

AONE houses the national program office of the RWJF Academic Progression in Nursing program.

Friday, June 20, 2014

Nurses Collaborate Across Oncology Departments to Address Fractured Care

A team of oncology nurses at the Torrance Memorial Medical Center in California recognized that patient care was hindered by inconsistent communication between departments and weak collaboration among providers. To address this problem, they conducted an analysis of patient feedback and then initiated regular meetings to improve patients' oncology care experiences through a collaborative approach, Oncology Nurse Advisor reports.

In a poster presentation from Torrance’s Miriam Sleven at the National Coalition of Oncology Nurse Navigators Conference in Atlanta, she outlined how the team addressed the fragmented care that was occurring across settings at their facility.

Nurses representing clinical, administrative, inpatient oncology, outpatient infusion, palliative care, and radiation oncology departments, as well as the Breast Diagnostic Center, and the Cancer Resource Center, met monthly and discussed projects they were working on to improve cancer services from the planning to the evaluation stage. During the meetings, the nurses identified issues and projects that spanned the scope of oncology nursing practice and the patient experience.

The meetings were successful, leading to improved communication between all oncology nurses, and improved patient experience, reports Oncology Nurse Advisor.

Thursday, June 19, 2014

National Nurse Leadership Training Program Yields Results in Boston

A nursing team from Boston that took part in a national leadership training program has shown measurably improved patient outcomes and a combined $8 million in anticipated annual savings for their hospitals. The Boston initiative is part of a broader training program conducted by the American Association of Critical-Care Nurses (AACN).

AACN directs and funds the AACN Clinical Scene Investigator (CSI) Academy, a 16-month, hospital-based nurse leadership and innovation training program. The program empowers bedside nurses as clinician leaders whose initiatives generate quantifiable improvements in patient care and cost savings, according to an AACN media statement. Teams of staff nurses from participating hospitals take part in the training.

The Massachusetts AACN CSI Academy teams recently presented the results of their projects at an Innovation Conference in Boston, reporting successes such as:
  • Decreased the average length of stay in the intensive care unit (ICU) for ventilated patients by nearly eight days using an early mobility program;
  • Reduced incidence of pressure ulcers acquired while in the ICU by 50 percent;
  • Improved communication between units, leading to a 100 percent decrease in patient handoff incident reports;
  • Decreased the average number of mechanical ventilation days for ICU patients; and
  • Improved assessment of ICU-related delirium in critical care patients, leading to improved cognitive scores and decreased benzodiazepine use in patients with documented delirium.
The Massachusetts team is the third group to complete the Academy, after Indiana and North Carolina. Hospitals in New York, Pennsylvania, and Texas are currently participating and nursing teams from 42 hospitals will have completed the program by the end of 2014, according to AACN.

AACN’s searchable Innovation Database provides access to a compilation of CSI team results and documentation, including real-world project plans, clinical interventions, data collection tools, outcomes and references.