Purpose: The aim of this quality improvement project was to increase the knowledge base and self-efficacy of ambulatory care registered nurses (RN) around diabetes education.
Background/significance: Diabetes mellitus (DM) is a preventable disease that increases the risk for serious complications, increases the risk of death by 50%, and requires chronic management. Many studies have shown that nurses do not possess adequate knowledge about diabetes to lead patient education effectively. Knowledge deficits are greatest in the areas of medications, insulin treatment, blood glucose monitoring, dietary recommendations, symptoms, and complications. Inadequate patient self-management could be improved if nurses received more in-depth training to increase their basic foundational knowledge.
Methods: Participants were recruited through convenience and snowball sampling from several ambulatory care clinics of a large academic medical center. The intervention consisted of four modules focused on DM self-management education which included pathophysiology, symptom management, and blood glucose monitoring; medications and treatment; complications, diet and health care; and patient teaching and motivational interviewing. A validated tool, adapted from 4 validated instruments from previous studies (diabetes self-report tool, diabetes knowledge tool, diabetes survival knowledge test, and diabetes knowledge questionnaire), was used to assess actual and perceived knowledge of diabetes management before and after each module.
Assessments were completed in REDCap, and IBM SPSS version 24 was used for statistical analysis. Paired t-tests were performed to analyze scores before and after the intervention. Partial eta squared values were calculated to determine effect size and statistical significance was set at p = 0.05. Descriptive statistics were used for the demographic survey and program evaluation.
Results: There were about 16 participants in the program, and more than half have been nurses for ten years or less. Post-education scores for module 1 and 2 were statistically significant (p ˂ 0.001), and the effect sizes were large at 65% and 45%, respectively. Modules 3 and 4 were not statistically significant. Aggregate data for modules 1-3, n=45, resulted in statistical significance (p ˂ 0.001). Aggregate effect size was large at 31%. Close to 60% of participants found this educational intervention very helpful, with 55% stating that they are very comfortable leading diabetes care and education as a result of program participation.
Conclusions and implications: A significant finding is that despite a fully virtual platform, this educational intervention was effective in increasing nurse knowledge related to diabetes. Continuing to promote the virtual platform for education as well as incorporating role playing and recording options into future programs will be important in engaging nurses in a way that is helpful to their practice and provides the flexibility necessary within the unpredictable ambulatory care environment. More than a third of our population has pre-diabetes, and our findings suggest that educational interventions are necessary, welcomed, and effective in providing outpatient nurses with the knowledge necessary to lead diabetes and prediabetes care and education. Nurses are well-positioned to support the shift in care to population health management, help prevent or delay type 2 diabetes, and promote overall wellness with a focus on quality outcomes.
The National Institute for Occupational Safety and Health (NIOSH) estimates that 8 million health care workers who handle or administer hazardous drugs (HDs) may be exposed in the workplace. Exposure to HDs can cause short-term or long-term side effects including skin disorders, infertility, and/or cancer. Although guidelines on handling and administering HDs have been published, there were previously no enforceable standards. USP General Chapter Hazardous Drugs – Handling in Healthcare Settings specifies practice and quality standards to promote patient and employee safety, as well as environmental protections. USP , which was initially published in 2014 and finalized in 2016, was set to be enforceable on December 1, 2019, by The Joint Commission® and state pharmacy boards. However, it has been delayed as the process of HD compounding is still being finalized. Once this has been finalized, USP will be enforceable. In the interim, health care organizations can choose to adopt USP standards, which has been encouraged by USP® to ensure safe work practices.
Non-oncology ambulatory care environments will need to make significant practice changes to be in compliance with USP . New workflows and practices need to be developed including wearing personal protection equipment (PPE), using a closed-system transfer device and safely cleaning up a spill. Although the oncology environments will also be impacted, the standards are not new as they are based, at least partly, on the Oncology Nursing Society guidelines. Therefore, in these environments, practice changes have already started to take place.
The objective of this poster is to describe how non-oncology ambulatory care environments can prepare for USP . The first step in being successful will be to create an interdisciplinary team with oncology, inpatient, occupational health, and pharmacy. Partnering with these disciplines allows for individual expertise to inform how to safely implement USP . The second step will be development of an educational plan for clinical staff (RNs, LPNs, MD/APPs) administering and cleaning HD spills. In addition, an educational plan will need to be developed for ambulatory care leadership to guide them on the supplies they will need (e.g., PPE, HD waste containers, spill kits, etc.), as well as the operational workflows to ensure employee and patient safety. The final step in successfully preparing for USP in the non-oncology ambulatory care environments will be to develop resources to support the implementation of the program (e.g., skill validations, online learning tools, etc.).
At our academic institution, the ambulatory care environment includes over 50 non-oncology ambulatory care clinics, comprising of approximately 150 clinical staff administering HDs. Preparing to implement USP standards will require substantial change in the non-oncology ambulatory care environments. In order to be successful, it will require working as an interdisciplinary team to develop educational plans, implementing safe work practices, and developing resources to support clinical staff and ambulatory care leadership to comply with USP standards.
Problem/purpose: To promote consistent clinical orientation experiences and clinical practice in a complex health care system with two separate human resource departments and diverse practice settings.
Design: Partnership among 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 to 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 participating 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 health care system expansions, other organizations may benefit from a similar approach to integrating orientation for a consistent experience and standardized practice and documentation.
Purpose: A HRSA grant targeting the integration of primary care content into a BSN pre-licensure program led to the creation of a new academic-practice partnership with a federally qualified health center (FQHC). Senior level students completed clinical learning experiences in primary care clinics of the FQHC. Clinical placement in the primary care setting is a relatively new learning environment for BSN students. Therefore, nurses now functioning as preceptors, have not recently received professional development related to the knowledge and skills of precepting. A learning needs assessment revealed that although preceptors indicated basic knowledge, they also had a desire to learn more related to current strategies for appropriate oversight and clinical teaching of BSN students.
The purpose of this poster is to share the novel aspects of design, delivery, and evaluation of a pilot preceptor education series for a new academic-practice partnership, while incorporating a preceptor learning needs self-assessment.
Description: Nurse managers identified a lack of recent experience with RN student learning and formal preceptor development opportunities. While potential learning needs were discussed at that time, a self-assessment was constructed and completed by potential preceptors. Education topics were derived from the self-assessment, core preceptor competencies, and educator expertise.
Evidence-based content was delivered in 30-minute sessions scheduled at the beginning of the RN work day.
A virtual delivery format allowed individual preceptors from various practice or academic locations to join in group discussions which would not have been possible in face-to-face training.
Clinical faculty, site managers (RNs) and potential RN preceptors attended an initial one-hour session focused on the new academic-practice partnership and orientation to academic course requirements. A facility specific preceptor handbook was distributed to support the session content and included preceptor expectations, student evaluation templates, and tips for precepting in the primary care setting.
The educational series was designed building from simple supportive teaching strategies to complex, evaluative, and accountability strategies. Each session can be completed independently but builds upon the previous module’s content. Sessions included precepting processes, reflection on past experience, and analysis for future application. Continuing education credit was awarded for individual sessions as live or recorded events.
Evaluation/outcome: Session outcomes were assessed through group discussions and individual evaluations revealing new insights about application of the topics to the primary care setting. Examples include allowing students to determine learning goals while working in a drive-up clinic setting, encouraging students to take a leadership role when designing a flu clinic, and engaging students through provision of formative evaluation. Participants also discussed applying their new knowledge in other interprofessional relationships within the practice setting. A collective evaluation score of 4.66 (of 5-point scale) indicated that participants found the session content and presenters to be effective in achieving session outcomes.
The series will be evaluated using grant-required evaluation questions, general applicability of the content to practice, and usefulness of the novel delivery approach. Attendance ranged from 40-60%; however, the model accommodated independent learning so additional preceptors and RN staff can benefit from the professional development opportunities.
Purpose: Many challenges arise when considering emergency response in an ambulatory care setting. After thoughtful assessment of an organization’s 30 practice sites in eastern Massachusetts, it was recognized that change was necessary to be more in line with ambulatory care evidence-based practice and ambulatory care professional association recommendations. Research indicates that patients who received basic life support (BLS) in a pre-hospital setting have higher survival rates and lower mortality rates than those who received advanced cardiac life support (ACLS) (Ann Internal Medicine, 2015; JAMA Intern Med, 2015).
Description: Management of medical emergencies at the multi-practice ambulatory care center included ACLS response with the use of code cart equipment and medications. Acknowledging the varying frequency in which emergencies that required this level of response occurred confirmed that change was necessary. When ACLS skills are infrequently used in practice, comfort and competence levels are low. Review of safety event reports revealed that common medical emergencies seen throughout the organization included minor medical events such as fainting, nausea, falls, seizures, and bleeding. The medical emergency response model shifted to focus on BLS, including first aid, automated external defibrillation (AED), and activation of emergency medical services (EMS) when needed.
This change required buy-in from key stakeholders including operational and clinical leaders, physicians, advanced practice clinicians, nurses, and other direct care employees. Policies were revised to anchor on the new model. The initial steps included the purchase and installation of 120 AEDs, with onsite training and requiring all direct patient care employees to receive American Heart Association (AHA) BLS certification, and additional training on handling other common medical emergencies. In order to replace code carts in most areas of care, 188 rapid response (RR) bags were deployed across the practice sites. The RR bags include supplies and medications to manage minor medical emergencies and initiate BLS. Due to the acuity of care provided by procedural and some specialty areas; certain departments, including urgent care, cardiac testing, endoscopy, and the special procedures unit will retain code carts and will be certified to provide an ACLS response. Using a standardized template that anchors on principles outlined in the policy, RR plans will be developed and implemented on a local site level.
Ongoing training is critical to ensure the knowledge and skills to recognize early signs and symptoms of a decompensating patient and manage minor medical emergencies are present. Mock events, which will be informed by common themes reviewed through the safety reporting system, will engage staff and allow for practice and further development of these essential skills.
Evaluation/outcome: Creating safe response to medical emergencies with the development of RR in a multi-location ambulatory care center requires a great deal of ongoing assessment and review. Measurable outcomes include posting local site plans centrally on the organization’s intranet after development and increasing staff preparedness and confidence to handle an event with the use of the RR bag. Feedback from staff on this model will be reviewed after every mock event. Safety events will be tracked to ensure appropriate response to a patient event.
Primary care focuses on maintenance of health and management of chronic conditions. According to the Georgia Department of Public Health (GDPH), the Centers for Disease Control (CDC) and the American Diabetes Association (ADA), approximately 14.2% of the adult population have been diagnosed with diabetes mellitus (DM), and an additional 36.1% of the adult population have prediabetes. Diabetes mellitus is a leading cause of morbidity and mortality and requires consistent monitoring and treatment to minimize complications. COVID-19 has disrupted the consistent delivery of care for patients with DM and hence potentially placing them at risk for worsening disease management.
A large academic medical center in Georgia month to month monitors A1C metrics in relation to care of the person who has DM. The metrics include both an A1C greater than nine and missing A1C value. Review of data revealed an increase in both metrics beginning in March 2020 and trending upward through September 2020. An interdisciplinary group in primary care consisting of registered nurses, medical assistants, administrators, and providers reviewed the trending data in correlation with clinic closures and decreased access to primary care. The data revealed a 3% increase in the number of missing A1Cs and a 4% increase of the number of patients with an A1C greater than nine. The team wanted to understand the progressive increases. The team created a standard process to directly outreach/education to patients with diabetes, understand barriers and address the need for an A1C in accordance with the ADA standards of medical care in diabetes (2020).
The quality improvement project used A3 methodology and PDSA to create, implement, and review a standard process for direct patient outreach/education. The project included multiple components around data collection and review: access of data, identification of clinic and provider, understanding of metrics/data, review for duplication, antidotal barrier comments from patients, and a mechanism for tracking the information. Additionally, a foundational process was created which included identification of staff for outreach/education, process for outreach/education, communication scripting, scheduling patients for lab and provider visits, and follow-up. Patients who were missing an A1C received direct outreach/education from the clinical staff to include phone calls using scripted communication and education.
Over a period of two months, 1385 patients were identified as missing an A1C. Of these patients, 100% received direct outreach/education from the clinical staff, 990 provider appointments were scheduled with an A1C obtained decreasing the number of patients with a missing A1C from 1385 to 395. Anecdotal feedback from patients identified fear and lack of urgency in getting the A1C completed in the clinic. Additionally, patients expressed appreciation for the phone calls and education. As COVID-19 continues the quality improvement project will subsist to understand barriers for patients and how clinical staff can provide the support, education and access needed to care for patients with DM.
Purpose: To increase the compliance in patients with diabetes to complete the recommended diabetic eye exams in order to rule out diabetic retinopathy. Diabetic retinopathy is the leading cause of blindness among U.S. working-age adults per the National Eye Institute. It is expected that by 2050, there will be close to 14.6 million Americans living with diabetic retinopathy with Hispanic Americans being disproportionately affected. Diabetic retinopathy is treatable and more readily so in the early stages of the disease. The American Diabetes Association (ADA) has outlined in their standards of medical care in diabetes 2020 which state that comprehensive eye exams be performed every 1-2 years if there is no evidence of retinopathy and at least annually if any level of diabetic retinopathy is present.
Description: In a large academic medical center in Southern California where close to 6,000 diabetic patients receive care, around 40% of those patients were not completing the recommended diabetic eye exam. A root cause analysis was performed to determine reasons for noncompliance, and it was found that many patients deemed the testing to be inconvenient. Diabetic eye exams had historically been done in one clinic location that services much of the larger metropolitan area for their eye care and was notoriously difficult to receive an appointment. A workgroup was formed that consisted of ambulatory care clinic leaders, ophthalmologists, physicians, and nurses to develop a strategy that would increase the likelihood that patients would receive their diabetic eye exam. After extensive research on varying options, the team decided to pilot three retinal cameras in internal medicine and primary care clinics that would send patient images electronically to ophthalmologists. The team sought to answer for the diabetic patient population: how does offering retinal imaging in primary care offices compared to referring patients to another clinic for their diabetic eye exam affect patient compliance in receiving the diabetic eye exam during a pilot phase from October 12, 2020, to December 31, 2020.
Evaluation/Outcome: The pilot is still ongoing with varied success. Workflow continues to evolve along with clinical staff and provider engagement. However, during the first three weeks of testing, the pilot has provided some promising patient outcomes. In one example, a clinic imaged a 38-year-old patient who had never had an eye exam previously and was found to have severe proliferative diabetic retinopathy. The in-clinic exam enabled swift referrals to acute care that the patient would not have had otherwise.
More data will be collected in order to validate the proposed PICOT question; however, patients reported satisfaction in the “one-stop shop” availability for their diabetic care suggesting that the implementation of tele-retina eye exams in clinic may prove successful.
This study assesses the impact of a remote patient monitoring (RPM) program on diabetic patients’ perception of their diabetes knowledge. This study also examines if there is a difference in perceived levels of diabetes knowledge between patients younger than 65 years and patients who are 65 and older. The growing diabetic epidemic in the United States has created additional chronic health problems and increased health care costs. To manage a complex disease such as diabetes, knowledge of disease processes and confidence to perform the recommended health care management tasks are vital for patients. Inadequate perception of knowledge often leads to the inability to complete tasks, process new information, or make proper judgments (Ziegler & Montplaisir, 2017). The learning for this presentation includes the effect of the 90-day RPM program on all participants’ perceived levels of diabetes knowledge and the effect of the 90-day RPM program on participants who are 65 and older versus those under 65 regarding their perceived levels of diabetes knowledge. Patients who participated in a 90-day RPM program conducted between June 2019 and August 2020 completed perceived diabetes knowledge questions before and after their RPM program experience. This study is a retrospective secondary analysis of perceived diabetes knowledge responses to a subset of the Robert Wood Johnson Foundation Diabetes Knowledge Assessment Questionnaire. Descriptive statistics were used to analyze continuous variables. Total and percentages were used for categorical variables. The paired t-test was used to analyze within-group differences between pre-program and post-program perceived levels of diabetes knowledge. The Mann Whitney U test was used to analyze the differences in perceived levels of diabetes knowledge between the two age populations participating in the RPM program. 37 diabetic patients (male 43.2 %, female 56.8%; 32.4% white, 67.6% African-American; 86.5%Learning Objective:
Purpose: This project was supported by the CARES Act supplemental funding for NEPQR awardees, enhanced telehealth training opportunities for bachelor of science in nursing (BSN) students to prevent, prepare, and respond to COVID-19 in a large academic university.
Background/significance: This project evaluated how exposure to an e-learning module and virtual simulation course on the electronic health record (EHR) inbox management in the ambulatory care setting supports preparation to address the needs arising from COVID-19. This course was implemented in pre-licensure nursing curricula during a nursing clinical course in fall 2020 quarter.
Methods: A mixed methods qualitative and quantitative survey was used to evaluate the effectiveness of an educational intervention on a sample of 80 BSN nursing students. This project focused on educating students on EHR inbox prioritization, telephone triage, and team communication in a two-part simulation format. Students took a self-paced interactive virtual inbox simulation (part 1) online and continued the course in a scheduled virtual class via the Zoom platform to complete (part 2) of the simulation content. Information was collected using an anonymous voluntary Google forms survey at the end of the course. Students were asked multiple choice questions related to the learning objectives and rated the system usability using a modified system usability scale (SUS) to measure generic product usability along with a free text qualitative question.
Results: Among those who entered the study (N=83), 41.2%, (N=35) participants completed all of the survey measures. Response was double the goal of 20% participation. Preliminary data suggests that learning objectives were overwhelmingly met. The majority of students strongly agreed (N=, 88.5%) that they are able to “describe the role of the nurse in managing and responding to patient messages received through electronic communication.” (N=85.71%) strongly agree that they are better able to “prioritize messages using the nursing process an emphasizing patient safety.” (N=77.14%) report “I better understand how ambulatory care nurses use the inbox” and (N=80%) report “I feel my knowledge and skills with the EHR have improved.” When students were asked if the simulation helped them understand how to “engage the health care team as needed to delegate tasks (to medical assistants or LPNs) or seek provider input as appropriate.” (N=57%) strongly agreed and (N=34%) somewhat agreed, indicating a need for further education in this area. Students reported usability data with (N=77%) stating “I feel the module was easy to navigate,” and (N=82.85%) indicated “I found the various functions in the module were well integrated.” The free-text question “How do you imagine you will use the concepts learned in this simulation in your work as a nurse?” received a (N= 68.57%) response and indicated that the SOAP documentation technique and SBAR exercises during the virtual simulation were valuable to the majority of respondents.
Conclusions and implications: This research highlights the need further education on the electronic tools that facilitate patient assessment, team communication, and proper documentation in the electronic health record. This study may form as a guide for future education for ongoing nursing clinical courses.
Objective: In this presentation, we describe the process of using standardized patients (SPs) during a virtual telehealth-enabled COVID-19 triage simulation in a pre-licensure nursing program, and the effectiveness of the simulation on the students’ confidence and competence.
Background: Simulation-based learning experiences (SBLEs) have long-been recognized as an effective educational tool in BSN education (Aebersold, 2018). The addition of standardized patients (SPs) who have training in providing the most realistic possible scenario adds additional benefit to the simulation experience. SPs have been used extensively in medical education and more recently in nursing education (Speeney, Kameg, Cline, Szpak, & Bagwell, 2018).
For this simulation, the university school of nursing collaborated with the school of medicine to obtain actors who had served as SPs in their program. These actors were provided with the script for the simulation well in advance, and provided a level of realism not possible when those roles were played by faculty or non-professional volunteers.
Funding for the use of SPs was provided to the school of nursing through a supplemental grant by the Health Resources and Services Administration to strengthen telehealth training to address COVID-19 care in primary care. Use of telehealth and COVID-19 triage protocol via virtual simulation is one way for nursing schools to prepare nurses to provide telehealth-enabled COVID-19 care to the community.
Method: 89 students in an ambulatory care course during the last semester of their pre-licensure bachelor of science in nursing degree program participated in a 2.25-hour virtual telehealth simulation. The course faculty modified a previous telephone triage in-person simulation to include a COVID-19 exposure scenario and added a team of actors who were experienced simulation educators to act as SPs. These SPs were provided with the script and background information for their role, and after each individual simulation they offered feedback to the participating students.
Using Zoom as a virtual learning platform, learners participated in a 45-minute pre-briefing, where they learned about the use of telehealth in nursing practice and about COVID-19 telephone triage and care protocol (CDC, 2020). They then participated in a 30-minute, one-on-one simulation with the SPs in a Zoom breakout room, including feedback from SPs and faculty, before joining a one-hour structured debriefing session. Change in the learners’ knowledge and confidence in providing telehealth-enabled COVID-19 care was measured with a 19-item pre- and post-survey.
Outcomes: The students completed a pre- and post-simulation survey assessment of their perceived confidence and competence in telehealth encounters related to COVID. These included question items such as confidence in assessment, triage, treatment and referral, patient education, and other factors. Analysis of the survey results indicates that the students perceived a significant increase in both confidence and competence in managing clients with possible COVID infection through a telehealth platform. Comments were generally positive about the experience.
Conclusion: The use of SPs provided a consistency in delivery of the telehealth simulation experience, and the structure and delivery of the simulation improved the students’ perceived confidence and competence in telehealth delivery of COVID care.