Learn It, Lead It, Live It: Strategies to Refocus on the Fundamentals of

Nursing CareKathleen Vollman MSN, RN, CCNS, FCCM, FCNS, FAAN

Clinical Nurse Specialist, Educator, ConsultantADVANCING NURSING LLC, Northville MI

kvollman@comcast.net

©ADVANCING NURISNG LLC 2019

Disclosures for Kathleen Vollman

• Consultant-Michigan Hospital Association Keystone Center

• Subject matter expert for CAUTI and CLABSI, HAPI, C-Diff and Sepsis for CMS/HIIN

• Consultant and speaker bureau:– Sage Products now a business

unit of Stryker– Eloquest Healthcare– Urology division of Medline

Industries– Baxter Healthcare Advisory

Board

Objectives• Describe the forces within the current health care

environment that are driving the need resuscitate the basics with evidence to create a safer patient environment

• Compare and contrast the different tools and techniques to create a culture driven by the evidence where nurses feel empowered to engage & own their own practice

• Discuss measurable outcomes to determine a successful culture change & an early adopter environment of new information

Patient Safety in the EU: Harm Facts

• WHO states patient harm 14 leading cause of global disease burden

• 1 in 10 patients are harmed at one point during their treatment• Variation in level of surveillance of patient safety issues by

country• If EU reduced AE’s through safety initiatives

• 750,000 less harm events• 3.2 million fewer hospital days• 95,000 fewer deaths

• ½ the patients in Europe think they could be harmed by hospital care

• US has saved 28 billion between 2010-2015 thru safety prevention

.OECD, The Economics of Patient Safety, March 2017 https://www.oecd.org/els/health-systems/Theeconomics-of-patient-safety-March-2017.pdf Eurobarometer, Special Eurobarometer on Patient Safety and Quality Care, 411/2014OECD, The Economics of Patient Safety: Strengthening a value-based approach to reducing patient harm at national level, March 2017

Understanding The Journey

NursingOrganizations

• How many nurses went into the profession with the belief they could help people and be able to make a difference?

• How many nurses graduated from nursing school with a somewhat clear understanding of the skills and interventions used by the profession to achieve quality nurse patient outcomes?

• How many nurses still feel the ability to make a difference and understand what nursing uniquely contributes to quality patient outcomes?

That’s not the way we do it here!!!

What is a Culture?

Represents a set of shared attitudes, values, goals, practice & behaviors that makes one unit distinct from the next

Pronovost, PJ et al. Clin Chest Med, 2009;30:169-179

Driving Components in a Work Culture

Reasons for Confusion & Disillusionment in Nursing

A narrow definition of health How we define autonomy Nursing’s unique contribution Absence of recognition for basic nursing care

activities

Vollman KM, Stewart KH. AACN Clin Issues. 1996;7(2):315-323.

A 

Narrow

Definition

of 

Health

Medicine’s Health Definition

The absence of disease and measured in terms of morbidity and mortality

Nightingale’s Health Definition

Health is not only to be well but to be able to use what ever power we have.

Wellness & IllnessWellness & Illness

Wellness is comfortable somatic sensations accompanied by optimal functional ability whether we have a disease or not

Illness is uncomfortable somatic sensations or a decreased functional ability whether we have a disease or not

Autonomy

Means the self-directed diagnosis & treatment or it is a self determined and controlled action that does not require authorization from another

Confusing Autonomous Scope of Practice

Setting Judgments

AutonomousNursingScope of Practice

MedicalNursingScope of Practice

Florence Nightingale …

An expert in nursing’s autonomous scope of practice

Surveillance & monitoring of patient conditions for early detection of problems

Preventing complications

“I use the word nursing for want of a better. It has been limited to signify little more than the administration of medicines and the application of poultices. It ought to signify the proper use of fresh air, light, warmth, cleanliness, quiet, and the proper selection and administration of diet—all of these at the least expense of vital power to the patient”

Notes on Nursing (1860/1969 p. 8)

Florence Nightingale on:

The distinction between disease and illness

“… so deep-rooted and universal is the conviction that to give medicine is to be doing something or RATHER EVERYTHING; to give air, warmth, cleanliness, etc., is to do nothing.”

(emphasis added) Notes on Nursing, (1860/1969, pg. 9)

Self Directed Treatment Categories for Nursing

Hygiene-related activities Nutrition-related activities Elimination-related

activities Comfort-related activities Movement-related

activities Rest/activity relate

activities Learning and

development-related activities

Safety-related activities

Sense of normalcy-related activities

Interaction-related activities

Coping-related activities Physical environment-

related activities Alteration in ADL-related

activities

Recognition & Reprimand Structures within Acute Care Settings

• Recognition• Physiologic assessment • Completing medical treatments in a timely

fashion• Assisting physicians with activities

• Reprimand• Medication administration• Questioning content of medical orders

Behavior that is recognized and reinforced continues

Behavior that is ignored or not reinforced does not continue

Missed Nursing Care

• Any aspect of required patient care that is omitted (either in part or whole) or significantly delayed.

• A predictor of patient outcomes• Measures the process of nursing care

Kalish, R. et al. (2012) Am Jour Med Quality, 26(4), 291-299.

Hospital Variation in Missed Nursing Care

Kalish, R. et al. (2012) Am Jour Med Quality, 26(4), 291-299.

Outcomes of Missed Nursing Care: A Systematic Review

• 14 studies connecting missed nursing care with at least 1 patient outcome• Patient Satisfaction ↓ • Lower quality of care reported by nurses with greater missed care • Clinical Outcomes

• Medication errors• CLA-BSI’s• Pneumonia• UTI’s• Pressure Injuries• Falls• Failure to rescue

Recio-Saucedo A, et al. J of Clin Nurs. 2018;27:2248-2259

5 nurse sensitive adverse events in 22 med-surg units added

1300 additional hospital days for 166 patients &

$ 600,000 in excess costs

Tchouaket E. JAN. 2017;73:1696

Reasons for Missed Nursing Care

Kalisch, BJ, et al. American Journal of Medical Quality. 2011; 26(4), 291–299Ball JE, et al. BMJ Quality and Safety 2014 Feb;23(2):116-25.

9.4% variance in missed nursing care

Qualitative Review• Interruptions/multitasking/task

switching• Fatigue & physical exhaustion• Cognitive biases• Lack of patient & family

engagement• Lack of physician resources• Leadership issues• Moral distress & compassion fatigue• Documentation load• Large proportion of new nurses on

unit• ComplacencyPractice environment correlates to missed nursing care

Rationing Care-How we Prioritize

• Highest priority activities for nurses• Those which are likely to have an immediate negative

impact• Administering meds• Medical directed treatments• Procedures-wound dressings, labs

• Lower priority activities for nurses• Those which show no immediate negative harm

• Ambulation• Oral hygiene• Emotional support• Teaching

Bail K, et al. International Journal of Nursing Studies. 2016;63:146-161

Rationing contributes to functional and cognitive decline

Bail K, et al. International Journal of Nursing Studies. 2016;63:146-161

Fundamentals of Care Framework

The Fundamentals of Care Framework. Reprinted from Conroy, Feo, Alderman, and Kitson (2016)

• Fundamental care involves actions on the part of the nurse that respect and focus on a persons essential needs to ensure their physical & psychosocial wellbeing.

• These needs are met by developing a positive & trusting relationship with the person being care for as well as their families/carers

Feo R, et al. J of Clin Nurs. 2018;27:2285-2299

Patient Perceptions of Missed Nursing Care

Kalisch, B et al. (2012). TJC Jour Qual Patient Safety,38(4), 161-167.

Reconnect With Our Professional Purpose

“It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm.”

Florence NightingaleNotes on Hospitals: 1859

Advocacy = Safety

Protect The Patient From Bad Things

Happening on Your Watch

Interventional Patient Hygiene

• Hygiene…the science and practice of the establishment and maintenance of health

• Interventional Patient Hygiene….nursing action plan directly focused on fortifying the patients host defense through proactive use of evidence based hygiene care strategies

Incontinence Associated Dermatitis Prevention

Program

INTERVENTIONAL PATIENT HYGIENE(IPH)

Oral Care/ Mobility

VAP/HAP

Catheter Care

CA-UTI CLA-BSI

Skin Care/ Bathing/Mobility

HASISSI

Patient

Vollman KM. Intensive Crit Care Nurs, 2013;22(4): 152-154

Falls

PATIENT

CLEAN GLOVES

CLEAN GLOVES

HAND HYGIENE

HAND HYGIENE

INTERVENTIONAL PATIENT

HYGIENE(IPH):The Physical

Fundamentals of CareOral Care/

Mobility/Comfort

VAP/HAP

Medication Management

CA-UTI CLA-BSI

Skin Care/NutritionBathing/Mobility

SSI

Patient

Vollman KM. Intensive Crit Care Nurs, 2013;22(4): 152-154

PATIENT

CLEAN GLOVES

CLEAN GLOVES

HAND HYGIENE

HAND HYGIENE

VTECatheter Care

Falls

HASI

SSI

Adverse Drug Events/

Medication Errors

Norway’s National Patient Safety Campaign 2014-2018

• Aims were to: 1) reduce patient harm, 2) build sustainable structures for patient safety and 3) improve patient safety culture. • Falls• Urinary tract infections• Central line infections• Pressure injuries• Safe surgery/postoperative infections• Stroke treatment, • Prevent overdose and suicide• Medication reconciliations, drug review in home care and in

nursing homes

Lund J. 9th European Public Health Conference: Parallel Sessions in 2017

• Reduce incidents of harm by 25% from 2012 until 2019

• Increase 30-days survival after hip fracture by 2%

• At least 80% of respondents from health units will report a ripe patient safety climate.

Lund J. 9th European Public Health Conference: Parallel Sessions in 2017

Attitude &

Accountability

Factors Impacting theability to Achieve QualityNursing Outcomesat the Point of Care

Achieving the Use of the Evidence

ValueVollman KM. Intensive & Critical Care Nursing, 2013 Oct; 29(5): 250-5

Patient Advocacy/Safety Related to Clinical Practice

• Nurses knowledge of the Evidence based care• Ability to deliver the care to the right patient at the right time,

every time it is needed• The ability to communicate patient concerns in a concise,

data driven manner and take appropriate action• Understanding the chain of command when faced with

resistance and that we are the patients voice

Communication Strategies

• Tools to help structure communication• SBAR for communication with Doctors: Situation,

Background, Assessment and Recommendation• CUS Words: I am Concerned, I am

Uncomfortable, This is not Safe

Use CUS words when assertion of your communication fails…things go wrong…concern expressed but mutual decision not reached or proposed action doesn’t happen in time frame agreed upon

What Supports Our Ability to Advocate & Use the Evidence?

• Leadership support• Evidence-based knowledge• Experience• Effective communication• Respectful communication and being respected

• Goes both ways• If we as nurse don’t know or believe something different than

the doctors order what should we do?• Understanding that it’s worth it!!!!!

Understanding The Journey

Nursing Organizations

Culture Assessment is Critical

Assessment of Safety & Work Culture-Organization & Unit

• SAQ (Safety Attitudes Questionnaire)• Teamwork• Safety• Working conditions• Job satisfaction• Stress recognition• Perception of upper management• Perception of unit management

Strive for 80%, if < 60% SAQ scores correlates to decreases in clinical outcomes

AACN Healthy Work Environment Assessment tool-Unit Level

• Skilled communication• True collaboration• Effective decision making• Appropriate staffing• Meaningful recognition• Authentic leadership

Health Care QualityDonabedian Framework

STRUCTURE PROCESS OUTCOME

Having the right things in place

Doing the right things

Having the right things happen

Quality of care is represented by an entire systemic integration from structure to process and to outcome,

but not by one or the other independently

Organizational & Unit Structures that Supported the Empowerment

Shared Governance Model

Continuous Quality Improvement Model

Professional Practice Model/Clinical Ladder

Unit Based Leadership Model

Educational Support

Foundational Principles to Maximize Staff Empowerment

• Share Governance = Shared Leadership of Practice/Ownership

• Shared governance is a structural model that frames the professional practice within health care settings (Porter-O'Grady, 2012).

• Shared governance empowers nurses to participate in decision making, nursing practice, and development of nursing policies (Bednarski, 2009).

Foundational Principles to Maximize Staff Empowerment

• The Unit is the center of a shared governance model..the locus of control is at the point of service

• Staff need mentoring and leadership coaching• Shared leadership means the clinical and administrative

lead of the unit are part of the unit practice/governance council

• Defined accountability of all members• Sufficient time in meetings to formulate ideas and plan

work (unit meeting 4hrs)

One of the reasons people don’t achieve their dreams is that they desire to change

their results without changing their thinking

John C. Maxwell

Structure:Collaborative Practice Teams

CPT: Collaborative Practice Teams have responsibility for the different performance measures, P4P, VBP

Example Structure:Unit Based Accountability Teams

• Every patient care unit in hospital or group practice• Composition: Medical Director, Nurse manager, Clinical

Nurse Specialist, System Performance Improvement Leader

• Responsibilities:• Establish clinical/quality goals for unit• Responsible for unit outcomes---unit dashboard

• Clinical and operation measures• Quality• Patient Safety and safety culture• Patient satisfaction• Employee satisfaction

Helpful Hints to an Empowered Practice

• Encourage staff to be a part of unit governance council or on projects or task forces to solve clinical issues with the evidence

• Start up a journal club or participate…help them learn to read evidence

• Strategies to impact value of practice

Strategies to Impact Value Structure

• Patient Care Conferences

• Role Modeling

• Bedside Consultation

• Unit Process Improvement Projects

Patient Care Conferences

Medical FocusNursing Therapeutics

Nursing Rounds Format

1) Brief Medical History: Past history, reason for admission, stable/unstable

2) Pulmonary: Secretions/type and amount, single use or in-line catheter, ability to tolerate repositioning, assess need for continuous lateral rotation therapy and/or the prone position, assessment of functional readiness to wean

3) Psych/Coping: Assess for agitation/ Dx of anxiety, pain and/or delirium, safety issues, sleep/rest pattern, use of diversional activities, Dx of powerlessness

4) Family: Coping, support systems, discussion of code status, evaluation of home environment/discharge needs

5) Activity: Physical therapy needs, activity/exercise schedule, prevention of contractures

Purpose of the Rounds Format

Impact care practices that prolong LOS or create complications

Reinforce Ownership of nursing practice

As a Nursing practice reward structure

To enhance continuity of care

To build intellectual confidence

Strategies to Impact Value Structure

• Patient Care Conferences

• Role Modeling

• Bedside Consultation

• Unit Process Improvement Projects

Bedside Consultation:

Creating the

Ah-hah

Experience

Teaching Pathophysiology & Clinical Decision

Making Skills

bedside consultations self study

modules

Unit Process Improvement Projects

CNS/APRN guidance

Staff designed, implemented & evaluated

Develops sense of ownership, pride & accomplishment

Clinician and Financial Outcomes

It Takes a Village

Measurement is Key

Nurse Sensitive Care Indicators

• Death among surgical patients with treatable serious complication

• Pressure ulcer prevalence• Falls prevalence• Falls with injury• Restraint prevalence (vest

& limb only• UTI rate/ICU• Blood stream infections

(BSI) from invasive catheters (ICU and high risk nursery)

• Ventilator-associated pneumonia (VAP and high risk nursery)

• Smoking cessation for AMI

• Smoking cessation counseling for heart failure and pneumonia

• Skill mix• Nursing care hours per

day• Voluntary turnover• Nursing Environment

IndexNursing Quality Forum 2004

Additional Measures

• Non-ventilator hospital acquired pneumonia• Employee satisfaction• Retention of qualified experience staff• Staff Empowerment

• Culture and healthy work environment tools• Participation in process improvement & committees• Presentations-posters and podiums• Actively engaged in problem solving

DO NO HARM

Advocacy Starts with Us