Updated: 07/15/20
Problem/purpose: To promote consistent clinical orientation experiences and clinical practice in a complex healthcare system with two separate human resource departments and diverse practice settings.
Design: Partnership between nursing professional development practitioners, ambulatory care services leadership, and human resources departments to provide an integrated clinical orientation for new and transferring staff members.
Setting: Ambulatory care services at an academic health system in the Southeast
Participants/target audience: New hires and transfer employees starting at the organization’s hospital-based clinics and the physician practice clinics.
Methodology: In order to provide consistency of orientation information and documentation as well as consistent care across practice locations, discussions were held with key stakeholders in both organizations under the broader health system. While not all aspects of orientation could be combined due to separate HR departments and benefit structures, the clinical components and leadership presentations were combined to provide a consistent message and vision to new and transferring employees. Logistical challenges included where to hold orientation sessions, parking for off-campus orientees, essential orientation elements for new hires at greater geographic distances, creating one set of policies for all ambulatory care locations, and creating specialty-specific “competency-based orientation” (CBO) documents instead of clinic-specific CBOs.
Results/outcomes: After partnering with the key stakeholders and collaborating to meet essential integration components, the combined orientation began in February 2018. In the following 12 months, approximately 350 new hires and transfer employees have attended the integrated ambulatory care orientation. This has provided a format for all ambulatory care employees to meet with executive leadership within ambulatory care services and receive consistent communication on patient care goals and strategic vision, in addition to making a personal connection between leaders and new clinical staff. All RNs, LPNs, and medical assistants are also provided with information on clinical resources and complete a medication knowledge assessment utilizing these online resources. In addition, clinical staff complete learning modules and in-seat education on the electronic medical record, as well as participate in a class to complete their level I CBO (level II and level III are completed in their clinics). Most recently, an ambulatory care skills lab has been added to orientation, which includes a dosage calculation test, medication administration review and skills demonstration, EKG lead placement, and an emergency response drill (first five minutes of a code). Results have been positive from both orientees and leaders, and documentation of the orientation elements has improved.
Implications for future practice: With increased healthcare system expansions, other organizations may benefit from a similar approach to integrating orientation for a consistent experience and standardized practice and documentation.
Updated: 07/20/20
Updated: 07/20/20
Description: This quality improvement project assumed that each medical home team member functions at the highest level of their practice to support the patient in managing their hypertension. The quality improvement project added an additional strategy: a coach, who assisted the team to identify barriers to teamwork, enhance attention to patient-centered care, optimize quality improvement tools, map the PCC processes, provide relevant data retrieval for quality improvement, and facilitate PCC core team meeting for six months. The medical provider and patient guided the approach to the patient’s BP management. The team depended on the medical provider to use an algorithm for initiation or addition of anti-hypertensive medications. The LPN was coached in the use of the American Heart Association (AHA) guidelines to obtain an accurate BP readings. Both the LPN and RN provided patient education related to BP management and measurement following AHA guidelines. The clerk managed appointment scheduling, including provider and RN visits, and patients with missed or failed scheduling of appointments.
During the weekly team meeting, the coach provided team specific hypertension metrics. Team members were asked to generate and then initiate interventions that might impact their population’s BP. The provider began to write patient-specific BP medication orders for the next RN visit (usually within the same week). Nursing specific interventions included increasing patient visits for BP monitoring, medication management and review, home BP measurement education, and teach back; dispensing of blood pressure (BP) cuff at the RN or provider visit with immediate education and teach back with the RN; gifting zippered bags with the request to bring all medications and the BP cuff to future appointments; and phoning patients whose metrics indicated an out of control BP.
Evaluation/outcome: Patient BP readings above 140/90 were 30.6% at the beginning of the quality improvement program and were reduced to 20.6% after the intervention. Using a coach and an interprofessional team willing to evaluate its practice and generate team and role specific interventions was successful in improving hypertension control.
Updated: 07/19/20
Purpose: The purpose of this project was to partner ambulatory services (AS) nursing leaders and staff with the affiliated school of nursing (SON) students to provide a unique student nurse practicum focused on blending key acute and ambulatory care skills that support the population health across the care continuum.
Background/significance: A growing focus on population health and cost containment in the US healthcare delivery system has increased the demand for registered nurses (RN) in ambulatory care settings. Despite this growing need, schools of nursing struggle to find appropriate placements that provide ambulatory care-focused clinical experiences. These gaps in education and experience create significant challenges in meeting today’s health care demands. Innovative pre-licensure clinical education experiences outside the acute care setting will fully prepare nurses for this role.
Methods: The project team designed a blended acute and ambulatory care pilot practicum for nursing students in their final semester. The pilot lasted 3 semesters, with 3 cohorts totaling 10 student participants. Outpatient preceptors participated in pre-program training and post-program debriefing. Students were placed in 6 sub-specialty outpatient centers and 4 inpatient units. Students started with inpatient rotations and then transitioned to ambulatory care units where they cared for patients with similar conditions. The ambulatory care rotation focused on skills that support value-driven care such as care coordination, interprofessional care planning, post-hospitalization follow-up, patient and family teaching, and community outreach.
Results: Students and ambulatory care preceptors completed questionnaires evaluating the program structure and its effectiveness in preparing students to transition to practice. All preceptors and students in the first cohort recommended an increase in inpatient hours to maximize acute care skills development; the ratio was changed for remaining cohorts to 60% inpatient hours and 40% outpatient hours. Ambulatory care preceptors requested more input on student schedules, enabling them to be exposed to a greater variety of clinical experiences. Current completion data indicates 100% of students increased their understanding of the outpatient nurse’s role and 71% will consider working in ambulatory care at some point in their career. 28% of students commented that they felt the ambulatory care setting could provide a healthier work/life balance.
Conclusions/implications for practice: The practicum experience successfully provided nursing students an opportunity to develop essential ambulatory care nursing skills as they transition from the classroom to independent nursing practice. Integrating experiential ambulatory care learning the throughout pre-licensure nursing curriculum should also be explored.
References
1. American Academy of Ambulatory Care Nursing. (2017). Ambulatory Care Registered Nurse Residency Program: Transition to the Specialty of Ambulatory Care. J. Levine (Ed). Pitman, NJ.
2. Shaffer, Kathleen, Swan, B. & Bouchaud, Mary. (2018). Designing a New Model for Clinical Education: An Innovative Approach. Nurse Educator, 43(3), 145-148. doi:10.1097/NNE.0000000000000468
3. Windey, Maryann & Fritz, E. (2017). Transition to Practice in Ambulatory Care Nursing. Journal for Nurses in Professional Development, 33(5), 257-258. doi:10.1097/NND.0000000000000376
Updated: 07/19/20
Background: Communication and critical thinking are essential practice competencies for every registered nurse. However, newly licensed registered nurses (NLRN) often lack these skills on entry into practice contributing to low levels of clinical confidence (Fisher & King, 2013; Hommes, 2014). An association has been demonstrated between limited NLRN clinical confidence and increased medication error rates, self-doubt, and lack of interprofessional collaboration, ultimately impacting patient safety and quality of care as well as role satisfaction (Pfaff, Baxter, Jack, & Ploeg, 2014).
Purpose: The purpose of this quality improvement (QI) project is to implement and evaluate the effectiveness of simulation on clinical confidence among NLRNs.
Methods: This QI project is a mixed methods, pre-test and post-test design, targeting NLRNs in a 19-bed pediatric intensive care unit within an urban academic teaching hospital. Eligible participants were baccalaureate-prepared NLRNs who graduated within the last year and were either currently enrolled in the institution’s nurse residency program (NRP) or completed the residency program within the last year. During the QI project, NLRNs participated in two clinical simulations in small groups of three, utilizing dedicated simulation space and high-fidelity equipment at the project site. The clinical simulations reflected common PICU clinical practice and were developed by the project lead and two doctoral-prepared clinical simulation content-matter experts, utilizing the simulation module for assessment of resident’s targeted event responses (SMARTER) and the behavior assessment tool (BAT). The clinical simulations were delivered and debriefed by the project lead, certified clinical simulation educators, and facilitators at the project site. Newly licensed registered nurse confidence data were collected immediately pre-simulation and post-simulation, as well as one-month post-simulation using the self-report C-scale instrument of clinical confidence. Additionally, each NLRN was observed by a preceptor at project baseline, and again one-month post simulation, while engaged in routine nursing care. Qualitative data was collected by the preceptor using the C-scale instrument of clinical confidence. Paired sample t-tests will be used to determine if there is a significant change in confidence after each simulation, and at the completion of the project. Content analysis will be performed by two evaluators on the qualitative data derived from the C-scale observations to identify confidence themes and patterns.
Results: Paired sample t-tests revealed a significance increase in clinical confidence immediately after each of the three simulations and sustained one-month post simulation. Qualitative data collection of preceptor observations is still in progress.
Conclusions: Preliminary data indicates that simulation is an effective strategy to increase clinical confidence as perceived by the NLRNs and based on the observations of preceptors. Incorporation of simulation into transition-to-practice programs such as nurse residency or facility orientation is an evidence-based recommendation to improve development of clinical confidence and communication abilities in this population.
Updated: 07/19/20
Updated: 07/20/20
Background: In response to the rapidly changing health care arena, a new pre-licensure nursing education curriculum was developed and funded by a $2.5 million grant from Health Resources & Services Administration (HRSA) Nurse Education, Practice, Quality and Retention – Registered Nurses in Primary Care (NEPQR - RNPC) grant. The newly developed curriculum focuses on interprofessional primary care and is reflected in didactic, clinical, and simulation learning experiences. To capture accurate clinical experiences with a primary care focused BSN program, the initial question was as follows: How do we best evaluate the formation of primary care competencies in our students? One of the challenges in developing such an evaluation tool included ensuring that an evidence-based foundation would capture key primary, ambulatory care, acute care, and care coordination competencies that are measurable from the first to the last clinical semester in one continuous tool.
Purpose: A new clinical evaluation tool was developed with consideration of multiple evidence-based recommendations, resources, and tools to complement professional nursing practices with patient focused indicators for a more wholistic approach. This process would allow clinical instructors to evaluate student achievement of primary care competencies learned across the curriculum and applied in the clinical setting in one continuous document. The purpose of this poster is to describe the processes used in the development of the evidence-based competency evaluation tool.
Description: The existing acute care clinical evaluation tool was reviewed through the lens of Pender’s health promotion model as the framework for the initial step in the development of the comprehensive clinical competency evaluation tool. Using a cross-walk technique, multiple resources for primary, ambulatory care, and acute care competencies were reviewed and thematic analysis was conducted. The integration of primary care competencies with competencies required by accrediting bodies was an essential step in remaining true to the clinical focus. Themes were established to ensure the tool would provide a complete and comprehensive evaluation of the nursing students’ skills progression as the complexity of clinical patient care increases with each new semester built upon the previous semester’s learning trajectory. Once the initial competency indicators were identified as appropriate, the competency evaluation tool was built using Bloom’s taxonomy as a foundation for student progression toward competency. Levels were created with the intention of quantifying the progression toward a clinical grade. The evaluation tool allows for assessment at varied points in time within a semester as well as across the program. The clinical evaluation tool is comprehensive of primary, ambulatory care, acute care, and care coordination competencies.
Projected outcomes: This evaluation tool has been in use for 1.5 semesters. As a comprehensive, evolving tool over the student’s progress in in the program, there have been some challenges. Development is ongoing based on its use in the program.
Updated: 07/29/20
Growing challenges exist in health care related to the increasing needs of the American aging population requiring greater complexity of medical care. The changing healthcare environment dictate a workforce competently trained to address these health care issues. In primary care settings, the registered nurse’s scope of practice is limited such that these nurses are not working to the full capacity of their license (Macy Foundation, 2016). Also, noted is the lack of undergraduate nursing curricula that prepares for primary care practice (Wojnar & Whelan, 2017). Nursing educators face many logistical challenges for coordinating community-based clinical experiences.
Description: To prepare nurses for a career in primary health care, our nursing educational programs need an increased focus on care coordination, chronic disease management, transitional care nursing, and disease prevention, as well as mental health and substance use screening and treatment. A nursing curriculum gap analysis was completed based on the Scope and Standards of Practice for Professional Ambulatory Care Nursing (2017) to identify student learning needs. Gap analysis results identified learning needs in the areas of roles and professional standards for ambulatory care nursing, information technology and communication, and coordination of care and transition management.
In partnership with a local healthcare system, nursing faculty developed three nursing elective courses including didactic and 50 clinical hours per course. Students in the traditional BSN track that complete all three nursing electives along with select supporting social science courses are eligible for a minor in primary care nursing. Students in the RN-BSN track that complete all three nursing electives are eligible for a concentration in primary care nursing.
Evaluation/outcomes: Nine students were enrolled in the first primary care overview course. Seven clinical sites were secured in clinical rotations, and seven preceptors were trained. Standardized tools are being utilized to measure student perceptions of their curriculum and preceptors, including the self-efficacy and performance in self-management support instrument (Duprez et al., 2016). Students’ comments and course reflections will also be utilized for evaluation. Long-term evaluation will include employment rates for new graduates into primary care nursing positions.
References
1. AAACN. (2017). Scope & standards of practice for professional ambulatory care nursing. (9th ed.). Pitman, N.J: Author.
2. Duprez, V., VanHooft, S., Dwarswaard, J., VanStaa, A., VanHecke, A, & Starting, M. (2016). The development and psychometric validation of the self-efficacy and performance in self- management (SEPPS) instrument. Journal of Advanced Nursing, 72(6), 1381-1395. Retrieved from https://onlinelibrary.wiley.com/doi/abs/10.1111/jan.12918
3. Josiah Macy Jr. Foundation. (2016) Registered nurses: Partners in transforming care. Retrieved from: http://macyfoundation.org/publications/publication/conference-summary-registered-nurses-partners in transforming primary care
4. Wojnar, D. M. & Whelan, E. (2017). Preparing nursing students for enhanced roles in primary care: The current state of prelicensure and RN-to-BSN education. Nursing Outlook, 65, 222-232.
Updated: 07/20/20
Updated: 07/20/20
Data analysis: This is a descriptive study using data from 2018 data from a national nursing quality database. The sample consisted of 1704 outpatient clinics affiliated with 266 US acute care hospitals which submitted both patient falls and patient visit data for at least nine months. Annualized patient falls per 1,000 patient visits were calculated for each outpatient clinic. Descriptive statistics were calculated on fall injury level, whether the fall was assisted by an employee, whether the fall was the result of physiological event, and patient age. ANOVA modeling was used to determine statistical significance for the affiliated hospital characteristics of bed size, teaching status, and ANCC Magnet designation.
Results: The mean unit ambulatory care fall rate was 0.10 falls per 1,000 patient visits, and the median was zero. The majority of falls resulted in no injury (75%) and were not assisted by an employee (85%). Less than 40% of falls were the result of a physiological event. The mean age of patients who fell was 54 years old and approximately half of patients who fell were male (51%). No statistical difference was found based on affiliated hospital demographics of bed size < 300 and ≥ 300, teaching status, or ANCC Magnet designation.
Ambulatory care nursing implication: The rate of patient falls in ambulatory care settings is considerably lower than the rate in inpatient units. There is still room for improvement, however. One current opportunity for improvement in outpatient clinics is to implement precautions and provide additional assistance to patients known to be at risk for falls. Another is the identification and mitigation of environmental risk factors for falls. Additional research and more comprehensive patient risk assessment may also lead to more actionable data for reducing patient falls in outpatient clinics.
Updated: 07/15/20
Background: Research has shown lifestyle modifications that include weight management, regular physical activity, and stress reduction are associated with improved chronic disease risk factors and overall improvement in general health. A lifestyle management group (LMG) was initiated in a safety net, faculty-resident internal medicine practice that provides care to approximately 12,000 patients. Many patients have been diagnosed with obesity, mental health issues, and chronic diseases. An internal referral process was developed for providers or patients could self-refer with provider clearance. The LMG included a 2-hour, bi-weekly class for 6 months. Each class incorporated a short provider visit to establish and review health goals, group exercises modified to adapt all fitness levels, and various educational topics presented by multidisciplinary staff within the clinic. Patients were encouraged to attend as many sessions as able to achieve their goals and benefit from the program.
Purpose: This program was developed and implemented in an attempt to improve chronic health conditions in a vulnerable population through an affordable onsite lifestyle management program. The established patient outcomes focused on weight reduction and quality-of-life metrics (physical function, pain, and mood). A group setting offered structure, motivation, and socialization, along with accountability to keep patients moving toward their desired goals.
Results/outcomes: 64 patients were referred to the program; 13 (20.3%) attended at least 1 class, and 8 (12.5%) attended at least 3 of more classes. In order to determine the value of the LMG program, weight and patient-reported outcomes measurement information system metrics were evaluated according to physical function, pain, and mood. Although weight loss was not clinically significant (5 –10% reduction in body weight), more than half of the patients lost weight at program completion. Improvement in mood was both clinically and statistically significant and may be related to the positive benefits of participating in a group setting.
Conclusions: LMG has demonstrated weight reduction and an improvement in mood for attendees. Goals for subsequent LMGs may include weekly sessions to increase patient engagement and achieve personal goals, as well as staff education and participation to increase patient referrals. In addition, an “alumni group” has been designed to continue ongoing efforts and to facilitate utilization of community resources.
Purpose: This program was developed and implemented in an attempt to improve chronic health conditions in a vulnerable population through an affordable onsite lifestyle management program. The established patient outcomes focused on weight reduction and quality-of-life metrics (physical function, pain, and mood). A group setting offered structure, motivation, and socialization, along with accountability to keep patients moving toward their desired goals.
Results/outcomes: 64 patients were referred to the program; 13 (20.3%) attended at least 1 class and 8 (12.5%) attended at least 3 of more classes. In order to determine the value of the LMG program, weight and patient–reported outcomes measurement information system metrics were evaluated according to physical function, pain, and mood. Although weight loss was not clinically significant (5 –10% reduction in body weight), more than half of the patients lost weight at program completion. Improvement in mood was both clinically and statistically significant and may be related to the positive benefits of participating in a group setting.
Conclusions: LMG has demonstrated weight reduction and an improvement in mood for attendees. Goals for subsequent LMGs may include weekly sessions to increase patient engagement and achieve personal goals, as well as staff education and participation to increase patient referrals. In addition, an “alumni group” has been designed to continue ongoing efforts and to facilitate utilization of community resources.
Updated: 07/27/20
Access to nutritionally adequate and safe food is a basic human need. Yet, food insecurity--lack of consistent, dependable access to enough food for all household members for active, healthy living--affects millions of American households. Those who experience food insecurity at rates above the national average include people from all walks of life: households with children; households with children headed by a single female, households headed by a Hispanic or black non-Hispanic person. those living in rural areas, those living in the South or Southwest US, families of enlisted military service members and veterans, college students, and seniors. Consequences of food insecurity include physical impairments related to insufficient or improper dietary intake, psychological issues related to a lack of consistent food access, and socio-familial disturbances.
Methodology: For this study, we provided a fruit and vegetable prescription and education program for food-insecure diabetics with poor blood sugar control who were patients of a primary care clinic associated with a safety net hospital in a large urban area in the southeast US. We then studied the impact of this program on certain diabetes health parameters. The study subjects were referred to this program by their primary care physician. There was a six-week series of one-hour classes that were led by a certified dietitian. Each class included, in addition to the usual didactic education, an onsite preparation of a healthy, diabetes-friendly dish composed of locally available vegetables and/or fruits, with a portion for each attendee to try. At the end of each class, each participant was given the recipe for the dish that was prepared that day, and a 20-pound bag of similar locally available vegetables and/or fruits with which to practice at home.
Analysis: Hemoglobin A1c and BMI measurements were taken before and after the intervention. Before- and after-intervention questionnaires were done to assess self-efficacy, perceived value assigned to fruit and vegetable intake, nutrition and diabetes knowledge, current fruit and vegetable consumption, and diabetes distress.
Results: Study participants, on average, showed a significant post-intervention decrease in hemoglobin A1c, a significant decrease in diabetes distress, and increases both in knowledge about diabetes and nutrition, and perceived value of fruits and vegetables for health.
Updated: 07/15/20
Purpose: To develop a standard multidisciplinary approach that was utilized across the care continuum to reduce opioid prescription use in opioid naïve cardiac surgery patients.
Relevance: The United States is currently experiencing an opioid misuse epidemic across all disciplines in health care. An estimated 21 to 29 percent of patients who use opioids chronically misuse them, and 8-12 percent progress to develop an opioid use disorder. Addressing this crisis has become imperative in an acute post-operative period to prevent prolonged exposure in opioid naïve patients, as this population has an associated increased dependence risk with continued use.
Methods: In investigating our opioid use, we identified six root causes contributing to our overuse: lack of staff buy in, lack of preoperative education, no standard opioid regimen, a lack of caregiver awareness, unclear alternative pain therapies, and an absence of post-operative pain follow-up.
To address these barriers, we established multidisciplinary opioid reduction strategies, which included: 1) standard opioid and non-pharmacologic regimens, 2) standardized pre-operative education, 3) incorporated family members, 4) empowered patients and family members to wean their opioid therapy, 5) established realistic pain expectations, and 6) emphasized non-pharmacologic interventions.
Evaluation/outcome: Through our interventions across the care continuum, there has been a reduction in average pills prescribed from 65 to 29 pills, or by 44%, in one year. Prior to our interventions, our department prescribed an average of 62.9 tablets of Norco 5/325 mg, 68.1 tablets of oxycodone 5 mg, and 58.9 tablets of tramadol 50 mg. Following our interventions, our department prescribed an average of 31.5 tablets of Norco, 30.8 tablets of oxycodone, and 18.6 tablets of tramadol. This reduction was clinically significant with an associated p value of 2.77E-31. This decreased use showed no variance to our baseline length of stay, postoperative visit utilization, or patient satisfaction.
Conclusions: Through a multidisciplinary approach, we have the potential to significantly decrease perioperative and postoperative opioid use. A standardized approach across the continuum can decrease the exposure of vulnerable opioid naïve patients without affecting the quality or satisfaction with care.
